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The nurse is caring for a patient who is comatose. When preforming oral hygiene, which interval is most appropriate? a. Every shift b. Twice daily c. Every 4 hours d. Daily

ANS: C Oral care should be performed every 4 hours to prevent the colonization of bacteria. Less often than every 4 hours is not effective.

The student studying culture learns that which are characteristics of all cultures? (Select all that apply.) a. Integrated b. Shared c. Learned d. Symbolic e. Inherited

ANS: A, B, C, D Cultures are learned, symbolic, shared, and integrated. Since culture refers to patterns of beliefs, actions, values, and ways of life that are taught, they are not inherited.

The nurse correctly devises a dissemination plan at what point during the research process? a. Conclusion of the study b. After the literature review c. The beginning of the research process d. While conducting research

ANS: C A dissemination plan should be devised at the beginning of the research.

The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position? a. Flat b. 90 degrees c. 30 degrees d. 45 degrees

ANS: C When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

6. The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.) a. Where did you fall? b. What time did the fall occur? c. What were you doing when you fell? d. What types of injuries occurred after the fall? e. Did you obtain an electronic safety alert device after the fall? f. What are your medical problems that may have caused the fall?

The nursing student is taking a class in Nursing Research. In class the student has learned which term that identifies the most abstract level of knowledge? a. Metaparadigm b. Philosophy c. Conceptual framework d. Nursing theory

ANS: A A metaparadigm, as the most abstract level of knowledge, is defined as a global set of concepts that identify and describe the central phenomena of the discipline and explain the relationship between those concepts. For example, the metaparadigm for nursing focuses on the concepts of person, environment, health, and nursing. The next level of knowledge is a philosophy, which is a statement about the beliefs and values of nursing in relation to a specific phenomenon such as health. The third level of knowledge is a nursing conceptual framework, or model, which is a collection of interrelated concepts that provides direction for nursing practice, research, and education. The fourth level of nursing knowledge is a nursing theory, which represents a group of concepts that can be tested in practice and can be derived from a conceptual model.

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is the most appropriate? a) Assess the patient for fluid volume overload. b) Assess the patient for fluid volume deficit. c) Assess the patient's apical heart rate. d) Assess the patient's pulse deficit.

ANS: A A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume overload, or overhydration. The nurse should assess for this situation. The other actions are not necessary.

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.

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

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 nurse who plans, organizes, delivers, and evaluates nursing care for patients is functioning in what role? a. Patient care provider b. Patient advocate c. Case manager d. Clinical nurse leader

ANS: A A nurse does not have to be a manager to be a leader. Even at the bedside, nurses use leadership skills, although possibly in different ways than a nurse manager. The patient care provider must be able to plan, organize, deliver, and evaluate nursing care for patients. An advocate is someone who supports and promotes the interests of others. The RN acts as a patient advocate during treatment. Although many health care organizations have case managers to aid in moving the patient through the health care system, the bedside nurse also acts as a case manager. One important way a nurse can do this is by beginning discharge planning on admission. The clinical nurse leader (CNL) has a master's degree and certification from the American Association of Colleges of Nursing (AACN) Commission on Nurse Certification.

39. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care? a. A patient with neck surgery b. A patient with hypostatic pneumonia c. A patient with a total knee replacement d. A patient with a Stage IV pressure ulcer

ANS: A A nurse supervises and aids personnel when there is a health care provider's order to logroll a patient. Patients who have suffered from spinal cord injury or are recovering from neck, back, or spinal surgery often need to keep the spinal column in straight alignment to prevent further injury. Hypostatic pneumonia, total knee replacement, and Stage IV ulcers do not have to be logrolled.

30. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea b. A bedridden patient who has a reddened area on the buttocks who needs to be turned c. A patient on bed rest who has renal calculi and needs to go to the bathroom d. A patient after knee surgery who needs range of motion exercises

ANS: A A patient on prolonged bed rest will be prone to deep vein thrombosis, which can lead to an embolus. An embolus can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. While the patient with a reddened area needs to be turned, a patient with renal calculi needing the restroom, and a patient needing range of motion, these are not as life threatening as the chest pain and dyspnea.

When a nursing class volunteers to serve hot meals at a local homeless shelter on a Saturday afternoon, which term identifies this focus on serving the community? a. Altruism b. Accountability c. Autonomy d. Advocate

ANS: A A profession provides services needed by society. Additionally, practitioners' motivation is public service over personal gain (altruism). Service to the public requires intellectual activities, which include responsibility. This accountability has legal, ethical, and professional implications. Members of a profession have autonomy in decision making and practice and are self-regulating in that they develop their own policies in collaboration with one another. As the patient's advocate, the nurse interprets information and provides the necessary education. The nurse then accepts and respects the patient's decisions even if they are different from the nurse's own beliefs.

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

The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for the last several months to relieve knee pain from arthritis. Which assessment finding must be reported by the nurse to the provider promptly? a. The patient has abdominal pain and pale skin. b. The patient has constipation and takes stool softeners daily. c. The patient enjoys a glass of wine every Friday and Saturday evening. d. The patient has gained 15 lb in the last 3 months.

ANS: A A side effect of ibuprofen and other NSAIDs is the risk of gastrointestinal bleeding, especially with long-term use. Abdominal pain with pale skin in this patient may be indicative of a bleeding ulcer and should be reported to the provider promptly.

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.

The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, "My blood pressure medicine is really expensive. Do you think I really need it?" The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient's statement and chooses lack of knowledge as a diagnostic label. The nurse identifies the action taken is an example of what concept of Nursing diagnosis formation? a. Clustering unrelated data in the diagnostic statement b. Selecting erroneous data for use in the diagnostic statement c. Using medical diagnoses in the diagnostic statement d. Identifying multiple problems within one diagnostic statement

ANS: A A variety of errors in identification, statement structure, and statement content may occur when formulating Nursing diagnoses These include clustering unrelated data, accepting erroneous data, missing the true underlying etiology of a problem, using medical diagnoses as related factors in a NANDA-I Nursing diagnostic statement, and identifying multiple Nursing diagnosis labels in one NANDA-I Nursing diagnostic statement. Clustering unrelated data most often occurs when the nurse has not completed a thorough review of the patient's assessment information or is missing important data. The nurse assumes the patient is not taking the blood pressure medication because of the cost and chooses the diagnosis of noncompliance. The nurse fails to ask the patient if the medication is being taken as ordered. Errors in data collection (e.g., omitting key information) or an incomplete understanding or knowledge of assessment techniques or a patient's condition may lead to the inclusion of erroneous data in a Nursing diagnostic statement. When writing Nursing diagnoses, the nurse should avoid inclusion of more than one label in the statement. Regardless of the type of Nursing diagnosis being written, only one label should be used in each statement. The nurse does not commit this error here. "Lack of knowledge" is not a medical diagnosis.

19. Which activity will cause the nurse to monitor for equipment-related accidents? a. Uses a patient-controlled analgesic pump b. Uses a computer-based documentation record c. Uses a measuring device that measures urine d. Uses a manual medication-dispensing device

ANS: A Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient- controlled analgesic pumps need to have free-flow protection devices. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentation is only accepted in court if written by hand.

ANS: A Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered legal documentation and may be used in court.

26. 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.

A patient is diagnosed with pneumonia after an abrupt onset of fever, cough, and malaise. The patient is started on antibiotic therapy and is expected to improve in 2 to 3 weeks. Which statement by the nurse correctly identifies this illness? a) Acute b) Chronic c) Remission d) Exacerbation

ANS: A Acute illness is typically characterized by an abrupt onset and short duration (<6 months). Clinical manifestations of acute illness appear quickly. They may be severe or lethal, or they may soon resolve because they respond to treatment or are self-limiting. Chronic illness is characterized by a loss or abnormality of body function that lasts longer than 6 months and requires ongoing long-term care. Chronic health conditions may be controlled with lifestyle management or drug therapy, but they are considered to be irreversible. Chronic illness may be characterized by periods of wellness (i.e., remission) and exacerbation (worsening) of clinical manifestations, which can be life threatening. Individuals learn to adjust their lifestyles accordingly.

The nurse understands which statement about the use of electronic health records is true? a. They improve patient health status. b. They require a keyboard to enter data. c. They have not reduced medication errors. d. They require increased storage space.

ANS: A Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status. The most common benefits of electronic records are increased delivery of guideline-based care, better monitoring, reduced medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and increase portability in environments using wireless systems and hand-held devices. Although data are often entered by keyboard, they can also be entered by means of dictated voice recordings, light pens, or handwriting and pattern recognition systems.

The nurse on a busy medical-surgical floor contacts a social worker requesting a home care referral prior to a patient's discharge. This action is best illustrated by which of Swanson's five caring processes? a. Enabling b. Knowing c. Doing for d. Being with e. Maintaining belief

ANS: A Advocating for a patient's post-hospitalization care is an enabling process. Enabling also includes informing, anticipating, and preparing for the future. Swanson's five caring processes also include maintaining belief, knowing, being with, and doing for.

The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? a) Place a sign above the bed: "No blood pressures on the right arm." b) Place a sign above the bed: "No continuous blood pressures on the right arm." c) Place a sign above the bed: "Blood pressures in legs only." d) No specific action is needed for this situation.

ANS: A After a mastectomy or after lymph nodes have been removed, the patient should not have blood pressures taken on the operative side. Doing so can cause lymphedema. The nurse communicates this to all staff with a sign stating that no blood pressures are to be taken on the right side. The other actions are not warranted.

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 has conducted an Allen's test on a patient and the result was 8 seconds. What action by the nurse is best? a) Document the findings and continue the assessment. b) Notify the health care provider immediately. c) Elevate the patient's arm above the level of the heart. d) Assess the patient for other signs of circulatory problems.

ANS: A After the hand blanches in an Allen's test, when the nurse releases the pressure, normal color should return within 10 seconds. This patient's findings were normal, so the nurse should document the results and continue with the assessment. The other actions are not needed.

After completing a patient's initial assessment and developing a plan of care, what action by the nurse is most appropriate? a. Continuously reassess the patient. b. Restrict changes to the care interventions. c. Reassess the patient at the start of each shift. d. Evaluate patient goal attainment at intervals.

ANS: A After the nurse completes a patient's initial assessment and develops a plan of care, continual reassessment of the patient detects noticeable changes in the patient's condition, requiring adjustments to interventions outlined in the plan of care. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing essential care.

The nurse knows which law protects health care professionals from charges of negligence when providing emergency care at the scene of an accident? a. Good Samaritan Act b. HIPPA c. Licensure d. Living wills

ANS: A All 50 states have enacted Good Samaritan laws offering protection for physicians and other health care professionals who provide emergency care at the scene of a disaster, emergency, or accident. Good Samaritan laws protect health care professionals from charges of negligence in providing emergency care if: (1) the care is within the professional's scope of knowledge and standards of care and (2) no fee is received or charged for services. The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect the privacy of health care information. Licensure and certification of nurses seek to ensure professional competence. The laws of each state require graduates of accredited nursing schools and colleges pass the National Council Licensure Examination (NCLEX) before beginning professional practice. A living will specifies the treatment a person wants to receive when he/she is unconscious or no longer capable of making decisions independently.

The nurse understands which essential fact regarding documentation? a. It should be completed accurately and in a timely manner. b. It should not be computerized (EHR) because of disclosure risks. c. It is not a legal document although they can be helpful in lawsuits. d. It cannot be used in determining billing and reimbursement issues.

ANS: A All documentation entries should be completed in a timely, accurate, and professional manner. Documentation most often is charted in the patient's EHR and standardized flow sheets according to agency policy. Patient health records are legal documents. Within the Health Insurance Portability and Accountability Act (HIPAA) guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement.

All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome? a. Proper documentation facilitates communication with all members of the health care team. b. Proper documentation is only considered "legal" if documented in the paper chart. c. Proper documentation prevents errors of omission and repetition of care. d. Proper documentation does not directly measure goal achievement or outcomes.

ANS: A All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient's EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care although it cannot prevent them. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.

A patient is found unresponsive and pulseless. The nurse begins cardiopulmonary resuscitation (CPR) and calls for help. When help arrives, the nurse should take on which role? a. Autocratic leader b. Democratic leader c. Laissez-faire leader d. Bureaucratic leader

ANS: A Although autocratic leadership is a strict form of leadership, it is useful in crisis situations. A nurse may act as an autocratic leader when taking charge after a patient is found unresponsive. In this situation, it is helpful to have a leader who takes control and directs other members of the health care team. Democratic leaders may see themselves as equals with other team members and may consult with other nurses, exhibiting a democratic form of leadership. This style of leadership can be used in unit council meetings where nurses collaborate to identify solutions to common problems. A nurse in a leadership position who uses the laissez-faire style of leadership assigns patient care and expects all team members to set goals for the day and manage their time to complete the assignment. Successful implementation of this leadership style in nursing requires a highly efficient and reliable staff, such as seen in some specialized OR nursing teams with a history of working together on a set type of cases. The bureaucratic leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules.

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information? a. Admission summary b. Discharge summary c. Flow sheet d. Kardex

ANS: A An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.

What action by the nurse is inappropriate regarding denture care? a. Carrying the dentures to the sink wrapped in a paper towel b. Placing a towel in the sink and brushing the dentures over the towel c. Brushing the dentures as the nurse would the teeth of a conscious patient d. Applying adhesive, then inserting upper and then lower dentures

ANS: A Dentures should not be wrapped in a paper towel; they should be placed in the denture cup to carry them to the sink. The towel prevents the dentures from being damaged if the teeth are dropped. The nurse can brush the dentures as she would the teeth of a conscious patient. Apply denture adhesive (if used) and insert the dentures, inserting first the upper and then the lower plates, using 4 u 4 inch gauze.

A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. Which question is the priority for the nurse to ask the family before beginning postmortem care? a. "Is an autopsy going to be done?" b. "Which funeral home do you want to use?" c. "Would you like to assist in bathing your loved one?" d. "Do you want me to remove the lines and tubes before you see your loved one?"

ANS: A An autopsy or postmortem examination may be requested by the patient or the patient's family, as part of an institutional policy, or if required by law. Because the patient's death occurred as a result of long-term illness and not under suspicious circumstances, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know if the lines can be removed or not depending upon the family's response to the question. Asking about bathing the deceased patient is a valid question but is not a priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not a priority, because other actions must be taken before the deceased patient is transported from the hospital. Asking about removing the lines may not be an option depending on the response of the family to an autopsy.

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

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.

The nurse knows which is the best pain medication option for a patient to manage severe long-term cancer pain at home? a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours b. Meperidine (Demerol) 50 mg IM q 6 hours c. Hydromorphone (Dilaudid) 0.2 mg q 10 minutes IV via PCA pump d. Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter

ANS: A An opioid transdermal patch is the best pain management option for home use with patients who have long-term, severe cancer pain as no injections are required and the opioid is slowly released over 72 hours. Epidurals and PCA pumps are intended for hospital use. Frequent IM injections require nursing administration, are not comfortable for the patient and are not optimal for chronic long-term pain.

The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation? a. Insert an oral airway. b. Lower the head of the bed. c. Turn the patient's head to the side. d. Monitor the patient's pulse oximetry.

ANS: A An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway.

The nurse is caring for a patient admitted to the intensive care unit with malnutrition. The patient is unable to walk and has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why getting out of bed has stopped. When planning this patient's care, the nurse will include which key concept? a. Develop multiple Nursing diagnoses. b. Develop only one Nursing diagnosis to aid in focusing. c. Focus on the physical issues facing this patient. d. Deal primarily with the patient's psychological needs.

ANS: A Analysis of patient assessment data may yield several clusters of related data or cues. It is common to apply several Nursing diagnostic statements to one patient. This is especially true for acutely ill patients with multipleI problems related to complex physical or psychological needs.

The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority? a. Cultural norms in burial practices b. Genetic variables in disease acquisition c. Statistics related to incidence and prevalence d. Autopsy data on direct cause of death

ANS: A Analytic epidemiology hypothesizes why a disease is occurring in a community and looks at cultural practices, nutrition, and extrinsic factors such as the environment for links. Genetic variables and direct cause of death data are more related to epidemiology.

A values system is a set of somewhat consistent values and measures that are organized hierarchically into a belief system on a continuum of relative importance. The nurse knows that a value system is also identified by which concept? a. It is culturally based. b. It is unique to each individual. c. It is a poor basis for making decisions. d. It is rigid and uniform within a culture.

ANS: A Anthropologists and social scientists have noted that in every culture, a particular value system prevails and consists of culturally defined moral and ethical principles and rules that are learned in childhood. Everyone possesses a relatively small number of values and may share the same values with others, but to different degrees. A value system helps the person choose between alternatives, resolve values conflicts, and make decisions. Within every culture, however, values vary widely among subcultural groups and even between individuals on the basis of the person's gender, personal experiences, personality, education, and many other variables.

The nurse knows that the antigen-antibody reaction is an example of what type of immunity? a. Humoral b. Cellular c. Innate d. Passive

ANS: A Humoral immunity is a defense system that involves antibodies and white blood cells that are produced to fight antigens. Cellular immunity involves defense by white blood cells against any microorganisms that the body does not recognize as its own. The innate (nonspecific) immune system provides immediate defense against foreign antigens. Passive immunity occurs when a person receives an antibody produced in another body.

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 new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene? a. The nurse asks the UAP to assess the wound. b. The nurse asks the UAP to report increased wound drainage. c. The nurse asks the UAP to observe changes in dietary intake. d. The nurse asks the UAP to change the dressing.

ANS: A Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

45. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling? a. Use at least three people. b. Have the patient reach for the opposite side rail when turning. c. Move the top part of the patient's torso and then the bottom part. d. Do not use pillows after turning.

ANS: A At least three to four people are needed to perform this skill safely. Have the patient cross the arms on the chest to prevent injury to the arms. Move the patient as one unit in a smooth, continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for support.

The nurse is caring for a patient whose family does not want the patient to be told about the new diagnosis of cancer because of the poor prognosis. Keeping this secret from the patient is in direct conflict with which ethical concepts? a. Autonomy and veracity b. Veracity and advocacy c. Justice and nonmaleficence d. Confidentiality and justice

ANS: A Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Truthfulness defines the ethical concept of veracity. Supporting or promoting the interests of others or to do so for a cause greater than ourselves defines advocacy. To do justice is to act fairly and equitably. First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. Confidentiality is the ethical concept that limits sharing private patient information

A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better off dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. 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.

40. The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend? a. High protein, high calorie b. High carbohydrate, low fat c. High vitamin A, high vitamin E d. Fluid restricted, bland

ANS: A Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-fat diet is not beneficial for an immobilized patient. Vitamins B and C are needed rather than A and E. Fluid restriction can be detrimental to the immobilized patient; this can lead to dehydration. A bland diet is not necessary for immobilized patients.

The nurse is caring for a patient from a different culture. After assessing the patient and formulating the care plan, what action by the nurse is best? a. Review the care plan for acceptance by the patient. b. Delegate appropriate tasks to unlicensed assistive personnel. c. Go over the care plan with the charge nurse. d. Begin implementing the planned interventions.

ANS: A Care plans, with their goals and interventions, should always be validated by the patient. This is especially true when the patient is from a different culture than the nurse. The charge nurse may or may not need to view the care plan, but after validation with the patient, the nurse can begin implementing the plan, including delegating appropriate tasks.

nurse knows providing care that is consistent and predictable can make the health care experience less intimidating for the patient. What additional action can the nurse take to enhance this experience? a. Explaining what is going to take place beforehand b. Never making promises to patients c. Assuring the patient that his/her requests will get done eventually d. Protecting the patient from knowing why things are happening

ANS: A Care should be delivered in a way that conveys competence. Patients become alarmed when they detect that their nurse is unfamiliar with a procedure. It is best to seek assistance with any procedure or skill that the nurse cannot safely accomplish alone. Every task-oriented procedure should be explained to a patient, followed by feedback indicating patient understanding, before care is initiated. The remaining three actions do not reduce patients' feelings of intimidation.

The nurse examining a patient's skin correlates which conditions with which underlying pathology? (Select all that apply.) a) Albinism: Full-thickness burns b) Peripheral cyanosis: poor circulation c) Purpura: clotting disorders d) Jaundice: liver disease e) Vitiligo: skin infestation

ANS: B, C, D Peripheral cyanosis can result from poor circulation. Purpura can be seen in patients with clotting disorders. Jaundice often indicates liver disorders such as liver failure. Albinism is genetically determined. Vitiligo is thought to be an autoimmune response.

Which action observed by a nurse manager is not indicative of the qualities and behaviors of caring? a. A staff nurse orders extra desserts for a patient diagnosed with morbid obesity. b. A medication nurse administers scheduled pain medication to patients as ordered. c. A respiratory therapist teaches a patient's spouse how to adjust an oxygen mask. d. A nursing assistant encourages a patient to assist with the morning bath.

ANS: A Caring includes demonstrating to the patient and significant others "authentic concern". Giving extra dessert for a morbidly obese patient, even if the patient is asking for them, does not show authentic concern for the patient, the patient's conditions, and the possible consequences of the condition. Giving pain medications on time, teaching a spouse how to help provide care, and encouraging self-care all demonstrate this authentic concern.

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 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. Scrutinize 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.

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.

The nurse understands that computerized provider order entry (CPOE) is beneficial for what reason? a) CPOE decreases the number of transcribing errors. b) CPOE enhances provider acceptance because of new technology. c) CPOE decreases workflow issues in general. d) CPOE reduces dependence on technology and computers.

ANS: A Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department. CPOE systems ensure legible orders and have the potential to reduce ordering and transcribing errors. Disadvantages of CPOE include workflow issues, provider resistance to new technology, and overdependence on technology (AHRQ, 2012).

The nurse knows that computerized provider order entry (CPOE) has which outcome? a) CPOE allows orders to be communicated to the appropriate department. b) CPOE creates an intermediary for order transcription. c) CPOE slows documentation and provider communication. d) CPOE may lead to increased ordering and transcription errors.

ANS: A Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department—diet orders to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Elimination of an intermediary for order transcription decreases the potential for errors related to the ambiguity of handwritten orders and allows quicker responses by appropriate departments. Legibility and availability of computerized documentation improve provider communication. The Agency for Healthcare Research and Quality (AHRQ) recommends CPOE as one of the safe practices for better health care. CPOE systems ensure legible orders and have the potential to reduce ordering and transcribing errors. Disadvantages of CPOE include workflow issues, provider resistance to new technology, and overdependence on technology (AHRQ, 2017).

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

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

The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse? a. Obtain an arterial blood gas to check for carbon dioxide retention. b. Increase the patient's oxygen until the pulse oximetry is greater than 98%. c. Lower the head of the patient's bed and insert a nasal airway. d. Administer a mild sedative and reorient the patient as needed.

ANS: A Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.

A nurse is assessing a patient's cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best? a) Ask the patient about recent facial trauma. b) Inform the provider immediately. c) Document findings in the patient's chart. d) Have the patient frown and lift the eyebrows.

ANS: A Cranial nerve VI (abducens) is responsible for outward gaze of the eyes. Abnormal findings could indicate a fracture of the orbit or a brain tumor. The nurse asks the patient questions related to these two conditions. The provider needs to be informed and the nurse must document, but first the nurse conducts a thorough assessment. Frowning and lifting the eyes assesses cranial nerve VII.

The nurse is caring for a patient from a different cultural background. What action by the nurse best demonstrates cultural maintenance? a. Assist the patient with a healing ritual. b. Teach the patient a heart healthy diet. c. Instruct the patient on monitoring blood glucose. d. Discuss what self-care activities the patient is willing to do.

ANS: A Cultural maintenance maintains and preserves relevant cultural care values pertaining to health care. Assisting the patient with a healing ritual important to him/her is an example. Teaching a heart-healthy diet and blood glucose monitoring falls into cultural care repatterning. Discussing what changes the patient is willing to accommodate is an example of cultural care accommodation.

21. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a. Imbalance b. Hemiplegia c. Muscle sprain d. Lower extremity paralysis

ANS: A Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A complete transection of the spinal cord can lead to lower extremity paralysis.

The nurse is ready to analyze the data obtained through a qualitative study. What approach to data analysis should the nurse use? a. Content analysis b. Statistical analysis c. Coding of themes d. Dissemination

ANS: A Data analysis techniques are procedures used to summarize words or numbers and create a meaningful result for interpretation. Qualitative analysis involves content analysis. The qualitative data may contain quotations and require their interpretation. Quotations from study participants support the evidence that is provided by the study. Quantitative analysis involves statistical analysis. Many types of statistical analyses may be performed on the data, and the appropriate technique needs to be applied. This process requires coding of themes and analysis of the narrative

The patient is complaining of severe incisional pain 2 days after surgery. The patient has Morphine ordered intravenously or by mouth. When the nurse chooses to give the medication orally, this is an example of which thought process? a. Decision making b. Reasoning c. Problem solving d. Judgment

ANS: A Decision making requires choosing a solution to a problem. Reasoning is the process by which a nurse is able to focus and filter information and determine what is most important to consider. A systematic, analytic approach in finding solutions is termed problem solving, and judgment is the process of forming an opinion by comparing solutions through reasoning.

