Final Exam Review for Foundations
What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing
ANSWER: B
What statement made by a 2-year-old patient's mother indicates that she understands how to administer her son's eardrops? A. "To straighten his ear canal, I need to pull the outside part of his ear down and back." B. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." C. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." D. "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10 minutes."
ANSWER: B
While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the patient coughed. Which finding should the nurse document from the lung assessment? A. Rhonchi B. Coarse crackles C. Sibilant wheeze D. Pleural friction rub
ANSWER: B
A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A. Right antecubital and tympanic membrane B. Right popliteal and rectal C. Left antecubital and oral D. Left popliteal and temporal artery
ANSWER: A
A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as, "I'm such a failure ... I can't do anything right." What is the nurse's best response? A. Remain with the patient until he or she validates feeling more stable. B. Tell the patient that is not true and that every person has a purpose in life. C. Review recent behaviors or accomplishments that demonstrate skill ability. D. Reassure the patient that you know how he is feeling and that things will get better.
ANSWER: A
A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? A. Caring touch B. Protective touch C. Task-oriented touch D. Interpersonal touch
ANSWER: A
A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: A. Examining results of clinical data B. Comparing achieved effects with outcomes C. Recognizing error D. Self-reflection
ANSWER: A
A nurse is caring for a patient who recently lost a leg in a motor vehicle accident. The nurse best assists the patient to cope with this situation by applying which of the following theories? A. Roy B. Levine C. Watson D. Johnson
ANSWER: A
A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management
ANSWER: A
A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? A. Engage the patient in setting mutual outcomes for distance he is able to walk B. Confirm with the patient's health care provider about ambulation goals C. Have physical therapy assist with ambulation D. Refer to medical record regarding nature of patient's physical problem
ANSWER: A
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Obtain the next IV fluid bag from the medication room D. Explain when the health care provider is likely to visit
ANSWER: A
An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. The nurse's approach should be based on an understanding of which of the following? A. Patients need support in dealing with the loss of a body part. B. The patient's family should take the lead role in providing support. C. The nurse should explain that breast tissue is not essential to life. D. The patient should focus on the cure of the cancer rather than loss of the breast.
ANSWER: A
Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative
ANSWER: A
The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect care measure D. Lifesaving measure
ANSWER: A
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A. Appearance and behavior B. Measurement of vital signs C. Observing specific body systems D. Conducting a detailed health history
ANSWER: A
What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization
ANSWER: A
You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take? A. Call the health care provider to clarify the order B. Talk with your preceptor to help you interpret the order C. Refer to a medication manual before giving the medication D. Use your best judgment and critical thinking and administer the dose you think the health care provider ordered
ANSWER: A
A 20-year-old man who has been diagnosed with testicular cancer is about to begin treatment, including intense chemotherapy, radiation, and surgery. He says to the nurse, "I'm scared that I'll never be able to be a father." The most appropriate response by the nurse is: A. "You're young. You'll beat this cancer and have a long and happy life." B. "Tell me what you mean about your fear of never being a father." C. "Cancer treatment has really improved, and more people are surviving it." D. "Your doctor is really good and has a high cure rate. He'll take care of you. "
ANSWER: B
A child is taking albuterol through a pressurized metered-dose inhaler (pMDI) that contains a total of 64 puffs. The dose is 2 puffs every 6 hours. How many days will the pMDI last? A. 6 days B. 8 days C. 12 days D. 30 days
ANSWER: B
A health care provider ordered enalapril (Vasotec) 2 mg IV push for a patient with hypertension. The pharmacy sent vials marked 1.25 mg enalapril/mL. How many mL does the nurse administer? ___ Ml A. 2.6 mL B. 1.6 mL C. 2.4 mL D. 5.2 mL
ANSWER: B
A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? A. Patient weight B. Asking patient to identify three low-sodium foods to eat for lunch C. A calorie count of food D. Patient description of how food selections are made
ANSWER: B
A nurse is working with a new group of immigrants and wants to learn more about their culture. Which method of cultural assessment should the nurse perform to gain a long-term understanding of this culture? A. Observe a group. B. Participate in the community. C. Interview a client. D. Visit a group of clients.