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.

The nurse manager is creating the patient assignment for today. She has five registered nurses (RNs), two licensed practical nurses (LNPNTs), and five nurse technicians (NAs) scheduled. When making the assignment, the nurse manager needs to remember which fact of delegation? a. RNs are responsible for all care delegated to unlicensed nursing personnel. b. Delegation is considered direct intervention for patient care. c. LPNs operate independently and may delegate patient care. d. Nursing practice is clearly delineated and is standard across the country.

ANS: A Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable. Delegation is an indirect intervention based on assessment findings and established care priorities. Nurses must be familiar with the nurse practice act in their practice jurisdiction to ensure legal delegation. The nursing process cannot be delegated. In most jurisdictions, LPNs function in a dependent role and may not delegate.

The nurse is providing patient care and pays special attention to meeting the needs of the patient while maintaining the patient's right to privacy, confidentiality, autonomy, and dignity. This nurse is applying what ethical theory? a. Deontology b. Utilitarianism c. Autonomy d. Accountability

ANS: A Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

The nurse is providing discharge education to the patient with diabetes regarding foot care. Which statement by the patient indicates a need for further education? a. "I can go barefoot outside only in the summer." b. "I should wear good fitting shoes." c. "I cannot soak my feet in a hot tub." d. "I can use lotion on my feet."

ANS: A Diabetic patients should not go barefoot outside even in the summer as they often have neuropathy, which decreases the patient's ability to discern touch, especially in the lower extremities. This can lead to foot injuries that can become infected and are slow to heal. The patient should wear good fitting shoes, should avoid extreme temperatures, and can use lotion to keep their skin moist to avoid overly dry skin.

The nurse identifies which action as a direct-care intervention? a. Administration of an injection b. Making the change-of-shift report c. Collaborating with members of the health care team d. Ensuring availability of needed equipment

ANS: A Direct care refers to interventions that are carried out by having personal contact with patients. For example, direct-care interventions include cleaning an incision, administering an injection, ambulating with a patient, and completing patient teaching at the bedside. Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. Examples of indirect care include making the change-of-shift report, communicating and collaborating with members of the interdisciplinary health care team, and ensuring availability of needed equipment.

26. The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning? a. At the time of admission b. The day before the patient is to be discharged c. When outpatient therapy will no longer be needed d. As soon as the patient's discharge destination is known

ANS: A Discharge planning begins when a patient enters the health care system. In anticipation of the patient's discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient's needs are met at home. Referrals to home care or outpatient therapy are often needed. Planning the day before discharge, when outpatient therapy is no longer needed, and as soon as the discharge destination is known is too late.

The new nurse tells the preceptor that since she is not prejudiced against ethnic minorities, they will not be discriminated against while in the hospital. What statement by the preceptor is most appropriate? a. Discrimination can occur at the societal level. b. The hospital needs more nurses like her. c. Prejudice and discrimination are not the same thing. d. There is always some discrimination against minorities.

ANS: A Discrimination can occur at the societal level, so even though this nurse is not prejudiced, patients from ethnic and cultural minorities can still suffer from discrimination. The other answers do not explain how discrimination can occur.

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

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for an interview to take place.

Which nurse has committed a serious documentation error? a. The nurse who documents all medications for assigned patients prior to administration. b. The nurse who documents medication administration as the medications are given. c. The nurse who documents assessments as soon as they are completed. d. The nurse who documents meal intake as meal trays are picked up.

ANS: A Documentation must be accurate to provide a realistic view of a patient's condition. Serious documentation errors include: (1) omitting documentation from patient records, (2) recording assessment findings obtained by another nurse or unlicensed assistive personnel (UAP), and (3) recording care not yet provided. Nurses sometimes document that a patient has received medication before its administration; this is a serious violation of the law and becomes a medication error of omission if the nurse is distracted before administering the patient's medication.

When the patient is diagnosed with pertussis, which isolation precaution should the nurse implement? a. Droplet b. Airborne c. Contact d. Protective

ANS: A Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods.

The nurse knows testing the application of theories in different situations with different populations is what type of research? a. Applied research b. Clinical research c. Basic research d. Quantitative research

ANS: A Research conducted to generate theories is basic research. These theories help to provide explanations for phenomena. Testing theories in different situations with different populations is applied research. Clinical research is conducted to test theories about the effectiveness of interventions. Each type of research contributes to the theoretical base for the practice of nursing. Quantitative research usually produces data in the form of numbers.

The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to the bones. The nurse notes that the patient's morphine dosage had to be increased to sufficiently manage the discomfort. What is the nurse's interpretation of this assessment finding? a. The patient became tolerant to the previous morphine dosage. b. The patient is becoming addicted to the pain medication. c. The patient has been abusing the prescribed pain medications. d. The patient may be seeking to end life with an overdose of morphine.

ANS: A Drug tolerance is an adaptation to the medication, which eventually leads to less effective pain relief. The patient is requiring higher doses of narcotic pain medication because of this tolerance. This is common when patients require long-term pain medication. Since the patient is taking morphine to control ongoing pain, the patient is not addicted to it. Need for increased morphine dosage is not indicative of drug abuse or a wish to die.

The nurse is ambulating a patient back from the bathroom when the patient begins to have a seizure. Which action should the nurse do first? a. Lower the patient to the floor if standing. b. Move sharp or hard objects away from the patient. c. Turn the patient's head to the side to prevent aspiration. d. Attempt to place a tongue blade to prevent choking.

ANS: A During a seizure, a patient should be protected from injury by first lowering the patient to the ground if standing. The nurse should then place the head on a soft surface and turn it to the side to prevent aspiration and move sharp or hard objects out of the way. The nurse should never attempt to force any object into a seizing patient's mouth.

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate? a. Assessment b. Planning c. Implementation d. Evaluation

The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The nurse recognizes that the health history is conducted in which step of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Evaluation

ANS: A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

The nurse is gathering data on a patient with acute bacterial pneumonia. The nurse recognizes that this is an example of which step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

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 nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best? a. Assess the patient's ability to read and understand. b. Determine if the patient wants to take written material home. c. Give the patient the same material as other patients get. d. Ask the patient if he/she has a need for written material

ANS: A Health literacy in an important concept in health. If the patient cannot read or comprehend written material, it will be of limited use. The nurse first assesses the patient's ability to read and comprehend written material before choosing the material with which to send him/her home. Patients may or may not realize what they need for discharge, if anything. Giving the patient the same material other patients get does not acknowledge their need for holistic and individualized care.

2. The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 3 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. This home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea due to food poisoning. This discussion about the patient's electrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient's risk for infections and food poisoning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient's face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient's heart and lungs. Which category of physical assessment is the basis for the nurse's response? a. Emergency assessment b. Focused assessment c. Complete assessment d. Initial comprehensive

ANS: A Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient's airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. During an emergency, the nurse may never have time to do a complete assessment and may work to stabilize one body system at a time. A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient's condition or the development of a new complication. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.

The nurse is caring for a patient with pneumonia, who is a retired soldier who served in World War II. With this information in mind, what should the nurse do in regarding this patient? a. Shake the patient's hand and allow the patient time to "warm up." b. Expect the patient to be optimistic and question everything. c. Allow the patient to multitask and talk in short "sound bites." d. Understand that the patient is probably technologically literate.

ANS: A Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider the patient's generational cohort, which may influence behavior, and willingness to share personal information during the interview process. Veterans (born before 1945) respect authority; are detail oriented; communicate in a discrete, formal, respectful way; may be slow to warm up; value family and community; and accept physical touch as an effective form of therapeutic communication. Baby Boomers (born 1946 to 1964) are optimistic, relationship oriented, and communicate by using open or direct speech, using body language, and answering questions thoroughly. They expect detailed information, question everything, and value success. Generation X members (born 1965 to 1976) are informal; are technology immigrants; multitask; communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share information frequently; and value time. Millennials, also called Generation Y (born 1977 to 1N994R) are flexible.; Care technologically literate or are technology natives; multitask; communicate by using action verbs and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and value individuality. Individuals from Generation Z (born 1995 to 2012) are digitally connected, value group work, want immediate feedback, are accepting of others, value honesty and family, and are entrepreneurial.

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

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.

The nurse is caring for a complex patient needing physical and emotional support. As the primary caregiver, the nurse has which responsibility? a. The nurse is ultimately responsible for assessment of patient needs and progress. b. The nurse delegates to people who know what they are doing and operate independently. c. The nurse provides total care to the patient after getting direction from other disciplines. d. The nurse understands that the patient is ultimately responsible for failure or success.

ANS: A Even though collaboration and delegation may occur, the nurse is ultimately responsible for the continued assessment of patient needs and progress. As delegator, the nurse must supervise other disciplines to make sure that the patient needs are being met. Detection of additional problems or lack of progress with the patient should prompt the nurse to reconsider the nursing process steps.

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.

The nursing student develops a plan of care based on a recently published article describing the effects of bed rest on a patient's calcium blood levels. When creating the plan of care, the nursing student has the obligation to consider which action? a. Critically appraise the evidence and determine validity. b. Ensure that the plan of care does not alter current practice. c. Change the process even when there is no problem identified. d. Maintain the plan of care regardless of initial outcome.

ANS: A Evidence-based practice (EBP) is an integration of the best-available research evidence with clinical judgment about a specific patient situation. The nurse assesses current and past research, clinical guidelines, and other resources to identify relevant literature. The application of EBP includes critically appraising the evidence to assess its validity, designing a change for practice, assessing the need for change and identifying a problem, and integrating and maintaining change while monitoring process and outcomes by reevaluating the application of evidence and assessing areas for improvement.

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 nursing student is preparing study notes from a recent lecture in nursing history. The student would credit Florence Nightingale for which definition of nursing? a. The imbalance between the patient and the environment decreases the capacity for health. b. The nurse needs to focus on interpersonal processes between nurse and patient. c. The nurse assists the patient with essential functions toward independence. d. Human beings are interacting in continuous motion as energy fields.

ANS: A Florence Nightingale's (1860) concept of the environment emphasized prevention and clean air, water, and housing. This theory states that the imbalance between the patient and the environment decreases the capacity for health and does not allow for conservation of energy. Hildegard Peplau (1952) focused on the roles played by the nurse and the interpersonal process between a nurse and a patient. Virginia Henderson described the nurse's role as substitutive (doing for the person), supplementary (helping the person), or complementary (working with the person), with the goal of independence for the patient. Martha Rogers (1970) developed the Science of Unitary Human Beings. She stated that human beings and their environments are interacting in continuous motion as infinite energy fields.

The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient's care plan related to this pump? a. Assess the patient's respiratory status frequently after PCA pump started. b. Review patient's medication profile to check for interactions with hydromorphone. c. Teach the patient how to use PCA pump when the pain level is still tolerable. d. Keep naloxone (Narcan) available at the bedside in case of respiratory depression.

ANS: A For patient safety, the nurse would check the patient's respirations frequently after the pump has been initiated due to possible respiratory depression. Reviewing the medication profile would occur prior to initiating the pump. Teaching the patient how to use the pump is important, but not the priority. Naloxone should be close by to treat respiratory depression but monitoring the respirations frequently would hopefully prevent depression.

The nurse administers a medication to the patient and then realizes that the medication had been discontinued. The error is immediately reported to the physician. The nurse recognizes which term that identifies complying with the standards of professional performance? a. Ethics b. Socialization c. Altruism d. Autonomy

ANS: A Guiding the nurse's professional practice are ethical behaviors. Ethics is the standards of right and wrong behavior. The main concepts in nursing ethics are accountability, advocacy, autonomy (be independent and self-motivated), beneficence (act in the best interest of the patient), confidentiality, fidelity (keep promises), justice (relate to others with fairness and equality), nonmaleficence (do no harm), responsibility, and veracity (be truthful). Ethical guidelines direct the nurse's decision making in routine situations and in ethical dilemmas. Socialization to professional nursing is a process that involves learning the theory and skills necessary for the role of nurse. A profession provides services needed by society. Additionally, practitioners' motivation is public service over personal gain (altruism). Members of a profession have autonomy in decision making and practice and are self-regulating in that they develop their own policies in collaboration with one another.

11. A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session? a. Proper fit of a bicycle helmet b. Proper fit of soccer shin guards c. Proper fit of swimming goggles d. Proper fit of baseball sliding shorts

ANS: A Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using which Gordon's Functional Health Pattern? a. Nutrition and metabolism b. Activity and exercise c. Sleep and rest d. Elimination

ANS: A Health assessment data is organized in frameworks that provide a comprehensive view of a patient's health. Gordon's Functional Health Pattern focuses on patient's strengths and relationships of the data collected. The focus of nutrition and metabolism is tissue integrity. Data collected during a wound assessment would be classified in this health pattern. Activities of daily living and musculoskeletal information are the focus of the activity and exercise pattern. Sleep and rest includes sleep patterns, relaxation activities, and levels of fatigue. Bowel and urinary concerns are the focus of the elimination pattern.

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.

12. 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.

25. A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? a. Remove the restraint. b. Place a blanket over the feet. c. Immediately do a complete head-to-toe neurologic assessment. d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

ANS: A If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Ask the nursing assistive personnel to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tell the nursing assistive personnel that catheter care is sloppy. 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. Telling that catheter care is sloppy does not correct the problem. The catheter does not need to be removed.

6. 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 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.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure

ANS: A In SOLER, 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 SOLER. 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.

The nurse knows which description would be classified as a closed wound? a. A large bruise on the side of the face b. A surgical incision that is sutured closed c. A puncture wound that is healing d. An abrasion on the leg

ANS: A In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

The nurse is conducting a literature review to determine the statistical results of all related studies and identifies this to be what type of review? a. A meta-analysis b. An integrative literature review c. A systematic review d. Grounded theory research

ANS: A Literature reviews include scholarly analyses of research. A meta-analysis merges statistical results from related studies to discover similarities and differences in their findings. An integrative literature review synthesizes research findings and formulates ideas about future research. A systematic review of the literature provides a comprehensive, unbiased analysis using a strict scientific design to select and assess each of the studies. Grounded theory research derives theories from the data collected in studies.

A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, "Why was the man convicted and imprisoned?" Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept? a. Beneficence b. Advocacy c. Confidentiality d. Autonomy

ANS: A In its simplest form, beneficence can be defined as doing good. Nurses demonstrate beneficence by acting on behalf of others and placing a priority on the needs of others rather than on personal thoughts and feelings. The ethical concept of beneficence necessitates providing care for the prisoner without reproach and provide compassionate care for all people in all circumstances. Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence.

37. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome? a. Patient is lying on side. b. Patient is lying on back. c. Patient is lying semiprone. d. Patient is lying on abdomen.

ANS: A In the side-lying (or lateral) position the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Patients in the supine position rest on their backs. Sims' position is semiprone. The patient in the prone position lies face or chest down on the abdomen.

According to the Health Belief Model, which of the following patients would be most likely to change health behavior? a) The person who perceives that he is at risk for colon cancer b) The person who recognizes that colon cancer is easily cured c) The person who believes that behavior can change outcomes d) The patient who faces multiple social barriers

ANS: A In the three primary components of the Health Belief Model, six main constructs influence an individual's decision to take action about disease prevention, screening, and controlling illness. The model suggests that individuals are motivated to take action if they believe that they are susceptible to the condition (i.e., perceived susceptibility), that the condition has serious consequences (i.e., perceived severity), that taking action would reduce the susceptibility or severity of the condition (i.e., perceived benefit), that the costs of taking action (i.e., perceived barriers) are outweighed by the benefits, that those who are exposed to factors (e.g., media campaigns, postcard reminders, and advice from others) will be prompted to action (i.e., cues to action), and that those who have confidence in their ability to perform an action will do so (i.e., perceived self-efficacy).

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.

The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when exercise is attempted. The nurse is concerned that the patient's decrease in activity may lead to which outcome? a. Orthostatic hypotension b. Increase risk of heart disease c. Loss of short-term memory d. Worsening shortness of breath

ANS: A Inactivity in patients with cardiopulmonary disease can lead to an unsafe drop in blood pressure with position changes, or orthostatic hypotension. The patient already has heart disease. Loss of short-term memory is not related to the shortness of breath. The lack of activity is not likely to worsen the shortness of breath; improving activity level may help things eventually.

When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task? a. Complete an incident report as a risk management document. b. Complete an incident report and add it to the medical record. c. Document that an incident report was completed in the medical record. d. Say nothing about the incident in the medical record.

ANS: A Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident report is not part of a medical record but is considered a risk management or quality-improvement document. The fact that an incident report was completed is not recorded in the patient's medical record; however, the details of a patient incident are documented.

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.

12. The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? a. Increased aggressiveness and blood spots on clothing may indicate substance abuse. b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing. c. Adolescents need information about the effects of uncoordination on accidents. d. Adolescents need to be reminded to use seat belts primarily on long trips.

ANS: A Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.

The nurse identifies change-of-shift report, collaboration with other health care members, and ensuring availability of needed equipment are examples of which term? a. Indirect care b. Direct care c. Referrals d. Delegation

ANS: A Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. Examples of indirect care include making the change-of-shift report, communicating and collaborating with members of the interdisciplinary health care team, and ensuring availability of needed equipment. Direct care refers to interventions that are carried out by having personal contact with patients. For example, direct-care interventions include cleaning an incision, administering an injection, ambulating with a patient, and completing patient teaching at the bedside. Referrals in health care involve sending a patient to another member of the interdisciplinary health care team for a consultation or other services. Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable.

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.

The nurse observes that a patient who recently had an indwelling urinary catheter removed complains of burning on urination and that the urine is cloudy and foul smelling. Based on this assessment, the nurse may reason that the patient has a urinary tract infection (UTI). The nurse comes to this conclusion using which reasoning concept? a. Inductive reasoning b. Deductive reasoning c. Intellectual thought processes d. Intuition

ANS: A Inductive reasoning uses specific facts or details to make conclusions and generalizations; it proceeds from specific to general. Deductive reasoning involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific). Intellectual standards that are essential to critical thinking include clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness. Intuition is the feeling that you know something without specific evidence.

The nurse is caring for a postoperative patient who has a history of COPD. What is the priority Nursing diagnosis for this patient? a. Ineffective airway clearance b. Readiness for enhanced knowledge c. Risk for delayed surgical recovery d. Activity intolerance

ANS: A Ineffective airway clearance is the priority diagnosis for the COPD patient undergoing surgery because the patient is at high risk for bronchoconstriction, increased mucus, and ineffective cough, which may easily become worse after the patient has received general anesthesia. The other Nursing diagnoses are applicable to the patient but are not as high priority.

The nurse uses what term to identify a disease-causing organism? a. Pathogen b. Normal flora c. Germ d. Microorganism

ANS: A Infectious agents include any disease-causing agent and are called pathogens. They include bacteria, fungi, viruses, and parasites. Normal flora is a group of non-disease-causing microorganisms that live in or on the body. Germ is a term used for microorganism. A microorganism is bacteria, fungi, or protozoa.

The nurse knows the integration of nursing, computers, and information science for the management and communication of data, information, knowledge, and wisdom is identified by which term? a) Nursing informatics b) Computer science c) Medical informatics d) Informatics

ANS: A Informatics is a broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science. Medical informatics refers to informatics related to health care and describes a distinct specialty in the discipline of medicine. Nursing informatics is a specialty area of informatics that addresses the use of health information systems to support nursing practice. The American Nurses Association (ANA, 2015) states that the specialty of nursing informatics integrates nursing computer and information science for the management and communication of data, information, knowledge, and wisdom.

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.

A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take? 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.

The nurse recognizes which term identifies nursing interventions that originate from the health care provider orders? a. Dependent b. Independent c. Collaborative d. Nursing interventions classifications

ANS: A Interventions originating from a provider's order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Nursing Interventions Classification (NIC) is a research-based, standardized collection of interventions and associated activities.

The nurse recognizes that physical therapy, speech therapy, home health care, and personal care are examples of which type of interventions? a. Collaborative interventions b. Dependent nursing interventions c. Independent nursing interventions d. Assessment interventions

ANS: A Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Interventions originating from a provider's order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. An assessment is done to gather data.

The nurse is assisting a co-worker who is preparing to change a deep wound dressing on a patient's abdomen. Several of the patient's out-of-town friends are at the bedside watching a football game. Which action is most appropriate for the nurse to consider prior to the dressing change? a. Ask the friends to leave the room. b. Pull the curtain around the bed. c. Allow visitors to stay in the room during the procedure. d. Ask the patient to turn up the volume on the television.

ANS: A It is appropriate for the nurse to ask visitors to leave a patient's room for a few minutes. Several factors affect the location appropriate for communication with patients. Privacy and confidentiality are critical during the interviewing and assessment process. Simply pulling a cubicle curtain around a patient's bed does not prevent the transmission of sound beyond the curtain. Make every effort to talk with patients in an environment with as few interruptions and distractions as possible. Ask the patient to turn off competing technology and to focus on the nurse-patient interaction as needed.

The nurse leader recognizes that to deliver quality care, focus needs to be placed on which participant? a. Patient b. Self c. Other staff members d. Health care provider

ANS: A It is important for nurse leaders to be focused on the patients rather than themselves to deliver good patient-focused care. Nurses must desire to improve the status quo to provide higher levels of quality in the care delivered. These qualities are also discussed in other works concerning effective managers (Delgado & Mitchell, 2016; Feather, Ebright, & Bakas, 2015).

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.

30. 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.

8. 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

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.

13. The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? a. "Smoking even at parties is not good for my body." b. "Our campus is safe; we leave our dorms unlocked all the time." c. "As long as I have only two drinks, I can still be the designated driver." d. "I am young, so I can work nights and go to school with 2 hours' sleep."

ANS: A Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.

A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate? a) Encourage deep breathing and coughing. b) Medicate the patient for pain as needed. c) Keep the head of the bed elevated. d) Monitor the length of time the patient doesn't breathe.

ANS: C Orthopnea is difficulty breathing in positions other than sitting up. To assist the patient who has orthopnea, the nurse keeps the head of the bed elevated to ease breathing.

The nurse has been involved sexually with a patient. The nurse manages becomes aware of this situation and tells the nurse this behavior is a which type of crime? a. Malpractice b. Libel c. Slander d. Battery

ANS: A Malpractice may occur when a professional such as nurse acts unethically, demonstrates deficient skills, or fails to meet standards of care required for safe practice. Examples of these types of malpractice include engaging in sexual activity with a patient and administering penicillin to a patient with a documented penicillin allergy, resulting in the patient's death from a severe allergic (anaphylactic) reaction. Written forms of defamation of character are considered libel. Broadcasting or reading statements aloud that have the potential to hurt the reputation of another person is considered libel. Oral defamation of character is slander. Actual physical harm caused to another person is battery.

Several models exist that describe the relationship between health and wellness. Which model is used to understand the interrelationship between elements of basic requirements for survival and the desires that drive personal growth and development and is represented as a pyramid? a) Maslow's hierarchy of needs b) Health Belief Model c) Health Promotion Model d) Holistic Health Model

ANS: A Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state. Holistic health models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind.

The nurse knows which response to be an example of a measurable goal? a. "The patient will be able to lift 10 lb. by the end of week one." b. "The patient will be able to lift weights by the end of the week." c. "The patient will be able to lift his normal weight amount." d. "The patient will be able to lift an acceptable amount of weight by week one."

ANS: A Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met. When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated. When terms such as acceptable or normal are used in a goal statement, goal attainment is difficult to judge because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings. The amount of weight a patient will lift at the end of the week is not specified. "Normal" and "acceptable" weight have not been defined.

The nurse knows which skill does not require the use of sterile technique? a. NG tube insertion b. Foley catheterization c. Tracheostomy care d. PICC line insertion

ANS: A NG tube insertion requires a clean, not sterile, technique as the gastrointestinal tract is not sterile. Use strict aseptic technique when inserting an intravenous (IV) or Foley catheter and when performing suctioning of the lower airway.

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.

1. 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.

When the nurse is supportive and works of behalf of patients, this role is identified by which term? a. Advocate b. Primary care provider c. Collaborator d. Delegator

ANS: A Nurses advocate by supporting and working on behalf of patients or persons for whom they have concern. Nurses advocate for patients by coordinating care and supporting the changes necessary to improve conditions and outcomes. Effective communication and collaboration regarding patient care are essential for patient safety and positive patient outcomes. The change-of-shift reports are an example. A PCP is usually a physician or advance practice nurse. Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable.

21. 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.

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.

The nurse recognizes that when developing a nursing practice, it is important for the nurse to: carry out which action? a. Be exposed to negative as well as positive role models. b. Avoid negative role models as much as possible. c. Understand that caring and compassion are taught in class. d. Consider another profession if he/she is not naturally compassionate.

ANS: A Nurses develop caring skills through life experiences, educational activities, observation of both positive and negative role models, and interaction with strong professional mentors. Although there has been disagreement in the past about whether or not it is possible to teach values—specifically caring, recent research suggests that care, compassion, and empathy can be taught

The nurse caring for a patient with chronic pain uses guided imagery, therapeutic touch, and relaxation techniques as interventions for pain. The nurse is using what type of approach? a) Holistic b) Eastern holistic c) Risk factor reduction d) Health protection

ANS: A Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence. Eastern holistic therapists have been using techniques such as acupuncture, yoga, and tai chi for thousands of years as methods of healing and, more recently, in conjunction with modern allopathic medical therapies. Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness.

12. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan? a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Coordinate with occupational therapy for gait training. d. Place the patient on bed rest to prevent fatigue.

ANS: A Nurses should encourage the older-adult patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores.

30. The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. a. 2, 1, 4, 3 b. 1, 2, 4, 3 c. 1, 2, 3, 4 d. 2, 1, 3, 4

ANS: A Nurses use the mnemonic RACE to set priorities in case of fire. The steps are as follows: Rescue and remove all patients in immediate danger; Activate the alarm; Confine the fire by closing doors and windows; and Extinguish the fire using an appropriate extinguisher.

18. A nurse is completing an OASIS data set on a patient. The nurse works in which area? 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.

27. 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).

The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which task would the nurse do next? a. Analyze and cluster the assessment information. b. Formulate a Nursing diagnosis addressing actual issues. c. Determine the need for potential Nursing diagnoses. d. Create health promotion diagnoses for the patient.

ANS: A Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The analysis of information is required to determine nursing diagnoses.

The nurse recognizes which statement to be accurate regarding what should be documented? a. Document facts and subjective data from the patient. b. Document how he/she feels about the care being provided. c. Document in a "block" fashion once per shift. d. Double document as often as possible in order to not miss anything.

ANS: A Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Subjective data from the patient should be included. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.

The nurse recognizes that nursing documentation is guided by what process? a. The nursing process b. NANDA-I, nursing diagnoses c. Nursing interventions classification d. Nursing Outcomes Classification

ANS: A Nursing documentation is guided by the five steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) Nursing Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process.

The nurse recognizes the nursing goal for individuals and families seeking preventative care is to have those groups carry out which action? a) Take responsibility for their health and wellness. b) Abandon the use of electronic educational media. c) Make lifestyle changes after diseases occur. d) Use temporary changes until the danger has passed.

ANS: A Nursing goals for all individuals and their families seeking preventive care are improvement of quality of life through positive lifestyle choices and taking responsibility for health and wellness. Nurses can refer patients to a variety of personal health quizzes, located in the online version of Healthy People 2020, for risk assessments of their health status and lifestyle. The quizzes allow people to track their health and wellness status over a period of years and identify trends in disease risk factors that can be modified through lifestyle interventions or preventive measures before the disease occurs. The Healthy People 2020 initiative helps nurses provide educational materials for individuals, families, and communities, enabling them to lead healthier lifestyles and to make permanent changes in wellness habits.

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.

The nurse manager is developing a training guide and identifies which organization that is the best for resources to help develop guidelines to prevent exposure to hazardous situations and decrease the risk of injury in the workplace? a. OSHA (Occupational Safety and Health Administration) b. CDC (Centers for Disease Control and Prevention) c. QSEN (Quality and Safety Education for Nurses) d. NIOSH (National Institute for Occupational Safety and Health)

ANS: A Occupational Safety and Health Administration (OSHA) was established in 1970 to provide employers with guidelines for preventing exposure to hazardous chemicals and hazardous situations and reducing the risk of injury in the workplace. The CDC is the Centers for Disease Control and Prevention and provides information to address exposure to infectious diseases. QSEN, or the Quality and Safety Education for Nurses, was funded by the RWJ to focus on preparing nurses of the future with the knowledge, skills, and attitudes to advance quality and safety on the job. NIOSH, or the National Institute for Occupational Safety and Health, is a federal agency within the CDC that was established to conduct research and recommend interventions for the prevention of work-related injury and illness.

One classification system for nursing informatics competencies uses technical, utility, and leadership categories. The nurse recognizes leadership competencies involve which concept? a) Maintaining privacy and confidentiality b) Using computers and other technological equipment c) Using a variety of software programs d) Addressing critical thinking applications

ANS: A One classification system for nursing informatics competencies uses technical, utility, and leadership categories. Leadership competencies address the ethical and management issues related to using IT in nursing practice, education, research, and administration. Technical competencies pertain to the use of computers and other technologic equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. Utility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making.

5. A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? a. Wash hands b. Wash wound c. Wear gloves d. Wear eye protection

ANS: A One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.

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

The nurse leader is conducting a staff meeting. During the meeting, staff members have verbalized dissatisfaction with the staffing pattern created by the nurse leader. The nurse listens intently as the staff come up with other options. The staff members recognize that the nurse leader is demonstrating which quality? a. Openness b. Integrity c. Dedication d. Magnanimity

ANS: A Openness refers to the leader's ability to listen to other points of view without prejudging or discouraging them. An effective leader considers others' opinions with an open mind because a wider variety of solutions to problems is offered. Openness by the nurse leader encourages creative solutions by providing an environment in which people feel comfortable "thinking outside the box." Integrity is the quality of having clear ethical principles and aligning one's actions with the stated values. Dedication is the ability to spend the time necessary to accomplish a task. Magnanimity means giving credit where credit is due. Good leaders reflect the work and success of accomplishing a goal by crediting those who helped reach it.

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.

19. A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. 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.

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. 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.

The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus? a. The patient will maintain pulse oximetry values of at least 95% on room air. b. The patient will verbalize understanding of ordered anticoagulants. c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale. d. The patient will ambulate 50 feet in hallway without shortness of breath.

ANS: A Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met.

Which assessment question helps the nurse determine the character of the patient's pain? a. "What does the pain feel like?" b. "When did the pain first start?" c. "What interventions make the pain better?" d. "Is there any pattern to when the pain occurs?"

ANS: A Pain character should be assessed using questions to learn more about what the pain feels like. Examples like stabbing, aching, burning may be used so that patients can understand what the nurse is requesting. Onset is determined by asking when the pain started. Exacerbating/relieving factors are determined by asking which interventions make the pain better. Time course is determined by asking if there is a pattern to when the pain occurs.

The nurse knows that paper records are being replaced by other forms of record keeping for what reason? a. Paper is fragile and susceptible to damage. b. Paper records are always available to multiple people at a time. c. Paper records can be stored without difficulty and are easily retrievable. d. Paper records are permanent and last indefinitely.

ANS: A Paper records have several potential problems. Paper is fragile, susceptible to damage, and can degrade over time. It may be difficult to locate a particular chart because it is being used by someone else, it is in a different department, or it is misfiled. Storage and control of paper records can be a major problem.

When discussing immunizations for infants and children with new parents, the nurse should focus on which approach? a) Providing scientific evidence to parents b) Stressing that nonimmunization is a crime c) Acknowledging that immunizations are not needed d) Informing the parents that they have no choice

ANS: A Parents need to have scientific, evidence-based information about immunizations and their consequences before choosing to accept or reject immunizations for their children. The parent's ability to make an informed decision is the primary goal for nurses educating people about childhood immunizations.

A patient refuses to take his blood pressure medication because "I feel totally fine and don't need it." What action should the nurse take first? a. Assess the patient's time orientation. b. Document the patient's noncompliance. c. Educate the patient about the medication. d. Warn the patient about possible complications.

ANS: A People with a present time orientation typically live in the "here and now" and may not see the benefit of adhering to medical regimens when they are not symptomatic. The nurse should assess the patient's time orientation. Documentation and education are both important but are not likely to secure the patient's cooperation.

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.

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 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 ulcer 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.

The nurse is caring for a patient scheduled for heart surgery. Which statement made by the patient requires further discussion? a. "My friend died on the operating table several months ago." b. "The surgeon has a great reputation in the community." c. "I believe that this surgery is going to make me better." d. "Yesterday I asked my pastor to visit me after the procedure."

ANS: A Personal beliefs are one of the most important factors in determining how a person responds to a health problem and its treatment. The patient has a concern about the possibility of dying during the surgery based on prior experiences. The nurse should further explore the concern and determine the patient's true meaning of the statement. Failure to consider the patient's belief systems may result in ineffective implementation of the plan of care. Belief in the surgeon's reputation, the success of the surgery, and the patient's ability to visit after the surgery indicates a positive belief.

33. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take? a. Place pillow under the patient's abdomen after turning. b. Turn head toward one side with large, soft pillow. c. Position legs flat against bed. d. Raise head of bed to 45 degrees.

ANS: A Placing a pillow under the patient's abdomen after turning decreases hyperextension of lumbar vertebrae and strain on lower back; breathing may also be enhanced. Head is turned toward one side with a small pillow to reduce flexion or hyperextension of cervical vertebrae. Legs should be supported with pillows to elevate toes and prevent footdrop. Forty-five degrees is the position for Fowler's position; prone is on the stomach.

32. A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up? a. Plastic grocery bags are neatly stored under the counter. b. Electric outlets are covered in all rooms. c. No bumper pads are in the crib. d. Crib slats are 5 cm apart.

ANS: A Plastic grocery bags increase the risk for suffocation. The nurse will follow up with instructions to remove or keep locked or out of reach. All the rest are correct and do not require follow-up. Electrical outlets should be covered to reduce electrical shock. Bumper pads are not used in the crib to prevent suffocation, strangulation, or entrapment. Crib slats should be less than 6 cm apart.

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 providing care for a patient who demands discharge from the hospital against the physician's orders. What action by the nurse is most appropriate? a. Have the patient sign an "Against medical advice" form. b. Follow the guidelines as presented in the code of Academic and Clinical Conduct. c. Review the ANA's Nursing Code of Ethics for guidance. d. Permit the patient to leave after an informed consent form is signed.

ANS: A Preventing patients from leaving a health care facility at their request may be considered false imprisonment. To prevent health care providers and institutions from being held liable if a patient chooses to leave a facility when physicians and nurses think that it is in the patient's best interest to remain hospitalized, the patient is asked to sign an against medical advice (AMA) form. A signed AMA form documents that the patient has chosen to leave the facility when leaving could jeopardize the patient's condition. The National Student Nurses Association adopted the Code of Academic and Clinical Conduct, in which students agree to "promote the highest level of moral and ethical principles" and "promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs." This document does not apply to the issue at hand. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession." While this is resource for nurses the described situation requires nurses to follow facility policy. Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal. This does not apply to the stated situation.

A nurse is planning primary prevention activities. Which activity would the nurse include in this plan? a. Safer sex education for teens b. Mammogram screening c. Medication compliance d. Annual physical exams

ANS: A Primary prevention includes activities designed to prevent a disease or condition from occurring in the first place. Examples of primary prevention activities include vaccinations, wellness programs, good nutrition for health, and safer sex programs. Mammograms and physical exams are secondary prevention measures. Medication compliance would be tertiary prevention.

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.

The nurse develops a list of Nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" The nurse identifies which diagnosis will have the highest priority? a. Disturbed body image b. Nausea c. Risk for bleeding d. Imbalanced nutrition: less than body requirements

ANS: A Priority of Nursing diagnoses is determined by the patient's preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For the patient, this is a prime focus. It is possible that the patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.

A nurse has been working with a patient for the entire shift. Which action by the nurse is unacceptable? a. Sharing a personal mobile phone number b. Touching the patient's hand during a painful procedure c. Standing 6 feet away from the patient when conversing d. Using the SBAR method of hand-off communication

ANS: A Professional role boundaries define the limits and responsibilities of nurses within a specific setting. It is unprofessional and unethical to share personal phone numbers or meet with patients outside of the health care setting. Therapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. This is especially true when a patient is undergoing a painful or stressful procedure. Conversing 6 feet away is appropriate because it falls in the realm of social space; intimate space is 0 to 1.5 feet, personal space is 1.5 to 4 feet, and public space is 12 feet or more. One method of interpersonal communication that has been adopted to increase interprofessional and hand-off communication is the SBAR model (situation, background, action/assessment/awareness, and recommendation).

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.

A nurse is working with a patient who has limited English proficiency. What action by the nurse is best? a. Use a qualified interpreter. b. Ask family members to translate. c. Use drawings and pictures. d. Speak in simple sentences.

ANS: A Qualified interpreters should be utilized when working with non- or limited-English speaking persons. Using a family member to interpret can upset the balance of power within the family, cause embarrassment, and lead to inaccuracies. Using drawings and pictures or speaking in simple sentences is not as effective as using an interpreter.

The nurse recognizes that when conducting a qualitative research study, what concept is a basis of this type of research? a. Qualitative research is based on a constructivist philosophy. b. Qualitative research assumes that reality is the same for everyone. c. Qualitative research is deductive in nature and approach. d. Qualitative research proceeds from specific facts to generalizations.

ANS: A Qualitative research is based on a constructivist philosophy, which assumes that reality is composed of multiple socially constructed realities of each person or group and is therefore value laden, focusing on personal beliefs, thoughts, and feelings. Constructivism assumes an approach that is inductive (Creswell, 2014). Inductive reasoning generalizes from specific facts. Qualitative research usually results in data expressed in words, often in the form of a narrative.

When the nurse is conducting a quantitative research study, what concept is implemented? a. Quantitative research assumes that reality is fixed and stable. b. Quantitative research is based on an inductive approach. c. Quantitative research seeks to gain knowledge through observation. d. Quantitative research usually produces data in narrative format.

ANS: A Quantitative research is based on a postpositivist philosophy, which assumes that reality is objective, fixed, stable, observable, measurable, and value free. Positivism assumes that the approach is deductive in nature, and it seeks to gain knowledge through scientific and experimental research. Quantitative research usually produces data in the form of numbers.

The staff nurse knows that many health care facilities use the fire emergency response defined by which acronym? a. RACE b. PASS c. PACE d. QSEN

ANS: A RACE stands for rescue, alarm, contain, and extinguish. QSEN is the Quality and Safety Education for Nurses. PASS is pull, aim, squeeze, and sweep for fire extinguishers. PACE is not a health care acronym.

7. A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally? a. Charts legibly 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.

The nurse is caring for a patient who just underwent laparoscopic appendectomy. The patient complains of severe postoperative pain between the shoulder blades. Which term best describes the pain that this patient is having? a. Referred pain b. Phantom pain c. Neuropathic pain d. Psychogenic pain

ANS: A Referred pain is pain that occurs when discomfort is felt in a different area than the source of the pain. Phantom pain occurs in amputees when pain is felt in the missing limb. Neuropathic pain occurs in the nervous system and often feels like burning or tingling. Psychogenic pain is discomfort felt by the patient that has no physical cause.

The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education? a) Adolescent who uses a tanning bed b) Middle-aged adult who walks for fitness c) Older woman who sits in the sun for 10 minutes daily d) Person who works indoors under fluorescent lights

ANS: A Research indicates that indoor tanning before the age of 35 increases a person's risk for the deadliest form of skin cancer, melanoma, by 59% with each exposure. The adolescent who tans is the highest priority for this education. The others do not have as high a risk.

The nurse is preparing to conduct a study involving the "postprandial" blood sugars in patients who have received intensive diabetic rehabilitation versus diabetics undergoing "usual care." For the consent to be valid, the nurse would have to carry out which action? a. Change the language of the consent. b. Keep explanations to a minimum to reduce stress. c. Keep potential risks undisclosed. d. Insist that the participant sign the consent right away.

ANS: A Research participants require an explanation of the study in which they are subjects. Any information provided needs to be in a language that is understandable to them. Procedures and the purpose of the study need to be explained. The way subject anonymity and confidentiality will be protected needs to be explained. Any potential harm, including physical or mental discomfort, and possible benefits from participation should be explained. Questions should be answered so that participants fully understand the research and their part in the process. All subjects need to be given time to decide about participation. Study participants are voluntary, may withdraw at any time, or may choose not to complete tasks.

The nurse identifies which statement to be accurate regarding discharge planning? a. "It may decrease the incidence of patients who need to return to the hospital." b. "It increases complications and readmissions in most cases." c. "It adapts to the situation as the patient's conditions changes." d. "It should begin as soon as the patient is discharged home."

ANS: A Research shows that comprehensive discharge planning reduces complications and readmissions. Home care planning adapts to the situation as the patient's condition improves or deteriorates as a result of advancing disease. Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.

An overweight, sedentary middle-aged smoker with a family history of cardiac disease has noticed a steady rise in resting blood pressure over a 3- to 4-year period. The patient is concerned about his slightly elevated blood pressure and begins walking 20 to 30 minutes in the evenings with his wife and reduces his pack-a-day cigarette habit to ten cigarettes a day. The nurse identifies these actions are the initial step of which behavior? a) Risk factor reduction b) Self-actualization c) Self-transcendence d) Health promotion

ANS: A Risk factor reduction is step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his/her position in the greater structure of life. Health promotion is behavior motivated by the desire to increase well-being (as opposed to preventing illness) and optimize health status.

A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best? a. Work with the patient to allow the shaman to perform the ritual. b. Investigate whether the ritual will harm the patient. c. Check to see if the ritual breaks laws or policies. d. Offer to call the hospital chaplain instead.

ANS: A Rituals are deeply powerful and have great meaning for individuals who practice them. The nurse should work with the patient to facilitate the ritual. Investigating the ritual for patient harm or illegality is ethnocentric; the nurse's first thoughts should not be on the potential negative aspects of a deeply meaningful activity the patient has not requested the chaplain; offering to call the chaplain shows ethnocentrism and lack of respect for the patient. While working to facilitate the ritual, the nurse will discover if any aspect of it might be problematic and can collaborate with the patient and shaman to resolve the situation (e.g., if lighted candles are needed but prohibited by policy and fire code).

The nurse knows that the third phase of evidence-based research involves what action? a. Searching for evidence and evaluating b. Assessing the problem c. Developing a question d. Performing a critical appraisal

ANS: A Searching the database for the evidence begins the third phase. The nurse may need to consult three categories of information resources, which are reviewed in sequential order depending on need and applicability. The categories are general information (background) resources, filtered resources, and unfiltered resources. The second phase of evidence-based research consists of formulating a specific research question so that the nurse can effectively search the literature databases. The first phase of evidence-based research consists of assessing the need for change in practice by identifying a problem. After identifying an article or systematic review resource that seems appropriate to the question, the nurse must critically appraise the information.

11. 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

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.

Setting priorities among identified Nursing diagnoses is the first step in the planning process. The nurse knows this prioritization includes which action? a. Monitoring patient responses b. Carrying out the health care provider's plan of care c. Providing all interventions d. Collaborating with other disciplines

ANS: A Setting priorities among identified Nursing diagnoses is the first step in the planning process. The nurse is responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions, including interdisciplinary collaboration and referral, as needed. The nurse is significantly accountable for achieving the desired outcomes.

The nurse is acting as a leader in the role of charge nurse and notes that the unlicensed assistive personnel (UAP) on the floor are stressed related to their increased workload. The nurse changes the original planned approach based on the presenting situation. Which theory of leadership is the nurse implementing with this action? a. Situational b. Transactional c. Transformational d. Autocratic

ANS: A Situational theories suggest that leaders change their approach depending on the situation. Transactional leaders use reward and punishment to gain the cooperation of followers. Transformational leaders use methods that inspire people to follow their lead. Transformational leaders work toward transforming an organization with the help of others. The authoritarian or autocratic leader exercises strong control over subordinates.

The nurse knows that which patient has a teaching need based on statements by the patient's parents? a. "My 6-month-old daughter only sleeps with me when she's ill." b. "I do not put pillows in the bed with my 3-month-old son." c. "I do not feed popcorn to my 2-year-old." d. "I have discussed the risks of the 'choking game' with my 16-year-old."

ANS: A Small children should never sleep in the bed with others because of the risk of suffocation. The rest of the statements are appropriate. Pillows do present a hazard to a 3-month-old, and popcorn is a choking risk for a 2-year-old. The choking game is a risk to any adolescent.

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.

When planning interventions for a community, what action by the nurse is best? a. Involve community leaders in planning. b. Create a plan of action addressing priorities. c. Determine what resources are available. d. Attempt to find funding for the plan.

ANS: A Stakeholders need to be involved in planning to ensure buy-in from the community. The stakeholders could be community or business leaders. The other actions are important, but if the community leaders are not committed to the plan, the plan is unlikely to work.

The nurse is documenting data collected during a health assessment interview. Which statement by the nurse indicates subjective data? a. "My last bowel movement was 4 days ago." b. Abdomen distended; firm and tender. c. Dark colored; hard pellet-shaped stool. d. Color pink. Skin warm and dry. No sign of discomfort.

ANS: A Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.

The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 a.m. to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained? a. 10:30 a.m. b. 11:00 a.m. c. 11:30 a.m. d. 12:00 noon

ANS: A Sublingual pain medications should be working well 15 to 30 minutes after administration, so the nurse should reassess the patient's pain at 10:30 a.m.

The nurse is providing care for a patient who has had a stroke recently and has multiple self-care deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of needed equipment. Which ethical concept is the nurse applying? a. Advocacy b. Confidentiality c. Autonomy d. Accountability

ANS: A Supporting or promoting the interests of others or doing so for a cause greater than ourselves defines advocacy. Confidentiality is the ethical concept that limits sharing private patient information. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions.

A female patient is admitted to the emergency department after being raped by a neighbor. The patient refuses to discuss the circumstances surrounding the event with the sexual assault nurse examiner. The nurse identifies that the patient is utilizing which defense mechanism? a. Suppression b. Sublimation c. Displacement d. Rationalization

ANS: A Suppression is the conscious decision to conceal unacceptable or painful thoughts. The patient refuses to talk about the rape possibly because of the emotional and physical pain associated with the act. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities. Displacement is an unconscious defense mechanism used to avoid conflict and anxiety by transferring emotions from one object to another object that produces less anxiety. Rationalization is the act of suggesting a different explanation for one that is painful, negative, or unacceptable.

17. The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? a. Assess the patient. b. Gather restraint supplies. c. Try alternatives to restraint. d. Call the health care provider for a restraint order.

ANS: A When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.

The nurse is observed sitting at the bedside of a patient discussing the nursing care plan for the shift. The nurse identifies which theory or model most accurately reflects this nurse-patient relationship? a. Swanson's Theory of Caring b. Travelbee's human-to-human relationship model c. Watson's Theory of Caring d. Leininger Cultural Care Theory

ANS: A Swanson's five caring processes include being with and enabling. Sitting at the bedside and sharing information are activities that exemplify these behaviors. Travelbee's model describes steps toward compassionate and empathetic care. Watson's Theory of Caring impacts both the person and the universe and is built upon 10 caritas processes. Leininger describes patient care and its relationship to cultural diversity.

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? a) Assess the patient for causes of tachycardia. b) Take an apical heart rate and compare the two. c) Document the findings in the patient's chart. d) Notify the patient's health care provider.

ANS: A Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or fluid volume alterations. The nurse should assess the patient thoroughly for possible causative factors. Since the pulse is regular, there is no reason to take an apical pulse. The findings should be documented, but the nurse needs to do more. The provider may or may not need to be notified, depending on the outcome of the nurse's assessment.

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

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

The home health nurse provides care for a patient with congestive heart failure. Daily the patient weighs himself and takes his own temperature, pulse, respirations, and blood pressure. That information is sent as electronic data to the patient's physician and nurse daily to adjust the plan of care as indicated. The nurse understands this is an example of which concept? a) Telehealth nursing b) Computerized decision support system (DSS) c) Computerized provider order entry (CPOE) d) Point-of-care technology

ANS: A Telehealth nursing is the transmission by a nurse of electronic data, images, or audio from a patient's bedside or home to other health providers for the purpose of providing care and improving outcomes. Patients may have telehealth hardware in their homes to provide in-home monitoring and direct reporting to their health care providers. Computerized decision support systems (DSSs) include safe practice alerts and reminders that improve the quality of care. Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department—diet orders to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Computers, tablets, or pocket devices used at the bedside for documentation are examples of point-of-care technology. Patient data collected by a nurse and recorded electronically are immediately available to all members of the health care team.

The nurse correctly identifies which patient as having the greatest risk for infection? a. An 80-year-old male with an enlarged prostate b. A 24-year-old female long-distance runner c. A 50-year-old obese male d. A 40-year-old sexually active female

ANS: A The 80-year-old male has more risk factors because he is elderly and has increased risk of urinary tract infection related to prostate enlargement, so he has two risk factors. A 24-year-old female runner is likely healthy with no additional risk factors. The 50-year-old obese male has one additional risk factor. The 40-year-old sexually active female may not have additional risk factors if she is using protection and does not have multiple partners.