ANSWER: B
A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? A. Reverse isolation B. Droplet precautions C. Standard precautions D. Contact precautions
ANSWER: B
A registered nurse assessing a postoperative ileostomy will interpret that a stoma has lost its vascular supply, if the stoma appears: A. Red B. Cyanotic C. Dry D. Moist
ANSWER: B
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? A. Binder B. Ice bag C. Elastic bandage D. Absorptive dressing
ANSWER: B
In conducting a research study, the researcher must guarantee 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. This concept is known as? A. The research process. B. Confidentiality. C. Informed consent. D. Anonymity.
ANSWER: B
Several staff members complain about an adult patient's constant questions such as, "Should I have a cup of coffee or a cup of tea?" and "Should I take a shower now or wait until later?" Which interpretation of the patient's behavior helps the nurses provide optimal care? A. Asking questions is attention-seeking behavior. B. Inability to make decisions reflects a self-concept issue. C. Dependence on staff must be stopped immediately. D. Indecisiveness is aimed at testing how the staff reacts.
ANSWER: B
The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? A. Percussion B. Inspection C. Auscultation D. Palpation
ANSWER: B
You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, his heart rate is 110. What is your next action? A. Stop exercise immediately and have him sit in a nearby chair. B. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. C. Tell him that he needs to walk further to reach a heart rate of 120. D. Have him walk slower; he has reached his maximum.
ANSWER: B
A 50-year-old woman is recovering from a bilateral mastectomy. She refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse? A. "What's the special occasion?" B. "You must be feeling better today." C. "This is the first time I've seen you look this good." D. "I see that you've combed your hair and put on makeup."
ANSWER: C
A family that includes relatives ( aunts, cousins, uncles) in adition to the nuclear family is an example of? A. Single-parent family B. Blended family C. Extended family D. Nuclear family
ANSWER: C
A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? A. Give the medications after identifying the patient using two patient identifiers B. Provide medication education to the patient to help with adherence to the medical plan C. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications D. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital
ANSWER: C
A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? A. The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. B. The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. C. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. D. The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.
ANSWER: C
During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? A. Nodule B. Macule C. Wheal D. Pustule
ANSWER: C
A nurse reviews the medical record of a 40-year-old patient newly admitted to the medical nursing unit for evaluation of diabetes. While reviewing the medical history, the nurse notices that the patient had bladder surgery 3 years ago. Which of the following assessment questions is most appropriate for the nurse to ask to determine if the patient is a cancer survivor? A. Determining if the patient had additional surgeries recently B. Assessing the patient's medication history C. Determining if the surgery was cancer related D. Assessing if the patient's parents had cancer
ANSWER: C
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? A. Provide a dark, quiet room to calm the patient. B. Reduce the level of precautions to keep the patient from becoming angry. C. Explain the reasons for isolation procedures and provide meaningful stimulation. D. Limit family and other caregiver visits to reduce the risk of spreading the infection.
ANSWER: C
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 4D. What is your priority intervention? A. Request that the nursing assistant repeat the pulse check B. Call for a stat electrocardiogram (ECG) C. Assess the patient's apical pulse and evidence of a pulse deficit D. Prepare to administer cardiac-stimulating medications
ANSWER: C
According to the Office of Minority Health (OMH), the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups are known as? A. Subculture. B. Ethnicity. C. Culture. D. Cultural backlash.
ANSWER: C
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. C. Nail polish interferes with sensor function. D. Nail polish creates excessive heat in sensor probe.
ANSWER: C
The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? A. Auscultation of an apical heart rate of 76 B. Absence of bowel sounds on abdominal assessment C. Respiratory rate of 8 breaths/min D. Palpation of dorsalis pedis pulses with strength of +2
ANSWER: C
The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? A. 96/40 mm Hg B. 110/66 mm Hg C. 130/90 mm Hg D. 156/82 mm Hg
ANSWER: C
What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? A. Measures a nurse's competency in interdisciplinary care B. Measures the number of adverse events in a hospital C. Measures quality of care within hospitals D. Measures referrals to a health care agency
ANSWER: C
Which patient is at highest risk for tachycardia? A. A healthy basketball player during warmup exercises B. A patient admitted with hypothermia C. A patient with a fever of 39.4 degrees C (103 degrees F) D. A 90-year-old male taking beta blockers
ANSWER: C
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? A. Knowing the source of the guideline B. Reviewing the evidence used to develop the guideline C. Individualizing how to apply the clinical guideline for a patient D. Explaining to a patient the purpose of the guideline
ANSWER: C
While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? A. Disease, spirit, and family interactions B. Desires and emotions of the patient C. Mind-body-spirit of patients and their families D. Muscles, nerves, and spine disorders
ANSWER: C
A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? A. Wear gloves before eating or handling food. B. Place any soiled materials into a bag and double bag it. C. Have the family member check with the health care provider about need for immunization. D. Perform hand hygiene after care and/or handling contaminated equipment or material.