Which tool is used by the nurse to determine risk for impaired skin integrity? a. Braden scale b. Glasgow scale c. Vanderbilt scale d. MMSE scale

ANS: A The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.

The nurse knows which statement indicates an appropriate understanding of ethical practice by the student nurse? a. "I will be held to the same ethical standards as professional nurses." b. "I will not be held ethically accountable until I graduate." c. "My nurse educators are responsible for my ethical standards." d. "Ethics are not important as a student."

ANS: A The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual (not just nurse educators) who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society." This is a powerful mandate for all nurses to communicate and act professionally to prevent inflicting physical or emotional pain on others while pursuing nursing education and engaging in nursing practice.

The Computer Ethics Institute has developed guidelines for ethics in the development and use of computer technologies. The nurse knows these guidelines are identified by which term? a) The Ten Commandments of Computer Ethics b) The eHealth Code of Ethics c) HIPAA guidelines d) The Health on the Net Foundation

ANS: A The Computer Ethics Institute (CEI) was founded in 1985 to serve as a forum and resource for identifying, assessing, and responding to ethical issues associated with the advancement of information technologies and to facilitate the recognition of ethics in the development and use of computer technologies. CEI developed the Ten Commandments of Computer Ethics. The eHealth Code of Ethics, developed by Health Informatics Europe (2005), is "to ensure that people worldwide can confidently and with full understanding of known risks realize the potential of the Internet in managing their own health and the health of those in their care." The Health Insurance Portability and Accountability Act (HIPAA) of 1996 sets the standards on how security and confidentiality of health care information must be maintained. The act also sets the penalties for any breach in security of health care data. The Health on the Net Foundation promotes the use of reliable internet health sites.

The nurse knows that which assessment tool is not used to assess fall risk? a. Glasgow Falls Scale b. Johns Hopkins Hospital Fall Assessment Tool c. Morse Fall Scale d. Hendrich II Fall Risk Model

ANS: A The Glasgow is a coma scale used to measure level of consciousness, not falls. The rest are scales used to assess the risk for falls in patients.

The nursing instructor is researching the five proficiencies regarded as essential for students and professionals. The nursing instructor identifies which organization would be found to have added safety as a sixth competency? a. Quality and Safety Education for Nurses (QSEN) b. Institute of Medicine (IOM) c. American Association of Colleges of Nursing (AACN) d. National League for Nursing (NLN)

ANS: A The Institute of Medicine repNort,RHeIalthGProBfe.ssCionMs Education: A Bridge to Quality (2003), outlines five core competencies. These include patient-centered care, interdisciplinary teamwork, use of evidence-based medicine, quality improvement, and use of information technology. QSEN added safety as a sixth competency. The Essentials of Baccalaureate Education for Professional Nursing Practice are provided and updated by the American Association of Colleges of Nursing (AACN) (2008). The document offers a framework for the education of professional nurses with outcomes for students to meet. The National League for Nursing (NLN) outlines and updates competencies for practical, associate, baccalaureate, and graduate nursing education programs.

16. 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.

14. The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to taste spices like before?" d. "Are you able to open a jar of pickles?

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.

According to Fayol, controlling is a function of management. The nurse understands controlling compares to what phase of the nursing process? a. Evaluation b. Diagnosis c. Assessment d. Implementation

ANS: A The act of controlling involves comparing expected results of the planned work with the actual results. In the nursing process, evaluation is comparable to controlling. The planning function of a manager is comparable to the assessment, diagnosis, and planning portions of the nursing process.

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

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.

3. 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.

Upon entering a patient's room the nurse notes the patient is unresponsive. The nurse takes control and begins to direct other members of the health care team during this crisis. The nurse is demonstrating characteristics of which type of nursing leadership? a. Autocratic b. Democratic c. Laissez-faire d. Bureaucratic

ANS: A The authoritarian or autocratic leader exercises strong control over subordinates. In this scenario, the nurse takes charge and gives directions that others will follow. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. Like the democratic leader, the permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own. Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules.

The nurse knows that which statement is true regarding the importance of hygiene? a. The nurse can assess other body systems during the bath. b. UAPs perform hygiene because there is no benefit of nurses doing this care. c. The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. d. The main purpose of bathing is to decrease the patient's body odor.

ANS: A The bath is an excellent opportunity for the nurse to assess multiple body systems. Although the UAP can perform hygiene, there is benefit to the nurse doing it because of the ability to assess the patient. The mucous membranes are a part of the integumentary system, and bathing cleanses the skin, reduces odor, provides comfort, and contributes to the patient's health and well-being.

The nurse is caring for a patient who only speaks a foreign language. What is the best method for the nurse to assess the patient's pain level? a. Perform a pain assessment using a translator. b. Check the patient's vital signs and pulse oximetry. c. Check the patient's respiratory rate, depth, and rhythm. d. Look to see if the patient appears to be resting comfortably.

ANS: A The best method to determine pain in a patient who speaks only a foreign language is to use an interpreter. The Universal Pain Assessment Tool is available with foreign-language phrases that may also be used if the patient is resting comfortably are not accurate pain assessment techniques.

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

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

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

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.

Which statement does the nurse recognize as accurate regarding the use of electronic medical records (EMR)? a) EMR holds the documentation of a single episode of care. b) EMR is a longitudinal record of care for each patient. c) EMR is widely used for individual health care encounters. d) EMR includes progress notes for all disciplines.

ANS: A The electronic medical record (EMR), which is the documentation of a single episode of care (i.e., outpatient visit or inpatient stay), becomes a part of the electronic health record (EHR), which is a longitudinal record of care. EHRs are becoming widely used for individual health care encounters and for maintaining patients' health records over long periods. As EHRs become fully implemented, they include provider order entries, progress notes for all disciplines, computerized medication profiles, access to diagnostic test results on a timely basis, decision support systems, and online clinical reminders and alerts.

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.

The nurse recognizes which concept that correctly completes the definition of the genetic vulnerability of an organism (risk of disease expression based on genotype)? a) It is involuntarily passed from biologic parents to offspring. b) It is totally unrelated to environmental factors. c) It is nonresponsive to alteration by way of lifestyle modification. d) It is not a factor in mental illness because it is behavioral.

ANS: A The genetic vulnerability of an organism, or risk of disease expression based on genotype, is involuntarily passed from biologic parents to their offspring. Societal attitudes about testing and management of high-risk populations depend on the potential for expression of genetic disorders that may be triggered by environmental factors. Controlling factors that place stress on physiologic function can reduce pathologic genetic expression and susceptibility to disease. For example, a person with a family history of hyperlipidemia and atherosclerosis is at risk for developing cardiovascular disease later in life. Lifestyle-modifying factors, such as weight reduction, daily exercise, and balanced nutritional intake, can help reduce the likelihood that the genetic risk factor for heart disease will be expressed. Diabetes, cancer, mental illness, and renal disease also have genetic components and are amenable to interventions that reduce risk.

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.

The nurse is caring for a patient who is recovering from thoracotomy surgery and notes that the patient's pain is rated 9/10 and is unable to focus on anything. Which intervention by the nurse is the highest priority? a. Administer prescribed IV pain medication and evaluate impact in 30 minutes. b. Ask the patient to describe prior pain experiences and methods used to manage pain. c. Explain that comfort is a priority goal of nursing care in the postoperative period. d. Assist the patient to minimize the effects of pain on interpersonal relationships with family members.

ANS: A The highest priority intervention for a patient in acute pain is to provide pain relief. The other interventions do not address acute pain relief.

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 nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best? a) Get the provider; assist patient into lithotomy position. b) Assist the patient into lithotomy position; get the provider. c) Get the provider; assist patient into Sims position. d) Assist the patient into Sims position; get the provider.

ANS: A The lithotomy position is used to examine female genitalia. It is an uncomfortable and embarrassing position, so the nurse ensures time spent in that position is limited. The nurse gets the provider, then assists the patient into the position. The Sims position is used to examine the rectal and perineal areas.

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.

When developing the nursing care plan, the nurse includes which concept when creating goals? a. Develops the goals with the patient and possibly the family. b. Creates the goals that the nurse wants the patient to achieve. c. Includes the actions that are needed to accomplish the goal. d. Focus on goals that are aggressive to ensure success.

ANS: A The nurse creates goals with the patient and possibly with the family by discussing the patient's current condition, the condition to which the patient wants to progress, and the actions the patient and nurse undertake to accomplish the goal. If the goals are simply what the nurse wants the patient may have other goals in mind to which he or she gives more attention and effort. The goal does not include the interventions or actions needed; however they must be discussed so the patient understands the care he or she is to receive and what part the patient plays in achieving the goals. The nurse works with the patient to develop a plan of care that is appropriately challenging and promotes patient success in attaining goals.

A nurse is assigned to care for the following patients who all need vital signs taken right 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 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.

24. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take? a. Establish goals that are measurable and realistic. b. Set goals that are a little beyond the capabilities of the patient. c. Use the nurse's own judgment and not be swayed by family desires. d. Explain that without taking alignment risks, there can be no progress.

ANS: A The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.

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 male nurse is caring for a female patient who needs a complete bed bath. The patient requests that a female nurse bathe her. The male nurse recognizes this request as an example of what type of diversity? a. Gender diversity involving generational norms. b. Life span diversity c. Disability diversity d. Morphology diversity

ANS: A The nurse must perform the procedures competently and safely, taking into consideration any special needs of the patient. Gender diversity occurs with the identification of gender roles that may affect care delivery. Some patients may prefer care from nurses of the same gender. This preference may stem from generational norms, personal comfort, or cultural considerations. With life span diversity, interventions must always be age or developmental level appropriate. Disability diversity requires that interventions be individualized for each patient and adapted for any limitations. The nurse must ensure safe practice in relation to patient body size (morphology diversity) and should seek additional support or equipment when necessary.

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.

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 has assessed a community and has found many areas in which health can be improved. As a result, the nurse has multiple ideas for programming. What action by the nurse is best? a. Determine what the community thinks is most important. b. Use vital statistics to determine which is most important. c. See what other communities are focusing programming on. d. Choose the easiest problem to address first.

ANS: A The nurse's priorities may be very different from the community's. For programming to be successful, there must be buy-in from members of the community. Unless programming addresses a need the community thinks is important, it is unlikely to be successful.

The nurse identifies the nursing process as the foundation of professional nursing practice and can define it in which appropriate terms? a. The framework that nurses use to provide care. b. A complex process during which nurses think about their thinking. c. The process that allows nurses to collect essential data. d. Thinking like a nurse in developing plans of care.

ANS: A The nursing process is the foundation of professional nursing practice. It is the framework within which nurses provide care to patients in an organized and effective manner. Paul describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent. Critical thinking using the nursing process allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, realistic goals, and customized interventions with members of the health care team. Thinking like a nurse is facilitated by nurses using the nursing process in the development of individualized patient plans of care.

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

ANS: A The only scenario that validates a patient's report with a nurse's observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse's assessment.

The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly? a. The patient breathes into the spirometer so that the marker rises slowly. b. The patient uses the spirometer 5 to 12 times every 1 to 2 hours while awake. c. The patient seals his lips tightly around the spirometer mouthpiece. d. The patient should hold each inhaled breath 3 to 5 seconds.

ANS: A The patient must take in a deep breath while holding the spirometer to the mouth so that the device can indicate how much air is being inhaled into the lungs. The remaining responses are correct components of the procedure.

Which delegation of tasks would require the nurse manager to intervene? a. The UAP re-delegates vital signs to the student nurse. b. The RN delegates assistance with bathing to the student nurse. c. The RN delegates monitoring of intake and output to the UAP. d. The RN delegates assistance with mobility to the UAP.

ANS: A The person to whom the assignment was delegated cannot delegate that assignment to someone else. If the person cannot carry out the assignment, the individual needs to notify the delegating RN so that the task may be reassigned or completed by the RN. The RN must remember to delegate tasks that do not require nursing judgment. Only tasks that are routine such as bathing, monitoring intake and output, and assisting with mobility, and do not require variation from a standardized procedure should be delegated.

28. A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Check on patient every 15 minutes. b. Risk for suffocation: Place "Oxygen in Use" sign on door. c. Disturbed body image: Encourage patient to express concerns about body. d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

ANS: A The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate

The nurse is developing a plan of care for a patient who had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, difficulty with walking and balance, and headache. The nurse identifies which response would best represent the etiology of the patient's gait and balance problems? a. Lack of muscle motor movement b. Decreased sensation to touch c. Inability to speak clearly d. Pain in back of head

ANS: A The related factor in an actual Nursing diagnosis needs to address the underlying etiology of the patient's problem expressed by the Nursing diagnostic label rather than listing data that are defining characteristics. The decreased sensation to touch, inability to speak clearly, and pain in the back of the head are only reiterations of the defining characteristics (numbness in face, slurred speech, and headache).

The nurse has identified a research problem and knows what to be. What is the next step with this problem? a. Conduct a literature review. b. Address ethical procedures. c. Collect data. d. Analyze data.

ANS: A The research process involves many different components. The literature review is conducted after a research problem is identified. Ethical procedures must be addressed before the study begins. Data are then collected and analyzed before discussion of the research results.

What is the priority nursing assessment for a patient who is receiving postoperative epidural analgesia with hydromorphone (Dilaudid)? a. Respiratory rate, depth, and pattern b. Skin underneath the epidural dressing c. Bladder scanning to check for urinary retention d. Itching on the trunk and/or extremities

ANS: A The respiratory system is the priority nursing assessment for patients receiving narcotic pain medication via any route. This is because narcotics can cause respiratory suppression. The other assessments are a lower priority and may be done after a respiratory assessment is completed.

The nurse is conducting a health assessment on a patient from a foreign country. Which concepts should be addressed by the nurse during the interview? (Select all that apply.) a. Food preferences b. Religious practices c. Health beliefs d. Family orientation e. Politics

ANS: A, B, C, D Culture is the integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

A nurse is wondering if home health care nursing is a good fit. What characteristic or ability does the experienced home health care nurse suggest is most important? a. Clinical reasoning b. Organization c. Assessment skills d. Time management

ANS: A The role of the registered nurse in home health care is essentially autonomous in that the nurse must be highly proficient in health assessment (physical and psychosocial), be well versed in complex technical and clinical skills, possess strong critical-thinking and clinical reasoning abilities, and demonstrate excellent organizational skills. All choices are important characteristics or abilities of home health care nurses. However, since the nurse working out in the community may not have the resources (personnel or materiel) available in an acute care facility and often must improvise, clinical reasoning would be the most important of the choices provided.

MULTIPLE CHOICE 1. A nurse is assessing body alignment. What is the nurse monitoring? a. The relationship of one body part to another while in different positions b. The coordinated efforts of the musculoskeletal and nervous systems c. The force that occurs in a direction to oppose movement d. The inability to move about freely

ANS: A The terms body alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the individual's center of gravity is stable. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in a direction to oppose movement. Immobility is the inability to move about freely.

The nursing student is reviewing the components of a Nursing diagnosis. Which statement made by the student indicates correct understanding of a health-promotion diagnostic statement? a. "The defining characteristics will include the patient's willingness to get better." b. "The risk factors are only psychological in nature, not physical." c. "The health-promotion diagnostic statement is composed of three parts." d. "An example of a health-promotion label is ineffective community coping."

ANS: A The three types of Nursing diagnostic statements are actual, risk, and health promotion. Determining which type is needed for each patient can be challenging. Health-promotion Nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The second part of the Nursing diagnosis consists of related factors (for actual Nursing diagnoses) and risk factors (for risk Nursing diagnoses). Related factors are the underlying cause or etiology of a patient's problem. Risk factors are environmental, physical, psychological, or situational. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. Actual diagnoses describe the person, family, or community's response to a health condition or life process that already has occurred. "Ineffective community coping" would be an example of an actual problem.

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.

The nurse knows that standardized care plans may be available and are utilized under which circumstance? a. They need to be individualized for each patient. b. They are implemented without adjustment. c. They remove the need for nurse involvement. d. They do not require the use of Nursing diagnoses.

ANS: A There are multiple formats in which to develop individualized care plans for patients, families, and communities. Each health care agency has its own form, including electronic formats, to facilitate the documentation of patient goals and individualized patient-centered plans of care. All formats contain areas in which the nurse identifies key assessment data, Nursing diagnostic statements, goals, interventions for care, and evaluation of outcomes. In many agencies and specialty units, standardized care plans that must be individualized for each patient are available to guide nurses in the planning process.

The nurse identifies which statement to be a correctly written Nursing diagnosis appropriate for a patient's plan of care? a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds. b. Imbalanced nutrition: less than body requirements. c. Impaired physical mobility related to contractures. d. Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.

ANS: A There are three types of diagnoses: actual, risk, and opportunities for improvement. Actual diagnoses have three parts: problem, etiology, and signs/symptoms. Risk diagnoses include only the identified need and the risk factors. The Nursing diagnosis, imbalanced nutrition: less than body requirements, is missing the problem, etiology, and signs and symptoms. Impaired physical mobility is missing the evidence. Risk for suffocation should have only two parts: the potential problem and etiology. There are no signs and symptoms if the patient is at risk.

The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.) a. Decreased cough reflex b. Decreased lung elasticity c. Increased activity of the cilia d. Abnormal swallowing reflex e. Increased sputum product

ANS: A, B, D The elderly are at an increased risk for respiratory infections because of decreased cough reflex, decreased elastic recoil of the lungs, decreased activity of the cilia, and abnormal swallowing reflex. They do not generally have increased sputum production.

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best? a) Instruct the patient not to get up without help. b) Document the findings and continue to monitor. c) Reassure the patient that these findings are normal. d) Reassess the blood pressures in 1 hour.

ANS: A This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.

A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best? a) Assess the patient for a barrel-chest appearance. b) Palpate the patient's abdomen for tenderness. c) Inspect the patient's spine for deformities. d) Ask the patient if he/she is experiencing dizziness.

ANS: A This patient is sitting in a tripod position, often seen in patients with chronic obstructive pulmonary disease. These patients also often have a barrel-chest appearance, so the nurse assesses for this finding. The other actions are not related to a tripod position.

When the nurse is dealing with the concept of beliefs and values, the nurse recognizes which type is based in the unconscious? a. Zero-order beliefs b. First-order beliefs c. Higher-order beliefs d. Prejudices

ANS: A Three types of beliefs are recognized: zero-order beliefs, most of which are unconscious, such as object permanence; first-order beliefs, which are conscious, typically based on direct experiences; and higher-order beliefs, which are generalizations or ideas that are derived from first-order beliefs and reasoning. A prejudice is a preformed opinion, usually an unfavorable one, about an entire group of people that is based on insufficient knowledge, irrational feelings, or inaccurate stereotypes.

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

ANS: A To conduct an accurate and complete assessment, consider a patient's cultural background. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation or to force eye contact is inappropriate.

26. 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

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.

When working on the ability to critically think, the nurse needs to develop a critical-thinking character that includes which quality? a. Developing honesty and confidence b. Learning from experiences c. Enhancing self-reliance d. Growing a "thick skin" to withstand criticism

ANS: A To develop critical thinking, the nurse needs to develop a critical-thinking character, which includes maintaining high standards and developing critical-thinking qualities such as honesty, fair-mindedness, creativity, patience, persistence, and confidence. The next step in the development of critical thinking includes taking responsibility for personal learning and seeking needed experiences that can provide the necessary knowledge on which to base the thinking. Fostering interpersonal Skills, such as teamwork, conflict management, and advocacy, is important in the development of critical thinking. Self-evaluation and having thinking evaluated by others require the ability to accept and use constructive criticism.

The nurse recognizes which leadership theory that assumes that leaders are born with certain leadership skill that few people possess? a. Trait theory b. Behavioral theory c. Situational theory d. Transformational theory

ANS: A Trait theories assume that leaders are born with the personality traits necessary for leadership, which few people are thought to possess. Behavioral theories assume that leaders learn certain behaviors. These theories focus on what leaders do, rather than on what characteristics they innately possess. Situational theories suggest that leaders change their approach depending on the situation. Transformational leaders use methods that inspire people to follow their lead. Transformational leaders work toward transforming an organization with the help of others.

The nurse manager of a unit is sharing the most recent results of a patient satisfaction survey to motivate staff. This approach is a characteristic of what type of nursing leader? a. Transformational b. Transactional c. Situational d. Autocratic

ANS: A Transformational leaders use methods that inspire people to follow their lead. Transformational leaders work toward transforming an organization with the help of others sharing survey results may work to inspire staff. Transactional leaders use reward and punishment to gain the cooperation of followers. The authoritarian or autocratic leader exercises strong control over subordinates. Situational theories suggest that leaders change their approach depending on the situation.

Several nurses on a medical-surgical unit have been asked by the nurse manager to form a group and gather data regarding patient complaints of late meals. When the nurses meet and establish ground rules, this would be what phase of group development? a. Forming b. Storming c. Norming d. Performing

ANS: A Tuckerman's model of group performance includes forming, storming, norming, and performing. In the forming phase, there is little agreement on team goals other than those received from the leader, and there is a high dependence on the leader for guidance and direction. Ground rules are estaUblisShedNandTtrust aOmong the members begins to develop. There is unrest in the storming phase as the individual team members struggle for power and form cliques. Decisions do not come easily at this stage. In the norming phase, the leader plays a facilitating and enabling role as the team begins to agree and engage in group decisions. Both commitment and unity are strong. The team, in the performing phase, has a shared vision and works together to achieve the goals.

The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy. I wouldn't know how to manage it." The patient is complaining of severe surgical pain and has an order for morphine sulfate. The nurse is correct when addressing which Nursing diagnosis first? a. Pain b. Alteration in body image c. Knowledge deficit d. Risk for falls

ANS: A Using Maslow's hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow's theory suggests that basic needs, such as physiologic needs, must be met before higher needs, such as self-esteem. The nurse also realizes that an actual problem takes priority over a potential problem. By using the nursing process appropriately, the nurse correctly chooses the actual, physiological problem first: pain. Once the patient has the morphine, the risk for falls becomes a higher priority than knowledge deficit or alteration in body image because the morphine might confuse the patient, cause dizziness or faintness, and lead to a fall.

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. 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.

The nurse is caring for a patient who is suspected of having early stages of dementia and observes mild confusion, short-term memory loss, and restlessness. When the nurse conducts a mini-mental status exam, the nurse is using which component of critical thinking? a. Validation b. Interpretation c. Intuition d. Reasoning

ANS: A Validation is the process of gathering information to determine whether the information or data collected are factual and true. Examining how information is organized and given meaning guides the interpretation of the information. Interpretations must be differentiated from facts and evidence because they are based on personal conceptions, experiences, and perspective. Intuition is the feeling that you know something without specific evidence. The terms thinking and reasoning are often used synonymously, although reasoning is more formal because it usually is aimed at finding answers, providing explanations, and forming conclusions.

The nurse identifies the concept of enduring ideas about what a person considers desirable or has worth in life is known by which term? a. Values b. First-order belief c. Higher-order belief d. Stereotype

ANS: A Values are enduring ideas about what a person considers is the good, the best, and the "right" thing to do and their opposites—the bad, worst, and wrong things to do—and about what is desirable or has worth in life. First-order beliefs serve as the foundation or the basis of an individual's belief system. Higher-order beliefs are ideas derived from a person's first-order beliefs through inductive or deductive reasoning. A stereotype is a belief about a person, a group, or an event that is thought to be typical of all others in that category.

The nurse is teaching a group of patients about diseases that are transmitted by ticks. Which term would the nurse use when identifying the function of a tick in spreading disease? a. Vectors b. Bacteria c. Viruses d. Fungi

ANS: A Vectors carry pathogens from one host to another. Bacteria are single-cell organisms. Viruses are the smallest organisms. Fungi are single-cell organisms that can cause infection.

The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. The nurse recognizes which type of pain is this patient experiencing? a. Visceral pain b. Somatic pain c. Radiating pain d. Referred pain

ANS: A Visceral pain arises from the organs of the body and occurs when inflammation and tissue damage occur, such as with cholecystitis. Somatic pain occurs when there is tissue damage to skin, muscle, joints, and bones. Referred pain occurs when the discomfort is felt at a location other than the origin of the pain. Radiating pain extends to another area of the body.

The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate? a. To promote circulation b. To maintain asepsis c. To maintain comfort d. To maintain tradition

ANS: A Washing from distal to proximal promotes circulation and blood return. Asepsis is the state of being free from disease-causing contaminates. There is no difference in comfort. Tradition is a custom.

The nurse recognizes which statement by the patient indicates a teaching need? a. "I use bobby pins to remove excessive ear wax." b. "I use soap and a warm cloth to clean the outside of my ear." c. "My doctor sometimes gives me oil drops for my ears." d. "I never use Q-Tips."