ANSWER: D
A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician 269comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? A. Environment B. Personnel C. Equipment D. Patient
ANSWER: D
A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? A. A medication cup B. A teaspoon C. A 5-mL syringe D. An oral-dosing syringe
ANSWER: D
In the postanesthesia care unit (PACU) a nurse notes that a patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse's priority intervention at this time is: A. Suction the pharynx and bronchial tree. B. Give oxygen through a mask at 4 L/min. C. Ask the patient to use an incentive spirometer. D. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.
ANSWER: D
Listening is not only "taking in" what a patient says, but it also includes: A. Incorporating the views of the physician. B. Correcting any errors in the patient's understanding. C. Injecting the nurse's personal views and statements. D. Interpreting and understanding what the patient means.
ANSWER: D
The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? A. Encourage the patient to rearrange her home furnishings regularly to keep active. B. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility. C. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. D. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.
ANSWER: D
The nurse writes an expected outcome statement in measurable terms. An example is: A. Patient will have normal stool evacuation. B. Patient will have fewer bowel movements. C. Patient will take stool softener every 4 hours. D. Patient will report stool soft and formed with each defecation.
ANSWER: D
What is the step of the nursing process that includes data collection by health history, physical examination, and interview? A. Diagnosis B. Planning C. Evaluation D. Assessment
ANSWER: D
When caring for an 87-year-old patient, the nurse needs to understand that which of the following most directly influences the patient's current self-concept? A. Attitude and behaviors of relatives providing care B. Caring behaviors of the nurse and health care team C. Level of education, economic status, and living conditions D. Adjustment to role change, loss of loved ones, and physical energy
ANSWER: D
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A. Necrotic tissue B. Wound drainage C. Wound circumference D. Cleansed wound
ANSWER: D
When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? A. Lupus and diabetes B. Ulcers and hepatitis C. Heart disease and pancreatitis D. Chronic back pain and arthritis
ANSWER: D
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode
ANSWER: D
Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface
ANSWER: D
Which statement best describes the evidence associated with complementary therapies as a whole? A. Many clinical trials in complementary therapies support their effectiveness in a wide range of clinical problems. B. It is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use. C. The science supporting the effectiveness of complementary therapies is early in its development. D. Most of the research examining complementary and alternative therapies has found little evidence, suggesting that, although people like them, they are not effective.
ANSWER: D
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.
ANSWER: A
Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia? A. Ask open-ended questions B. Speak to the patient as if he or she is a child C. Use a dry-erase board or paper and pen for writing messages D. Avoid the use of gestures and other nonverbal forms of communication
ANSWER: C
A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? A. Include communication while performing tasks such as changing dressings and checking vital signs. B. Ask the patient if you can talk during the last few minutes of visiting hours. C. Ask Pastoral care to come back a little later in the day. D. Remind the nurse to complete all her tasks and then set up remaining time for communication.
ANSWER: A
A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? A. Working phase B. Pre-interaction phase C. Termination phase D. Orientation phase
ANSWER: A
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? A. Encouraging use of an overhead trapeze for positioning and transfer B. Frequent family visits C. Assisting the patient to a wheelchair once per day D. Ensuring that there is an order for physical therapy
ANSWER: A
A nurse is using data collected from the unit to monitor the incidence of falls after the unit implemented a new fall protocol. The nurse is working in which area? A. Quality improvement (QI) B. Health care patient system C. Nursing informatics D. Computerized nursing network
ANSWER: A
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: A. Decreased peristalsis B. Decreased heart rate C. Increased blood pressure D. Increased urinary output
ANSWER: A
A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? A. Telling approach B. Selling approach C. Entrusting approach D. Participating approach
ANSWER: A
A registered nurse (RN) is providing care to a patient who had abdominal surgery 2 days ago. Which task is appropriate to delegate to the nursing assistant? A. Helping the patient ambulate in the hall B. Changing surgical wound dressing C. Irrigating the nasogastric tube D. Providing brochures to the patient on health diet
ANSWER: A
A registered nurse is caring for a patient who is having difficulty understanding the written and spoken word. The patient is able to express words, however he is unable to understand questions or comments of others.Which type of aphasia will the nurse report to the oncoming shift? A. Receptive B. Expressive C. Motor D. Combination
ANSWER: A
A registered nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced: A. Phlebitis of the vein B. Infiltration of the IV line C. Erythema and palpable venous cord D. Hypersensitivity to the IV solution
ANSWER: A
A rgistered nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who needs to receive 3 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? A. Nasal cannula B. Partial non-rebreather mask C. Non-rebreather mask D. Rebreather mask
ANSWER: A
At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to resume normal operations D. Evacuate patients per the disaster plan
ANSWER: A
During a routine physical examination of a 70-year-old patient, a turbulent blood passing through a narrowed blood vessel was found during the auscultation of the left carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as: A. Bruit. B. Phlebitis. C. Jugular venous distention. D. Clubbing.
ANSWER: A
Patient's vision is recorded as 20/40 when the Snellen eye chart is used. The nurse interprets these results to indicate that: A. The patient can read at 20 feet what a person with normal vision can read at 40 feet. B. The patient can read the chart from 20 feet in the left eye and 40 feet in the right eye. C. The patient can read from 40 feet what a person with normal vision can read from 20 feet. D. At 40 feet the patient can read the entire chart.
ANSWER: A
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? A. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert B. Hot dog on whole wheat bun with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert D. Turkey salad on toast with tomato and lettuce and honey bun for dessert
ANSWER: A
The nurse spends time with the patient and family reviewing the dressing change procedure for the patient's wounD. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? A. Educator B. Advocate C. Caregiver D. Case manager
ANSWER: A
While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. The nurse is exercising: A. Authority. B. Responsibility. C. Accountability. D. Decision making.
ANSWER: C
When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy
ANSWER: A
Which patient is most likely to experience sensory overload? A. A patient in the intensive care unit whose pain is not well controlled B. A patient with a protective patch on her right eye following cataract surgery C. A woman whose hearing aids were lost when she transferred to a long-term care facility D. A visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities
ANSWER: A
You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? A. Call the nursing supervisor to discuss the situation B. Discuss the problem with a colleague C. Leave the nursing unit and go home D. Say nothing and begin your work
ANSWER: A
A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?" A. Sharing feelings about the importance of having regular woman's health examinations B. Gaining an understanding of what a woman's health examination means to the patient C. Recognizing that the patient is modest; and obtaining gender-congruent caregiver D. Explaining the risk factors for cervical cancer
ANSWER: B
A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy
ANSWER: B
A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? A. Achieving wound healing of the foot ulcer B. Enhancing patient knowledge about the effects of diabetes C. Providing a dietitian consultation for diet retraining D. Improving patient adherence to diabetic diet
ANSWER: B
A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: A. Educator. B. Advocate. C. Caregiver. D. Case manager.
ANSWER: B
A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? A. Family member B. Surgeon C. Nurse D. Nurse manager
ANSWER: B
A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange 334is an example of which element of the transactional communication process? A. Message B. Obtaining feedback C. Channel D. Referent
ANSWER: B
A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? A. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C. The patient cannot make changes in the advance directive once admitted to the hospital. D. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
ANSWER: B
A patient asks a nurse what the patient-centered care model for the hospital means. What is the nurse's best answer? A. "This model ensures that all patients have private rooms when they are admitted to the hospital." B. "In this model you and the health care team are full partners in decisions related to your health care." C. "This model focuses on making the patient experience a good one by providing amenities such as restaurant-style food service." D. "Patients and families sign a document providing them full access to their medical charts."
ANSWER: B
A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? A. "Only your family can read your medical record." B. "You have the right to read your record." C. "Patients are not allowed to read their records." D. "Only health care workers have access to patient records.