ANS: A Washing the ear with a washcloth and soap is sufficient in most patients. If the patient has a buildup of wax, or cerumen, the health care provider may order special oil drops to soften the wax before irrigating the ear canal. Do not try to remove the wax using a cotton-tipped applicator because this can push the wax farther into the ear canal. Caution patients to never insert anything sharp into the ear, such as bobby pins. Sharp objects can rupture the tympanic membrane.

When the nurse realizes that the patient's short-term goals have not been met, the nurse should carry out which task? a. Revise or adapt the plan of care. b. Assume that the patient did not want to achieve his goals. c. Understand that a plan of care is almost never changed. d. Reassess plans of care only after major patient-nurse interactions.

ANS: A When a patient goal is unmet or only partially met, the plan of care may need to be revised or adapted to support goal attainment. There are many reasons why goals are not met, including changes in the patient condition, unrealistic goals, or inappropriate interventions that do not help meet the goal. It is common for plans of care to change to meet evolving needs. Reassessment occurs with each patient-nurse interaction. As changes in a patient's condition occur, the plan of care should be revised.

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

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.

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.

14. A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed "S" pattern. b. When observed posteriorly, the hips and shoulders form an "S" pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out.

ANS: A When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed "S" pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.

If the nurse is trying to determine the best treatment or course of action and wants to incorporate the most reliable evidence into the decision, the nurse will use what filtered resource? a. Cochrane Reviews b. UpToDate c. STAT!Ref d. MD Consult

ANS: A When trying to determine the best treatment or course of action and wanting to incorporate the most reliable evidence into the decision, the nurse can use a filtered resource such as the Cochrane Reviews or the Joanna Briggs Institute Library of Systematic Reviews. The filtered resource provides the best available evidence. In filtered resources, clinical and subject experts have asked a question and then synthesized evidence to establish conclusions based on the research. This pre-evaluation process is already completed for nurses and allows the resources to be used while caring for patients. The conclusions from filtered resources still need to be evaluated by clinicians in terms of a specific patient. Filtered resources produce systematic reviews of the literature. Nurses may encounter conditions outside their specialty area and need an overview. Background resources provide detailed information. If the nurse is looking for a presentation of information or types of therapies, the best source is a background resource. Background resources include UpToDate, STAT!Ref, and MD Consult, which are web-based databases. Another source of background information is a current nursing textbook.

A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process? a. Pericarditis b. Acute pain c. Anxiety d. Activity intolerance

ANS: A Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, nursing diagnoses are much broader in and consider a patient's response to medical diagnoses and life situations. The underlying etiology, or cause of a patient's concern or situation, rather than a medical diagnosis, should be used as a related factor when writing an ICNP nursing diagnosis statement and can be included in the list of supporting data in the EMR. Pericarditis is a medical diagnosis defined as an inflammation of the pericardium. Pain, anxiety and intolerance to activity are all possible patient responses to the medical condition of pericarditis.

The nurse is preparing to restart a patient's intravenous line and discovers that the patient has no usable veins in either arm. When working to solve this problem, the nurse should carry out which action? a. Discuss the problem with the nurse in charge. b. Not start the intravenous line. c. Conduct an Internet search for infusion journal articles. d. Contact the provider and report the concern.

ANS: A Whether in an academic setting or in the clinical area, discussion of a problem, issue, or situation with colleagues may improve critical thinking. Through dialogue with others who have expertise or experience with the issue being faced, knowledge gaps can be filled, erroneous assumptions exposed, and unconscious biases addressed. Not starting the intravenous line is not an option at this point. A literature review to gain published information about intravenous complications may be appropriate after the patient's concern has been addressed. Initially contacting the provider without fully exploring the option for alternate is neither wise nor recommended.

2. 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.

While adopting new technology to enhance patient care and safety, nurses can continue to provide what service? a) Compassionate care b) Consumer empowerment c) Self-management of wellness d) Education about health care

ANS: A While adopting new technology that enhances patient care and safety, it is the nurse's responsibility to continue to provide compassionate care. The spread of IT supports consumer empowerment and self-management of wellness and disease. Consumers can electronically access their own health information, communicate with their health care providers, and seek needed education about health care.

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 development 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.

The nurse asks the patient for permission to involve the patient's family members in the teaching plan for the patient. Which response is the best rationale to support this involvement? a. Involving the family empowers the patients and their support system. b. Teaching family members decreases the number of questions they may ask. c. Educated family members ensure the patient will comply with the treatment plan. d. The family members may be interested in the information.

ANS: A With the patient's permission, the nurse should share instructions with the people who may assist with care. Nurses empower patients and their support systems through effective teaching. When nurses provide patients and their families with opportunities to ask questions and comprehend health care information, they become an integral part of the health care process. The family members may ask fewer questions but that is not a reason to involve them. Nothing will ensure patient compliance other that the patient deciding to do so. Family members may be interested in the information, but that is not the main reason to include them.

The nurse recognizes which response as a barrier to achieving goals? a. The effects of pain and/or clinical depression b. Patient involvement in setting patient goals c. Family involvement in setting patient goals d. Realistic expectations of the patient's capabilities

ANS: A Pain and depression both can lead the patient away from cooperation and motivation in working towards goal achievement. The nurse must address either problem in order to have the best chance of success for the patient in meeting goals. Patient and family involvement help create "buy-in" and cooperation. Realistic expectations lead to reasonable and achievable goals.

A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis does the nurse use to address this concern? a. Risk b. Actual c. Health-promotion d. Medical diagnosis

ANS: A The three types of nursing diagnostic statements are actual, risk, and health promotion. Determining which type is needed for each patient can be challenging. Risk (potential) Nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Actual Nursing diagnoses identify existing problems or concerns of a patient. Health-promotion Nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Medical diagnoses identify and label medical (physical and psychological) illnesses.

The nurse demonstrates a thorough understanding of the planning phase of the nursing process when making which statement? a. "Patients should be included in the planning process." b. "Patient families should not interfere in the planning process." c. "The planning process should focus on short-term goals only." d. "Planning is the first phase of the nursing process."

ANS: A' Planning is the third step of the nursing process. During the planning phase, the professional nurse prioritizes the patient's Nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. Patients should be included in the planning process. Involving patients in planning their care helps them to: (1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions. Depending on the patient's condition or circumstances, it may be advantageous to include members of the patient's support system (i.e., family, friends, and caregivers) in the planning phase.

A patient is admitted to the Emergency Department after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, "My father died suddenly of a heart attack at the age of 52. I'm so scared." Which Nursing diagnoses are appropriate for this situation? (Select all that apply.) a. Acute pain b. Fear c. Risk for aspiration d. Risk for infection e. Impaired role performance

ANS: A, B One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. The patient is reporting severe chest pain with an inability to take deep breaths. The Nursing diagnostic label of acute pain is appropriate. Being scared is a defining characteristic of the Nursing diagnosis of fear. The patient is not at risk for aspiration or infection based on the data presented.

Which community-based nursing activities indicate the nurse is working in the role of educator? (Select all that apply.) a. Offers prenatal classes b. Offers a child safety program c. Offers to defend patients' decisions d. Offers creative solutions to local problems e. Offers 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 is attempting to develop Nursing diagnoses for a patient. The nurse understands that Nursing diagnoses have which characteristics? (Select all that apply.) a. Nursing diagnoses identify actual or potential problems as well as responses to a problem. b. Nursing diagnoses require naming patient problems using Nursing diagnostic labels. c. Nursing diagnoses utilize objective data since subjective data are often inaccurate. d. Nursing diagnoses include unvalidated data to determine an accurate and thorough diagnosis. e. Nursing diagnoses are similar to medical diagnoses since they both are labels for diseases.

ANS: A, B The Nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of Nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using Nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas Nursing diagnoses describe a response to an actual or potential problem or life process.

Health care providers are required to supply patients with written information regarding their rights to make medical decisions and implement advance directives, which consist of three documents. The nurse knows which items are considered "advanced directives"? (Select all that apply.) a. Living will b. Durable power of attorney c. Health care proxy d. Patient's Bill of Rights e. The Uniform Anatomical gift act

ANS: A, B, C Advance directives consist of three documents: (1) living will, (2) durable power of attorney, and (3) health care proxy, commonly referred to as a durable power of attorney for health care. The Patient's Bill of Rights informs consumers of health care about specific privileges of which they should be aware. Patients should expect: (1) excellent care, (2) a safe environment, (3) participation in planning their care, (4) privacy, (5) help with discharge arrangements, and (6) assistance with fulfilling financial responsibilities. The Uniform Anatomical Gift Act was approved to allow people over the age of 18 to donate their bodies or body parts after death for transplantation, deposit in tissue banks, or research.

Which recommendations would the nurse identify as appropriate screening guidelines? (Select all that apply.) a) Women ages 21 to 29 should have a Pap test every 3 years. b) Self-breast exams should be addressed with male and female patients. c) Adolescent males should perform monthly self-testicular exams. d) Women ages 30 to 65 should receive Pap tests every 10 years. e) After a total hysterectomy, Pap testing should be more frequent.

ANS: A, B, C All women should begin cervical cancer screening at the age of 21 years. Women between the ages of 21 and 29 years should have a Papanicolaou (Pap) test every 3 years. A priority assessment task for nurses in a variety of care settings is to ask female and male patients about breast self-examination. An adolescent male should be assessed for testicular self-examination habits, and older males should have an annual prostate examination. Women between the ages of 30 and 65 years should have a Pap test plus a human papillomavirus (HPV) test (i.e., co-testing) every 5 years. Women 65 years of age or older who have had normal results for previous Pap tests should no longer be screened. Women who have had a total hysterectomy (i.e., removal of the uterus and cervix) should not be tested, unless the surgery was done as a treatment for cervical cancer or pre-cancer.

The nurse understands that Florence Nightingale is noted to have provided the initial basis for evidence-based practice (EBP) by doing which action? (Select all that apply.) a. Basing her work in trial and error as well as observation b. Using statistical data as a basis for improvements c. Applying statistical methods such as "pie charting" to display results d. Focusing on bedside care and ignoring nursing education e. Publishing the first EBP journal

ANS: A, B, C Florence Nightingale, in her Notes on Nursing in 1859, outlined basic principles of nursing science. Nightingale's method of nursing included rigorous monitoring of the effectiveness of interventions and treatments. This provided the initial basis for EBP. Her work was based on trial and error, careful observation, discussion with patients, and clinical experience. She used statistical data to improve sanitation, health, nursing education, and health administration. Nightingale applied a statistical approach to the study of public health and mortality data and used a pie chart to display research findings. However, nursing did not publish its first EBP journal, Evidence-Based Nursing, until 1998.

The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk? (Select all that apply.) a. "I should do weight-bearing exercises." b. "I should get adequate intake of calcium and vitamin D." c. "I should exercise regularly." d. "I need to do yoga exercises." e. "I wish I could reduce my risk but i cant do anything

ANS: A, B, C Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which would the nurse evaluate during the physical assessment? (Select all that apply.) a. Blood test results b. X-ray results c. Recent vital signs d. Patient's health history e. Subjective data

ANS: A, B, C On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical examination.

Patient-centered care requires the nurse to complete which actions? (Select all that apply.) a. Have an understanding of patient preferences. b. Be aware of family values. c. Recognize the patient's expectations. d. Base conclusions on the nurse's personal experiences. e. Provide care in a standardized manner.

ANS: A, B, C Patient-centered care requires the nurse to understand patient and family preferences and values. Nurses must recognize patients' expectations for care and provide care with respect for the diversity of human experience. While interpreting data, the nurse must be careful to avoid inaccurate inferences (i.e., conclusions) based on the nurse's personal preferences, past experiences, generalizations, or outdated and inaccurate health care information.

The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.) a) Brain b) Lungs c) Heart d) Liver e) Skeletal muscle

ANS: A, B, C Problems in the brain, heart, and lungs can directly lead to changes in respiratory rate and effort. Problems in the liver and skeletal muscle do not affect respirations directly.

A nurse is educating women on breast cancer risk reduction. What topics does the nurse include in the presentation? (Select all that apply.) a) Exercise b) Limiting alcohol c) Low-fat diet d) Breast self-exams e) Milk intake

ANS: A, B, C Reducing breast cancer risk can be accomplished by getting regular exercise, limiting alcohol, and eating a low-fat diet. Performing breast self-examinations will not reduce risk but may help women find abnormalities early. Milk intake is not related.

The nurse should avoid soaking the feet of which patient population? (Select all that apply.) a. Patients with peripheral vascular disease b. Patients with a stroke c. Patients with diabetes d. Patients with arthritis e. Patients who are malnourished

ANS: A, B, C Soaking the feet of patients with peripheral vascular disease, cardiovascular disease such as strokes and diabetes are contraindicated because it may cause skin breakdown or infection. Patient with arthritis or malnourished have no contraindications to having their feet soaked.

The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances? (Select all that apply.) a. To provide treatment for the patient b. To determine billing and payment issues c. To enhance health care operations related to the patient d. In public areas such as the cafeteria or elevator e. Over the telephone with any family member

ANS: A, B, C The Health Insurance Portability and Accountability Act (HIPAA), originally passed in 1996, created standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium. The act clearly mandates that protected health information may be used only for treatment, payment, or health care operations. HIPAA privacy standards should be applied during phone, fax, e-mail, or Internet transmission of protected patient information.

The home health care nurse educates patients on which goals of hospice care? (Select all that apply.) a. Relieve suffering. b. Support the patient and family. c. Provide grief support. d. Keep patients out of the hospital. e. Lower medical expenses.

ANS: A, B, C The goals of hospice care include relief of suffering, supporting the family and patient, and providing grief support after the patient dies. Goals do not include keeping patients out of the hospital or lowering medical costs.

The nurse recognizes which statements by the student nurse regarding handwashing indicate a need for further education? (Select all that apply.) a. Wash hands first, then wrists. b. Rinse from fingertips to wrists. c. Dry using a scrubbing motion. d. Turn off faucet with clean, dry paper towel. e. Dry the hands in the same order as washing them.

ANS: A, B, C When washing hands, first wet the wrists and hands; with fingers pointing downward, first wash the wrists and then the hands below the wrists. Then apply soap, lather, and rub using a circular motion for 15 to 20 seconds. When rinsing, rinse from wrist to fingertips, keeping hands with fingers pointing downward. Using clean paper towels, dry thoroughly in the same order (from wrists to fingers) using a patting motion. Turn off the faucet with a clean, dry paper towel.

The nurse is creating a care plan for a patient admitted with severe bone pain related to an infected leg wound. Which diagnosis written on the plan indicates an understanding of the components of a Nursing diagnosis? (Select all that apply.) a. Acute pain b. Risk for impaired walking c. Ineffective bone tissue perfusion d. Osteomyelitis e. Infection

ANS: A, B, C Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, Nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient's response to medical diagnoses and life situations in addition to making clinical judgments based on a patient's actual medical diagnoses and conditions. Pain, potential inability to ambulate, and decreased blood flow to the bone are a patient's response to the medical condition of osteomyelitis. Medical diagnoses identify the specific physical or psychological condition. Osteomyelitis and infection are medical diagnoses defined as inflammation and an infection of the bone usually caused by bacteria.

7. The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Move bedridden patients in their bed. e. Wait until the fire department arrives to act. f. Use type B fire extinguishers for electrical fires.

ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case evacuation is needed. You will move bedridden patients from the scene of a fire by a stretcher, bed, or wheelchair. The nurse cannot wait until the fire department arrives to act. Type C fire extinguishers are used for electrical fires; type B is used for flammable liquids.

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.

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

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

The nurse explains to the patient that which services will be covered under Medicare? (Select all that apply.) a. Infusion therapy b. Ostomy management c. Renal dialysis d. Chemotherapy e. Grocery shopping

ANS: A, B, C, D Medicare will reimburse for professionally rendered services provided by a licensed health care provider. Grocery shopping would not be covered. If homemaker services are provided to a patient also receiving skilled care, then they too are reimbursed.

1. 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.

The nurse identifies which examples listed indicate objective data? (Select all that apply.) a. Respirations—24 breaths/min b. Platelet count—350,000 mm3 c. Wound size—3 cm 2 cm d. Temperature—98.4 °F (36.8 °C) e. Reports severe abdominal pain

ANS: A, B, C, D Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms.

1. 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.

The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the nurse should complete which actions? (Select all that apply.) a. Prioritize Nursing diagnoses. b. Determine short- and long-term goals. c. Identify outcome indicators. d. List nursing interventions. e. Gather assessment data.

ANS: A, B, C, D Planning is the third step of the nursing process. During the planning phase, the professional nurse prioritizes the patient's Nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. Each of these actions requires careful consideration of assessment data (collected earlier) and a thorough understanding of the relationship among Nursing diagnoses, goals, and evidence-based interventions.

The nursing student is writing a report on the use of nonverbal techniques to encourage therapeutic communication. Which examples would be included in the report? (Select all that apply.) a. Providing a backrub b. Remaining silent c. Refraining from distracting body movements d. Facing the patient e. Avoiding eye contact

ANS: A, B, C, D Providing a backrub is considered therapeutic touch; additional examples include holding a patient's hand and gently touching a patient's arm. Silence refers to being present with a patient without verbal communication. Facing the patient and refraining from unusual body movements are active listening techniques. Avoiding eye contact does not facilitate communication.

The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.) a. Threats of killing oneself b. Chronic pain c. History of prior suicide attempt d. Loneliness e. Stable heart rhythm

ANS: A, B, C, D Risk factors may be environmental, physical, psychological, or situational concerns. The nurse is concerned that the patient may be at risk for suicide. Verbal statements by the patient, physical illness such as chronic pain, prior attempts to commit suicide, and a lack of social interaction are potential causes for the act of suicide. A stable heart rhythm would not be a safety concern.

The nurse understands the use of standardized language in care planning is beneficial for what reasons? (Select all that apply.) a. Standardized language provides consistency. b. Standardized language improves communication among nurses. c. Standardized language increases the visibility of nursing interventions. d. Standardized language enhances data collection. Standardized language supports adherence to care standards.

ANS: A, B, C, D Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) Nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process. Use of standardized language provides consistency, improves communication among nurses and with other health care providers, increases the visibility of nursing interventions, improves patient care, enhances data collection to evaluate nursing care outcomes, and supports adherence to care standards.

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.) a. Activity b. Friction and shear c. Moisture d. Sensory perception e. Cognition

ANS: A, B, C, D The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

The nurse is caring for a patient admitted for the removal of an infected appendix. Which actions by the nurse would indicate an understanding of the 2018 hospital safety goals? (Select all that apply.) a. Places an identification band on the right arm. b. Marks the surgical site with a black-felt pen. c. Checks medications three times before administration. d. Washes hands between patients and/or when soiled. e. Removes allergy bands prior to transfer to surgery.

ANS: A, B, C, D The Joint Commission identifies each category and has specific elements of performance that are required for the health care worker to meet the goals. As new problems in patient care emerge, the safety goals are reassessed and revised. The 2018 hospital goals include the following broad categories: improve the accuracy of patient identification, improve the effectiveness of communication among caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections. The organization identifies safety risks inherent in its patient population. Improve the accuracy of patient identification. (Placing an ID band on the right are), improve the safety of using medications (check medications three times before administration), reduce the risk of health care-associated infections. (Washing hands), and the organization identifies safety risks inherent in its patient population. (Mark the surgical site with a black-felt pen) are all examples of actions that comply with the 2018 safety goals. Removing allergy bands would prevent identification of that patient's safety risk.

The nurse documents that patient laboratory results often take 4 hours to populate into the electronic medical record. The lengthy time frame has contributed to delayed antibiotic administration. From this point, what should the nurse do to produce change using Evidence-Based practice? (Select all that apply.) a. Identify a problem affecting patient care. b. Realize the facility resources may influence the decision. c. Review pertinent journal articles from the literature search. d. Apply the findings to clinical practice considering patient preferences. e. Using the process recommended by the best clinical article.

ANS: A, B, C, D The process of using evidence-based practice (EBP) starts with the identification of a problem. The nurse then conducts a literature search to find the best evidence pertaining to the problem. Facility resources may impact the ability to implement the chosen decision. Patient preferences need to be incorporated into the use of evidence from the literature combined with clinical expertise. The nurse would not use just one clinical article to determine a solution to the issue.

Since in the planning phase, the significance of developing organized plans of care for patients is important, the nurse must take seriously which of these responsibilities? (Select all that apply.) a. Prioritizing patient needs b. Developing mutually agreed-on goals c. Determining outcome criteria d. Identifying interventions e. Implementation of the patient's plan of care

ANS: A, B, C, D The significance of developing organized plans of care for patients cannot be stressed enough. The nurse must take seriously the responsibility of prioritizing patient needs, developing mutually agreed-on goals, determining outcome criteria, and identifying interventions that can help patients to achieve positive outcomes. After these actions are completed in the planning phase of the nursing process, it is time for implementation of the patient's plan of care (implementation phase).

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.

The nurse knows what should be included in an in-depth health history? (Select all that apply.) a. Demographic data b. Patient's allergies c. Family history of diseases d. Patient's health promotion practices e. Patient's history of illness and surgery

ANS: A, B, C, D, E An in-depth health history includes all pertinent information that can guide the development of a patient-centered plan of care. The health history includes demographic data, which are collected during the orientation phase of the interview; a patient's chief complaint or reason for seeking health care; history of current and past illnesses and surgery; allergies; medications; adverse reactions to medications; medical history; family and social history; and health promotion practices. Because a patient's health history is continuously evolving, the data collection is ongoing, progressive, and methodical.

A nurse is conducting a physical examination using palpation. Which assessments might the nurse note? (Select all that apply.) a) Rebound tenderness b) Crepitation c) Guarding d) Turgor e) Consistency

ANS: A, B, C, D, E Crepitation is crackling or rubbing felt (and perhaps heard) during palpation. Turgor is the amount of tension in body tissues caused by fluid content. Consistency compares organs for their location and size related to the norms. Rebound tenderness occurs after the stimulation is discontinued but is elicited with palpation. Guarding is positioning to prevent movement of a painful body part. In this scenario, the patient would guard to prevent the nurse from palpating a painful area.

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that apply.) a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy.

ANS: A, B, C, D, E Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

3. When the nurse is assisting patients with hygiene care, which tasks should be included? (Select all that apply.) a. Bathing b. Oral care c. Perineal care d. Foot care e. Patient communication

ANS: A, B, C, D, E Hygienic practices include bathing, oral care, perineal care (cleansing of the genital area, urinary meatus, and anus), foot care, and shaving. During hygiene care the nurse communicates with the patient, assesses the skin, and observes for any abnormalities.

The nurse recognizes which interventions to be prevention oriented? (Select all that apply.) a. Immunization programs b. Cleansing an incision c. Cardiac risk factor modification d. Placing infants prone when they sleep e. Teaching patients to ask their providers to wash their hands

ANS: A, B, C, D, E Some interventions prevent illness or complications and promote healthy activities or lifestyles. Interventions such as patient education and immunization programs are prevention oriented. Cleansing an incision is a nursing intervention that can help prevent infection. Educating a patient about risk-factor modification for cardiovascular disease may prevent a future myocardial infarction. Placing infants on their backs to sleep may reduce the risk of sudden infant death syndrome. Patients should be instructed to ask their care providers to wash their hands if they have not observed them doing so.

A nurse uses the five rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.) a. Right task b. Right person c. Right direction d. Right supervision e. Right circumstances f. Right 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.

The nurse knows which items are included in the documentation for a patient on fall precautions? (Select all that apply.) a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall

ANS: A, B, C, D, E The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices are also documented. Thoroughly document a fall or reported fall.

The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.) a. Intensity of the pressure b. Duration of the pressure c. Tissue's ability to tolerate the pressure d. Person's age e. Person's nutritional status

ANS: A, B, C, D, E The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue's ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation? (Select all that apply.) a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment d. Patient's pain level e. Presence of drainage

ANS: A, B, C, E A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. The patient's pain level would be documented with his/her pain assessment.

A nurse has finished examining a patient. What actions does the nurse take next? (Select all that apply.) a) Document all findings. b) Provide privacy for dressing. c) Provide any hygiene material needed. d) Tells the patient he/she can leave. e) Cleans the room after the patient leaves.

ANS: A, B, C, E After finishing the exam, the nurse provides the patient with privacy for changing back into street clothes and any needed hygiene material. The nurse also documents the findings and cleans the room before the next patient is seen. The nurse does not simply tell the patient he/she may leave. The nurse should indicate what will happen next before the patient leaves (i.e., providing written material summarizing the visit, scheduling the next appointment).

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.