ANSWER: B
A researcher is studying the effectiveness of an individualized evidence-based teaching plan on young women's intention to wear sunscreen to prevent skin cancer. In this study which of the following research terms best describes the individualized evidence-based teaching plan? A. Sample B. Intervention C. Survey D. Results
ANSWER: B
After a class on Pender's health promotion model, students make the following statements. Which statement does the faculty member need to clarify? A. "The desired outcome of the model is health-promoting behavior." B. "Perceived self-efficacy is not related to the model." C. "The individual has unique characteristics and experiences that affect his or her actions." D. "Patients need to commit to a plan of action before they adopt a health-promoting behavior."
ANSWER: B
As a nurse, you are assigned to four patients. Which patient do you need to see first? A. The patient who had abdominal surgery 2 days ago who is requesting pain medication B. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness C. A patient with a wound drain who needs teaching before discharge in the early afternoon D. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery
ANSWER: B
A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain
ANSWER: D
The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? A. Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. B. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. C. Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. D. Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.
ANSWER: B
The nurse is caring for a patient admitted to the neurological unit with the diagnosis of a stroke and right-sided weakness. The nurse assumes responsibility for bathing and feeding the patient until the patient is able to begin performing these activities. The nurse in this situation is applying the theory developed by: A. Neuman. B. Orem. C. Roy. D. Peplau.
ANSWER: B
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): A. Risk nursing diagnosis. B. Problem-focused nursing diagnosis. C. Health promotion nursing diagnosis. D. Wellness nursing diagnosis.
ANSWER: B
To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? A. Turn, cough, and deep breathe every 30 minutes while awake B. Ambulate patient to chair in the hall C. Passive range of motion 4 times a day D. Immobility is not a concern the first postoperative day
ANSWER: B
Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. A. Self-actualization B. Air, water, and nutrition C. Safety D. Esteem and self-esteem needs
ANSWER: B
Which of the following types of theory influence the "evidence" in current "evidence-based practice (EBP)"? A. Grand theory B. Middle-range theory C. Practice theory D. Shared theory
ANSWER: B
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time needed for health care providers to write orders." C. "CPOE eliminates verbal and telephone orders from health care providers." D. "CPOE reduces the time nurses use to communicate with health care providers."
ANSWER: C
A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? A. Document her findings and treat the patient B. Instruct the mother on safe handling of a 2-year-old child C. Contact a child abuse hotline D. Discuss this story with a colleague
ANSWER: C
A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? A. Challenge the nurses in a public forum to embarrass them and change their behavior B. Talk with the department secretary and ask if this has been a problem for other nurses C. Talk with the preceptor or manager and ask for assistance in handling this issue D. Say nothing and hope things get better
ANSWER: C
A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? A. Giving the enema on time B. Talking with the patient about her past experiences with illness C. Talking with the patient about her concerns and acknowledging her sense of unfairness D. Beginning instruction on postoperative procedures
ANSWER: C
A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain
ANSWER: C
A nurse is preparing to begin intravenous fluid therapy for a patient. Which category of theory would be most helpful to the nurse at this time? A. Grand theory B. Middle-range theory C. Practice theory D. Shared theory
ANSWER: C
A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient? A. Low priority B. High priority C. Intermediate priority D. Nonemergency priority
ANSWER: C
A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? A. Patient Protection and Affordable Care Act (PPACA) B. Patient Self-Determination Act (PSDA) C. Health Insurance Portability and Accountability Act (HIPAA) D. Emergency Medical Treatment and Active Labor Act
ANSWER: C
A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A. The nurse's automobile insurance B. The nurse's homeowner's insurance C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence D. The Patient Care Partnership, which may grant immunity from suit if the injured party consents
ANSWER: C
When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner? A. Printed pamphlets on cardiovascular disease and dietary recommendations from the American Heart Association B. A role-play activity requiring the patient to select proper foods from a wide selection C. Colored visual diagrams that categorize foods according to fat and sodium content D. A lecture-style discussion on heart healthy diet options
ANSWER: C
A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely
ANSWER: C
A patient had surgery for a total knee replacement a week ago and is currently participating in daily physical rehabilitation sessions at the surgeon's office. In what level of prevention is the patient participating? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Quaternary prevention
ANSWER: C
A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? A. "Why did you drive after you had been drinking?" B. "We have multiple patients to see tonight as a result of this accident." C. "Tell me what happened before, during, and after the automobile accident tonight." D. "It will be okay. No one was seriously hurt in the accident."
ANSWER: C
A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Focus on knowledge the patient will need in a few weeks C. Provide only the information that the patient needs to go home D. Convince the patient that learning about her health is necessary
ANSWER: C
A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus
ANSWER: C
A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? A. Arrange for a Spanish-speaking social worker to explain the procedure B. Ask a fellow Spanish-speaking patient to help explain the procedure C. Use a professional interpreter to provide wound care education in Spanish D. Ask the patient to write down questions that he or she has for the nurse
ANSWER: C
A registered nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as A. Elective. B. Urgent. C. Emergency. D. Major.
ANSWER: C
After a nurse receives a change-of-shift report on his assigned patients, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice? A. Organizational skills B. Use of resources C. Time management D. Evaluation
ANSWER: C
An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A. Speaks loudly. B. Presents the information once. C. Expects the patient to understand the information quickly. D. Allows the patient time to express himself or herself and ask questions.
ANSWER: C
Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: A. Avoid activities in which there may be crowds. B. Delay childhood immunizations until hearing can be verified. C. Take precautions when involved in activities associated with high-intensity noises. D. Prophylactically administer antibiotics to reduce the incidence of infections.
ANSWER: C
Of the five caring processes described by Swanson, which describes "knowing the patient?" A. Anticipating the patient's cultural preferences B. Determining the patient's physician preference C. Establishing an understanding of a specific patient D. Gathering task-oriented information during assessment
ANSWER: C
The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry
ANSWER: C
The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the 314 patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? A. Discussing patient conditions in the nursing report room at the change of shift B. Allowing nursing students to review patient charts before caring for patients to whom they are assigned C. Posting medical information about the patient on a message board in the patient's room D. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared
ANSWER: C
To honor cultural values of patients from different ethnic/religious groups, which actions does not demonstrate culturally sensitive care by the nurse? A. Allows fasting on Yom Kippur for a Jewish patient B. Serves no meat or fish to a Hindu patient C. Allows caffeine drinks for a Mormon patient D. Serves no ham products to a Muslim patient
ANSWER: C
What is the most effective way to control transmission of infection? A. Isolation precautions B. Identifying the infectious agent C. Hand hygiene practices D. Vaccinations
ANSWER: C
Which of the following categories of shared theories would be most appropriate for a patient who is grieving the loss of a spouse? A. Biomedical B. Leadership C. Psychosocial D. Developmental
ANSWER: C
A 45-year-old patient who has recurrent cancer is having nightmares and obsessive thoughts about the disease, is unable to focus on anything else, and has a breakdown in relationships with her family. These symptoms are associated with: A. Chemotherapy-related cognitive impairment (CRCI). B. Cancer-related fatigue (CRF). C. Family dysfunction caused by cancer. D. Posttraumatic stress disorder (PTSD).
ANSWER: D
A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? A. Health Insurance Portability and Accountability Act (HIPAA) B. Americans with Disabilities Act (ADA) C. Patient Self-Determination Act (PSDA) D. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed
ANSWER: D
A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? A. "Avoid rushing when documenting an entry in the medical record." B. "Use correction fluid to remove the entry." C. "Draw a single line through the statement and initial it." D. Enter only objective and factual information about a patient in the medical record.
ANSWER: D
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? A. Patient will be turned every 2 hours within 24 hours. B. Patient will have normal bowel function within 72 hours. C. Patient's skin integrity will remain intact through discharge. D. Erythema of skin will be mild to none within 48 hours.
ANSWER: D
A nurse ensures that each patient's room is clean; well ventilated; and free from clutter, excessive noise, and extremes in temperature. Which theorist's work is the nurse practicing in this example? A. Henderson B. Orem C. King D. Nightingale
ANSWER: D
A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: A. She does not touch the patients either. B. Touch is a type of verbal communication. C. Touch is only used when a patient is in pain. D. Touch forms a connection between nurse and patient.