Caring, according to the American Nurses Association (ANA) Code of Ethics (2015), is having concern or regard for that which affects the welfare of another. The nurse recognizes that as a profession, nursing can trace its earliest beginnings to what types of nurturing activities that demonstrate care? (Select all that apply.) a. Active listening b. Advocating for the vulnerable c. Valuing all individuals d. Separating healing from spirit e. Attempting to relieve pain

ANS: A, B, C, E Caring, according to the American Nurses Association (ANA) Code of Ethics, is having concern or regard for that which affects the welfare of another. As a profession, nursing can trace its earliest beginnings to the types of nurturing activities that demonstrate care, such as taking time to be with a suffering person, actively listening, advocating for the vulnerable, valuing and respecting all individuals, attempting to relieve pain, and making the healing process an act of the body, mind, and spirit.

A nurse conducting the general survey of a patient includes which items? (Select all that apply.) a) Hygiene and grooming b) Affect and mood c) Sex and gender orientation d) Sexual preferences and practices e) Age

ANS: A, B, C, E Components of the general survey include age, race, hygiene and grooming, affect and mood, clothing, sex and gender orientation, age, and safety. Sexual preferences and practices are not included.

The nurse is providing education to a community group on environmental safety. Which safety measures are effective in improving their environmental safety? (Select all that apply.) a. Use of night-lights throughout the home b. Illumination of stairwells and pathways c. Installation of motion-activated lighting on the exterior of the home d. Application of wax to all floors to increase shine e. Staying indoors when air pollution is high

ANS: A, B, C, E Inadequate lighting presents safety concerns in home, work, community, and health care environments. For an individual to safely and successfully navigate pathways and perform various activities while avoiding potential obstacles and hazards, the environment must be well illuminated. Well-lit, glare-free halls, stairways, rooms, and work spaces help to reduce the risk of tripping, slipping, and falling. Night-lights reduce the risk of injuries to children, guests, and older adults. Lighting the exterior of the house will also reduce the risk of falling. Staying indoors during episodes when air pollution is high can help prevent chronic lung disease. Waxed floors are slippery.

The nurse understands that which are important in the process of developing a cultural identity? (Select all that apply.) a. School b. Church/religious institution c. Family d. History e. Community

ANS: A, B, C, E Many institutions and groups, both formal and informal, assist an individual in developing a cultural identity, including school, religious institutions, family, and community.

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.

The nurse is using Giger and Davidhizar's Transcultural Assessment Model to gain information about a patient from an unfamiliar culture. What questions does the nurse ask that are relevant to this mode? (Select all that apply.) a. "Who would you like present to help answer questions?" b. "What do you believe caused your current illness?" c. "How important is planning for the future to you?" d. "Why don't you want to shake my hand?" e. "What activities would you do to control your health?"

ANS: A, B, C, E The Giger and Davidhizar Transcultural Assessment Model looks at communication, space, social orientation, time, environmental control, and biological variation. The questions all address these factors; however, asking why the patient does not want to shake the nurse's hand sounds judgmental and "why" questions are a communication barrier.

Regarding perineal care, whiNch UnRuSrsIinNg Gac Ttio Bn.sCar OeMappropriate? (Select all that apply.) a. The nurse applies gloves prior to performing perineal care. b. The nurse ignores the erection of a male patient during perineal care. c. The nurse documents the perineal care. d. The nurse only completes perineal care with daily bathing. e. The nurse can delegate perineal care.

ANS: A, B, C, E The nurse uses standard precautions (gloves) whenever contact with body fluids is expected. A male patient may have an erection during care, which is a normal response with tactile stimulation. The care provider can ignore the erection and continue with the procedure or return later to complete the care, depending on the comfort level and the situation. Documentation is part of hygienic care. Note any redness, drainage, odor, edema, or skin changes. Perineal care is provided during a bath or shower but may be necessary more frequently, especially in incontinent patients. Perineal care can be delegated.

A group of nursing students is discussing the importance of accurately selecting Nursing diagnoses. Which ideas offered in the students' discussion are reasons for choosing the diagnoses carefully? (Select all that apply.) a. Patient satisfaction b. Positive patient outcomes c. Quality patient care d. Help develop standardized care plans e. Determine appropriate interventions

ANS: A, B, C, E Ultimately, nurses are accountable for formulating accurate Nursing diagnoses and intervening appropriately. By collecting accurate and complete assessment data and articulating concise Nursing diagnoses for each patient, the professional nurse has a significant impact on patient care outcomes, the quality of patient care, and patient satisfaction. By identifying and writing clear Nursing diagnostic statements, the nurse enables accurate development of individualized patient plans of care. Nursing diagnoses and patient outcomes, which are established during the planning step, help the nurse to determine appropriate interventions for patient care.

The nursing student learns that the purpose of measuring a patient's vital signs includes which of the following rationale? (Select all that apply.) a) Monitor body systems functioning. b) Identify early signs of problems. c) Evaluate effectiveness of interventions. d) Determine if a cure has been obtained. e) Provide a baseline to compare against.

ANS: A, B, C, E Vital signs give information on the functioning of body systems, can lead the nurse to identify early signs of problems, can be used to evaluate the effectiveness of interventions, and provide a baseline to compare against subsequent readings. They are not used to solely determine if a disease has been cured.

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.

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

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.

2. 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.

The nurse is obtaining preoperative information for a patient who will be having emergency surgery shortly for a ruptured appendix. Which information is crucial for the nurse to assess? (Select all that apply.) a. All medications that the patient is taking b. Use of tobacco, alcohol, or recreational drugs c. Allergies to medications, foods, or other substances d. Date of last tetanus shot and flu vaccination e. Insurance coverage and preauthorization requirements f. Possibility of pregnancy

ANS: A, B, C, F Priority assessment must be completed prior to emergency surgery, including use of medications, alcohol, tobacco, or recreational drugs because these may interact with anesthesia medications. Allergies must be identified to prevent reactions in the operating room. Special precautions may be taken if the patient is pregnant, so this must also be determined preoperatively. Asking the patient about vaccinations or insurance coverage is not a priority prior to surgery.

The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient at risk? (Select all that apply.) a. Sudden loss of consciousness b. Diabetic retinopathy c. Stroke d. Peripheral neuropathy e. Memory loss

ANS: B, C, D, E Long-term complications of hyperglycemia may contribute to cognitive and sensory deficits such as memory loss. They also can lead to diabetic retinopathy, peripheral neuropathy, and stroke. Loss of consciousness is usually seen with hypoglycemia in diabetics.

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.

The nurse recognizes which statements contribute to the understanding that nursing is considered a profession? (Select all that apply.) a. Nursing requires specialized training. b. Nursing has a specialized body of knowledge. c. The ANA regulates nursing practice. d. Nurses make independent decisions within their scope of practice. e. Once licensure is complete, no further education is required.

ANS: A, B, D A profession is an occupation that requires at a minimum specialized training and a specialized body of knowledge. Nursing meets these minimum requirements. Thus nursing is considered to be a profession. Members of a profession have autonomy in decision making and practice and are self-regulating in that they develop their own policies in collaboration with one another. Nursing professionals make independent decisions within their scope of practice and are responsible for the results and consequences of those decisions. A profession is committed to competence and has a legally recognized license. Members are accountable for continuing their education. The ANA is a professional organization that provides standards (not regulation) of nursing practice.

The nurse recognizes that cold therapy is contraindicated in which conditions? (Select all that apply.) a. Edema b. Shivering c. Bleeding d. Circulatory problems e. Advanced age

ANS: A, B, D Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.

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.

The nurse recognizes measurable goal to have which characteristics? (Select all that apply.) a. Specific b. Concrete c. Vague d. Easy to judge e. Nonspecific

ANS: A, B, D Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met. When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated. When terms such as acceptable or normal are used in a goal statement, goal attainment is difficult to judge because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings.

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.

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.) a. A 28-year old patient scheduled to be discharged home today b. A 49-year-old patient with stable chronic lung disease c. A 78-year-old patient with recent onset of rectal bleeding d. A 35-year-old patient waiting for transfer to a rehabilitation center e. A 40-year-old patient being admitted from the emergency department

ANS: A, B, D Routine assessment of vital signs of a patient who is stable may be delegated to licensed practical or licensed vocational nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care or who are unstable cannot be delegated to UAPs. The patient with rectal bleeding may need critical care, and a new admission needs to be assessed by an RN. Stable patients such as the patient with stable lung disease or awaiting discharge or transfer can be delegated to UAP.

The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions will the nurse include? (Select all that apply.) a. Use grab bars in the tub and/or shower at home. b. Keep rooms well-lit and focus ahead when walking. c. Change positions quickly to avoid dizziness d. Use a cane or walker for stability. e. Ride in the back seat of the car and look ahead.

ANS: A, B, D The patient experiencing dizziness or vertigo exercises caution when changing positions. The patient suffering from motion sickness needs to ride in the front seat of the car and look far ahead through the car windshield. Keeping rooms well-lit and focusing ahead when walking, using grab bars in the shower and/or tub, and using canes or walkers are all good safety measures. Changing positions quickly may lead to dizziness.

The Institute of Medicine (IOM) Report identified several goals for nursing in the United States. The nurse identifies that the IOM offered which suggestions? (Select all that apply.) a. Nurses should practice to the full extent of their education. b. Nursing education should demonstrate seamless progression. c. Nurses should continue to be subservient to physicians in the hospital setting. d. Policy making requires better data collection and information infrastructure. e. Higher levels of education will not be needed by practicing nurses.

ANS: A, B, D NURSINGTB.COM The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) identified several goals for nursing in the United States: nurses should practice to the full extent of their education and training; Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; Nurses should be full partners with physicians and other health care professionals in redesigning health care in the United States; and Effective workforce planning and policy making require better data collection and an improved information infrastructure.

The nurse is performing a health history to determine the patient's sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply.) a. "Do you ever lose your balance?" b. "Do you wear glasses?" c. "Do you like to read the newspaper?" d. "Can you feel the difference between hot and cold water?" e. "Do you wear a hearing aid?"

ANS: A, B, D, E Balance, eyesight, hearing, and sensation are all sensory function. Asking if the patient likes the newspaper does not specifically address vision.

The nurse identifies which components to be expected nursing documentation? (Select all that apply.) a. Nursing assessment b. The care plan c. Critique of the physician's care d. Interventions e. Patient responses to care

ANS: A, B, D, E Expected nursing documentation includes a nursing assessment, the care plan, interventions, the patient's outcomes or response to care, and assessment of the patient's ability to manage after discharge. Documentation should be factual and nonjudgmental.

A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.) a. Vaccination compliance b. Family structure c. Communication patterns d. Roles for women e. Education

ANS: A, B, D, E Income, education, health literacy, where people live or work, early childhood development, social exclusion, family structure, the status and role of women, and vaccination adherence are just some of the social determinants of health recognized worldwide. Communication patterns often are important to assess in culturally diverse individuals, families, and communities, but this is not considered a social determinant of health care.

The nurse is completing an assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply.) a. The patient does not remember where her son lives. b. The patient is unable to balance her checkbook. c. The patient got lost in a city she never traveled to before. d. The patient often has difficulty remembering words. e. The patient got lost going to her usual grocery store.

ANS: A, B, D, E Symptoms of cognitive impairment include disorientation, loss of language skills, loss of the ability to calculate, poor judgment, and memory loss. If a patient exhibits these symptoms, further investigation is needed. Some decline in cognitive function occurs with aging, such as the ability to navigate easily in new areas.

The nurse is caring for a patient who is hospitalized with cognitive impairment and recognizes which interventions will assist the patient in orientation? (Select all that apply.) a. Keep a photo of the family in the room. b. Use a clock on the wall. c. Make sure the room is kept bright and well lit. d. Avoid moving the patient from room to room. e. Have each nurse introduce himself or herself to the patient.

ANS: A, B, D, E The hospitalized patient with cognitive alterations is oriented by use of a clock, a calendar, and statements about the name of the location or name of the hospital. Orientation to person, place, and time is ongoing. Staff members are always identified by name, both verbally and nonverbally (with a name tag). The patient's environment is kept as constant as possible and moving the patient from room to room is avoided. Some familiar objects, such as a family photo, are placed near the patient if the hospital stay is longer than a few days. The environment is kept free of distractions such as loud noises and bright lights. Natural lighting to provide the patient with orientation to time of day can be accomplished by opening blinds or curtains during the day and darkening the room at night.

Which patient-specific factors does the nurse include when assessing pulse? (Select all that apply.) a) Age b) Gender c) Religion d) Exercise e) Medications

ANS: A, B, D, E The nurse should consider several patient-specific factors when assessing the pulse, age, gender, exercise, presence of fever, medications, fluid volume status, stress, and underlying disease processes. Religion is not an appropriate response.

The nurse recognizes the use of telemonitoring offers the opportunity to complete which tasks? (Select all that apply.) a) Reduce cost of health care. b) Improve patient satisfaction. c) Increase duplicate orders d) Improve patient outcomes. e) Improve organization.

ANS: A, B, D, E The use of telemonitoring offers the opportunity to reduce the cost of health care while improving outcomes and patient satisfaction. Use of health care IT has improved organization, communication, and decision making; reduced duplicate orders, charting time, and paperwork; made medication administration safer; and enhanced information access and administrative functions.

The nurse is caring for a patient who has pain following abdominal surgery. Which actions are independent nursing interventions that can be used to make the patient more comfortable? (Select all that apply.) a. Encourage the patient to relax and imagine resting on a tropical beach. b. Provide headphones so that the patient can listen to favorite music. c. Increase pain medication dosage if prescribed regimen is ineffective to manage pain. d. Teach the patient to take pain medication before discomfort becomes severe. e. Switch the patient from IV to oral pain medication when bowel sounds return. f. Demonstrate the use of relaxation breathing before painful procedures.

ANS: A, B, D, F Independent nursing interventions may be carried out without an order from the provider. Changing medication orders must be done by the provider; increasing pain medication dosage and switching the patient to PO pain medications are not independent nursing interventions.

A nurse is a member of the ethics committee. Which purposes will the nurse fulfill in this committee? (Select all that apply.) a. Education b. Case consultation c. Purchasing power d. Direct patient care e. Policy recommendation

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.

2. 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 is hurting. b. The patient is fatigued. c. The patient is mildly anxious. d. The patient is asking questions. e. The patient is febrile (high fever). f. The patient is in the acceptance phase.

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.

In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, what additional actions should the nurse take to practice within the law? (Select all that apply.) a. Maintain confidentiality. b. Follow legal guidelines for sharing information. c. Block document once per shift. d. Change nursing procedures according to latest journal articles. e. Meet licensure and continuing education requirements.

ANS: A, B, E In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, nurses should follow guidelines to practice legally and avoid charges of malpractice, maintain confidentiality, follow legal and ethical guidelines when sharing information, document punctually and accurately, adhere to established institutional policies governing safety and procedures, comply with legal requirements for handling and disposing of controlled substances, meet licensure and continuing education requirements, and practice responsibly within the scope of personal capabilities, professional experience, and education.

When assigning tasks to other health care providers, the nurse understands that each task must be delegated using which guidelines? (Select all that apply.) a. The task must be within the scope of the person to whom it is being delegated. b. The task is one that can be delegated to other health care providers. c. The task can be delegated whenever assessments are required. d. The task may be re-delegated by the person to whom it was first delegated. e. The task may require the nurse to procure resources to complete the task.

ANS: A, B, E Through quality improvement, the nurse appreciates the value of what each team member can do to improve patient care. When delegating to other health care providers, the nurse understands that the task must be within the scope and abilities of the person to whom it is being delegated. The nurse must know if the task is something that can be delegated. The RN is responsible for assessment of patients even if certain tasks are delegated to others. The person to whom the assignment was delegated cannot delegate that assignment to someone else. Adequate resources must be made available to the delegatee to complete the task.

3. The nurse is caring for a patient who has had a recent stroke and is paralyzed on the left side. The patient has no respiratory or cardiac issues but cannot walk. The patient cannot button a shirt and cannot feed self due to being left-handed and becomes frustrated very easily. The patient has been eating very little and has lost 2 lbs. The patient asks the nurse, "How can I go home like this? I'm not getting better." Which health care team members will the nurse need to consult? (Select all that apply.) a. Dietitian b. Physical therapist c. Respiratory therapist d. Cardiac rehabilitation therapist e. Occupational therapist f. Psychologist

ANS: A, B, E, F Physical therapists are a resource for planning ROM or strengthening exercises, and occupational therapists are a resource for planning ADLs that patients need to modify or relearn. Because of the loss of 2 lbs and eating very little, a dietitian will also be helpful. Referral to a mental health advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory function, respiratory therapy and cardiac rehabilitation probably are not needed at this time.

The nurse knows that professional nursing requires a commitment to which reasons for lifelong learning? (Select all that apply.) a. Treatment modalities and technology continue to advance. b. There are always new things to memorize and store in memory. c. Nurses are expected to update and maintain competency. d. Critical thinking is essential in nursing. e. Nursing school gives the nurse all one needs to be competent.

ANS: A, C, D Professional nursing requires a commitment to lifelong learning. Nurses must possess critical-thinking skills to maintain pace with ever-changing treatment modalities and technological advances. Outdated learning strategies that focus on remembering content must be replaced by a focus on understanding the rationales and outcomes. It is an expectation of professional practice that nurses update and maintain their competency and knowledge base. The increasing complexity of health care and information technology make critical thinking essential in nursing. No longer is rote memorization and recall of content sufficient for the complex decisions and judgment required in professional nursing practice. Because knowledge and technology continue to expand for nursing professionals, the content learned in nursing school is not sufficient to maintain competence in nursing practice.

In reviewing a patient's written chart, the nurse notes the use of the terms "bedsore," "decubitus ulcer," and "pressure ulcer." The nurse knows to reach maximum potential in computerized charting and data analysis that a standardized nursing terminology must be utilized. The nurse knows what concepts are associated with standardizing nursing terminology? (Select all that apply.) a) The Nursing Minimum Data Set (NMDS) was the first attempt to do so. b) The focus was to provide a shared understanding of patient problem labels. c) The NMDS data was completed and is the definitive source of patient labels. d) The ICNP was developed to provide a standard for international nurses. Standardized terminology can lead to better utilization of resources.

ANS: A, B, EA standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. An example is the choice between pressure ulcer, decubitus ulcer, and bedsore. Do all nurses in all settings have a shared understanding of these labels for a patient problem? The Nursing Minimum Data Set (NMDS) represents the first attempt to standardize the collection of essential nursing data. These core data, used on a regular basis by most nurses in the delivery of care across settings, provide accurate descriptions of the nursing diagnoses, nursing care, outcomes of care, and nursing resources used. Collected on an ongoing basis, the NMDS enables nurses to compare data across populations, settings, geographic areas, and time. The International Classification for Nursing Practice (ICNP) (2015), developed under the auspices of the International Council of Nurses (ICN), is a standard terminology that provides a dictionary to describe and report nursing practice in a systematic way. This information supports care and decision making to inform nursing education, research, and health policy.

The nurse understands that the nurse-patient relationship focuses on which areas? (Select all that apply.) a. Building trust b. Demonstrating sympathy c. Tearing down boundaries d. Developing a plan of care e. Applying cultural generalities

ANS: A, C, D A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. The focal point of the nurse-patient helping relationship is the patient and the patient's needs and concerns. Nurse-patient relationships focus on five areas: (1) building trust, (2) demonstrating empathy, (3) establishing boundaries, (4) recognizing and respecting cultural influences, and (5) developing a comprehensive plan of care.

The nurse recognizes which statements to be accurate regarding The Health Insurance Portability and Accountability Act (HIPAA) of 1996? (Select all that apply.) a) Requires the user to have verification codes. b) Ensures access to information without fear of audits. c) Sets the standards on how information is maintained. d) Sets the penalties for any breach in security of health data. e) Has no legal authority relative to security issues.

ANS: A, C, D Access to electronic records requires a user to have system access and verification codes as a measure of security and protection of the patient's privacy. The codes leave an electronic trail of authorized users that can be audited. HIPAA sets the standards on how security and confidentiality of health care information must be maintained. The act also sets the penalties for any breach in security of health care data.

The nurse recognizes which skills that are needed to be an effective manager? (Select all that apply.) a. Understand the concepts of budgeting. b. Run a unit efficiently without regard to cost c. Be able to staff the unit effectively. d. Be adept at information management. e. Achieve desired outcomes in any way possible.

ANS: A, C, D An effective manager must have business skills and a business sense. Part of quality care is ensuring that the care the patient receives is cost effective. The nurse manager must understand concepts of budgeting, staffing, marketing, and information management. An understanding of human resource management is equally important. The skillful nurse manager understands the way these elements interact and their influence in achieving expected outcomes in an economically responsible manner.

2. The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.) a. Footdrop b. Somnolence c. Hypostatic pneumonia d. Impaired skin integrity e. Increased socialization

ANS: A, C, D Immobility leads to complications such as hypostatic pneumonia. Other possible complications include footdrop and impaired skin integrity. Interruptions in the sleep-wake cycle and social isolation are more common complications than somnolence or increased socialization.

1. A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) a. Smoking in bed helps me relax and fall asleep. b. We never leave candles burning when we are gone. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher. e. There is a fire extinguisher in the kitchen and garage workshop.

ANS: A, C, D Incorrect information will cause the nurse to intervene. Accidental home fires typically result from smoking in bed. Advise families to only purchase newer model space heaters that have all of the current safety features. The PASS method is used for fire extinguishers. All the rest are correct and do not require follow-up. Candles should not be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage.

The nurse recognizes that by involving the patient in planning care, which patient results occur? (Select all that apply.) a. Being aware of identified needs b. Accepting that not all goals are measurable c. Embracing mutually agreed-on goals d. Feeling a sense of empowerment e. Overcoming unrealistic goals

ANS: A, C, D Patients should be included in the planning process. Involving patients in planning their care helps them to: (1) be aware oNf identified needs accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions. By accepting guidance and input from patients during the planning process, the nurse provides them with a greater sense of empowerment and control.

A nurse wants to create a community action plan for health problems related to air pollution from a nearby factory. Which stakeholders does the nurse consult as the priority? (Select all that apply.) a. Factory owners b. Stock shareholders c. Community residents d. Local health care providers e. Factory employees

ANS: A, C, D Stakeholders have a significant interest in a topic. The priority stakeholders the nurse would want to consult for this project include the factory owners, community residents, and health care providers. The stockholders would probably not be consulted. The employees could be a significant stakeholder if the action plan affected employment.

The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which statement(s) by the patient indicates further education is needed? (Select all that apply.) a. "I should take antibiotics every time I am sick." b. "I should take all antibiotics as prescribed." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better." e. "If I develop a rash while taking these I will call the provider."

ANS: A, C, D The overuse of antibiotics and inappropriate use, such as not completing prescriptions and sharing antibiotics, has led to increased resistance. Taking antibiotics as prescribed helps to ensure the infection will be treated correctly. A rash may indicate an allergic reaction and the patient needs to report this to the provider.

The nurse appropriately delegates care of the unit's patients to the properly trained UAP when that UAP is assigned which tasks? (Select all that apply.) a. UAP assigned to reposition the patient. b. UAP assigned to complete the MORSE falls risk scale. c. UAP assigned to provide range-of-motion exercises. d. UAP assigned to ambulate the patient in the hallway. e. UAP assigned to time the patient on a TUG test.

ANS: A, C, D UAPs provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment as is the Timed Up and Go (TUG) test.

Nurses use new information in their practice. In the process of implementing EBP, the nurse carries out which actions? (Select all that apply.) a. Develops clinical questions. b. Creates workshops and in-services. c. Seeks answers to support the clinical decision. d. Applies finding to patients. e. Publishes a bulletin.

ANS: A, C, D Workshops and in-service or focused training may be necessary if the plan involves a comprehensive change in care or it affects the entire health care agency or community. A bulletin can be provided that lists several safe practice concerns with rationales in the form of a safe practice alert. The fifth phase in the EBP process requires implementation of the change by applying the evidence. Nurses use the new information in their practice. In the process of implementing EBP, the nurse develops a clinical question, seeks answers to verify and support a clinical decision, and ultimately applies the findings to patients.

The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.) a. Use simple phrases. b. Speak louder than usual. c. Stand in front of the patient. d. Use a picture board. e. Be patient and unrushed.

ANS: A, C, D, E A patient with receptive aphasia cannot understand written or spoken language. Using simple phrases and talking either softly or loudly will not assist that patient. The sensory pathways are intact, but the words do not make sense. A picture board could be used by the nurse when assessing needs. As the patient participates in speech therapy, the ability to understand simple phrases may develop. Standing in front of the patient when talking may give non-verbal clues to the message.

The nurse is conducting a windshield survey. What items does the nurse assess? (Select all that apply.) a. Types of housing available b. Cars seen in parking lots c. Recreational facilities d. Health care facilities e. Places of worship

ANS: A, C, D, E A windshield survey is a type of community health assessment. The nurse walks or drives through a neighborhood and notes the type of housing available, the presence and condition of recreational facilities, the presence of health care facilities, and places of worship among other items. Types of cars noted in the neighborhood are not one of the assessments.

The nurse understands that which factors can increase blood pressure? (Select all that apply.) a) Head injury b) Decreased fluid volume c) Increasing age d) Recent food intake e) Pain

ANS: A, C, D, E Head injury, increasing age, recent food intake, pain, and increased (not decreased) fluid volume all can increase blood pressure.

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 Technology Informatics Guiding Education Reform (TIGER) initiative identified a set of skills needed by all nurses practicing in the 21st century. The nurse identifies the TIGER Vision Pillars include which concepts? (Select all that apply.) a) Management and leadership b) Certification by HIMSS c) Communication and Collaboration d) Informatics design e) IT policy and culture

ANS: A, C, D, E The Technology Informatics Guiding Education Reform (TIGER) initiative (2018) identified a set of skills needed by all nurses practicing in the 21st century. The TIGER Vision Pillars include management and leadership, education, communication and collaboration, informatics design, and IT policy and culture. Certification is not one of the pillars.

When dealing with patient who has a values conflict in which substance abuse or an addiction is involved, the nurse should conduct an assessment interview and use which techniques that will make the interview most effective? (Select all that apply.) a. Listen for subtle signs of denial. b. Directly confront the patient about his drug abuse. c. Use a matter-of-fact approach to inform the patient. d. Provide straightforward information. e. Avoid direct confrontation.

ANS: A, C, D, E The most effective approach for dealing with a values conflict in which substance abuse or an addiction is involved is to begin with an assessment interview, during which the nurse should: listen for the subtle signs of denial, avoid direct confrontation, use a matter-of-fact approach to inform the patient of the reality of the consequences of the harmful behavior, and provide straightforward information about the effects of the substance abuse.

When charting is done using the DAR charting format, the nurse documents which components? (Select all that apply.) a. The patient problems b. Subjective data c. Any actions initiated d. Objective data e. The patient's response to interventions

ANS: A, C, E A DAR note is used to chart the data (D) collected about the patient problems, the action (A) initiated, and the patient's response (R) to the actions. A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P).

The nurse recognizes that establishing short- and long-term goals to address Nursing diagnoses involve which actions? (Select all that apply.) a. Discussion with the patient b. Exclusion of family with making patient decisions c. Collaboration with other members of health care team d. Making the health care provider as the central figure e. Coordination of care as collaborative care

ANS: A, C, E Establishing short- and long-term goals to address Nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team. Coordinated, team-based patient care is called collaborative care. The patient's health care team members may include several nurses: the primary care provider; medical or surgical specialists; respiratory therapists; a dietitian; a physical therapist; occupational, music, or art therapists; a spiritual adviser; and social workers. The patient's primary nurse is often the central figure in coordinating collaborative care.

Which statements by the nurse are correct regarding informed consent and someone who requires an interpreter? (Select all that apply.) a. A professional interpreter is needed. b. A family member may interpret when convenient. c. Detailed medical information remains a priority. d. Professional interpreters are not effective in providing medical information. e. If necessary, family members can make decisions regarding informed consent.c

ANS: A, C, E If a patient is illiterate or requires an interpreter, the method of obtaining informed consent must be adapted appropriately. Use of a professional interpreter rather than a family member is essential to provide detailed medical information accurately. A patient whose culture prefers to allow other family members to make final health care decisions is inconsistent with nursing's ethical belief in autonomy. However, in this situation, the method of obtaining informed consent may need to be adapted to meet the patient's beliefs within the scope of the law.

The nurse identifies that knee-high SCD (Sequential Compression Device) sleeves are correctly placed on the patient when which conditions are met? (Select all that apply.) a. Both sleeves are connected to the SCD device. b. Two fingers fit inside when the SCDs are inflated. c. There are no kinks in the tubing. d. The ankle pressure is 55 to 65 mm Hg. e. The cooling control is on.

ANS: A, C, E Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. Wrap the sleeve around the leg and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated. Connect the sleeves to the device, ensure that there are no kinks in the tubing, and turn on the cooling and set it to 35 to 55 mm Hg.

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.

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of which conditions? (Select all that apply.) a. Decreased tissue perfusion b. Loss of sensation c. Hemiparesis d. Diminished respiratory capacity e. Muscle weakness

ANS: A, D Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person's ability to perform activities of daily living (ADLs) and exercise. Hemiparesis and loss of sensation are associated with nervous system disorders. Muscle weakness can be from a number of causes.

The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? (Select all that apply.) a. "I need to remove the throw rugs." b. "I should make sure I only take a bath." c. "I cannot use the stairs." d. "I need to place a nonskid mat in front of the kitchen sink." e. "I wish I had two ways of leaving the house."

ANS: A, D To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are. If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers. They can shower with a bench or chair in the shower for sitting. Patients need a clear the exit so they can get out of the house quickly in case of an emergency, but do not specifically need two exits because of the walker.

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 recognizes that after several years of work in the emergency room, compassion fatigue has developed. What symptoms associated with this condition would the nurse be experiencing? (Select all that apply.) a. Chronic depression b. Sleeping all the time c. Anorexia d. Poor concentration e. Feeling detached from patients f. Euphoria

ANS: A, D, E Compassion fatigue is an extreme state of distress experienced as the progressive and cumulative result of exposure to stress in the therapeutic use of self in caring for others. Compassion fatigue involves the nurse experiencing a feeling of being unable to meet the needs of patients arising from the inability to alleviate suffering. Compassion fatigue may result in feelings of vulnerability, anxiety, depression, and anger. Left unrecognized, compassion fatigue can produce physical and mental exhaustion manifested by difficulty sleeping, poor concentration, and low morale; and it can lead to compulsive behaviors, such as substance abuse. Nurses experiencing compassion fatigue often detach themselves from patients, have a higher risk of making errors, exercise poor judgment, and experience difficulty in maintaining interprofessional relationships.

The nurse recognizes which of the following to be a benefit of regular physical exercise? (Select all that apply.) a) Enhances the immune system. b) Decreases bone density. c) Limits joint mobility. d) Improves mental health. e. Helps to prevent type 2 diabetes.

ANS: A, D, E Exercise is essential for the prevention of illness and promotion of wellness. Physical exercise is any bodily activity or movement that enhances or maintains physical fitness levels and overall health. Exercise strengthens muscles, improves cardiovascular performance, hones athletic skills and endurance, and reduces or maintains weight, and it is performed for enjoyment (Powers and Howley, 2012). Regular physical exercise enhances the immune system, builds and maintains healthy bone density, increases joint mobility, and helps to prevent cardiovascular disease, type 2 diabetes, and obesity. Exercise also improves mental health and helps to prevent depression through the release of endorphins and other neurotransmitters that are responsible for exercise-induced euphoria (Powers and Howley, 2012).

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 working in a dermatology clinic observes that a patient of Mexican-American descent typically arrives 10 to 15 minutes late to every appointment. Based on an understanding of first-order beliefs, what characteristics can the nurse associate with this level of beliefs? (Select all that apply.) a. First-order beliefs serve as the basis of a person's belief system. b. First-order beliefs begin to develop in early adolescence. c. First-order beliefs are completely formed in childhood. d. People seldom question their first-order beliefs. e. Challenging a patient's first-order beliefs may cause cognitive upset.

ANS: A, D, E First-order beliefs serve as the foundation or the basis of an individual's belief system. People begin developing first-order beliefs about what is correct, real, and true in early childhood directly through experiences and indirectly from information shared by authority figures such as parents or teachers. People continue to develop first-order beliefs into adulthood through both direct experiences and the acquisition of knowledge from a vast number of sources with various degrees of expertise and levels of influence. People seldom question their first-order beliefs and rarely replace one, because to do so would require a great deal of rethinking about both that belief and similar or closely associated beliefs. Remember that presenting information to patients that challenges their first-order beliefs may cause a great deal of emotional or cognitive upset.

1. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.) a. Consult a dietitian. b. Increase fiber in the diet. c. Place on chest physiotherapy. d. Increase frequency of turning. e. Place on pressure-relieving mattress.

ANS: A, D, E If skin shows areas of erythema and breakdown, increase the frequency of turning and repositioning; place the turning schedule above the patient's bed; implement other activities per agency skin care policy or protocol (e.g., assess more frequently, consult dietitian, place patient on pressure-relieving mattress). Increased fiber will help constipation. Chest physiotherapy is for respiratory complications.

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.

The nurse has a question regarding scope of practice and delegation. Where should the nurse seek clarification? (Select all that apply.) a. The state's nurse practice act b. Theory X management c. Nurse's Code of Ethics d. The NCSBN website e. NCSBN journal articles

ANS: A, D, E Nurses must have knowledge of the nurse practice act in the state where they are licensed. Each state's nurse practice act defines the RN scope of practice and discusses appropriate delegation. A second resource in delegation is the use of the organization's policy and procedure manual. Employers must have job descriptions for each job class that outline the responsibilities and limitations of each position. The National Council of State Boards of Nursing (NCSBN) website and journal articles are other resources for understanding delegation. Nurses are expected to follow personal and professional ethics, as outlined in the American Nurses Association (ANA) Code of Ethics for Nurses to maintain integrity. Theory X—style managers believe that the average person dislikes work and will avoid it if given the opportunity to do so.

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

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

The nurse recognizes that when a patient is initially interviewed and assessed, the nurse must complete which tasks? (Select all that apply.) a. Analyze the patient's psychomotor status. b. Take the patient's vital signs. c. Weigh the patient using a bed scale. d. Evaluate the patient's emotional and spiritual needs. e. Ensure the coordination of the patient's care.

ANS: A, D, E When a patient is initially interviewed and assessed, the nurse must complete a thorough analysis of the patient's physical, emotional, spiritual, and psychomotor status. The nurse often works with unlicensed assistive personnel (UAP) to collect relevant data on height and weight, intake and output, and vital signs. Nurses collaborate with other health care professionals to coordinate care. Interdisciplinary clinical rounds, which include physicians, registered nurses, physical therapists, occupational therapists, and dietitians, are often undertaken to identify priorities of care, discuss overlapping areas of treatment, and ensure coordination of care.

The nurse is performing a health history to determine the patient's cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply.) a. "Are you able to drive to the store or do errands?" b. "Do you have any pain?" c. "Is your vision blurry?" d. "Are you able to smell different foods?" e. "Have you noticed any difficulty adding up numbers?"

ANS: A, E Driving and adding numbers relates to cognitive ability. The remaining three options have a sensory focus.

A nurse is studying intrinsic factors that influence the development of asthma in a community. What factors does the nurse assess? (Select all that apply.) a. Socioeconomic status b. Genetics c. Pollution in the area d. Water cleanliness e. Immunization status

ANS: A, E Host, or intrinsic factors are individual variables such as genetics, age, gender, ethnic group, immunization status, and human behavior that impact a person's health. The other options are all extrinsic factors, which pertain to environmental characteristics.

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.

The nurse knows that standard precautions are indicated for which group(s) of patients? (Select all that apply.) a. All patients b. Patients with HIV c. Patients with MRSA d. Patients with tuberculosis e. Patients who are bleeding

ANS: A, E The nurse can take steps at any link in the chain to halt the spread of infection. Standard precautions are used with all patients to limit direct exposure to blood and body fluids. The other choices are additional precautions such as airborne precautions are used with patients who have diseases such as tuberculosis and contact precautions with patients who have MRSA.

The nurse is caring for a patient who just had knee replacement surgery. Which factors will affect how the patient experiences pain after this surgery? (Select all that apply.) a. The patient has had rheumatoid arthritis for the last 16 years. b. The patient is allergic to aspirin and strawberries. c. The patient owns a business and is self-insured. d. The patient has been a vegetarian for the last 8 years. e. The patient had the other knee replaced 2 years ago. f. The patient was a marathon runner in high school and college.

ANS: A, E, F The patient's history of rheumatoid arthritis, previous knee replacement surgery, and marathon running indicate that the patient has had significant experience dealing with pain, which will affect how he or she experiences pain after this surgery. The other factors will not affect how the patient experiences pain.

A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process? (Select all that apply.) a) Typing intently on a keyboard when asking questions b) Allowing family to accompany the patient as requested c) Using gestures and eye contact to demonstrate interest d) Closing the door to the room to ensure privacy e) Providing nonverbal cues to negative thoughts

ANS: A, EDuring the interview process, the nurse needs to demonstrate interest in the patient by leaning slightly toward him/her, allowing requested family or friends to accompany the patient, and closing the door to the room to ensure privacy. Typing intently when the patient is talking can be interpreted as lack of interest. Providing nonverbal cues to the nurse's negative thoughts (such as scowling when the patient mentions something negative) does not promote comfort or trust.

Which patients would benefit from preoperative teaching about splinting of incisions to minimize discomfort? (Select all that apply.) a. Patient having coronary bypass graft surgery b. Patient having open breast biopsy c. Patient having total hip replacement surgery d. Patient having lumbar spine decompression surgery e. Patient having surgery to repair retinal detachment f. Patient having total abdominal hysterectomy

ANS: A, F Postoperative splinting is done by supporting the abdominal and chest muscles to minimize the pain of coughing and deep breathing after surgery. Patients who have just had heart or abdominal surgery will benefit from splinting. The other surgical procedures do not affect the chest or abdomen, and these patients would not benefit from teaching about splinting.

The nurse notices her 50-year-old patient is holding the lunch menu at arm's length while trying to read the choices. The nurse knows this is an indication of which condition? a. Retinopathy b. Presbyopia c. Cataracts d. Macular degeneration

ANS: B The patient demonstrates presbyopia by holding reading materials at a distance or by being unable to read normal-sized or small print. Retinopathy is damage to the retina and occurs in diabetics. Cataracts are a clouding of the lens. Macular degeneration is a chronic condition that causes loss of vision in the center of your field of vision.

27. Which goal is most appropriate for a patient who has had a total hip replacement? a. The patient will ambulate briskly on the treadmill by the time of discharge. b. The patient will walk 100 feet using a walker by the time of discharge. c. The nurse will assist the patient to ambulate in the hall 2 times a day. d. The patient will ambulate by the time of discharge.

ANS: B "The patient will walk 100 feet using a walker by the time of discharge" is individualized, realistic, and measurable. "Ambulating briskly on a treadmill" is not realistic for this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this is an intervention. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far.

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

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

36. An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a. Positions patient's buttocks close to the front of wheelchair seat b. Backs wheelchair into elevator, leading with large rear wheels first c. Places locked wheelchair on same side of bed as patient's weaker side d. Unlocks wheelchair for easy maneuverability when patient is transferring

ANS: B A correct action when using a wheelchair is to back wheelchair into an elevator, leading with large rear wheels first. A patient's buttocks should be well back into the seat. A locked wheelchair should be placed on a patient's strong or unaffected side. Brakes should be securely locked when a patient is transferring.

The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that was not present yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurologic status of the patient and knows this to be which type of assessment? a. Emergency assessment b. Focused assessment c. Complete physical examination d. Comprehensive assessment

ANS: B A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient's condition or the development of a new complication. Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient's airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.

36. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use? a. Hand rolls b. A foot cradle c. A trapeze bar d. A trochanter roll

ANS: B A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient's toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

34. A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? a. Run wires under the carpet. b. Disconnect items before cleaning. c. Grasp the cord when unplugging items. d. Use masking tape to secure cords to the floor.

ANS: B A guideline to prevent electrical shock is to disconnect items before cleaning. Do not run wires under carpeting. Grasp the plug, not the cord, when unplugging items. Use electrical tape to secure the cord to the floor, preferably against baseboards.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. "The wound will be red." b. "The wound will have pus." c. "The wound will be warm." d. "The wound will need to be treated"

ANS: B An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 /g of tissue sampled when cultured. The wound will need to be treated for the infection.

The nurse researcher understands a human subject is defined as a living individual about whom an investigator conducting research obtains what information? a. Data without direct or indirect interaction or intervention b. Information that is not expected to be made public c. No diagnostic information and does not manipulate the subject environment d. Information without any communication/contact during the research

ANS: B A human subject is defined as "a living individual about whom an investigator conducting research obtains: (1) data through intervention or interaction with the individual or (2) identifiable private information" (Office of Human Research Protection (OHRP), 2016). Interventions may include procedures such as gathering diagnostic information or manipulating the subject's environment. Interaction refers to any communication or contact during the research. Private information includes anything not expected to be made public, such as a medical record.

5. 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 knows while leadership behaviors and management skills often complement each other they differ in which way? a. Managers focus on relationships. b. A manager may not possess leadership traits. c. Leadership focuses on coordinating and directing others. d. A manager is a visionary who sets the direction for a group.

ANS: B A manager may not possess leadership traits, and a leader may lack management skills. Management is the process of coordinating others and directing them toward a common goal. Leadership focuses on relationships, using interpersonal skills to persuade others to work toward a common goal. Leaders are visionaries who set the overall direction for a group or organization.

The nurse manager sends an e-mail to the nursing staff as a reminder for a scheduled monthly meeting. In doing so, the nurse manager understands that e-mail could result in which issue? a. It is usually slower than other methods of communication. b. It has the potential for miscommunication. c. It cannot be used to deliver vital information. d. It is especially effective because of the absence of nonverbal cues.

ANS: B A message is the content transmitted during communication. Messages are transmitted through all forms of communication, including spoken, written, and nonverbal modalities. Electronic communication in the form of information referencing, e-mail, social networking, and blogging can quickly contribute to a person's knowledge, providing patients and health care professionals with vital information. However, the potential for miscommunication exists, in part because nonverbal cues are not apparent.

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? a) Move the oximeter probe to another finger. b) Assess the fingers for good circulation. c) Document that the reading cannot be obtained. d) Remove any fingernail polish present on the fingernail.

ANS: B A patient who is hypothermic may not have good circulation to the extremities. The nurse should assess the patient's circulation, and if it is poor to the extremities, choose another spot at which to measure the oxygen saturation. Moving the probe to another finger or removing nail polish will not help if the problem is poor circulation. The nurse should document appropriately but needs to do more than just charting that the reading could not be obtained.

29. 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.

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."

3. The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat? a. 60° to 64° F b. 65° to 75° F c. 15° to 17° C d. 25° to 28° C

ANS: B A person's comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). The other ranges are too low or too high and do not reflect the average person's comfort zone.

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 sugars. 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.

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

ANS: B A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

9. A nurse has taught the patient how to use 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.

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity? a. Wound will be completely healed in 72 hours. b. Wound will show signs of healing within 2 weeks. c. Patient will develop no new pressure ulcers. d. Patient will ambulate twice a day.

ANS: B A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement? a) Blood pressure 152/98 mm Hg b) Temperature 98.4 °F (36.8 °C) c) Apical pulse 82 beats/min d) Respirations 16 breaths/min

ANS: B A temperature of 98.4 °F is normal. "Afebrile" means having a normal temperature. The other readings are not related to this term.

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed? a. Using an airflow bed b. Using a slide board c. Using a trochanter roll d. Using a gel mattress

ANS: B A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.

The nurse is admitting a patient experiencing chest discomfort and shortness of breath, who has a history of stroke. When the nurse documents the Nursing diagnosis "Risk for impaired mobility related to history of stroke," the nurse knows which condition to be the risk factor? a. Stroke b. History of stroke c. Chest discomfort d. Shortness of breath

ANS: B A two-part risk, Nursing diagnostic statement contains only: (1) the patient's identified need or problem (i.e., NANDA-I Nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or "risk" issues. "Stroke" would be the identified potential problem.

The nurse is caring for a patient who is under arrest for murder and is attempting to perform nursing care duties while, at the same time, feeling a sense of repugnance toward the patient. The nurse recognizes this situation is identified by which term? a. Value clarification b. Value conflict c. First-order beliefs d. Higher-order beliefs

ANS: B A values conflict occurs wheNnUaRpeSrsIoNn'Gs vTaBlu.esCaOreMinconsistent with his or her behaviors or when the person's values are not consistent with the choices that are available. Providing care for a convicted murderer may elicit troubling feelings for a nurse, resulting in a values conflict between the nurse's commitment to care for all people and a personal repugnance for the act of murder. First-order beliefs serve as the foundation or the basis of an individual's belief system. Higher-order beliefs are ideas derived from a person's first-order beliefs, inductive, or syllogistic reasoning.

35. The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action? a. The patient removes the armband to bathe. b. The patient wears the red nonslip footwear. c. The patient insists on taking a "water" pill in the evening. d. The patient who is allergic to penicillin asks the name of a new medicine.

ANS: B A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. A red armband indicates an allergy. Give diuretics ("water" pill) in the morning to decrease risk of falls during the night—when most falls occur.

The nurse is working with a patient from an unfamiliar culture. After assessing the patient and the patient's cultural beliefs related to health care, what action by the nurse is best? a. Create a nursing plan of care for the patient. b. Recheck cultural beliefs with the patient. c. Use a standard plan of care for consistency. d. Have an interpreter validate the information

ANS: B According to Leininger, the nurse should recheck assumptions and findings related to culture with the patient. This is an important step prior to creating a care plan. A standard plan will not be culturally congruent. The stem does not indicate that the patient has limited English, but if he did, using an interpreter would be important.

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.

The nurse realizes that a medication error has been made. The nurse then reports the error and takes responsibility to ensure patient safety despite personal consequences. This nurse has exhibited what ethical concept? a. Autonomy b. Accountability c. Justice d. Advocacy

ANS: B Accountability is the willingness to accept responsibility for one's actions. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Supporting or promoting the interests of others or doing so for a cause greater than oneself defines advocacy. To do justice is to act fairly and equitably.

While providing care to a patient, the nurse is responsible, both professionally and legally. 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 explanation by the nurse best describes active assistive range of motion? a. The patient independently moves all joints. b. The patient to partially moves all joints. c. The caregiver must move the patient's joints. d. The patient performs isotonic exercises.

ANS: B Active assistive range of motion occurs when the caregiver minimally assists the patient, or the patient minimally assists himself/herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy.

The nurse recognizes that starting an intravenous (IV) infusion line on a patient against his will may be classified as which wrongdoing? a. Assault b. Battery c. Felony d. Misdemeanor

ANS: B Actual physical harm caused to another person is battery. Battery may involve angry, forceful touching of people, their clothes, or anything attached to them. Performing a surgical procedure without informed consent is an example of battery. Actions much more subtle, such as inserting an intravenous catheter or urinary catheter against the will of a patient, also may be classified as battery. Assault is a threat of bodily harm or violence caused by a demonstration of force by the perpetrator. A feeling of imminent harm or feeling of immediate danger must exist for assault to be claimed. A misdemeanor is a crime of lesser consequence that is punishable by a fine or incarceration in a local or county jail for up to 1 year. A felony is a more serious crime that results in the perpetrator's being imprisoned in a state or federal facility for more than 1 year.

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.

28. 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.

10. 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

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

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection, such as asking about the patient's current chief concerns or problems. Introductions occur before setting the agenda. Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient that medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client? a. Orient the patient frequently. b. Apply restraints. c. Move the patient to a room close to the nurse's station. d. Encourage the family to spend time with the patient.

ANS: B All alternatives to physical restraints should be considered prior to their use.

Which statement by the nurse indicates comprehension of ethical issues? a. Ethical issues are rare occurrences but take a great deal of time to resolve. b. Ethical issues have required The Joint Commission to mandate ethics committees. c. Ethical issues most frequently lead to legal intervention in patient care matters. d. Ethical issues lead to ethics committees made up entirely by nurses.

ANS: B All nurses are faced with ethical decisions each day in practice, and some choose to obtain further education and experience in the field of bioethics and participate on institutional ethics committees along with physicians, ethicists, attorneys, and academicians. Ethics committees are required by The Joint Commission to respond to ethical challenges related to patient care requiring consultation. The work of the ethics committees in health care institutions helps to prevent unnecessary legal intervention in patient care matters. Ethics committee members come from all areas of health care, not just nursing. If acceptable resolutions are not achieved through consultation with the ethics committee, patients, families, and health care providers, the legal system may become involved.

The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements? a. The patient will walk to the bathroom within 48 hours after surgery. b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. c. The patient will walk to the bathroom without experiencing shortness of breath. d. The patient will walk to the bathroom without experiencing shortness of breath after surgery.

ANS: B All short- and long-term goals must be: (1) patient focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the Nursing diagnosis of Activity intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.

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.

The nursing student has been assigned to help feed patients at lunch time. Which nursing intervention would be most effective when assisting a blind patient to eat a meal? a. Speak loudly to ensure that the patient understands. b. Describe the food arrangement using the numbers on a clock. c. Tell the patient what is on the plate since he has lost the sense of smell. d. Encourage the patient to eat faster so that the task will be done.

ANS: B An important factor to remember when caring for visually impaired or blind patients is that they are rarely hearing impaired. Typically, blind patients have heightened auditory and olfactory senses. Communication with blind patients can be characterized as anticipatory in nature, meaning that the nurse should alert visually impaired patients of potential hazards or object locations to provide necessary information and safe care. For example, the nurse may inform the visually impaired patient that the meat entrée is in the 6 o'clock position and the coffee cup is at 2 o'clock on the tray. This system may be helpful in orienting blind patients to their hospital rooms or informing them of where their food is on a plate or tray.

A recent immigrant who does not speak English is alert and 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.

The nurse completes the health interview and physical exam on a patient admitted with an infection of the gallbladder. The nurse reviews the medical record and compares the abnormal lab results to the normal standards. Which critical-thinking skill is the nurse using in this part of the nursing process? a. Interpretation b. Analysis c. Evaluation d. Inference

ANS: B Analysis includes investigating plans of action on the basis of examination of subjective and objective data is an example of nursing analysis. Interpretation is used to understand and explain the meaning of data. Evaluation occurs when information, including the reliability, credibility, and bias of the source, is assessed. Nurses also evaluate when determining whether the desired outcome for an intervention was achieved. Recapping the needle is not part of the desired outcome. Inference leads to accurate conclusions that are based on sound reasoning.

The nurse is caring for a patient recovering from knee replacement surgery. The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously. What is the nurse's best action? a. Administer another dose of the medication. b. Apply ice packs to the knee. c. Apply heat packs to the knee. d. Perform gentle range of motion.

ANS: B Application of cold decreases swelling and pain, produces local analgesia, and slows nerve conduction, which improves functioning. Examples of cold therapy are ice bags and cold compresses. The nurse should not administer another dose of medication without an order from the provider. Heat will increase blood flow to the area rather than reduce swelling. Gentle ROM will increase pain if done at this time.

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 patient with moderate lower back pain tells the nurse, "My urine smells awful and is as dark as my glass of tea." Which action by the nurse will assist in validating the patient's concern? a. Ask the patient to describe the back pain. b. Review the lab results of the most recent urinalysis. c. Request the nursing assistant to obtain a set of vital signs. d. Check the patient's history for urinary tract infections.

ANS: B As patient information is collected, consistency between subjective and objective data must be confirmed. Sometimes, the nurse can use laboratory and diagnostic test results to validate the subjective data. In this case, checking the urinalysis for congruency with the patient's subjective data will validate the patient's statements. Obtaining a set of vital signs, reviewing the patient's history, and exploring the patients pain are appropriate actions but cannot validate the current problem.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse 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.

16. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use? a. Supine position b. Lateral position c. Lateral position with positioning supports d. Supine position with no pillow under the patient's head

ANS: B Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning supports from the bed except for the pillow under the head, and support the body with an adequate mattress.

44. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient? a. Obtain assistance and physically transfer the patient to the chair. b. Assist with ambulation and measure how far the patient walks. c. Give pain medication after ambulation so the patient will have a clear mind. d. Bring the patient to the cafeteria for group instruction on ambulation.

ANS: B Assist with walking and measure how far the patient walks to quantify progress. The nurse should allow the patient to do as much for self as possible. Therefore, the nurse should observe the patient transferring from the bed to the chair using the walker and should provide assistance as needed. The patient should be encouraged to use adequate pain medication to decrease the effects of pain and to increase mobility. The patient should be instructed on safe transfer and ambulation techniques in an environment with few distractions, not in the cafeteria.

17. The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system? a. Inspect chest wall movements primarily during the expiratory cycle. b. Auscultate the entire lung region to assess lung sounds. c. Focus auscultation on the upper lung fields. d. Assess the patient at least every 4 hours.

ANS: B Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

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.

17. A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action is most appropriate for assessing this patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the 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.

A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action is most appropriate for assessing this patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the goals of patient care.

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

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).

The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect? a. The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. b. The nurse rolls dirty linens to the side then places the linens on the floor while finishing. c. The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. d. The nurse wears gloves to remove dirty linens.

ANS: B Bed linens should be placed in the linen hamper, not on the floor, after they are removed from the bed. The patient turns to each side while the bed linens are changed, and the nurse wears gloves.

The nurse manager is interviewing graduate nurses to fill existing staffing vacancies. When hiring graduate nurses, the nurse manager realizes that they will probably not be considered "competent" until they complete which task? a. They graduate and pass NCLEX. b. They have worked 2 to 3 years. c. Their last year of nursing school. d. They are actually hired.

ANS: B Benner's model identifies five levels of proficiency: novice, advanced beginner, competent, proficient, and expert. The student nurse progresses from novice to advanced beginner during nursing school and attains the competent level after approximately 2 to 3 years of work experience after graduation. To obtain the RN credential, a person must graduate from an approved school of nursing and pass a state licensing examination called the National Council Licensure Examination for Registered Nurses (NCLEX-RN) usually taken soon after completion of an approved nursing program.

15. The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding? a. The edge of the seat is in contact with the popliteal space. b. Both feet are supported on the floor with ankles flexed. c. The body weight is directly on the buttocks only. d. The arms hang comfortably at the sides.

ANS: B Both feet are supported on the floor, and the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair.

The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." What action will the nurse take next? a. Develop a comprehensive teaching plan related to the surgical procedure. b. Ask the patient what information the surgeon has explained about the surgery. c. Contact the surgeon to clarify information given to the patient. d. Focus on post-operative exercises and home-care following surgery.

ANS: B Careful observation and attention to detail help the nurse to notice subtle cues and recognize how best to validate and interpret patient data. The nurse must be careful not to make false assumptions or generalizations regarding the patient's responses to the health concern. The nurse is correct to ask the patient about the upcoming surgical procedure instead of assuming that the patient has limited knowledge. This is the nurse's best action to determine what the surgeon said to the patient. Developing a comprehensive teaching plan is not necessary until further clarification is obtained. Focusing on postoperative treatment plans is important but not the priority at this time. It is not appropriate to contact the surgeon unless the patient demonstrates an actual knowledge deficit.

A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role stress? a. Family eats dinner together every night. b. Family uses respite care one night a week. c. Family investigates research trials for patient. d. Family verbalizes exhaustion from caregiving.

ANS: B Caregiver role stress can occur when the caregiver(s) is unable to meet obligations or unable to take care of personal needs. Using a respite caregiver once a week gives the family a little time off to accomplish needed tasks. The other observations are not tied to this diagnosis.

6. A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up? a. The new nurse documents only for self. b. The new nurse charts consecutively on every other line. c. The new nurse ends each entry with signature and title. d. The new nurse keeps the password secure.

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 only for yourself is an appropriate behavior. End each entry with signature and title/credentials. For computer documentation, keep your password to yourself.

The nurse recognizes which action by the nursing student would be considered uncivil? a. Prompt arrival to class b. Texting during class c. Attentive listening d. Active participation in class

ANS: B Civility (i.e., acting politely) is essential in all interactions among faculty and nursing students. Respectful interaction between students and faculty members establishes professional communication patterns and affects the way in which students interact with patients. Texting in class is disrespectful and is an example of incivility. Arriving on time, listening attentively, and participating in class all show respect and civility.

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.

A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use? a) Placing a cooling fan in the patient's room b) Putting ice packs in the patient's axillae c) Spraying the patient with a fine mist of water d) Turning the temperature down in the room

ANS: B Conduction is the transfer of heat through direct contact with another object, such as an ice pack. A cooling fan would help lower temperature by convection. Spraying the patient with a mist of water would lead to evaporative cooling. Turning the temperature down is an example of radiation.

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.

Which isolation precaution should the nurse implement for the patient who has been diagnosed with hepatitis A? a. Airborne b. Contact c. Droplet d. Protective

ANS: B Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods. Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Protective isolation is used for patients who have compromised immune systems.

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. Which element will the nurse identify 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.

The nurse is assessing a patient's cranial nerve III. What technique is best? a) Have patient identify a common scent with closed eyes. b) Shine a light into the patient's eyes to assess pupil response. c) Have the patient read a newspaper or use the Snellen chart. d) Assess if patient can hear both spoken and whispered words.

ANS: B Cranial nerve III (oculomotor nerve) is assessed by observing the patient's pupil size and reaction to light and the direction of gaze. Identifying a common scent would test cranial nerve I. Assessing the patient's visual acuity tests cranial nerve II. Assessing hearing is cranial nerve VIII.

A new graduate nurse tells the manager that she does not believe she needs more in-service training on culturally congruent care because she already recognizes that there are significant differences among cultures to consider when providing care. What response by the manager is best? a. "You have done a great job becoming culturally competent." b. "Providing culturally congruent care takes ongoing work and effort." c. "That is a great start but be sure to sign up for the in-service." d. "Cultural sensitivity and cultural competence are not the same."

ANS: B Cultural sensitivity is the recognition that there are profound differences among cultures that can affect health care. But to provide culturally congruent care, the nurse must do more than just recognize these differences. This is an ongoing process. Option B is the only one that provides useful information to the nurse as to why she must continue to work on this aspect of her profession.

A nursing faculty member is contrasting culture and ethnicity to students. Which statement is most accurate? a. Culture is biologically determined; ethnicity is chosen. b. Culture is socially transmitted; ethnicity is identification with a group. c. Culture is a chosen identity whereas ethnicity is biologically based. d. Culture and ethnicity are similar constructs used interchangeably.

ANS: B Culture refers to the learned, shared, and transmitted knowledge of values, beliefs, and ways of life of a group that generally are transmitted from one generation to another and influence the individual person's thinking, decisions, and actions in patterned or certain ways. Ethnicity is the person's identification with or membership in a racial, national, or cultural group and observation of the group's customs, beliefs, and language. The words may be used interchangeably by some people, but this is not correct.

16. A graduate of a baccalaureate degree program is ready to start working as an 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's 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.

A patient, frequently admitted to the hospital for chronic back pain, asks the medication nurse for additional pain medication. The nurse has seen patients like this before, and "knows" that the only reason that these people come to the hospital is to get their pain medication. In this scenario, the nurse is demonstrating which concept? a. Illogical thinking b. Bias c. Closed-mindedness d. Erroneous assumption

ANS: B Decisions may be unduly influenced by bias, which is an inclination or tendency to favoritism or partiality. Bias may be related to a preconceived notion or prejudice such as believing that "these people seek their medication." It is important for nurses to examine personal biases because they can negatively impact care. Illogical thinking is characterized by a failure to follow rational, systematic processes when approaching an issue or problem. Often making hasty generalizations and assumptions that do not consider the evidence, the illogical thinker may jump to conclusions. Errors in thinking and decision making can result from intentionally overlooking alternatives suggested by others. When relevant information from patients or experts is ignored because of closed-mindedness, nursing care can be compromised. Closed-minded individuals often believe that their way is the best and preferred way. Assumptions are beliefs that are taken for granted and assumed to be true. Assumptions can be unjustified or justified, depending on whether there are good reasons for them. Erroneous assumptions can lead to safety issues in the clinical setting.

The nurse recognizes which task that cannot be delegated? a. Obtaining vital signs b. Assessing lung sounds c. Bathing a patient d. Ambulating a patient

ANS: B Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable. Obtaining vital signs, bathing, and ambulating are all tasks associated with the assessment part of the nursing process. The nursing process cannot be delegated.

The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2 hours. When the nurse administers this medication, which concept is being provided? a. Independent nursing intervention b. Dependent nursing intervention c. Referral d. Indirect care procedure

ANS: B Dependent nursing interventions are tasks that require an order from a physician or primary care provider (PCP). Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Referrals in health care involve sending a patient to another member of the interdisciplinary health care team for a consultation or other services. Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients.

The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education? a. "Depression can be caused by chemical changes in the brain." b. "Depression is always treated with medication." c. "Depression is a mood disorder." d. "Depression can have a rapid onset."

ANS: B Depression is usually reversible with treatment either by eliminating the underlying cause, providing counseling, or prescribing antidepressive agents. Depression is a mood disorder and is believed to be caused by chemical changes in the brain. Depression usually has a rapid onset, and the patient's mood is constant.

The nurse can see data relationships, can make judgments based on trends and patterns in the data, is skilled in information management and the use of computer technology, and is able to suggest areas for IT system improvement. The nurse's level of informatics competency can be described by which term? a) Beginner b) Experienced c) Specialist d) Innovator

ANS: B Descriptions of nursing informatics competencies often focus on levels that include beginner, experienced, specialist, and innovator. Beginner skills include computer, information, and web literacy; fundamental skills in information management and computer technology; and the ability to identify and collect relevant data. The nurse at the beginning level may have keyboarding skills, can document in the EHR, and look up medications and other health information on reputable Internet reference sites. The nurse at the experienced level of informatics competencies understands data relationships and makes judgments based on trends and patterns in data, demonstrates skill in information management and the use of computer technology, suggests areas for Internet technology system improvement, relates data posted by others to the nursing assessment, bases the nursing process and clinical decisions on the data, and devises better ways of using data from the EHR. The nurse at the specialist level of competency focuses on information needs for the practice of nursing; integrates and applies information science, computer science, and nursing science; and applies skills in critical thinking, data management, processing, and system development. At the specialist level of competency, the nurse may conduct research based on information trends or patient data, devise applications for computer technology in nursing, or develop new software to enhance nursing care. Nursing informatics innovators conduct research and generate theory. They develop solutions and understand the interdependence of systems, disciplines, and outcomes.

13. 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 understands that discharge planning begins at what point in the patient's hospitalization? a. The day before discharge b. Upon admission c. Prior to admission d. Day of discharge

ANS: B Discharge planning plays an important role in the success of a patient's transition to the home setting after hospitalization. Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.

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.

In which step of the nursing process does the nurse prioritize the Nursing diagnoses and identify interventions to address the patient goals? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: B During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patientU's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

29. A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do? a. Encourage dairy products. b. Monitor intake of vitamin D. c. Increase intake of caffeinated drinks. d. Try to do as much as possible for the patient.

ANS: B Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Patients who have lactose intolerance need dietary teaching about alternative sources of calcium. Caffeine should be decreased. The goal of the patient with osteoporosis is to maintain independence with ADLs. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence.

The staff is having a hard time 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.

The nurse is administering medications to a patient with high blood pressure. The patient states, "This pill made me so sick yesterday. Are you sure I have to take it now?" What action does the nurse take next? a. Give the medication because no one gets sick on this pill. b. Hold the medication and check the order since there may be a lack of information. c. Give the medication since he/she is the nurse and knows what should be done. d. Give the medication since the nurse did not see the provider come so the order is valid.

ANS: B Errors in thinking can lead to errors in nursing care. It is essential for the nurse to assess and validate the patient's concerns before proceeding with a planned action. This helps avoid decisions being made on personal biases caused by preconceived notions. The nurse should hold the medication and investigate further. Believing that "no one gets sick on this pill" is a preconceived bias. Giving the medication because "I know best" is an example of close-mindedness. Assuming the order is valid simply because the nurse did not see the provider is illogical thinking.

A nurse is experiencing an ethical dilemma with a patient. Which information 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.

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.

The student nurse learning about ethics expresses good knowledge when making which appropriate statement? a. "Ethics are internal values developed outside the influence of societal norms." b. "Ethics are influenced by many variables including family and friends." c. "Ethics are societal in nature and do not involve personal influences." d. "Ethics are totally independent from a person's character."

ANS: B Family, friends, beliefs, education, culture, and socioeconomic status influence the development of ethical behavior. The study of ethics considers the standards of moral conduct in a society. Personal ethics are influenced by values, societal norms, and practices. Behaviors that are judged as ethical or unethical, right or wrong, reflect a person's character.

The nurse is educating parents about firearm safety. Which parent statement indicates to the nurse a need for further education? a. "I should make sure I obtain the proper permits." b. "It is okay to store firearms with ammunition loaded." c. "I should store all firearms without ammunition." d. "I should make sure all firearms have trigger locks in place."

ANS: B Firearms should be stored in a secure location with trigger locks in place. Ammunition should be stored in a separate location also locked. Proper permits should be obtained as appropriate. Loaded firearms should never be stored where children can access them.

A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best? a) Tell the patient to lie still and go get the equipment. b) Call for another staff member to bring the equipment. c) Have the patient get into a chair and get the equipment. d) Finish the rest of the exam, get the equipment, and use it.

ANS: B For patient safety, some patients should never be left alone on an examination table: infants; small children; older adults who are confused, combative, or uncooperative, and people who are physically or chemically restrained. The nurse calls for another staff member to get the missing equipment. Getting up and down off the table is inconvenient and may be difficult. Finishing the exam and then retrieving the piece of equipment also involves the patient changing locations and is inconvenient for the patient.

38. A nurse is evaluating care of an immobilized patient. Which action will the nurse take? a. Focus on whether the interdisciplinary team is satisfied with the care. b. Compare the patient's actual outcomes with the outcomes in the care plan. c. Involve primarily the patient's family and health care team to determine goal achievement. d. Use objective data solely in determining whether interventions have been successful.

ANS: B From your perspective as the nurse, you are to evaluate outcomes and response to nursing care and compare the patient's actual outcomes with the outcomes selected during planning. Ask if the patient's expectations (subjective data) of care are being met, and use objective data to determine the success of interventions. Just as it was important to include the patient during the assessment and planning phase of the care plan, it is essential to have the patient's evaluation of the plan of care, not just the patient's family and health care team.

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

ANS: B Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment. Therefore, the charge nurse must correct this misconception. When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Thus, the charge nurse does not need to intervene or follow up.

The nurse is caring for a patient with chronic lung disease. When the patient demands a cigarette after eating breakfast, the nurse responds, "If that was me, I wouldn't be asking for a cigarette. That is what has made you so sick in the first place." This nontherapeutic response is an example of what communication technique? a. Changing the subject b. Giving advice c. A stereotypical response d. Defensiveness

ANS: B Giving advice implies that the patient cannot make his or her own decisions and the nurse accepts the responsibility for the action. Changing the subject ignores the patient's concerns. Stereotypical or generalized responses such as, "Don't cry over spilled milk" may be judgmental. A defensive response such as, "The nurses work very hard to take care of you" moves the focus of the conversation from the patient and limits further discussion.

What fact is the nurse aware of when charting using electronic documentation? a. Errors can be corrected and totally removed from the record in the screen view. b. Log-on access to the electronic record identifies the person charting. c. Each entry requires the nurse to sign her/his name and credentials. d. Documenting significant changes in the electronic record ends the nurse's responsibility.

ANS: B Log-on access to the electronic record identifies the person charting or making a change. If an error is made in electronic documentation, it can be corrected on the screen view but the error and correction process remain in the permanent electronic record. Any correction in documentation that indicates a significant change in patient status should include notification of the primary care provider.

The nurse is caring for a trauma patient with the Nursing diagnosis of acute pain r/t fracture and muscle spasms. Which is an appropriate goal for this Nursing diagnosis? a. The patient will experience less pain when participating in physical therapy. b. The patient will describe meditation techniques that can be used to cope with pain. c. Nursing staff will explain the ordered pain management approach to the patient. d. The patient will feel less pain each day when range-of-motion therapy is performed.

ANS: B Goals must be measurable and objective so that nursing staff can determine when each of the goals has been met. Having the patient describe meditation techniques is measurable because the nursing staff can determine whether he can actually describe them. Goals are achieved by the patient, not nursing staff. The nursing staff cannot accurately measure whether the patient is experiencing or feeling less pain. The goal statements "The patient will report less pain ... or state that he has less pain ..." are not measurable and appropriate.

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

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

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 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.

31. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient? a. Thick, tenacious pulmonary secretions b. Low-molecular-weight heparin doses c. SCDs wrapped around the legs d. Elastic stockings (TED hose)

ANS: B Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of deep vein thrombosis. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.

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

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

If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed? a. The order must be taken by an RN or LPN. b. The order must be repeated verbatim to confirm accuracy. c. The order is documented as a written order. d. The order does not need further verification by the provider.

ANS: B If a verbal or phone order is necessary in an emergency, the order must be taken by a registered nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, physician's name, and RN's signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined time period.

The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions? a. The bed is placed in the low position b. The patient is wearing socks. c. The patient's cell phone is by the bedside. d. The patient's call light is within reach.

ANS: B If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position.

8. When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding? a. The patient is allergic to certain medications or foods. b. The patient has do not resuscitate preferences. c. The patient has a high risk for falls. d. The patient is at risk for seizures.

ANS: B In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.

In researching the effectiveness of an antihypertensive medication, the nurse knows that the medication would be what type of variable? a. Dependent b. Independent c. Treatment d. Controlled

ANS: B In experimental research, the independent variable is referred to as an experimental variable or treatment variable. An independent variable is a concept or idea whose value determines the value of other (dependent) variables. In research, the independent variable comprises the experimental treatment or intervention, and it is manipulated by the researcher to yield various outcomes. The dependent variable is the outcome that is affected by manipulation of the independent variable. For example, in researching the effectiveness of an antihypertensive medication, the medication is the independent variable and the person's blood pressure is the dependent variable. In a controlled study, some of the participants are assigned to the treatment group, and others are assigned to the control group by a random process. The control group does not receive the treatment. In the clinical trial of a medication, the control group receives a placebo. The purpose of a control group is to prevent bias and ensure that the outcome results from the treatment rather than some other factor.

The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which response by the patient indicates a need for further education? a. "I should take my blood pressure once a day at home." b. "I should get up quickly to avoid my blood pressure dropping." c. "I should drink plenty of water during the day." d. "I should get up slowly and carefully."

ANS: B In orthostatic hypotension, dizziness and loss of consciousness may occur if a patient changes position too quickly. Instead they should change positions slowly. A patient can take their blood pressure at home to monitor it. Drinking water will keep them hydrated.

Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. Which initial action should the nurse take? a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. b. Tell the cameraman where the hospital's public relations department is located. c. Have the cameraman wait for permission from the health care provider. d. Ask the cameraman how the pictures are to be used in the newspaper.

ANS: B In some cases, information about a scientific discovery or a major medical breakthrough or an unusual situation is newsworthy. In this case, anyone seeking information needs to contact the hospital's public relations department to ensure that invasion of privacy does not occur. It is not the nurse's responsibility to decide independently the legality of disclosing information. The nurse does not have the right to allow the cameraman access to the neonatal unit. This would constitute invasion of privacy. The health care provider has no responsibility regarding this situation and cannot allow the cameraman on the unit. It is not the nurse's responsibility to find out how the pictures are to be used. This is a task for the public relations department.

A patient in the emergency department needs an emergency operation. The patient refuses to consent and wants the nurse to call a respected elder in the community for consent. What action by the nurse is best? a. Explain that this violates privacy laws. b. Call the elder to get consent for the operation. c. Tell the woman she has the right to consent. d. Arrange for admission without the operation.

ANS: B In some cultures, decisions are made by men or community leaders. Although the patient may have the legal right to consent, if she comes from a culture in which gender and/or social roles do not permit decision making, she will likely refuse to consent. The best action is for the nurse to contact the elder and have him participate in the decision-making process per the patient's wishes. If the patient has given permission to share the information, doing so does not violate privacy laws. Admitting the patient without the operation does not help her medically.

43. A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe? a. Chin, elbow, hips b. Ileum, clavicle, knees c. Shoulder, anterior iliac spine, ankles d. Occipital region of the head, coccyx, heels

ANS: B In the Sims' position pressure points include the ileum, humerus, clavicle, knees, and ankles. The lateral position pressure points include the ear, shoulder, anterior iliac spine, and ankles. The prone position pressure points include the chin, elbows, female breasts, hips, knees, and toes. Supine position pressure points include the occipital region of the head, vertebrae, coccyx, elbows, and heels.

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.

The nurse identifies repositioning a patient, providing hygiene, and active listening as examples of what concept? a. Dependent interventions b. Independent nursing interventions c. Standing orders d. Counseling

ANS: B Independent nursing interventions are tasks within the nurse's scope of practice and do not require an order from a physician. Dependent nursing interventions are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary care provider to be implemented. Some physician orders are received through a preapproved standardized order set knownNasRstanIdinGg orBde.rCs. CMounseling is the process through which individuals use professional guidance to address personal conflicts or emotional problems.

The patient is asking about using the Internet for resources regarding lifestyle behaviors and benefits of modification. What is the best response that the nurse should provide the patient? a) Information on lifestyle behaviors is not available on the Internet. b) The patient should use websites that are easy to understand. c) Most websites are designed for health care providers only. d) Only negative outcomes are evaluated on the Internet.

ANS: B Information on lifestyle behaviors that lead to disease is available at research-sponsored websites that have peer-reviewed material and expert analyses. Website content should be easy to read and understandable for the general population. Most sites that discuss the latest information about health risks, lifestyle behaviors, and outcomes have separate information specifically for health care providers. Research that evaluates positive and negative lifestyle-behavior outcomes is constantly evolving as discoveries are made about the physiologic changes bodies experience with disease and illness.

11. The nurse recognizes which goal to be appropriate for the patient with a Nursing diagnosis of social isolation? a. The patient will participate in cognitive exercises. b. The patient will interact with other residents during activities. c. The patient will communicate basic needs through use of photos. d. The patient will remain within the unit while in long-term care.

ANS: B