ANSWER: D
A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster
ANSWER: D
A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? A. Validation B. Empathy C. Sarcasm D. Humility
ANSWER: D
A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed? A. "I am at risk for injury from temperature extremes." B. "I may be able to dress more easily with zippers or pullover sweaters." C. "A home care nurse may help me figure out how to be more independent." D. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."
ANSWER: D
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
ANSWER: D
A nurse researcher studies the effectiveness of a new program designed to educate parents to promote the immunization of children. The nurse divides the parents randomly into two groups. One group receives the typical educational program and the other group receives the new program. This is an example of which type of study? A. Historical B. Qualitative C. Correlational D. Experimental
ANSWER: D
A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? A. Children B. Therapy dogs C. The pediatric unit D. Anxiety
ANSWER: D
A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? A. Planning B. Assessment C. Intervention D. Evaluation
ANSWER: D
A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? A. Only infants and toddlers need to ride in the back seat. B. All toddlers can move to a forward facing car seat when they reach age 2. C. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. D. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.
ANSWER: D
A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? A. Seeking out the nursing supervisor to talk with the patient B. Documenting patient fears in the medical record in a timely manner C. Working to change the hospital environment D. Assessing the patient's point of view and preparing to articulate it
ANSWER: D
A registered nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). Which goal is the most important for this patient? A. The patient will not experience involuntary urination during coughing or sneezing. B. The patient will demonstrate how to appropriately use urinary incontinence products. C. The patient will carefully complete a voiding diary. D. The patient will not experience urinary tract infection.
ANSWER: D
A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? A. Obtain a court order to give the blood B. Coerce the husband into giving the blood C. Call security and have the husband removed from the hospital D. More information is needed about the wife's preference and if the husband has her medical power of attorney
ANSWER: D
An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A. Speaks loudly. B. Presents the information once. C. Expects the patient to understand the information quickly. D. Allows the patient time to express himself or herself and ask questions.
ANSWER: D
An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? A. Loss of appetite B. Gum soreness C. Difficulty swallowing D. Left ankle joint stiffness
ANSWER: D
The nurse is preparing to reposition a patient. Before doing so, the nurse must: A. Attempt to manually lift the patient alone before asking for assistance. B. b. Not use the agency lift team if a mechanical lift is available. C. Attempt a manual lift only when lifting most or all of the patient's weight. D. Assess the weight to be lifted and the assistance needed.
ANSWER: D
The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity Intolerance B. Impaired Bed Mobility C. Acute Pain D. Risk for Falls
ANSWER: D
Vulnerable populations of patients are those who are more likely to develop health problems as a result of: A. Chronic diseases, homelessness, and poverty B. Poverty and limits in access to health care services C. Lack of transportation, dependence on others for care, and homelessness D. Excess risks, limits in access to health care services, and dependency on others for care
ANSWER: D
Which activity performed by a nurse is related to maintaining competency in nursing practice? A. Asking another nurse about how to change the settings on a medication pump B. Regularly attending unit staff meetings C. Participating as a member of the professional nursing council D. Attending a review course in preparation for a certification examination
ANSWER: D
Which of the following documentation entries is most accurate? A. "Patient walked up and down hallway with assistance, tolerated well." B. "Patient up, out of bed, walked down hallway and back to room, tolerated well." C. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." D. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."
ANSWER: D
Which task is appropriate for a registered nurse (RN) to delegate to a nursing assistant? A. Explaining to the patient the preoperative preparation before the surgery in the morning B. Administering the ordered antibiotic to the patient before surgery C. Obtaining the patient's signature on the surgical informed consent D. Helping the patient to the bathroom before leaving for the operating room
ANSWER: D
You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code? A. Improves self-health care B. Protects the patient's confidentiality C. Ensures identical care to all patients D. Defines the principles of right and wrong to provide patient care
ANSWER: D
You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? A. Give the family the record B. Discuss the issues that concern the family with them C. Call the nursing supervisor D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information
ANSWER: D
Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? A. Reinforce dressing with a clean, dry dressing and call the health care provider. B. Remove wet dressing and apply new dressing using sterile procedure. C. Put on gloves before removing the old dressing; then obtain a wound culture. D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.
ANSWER: D
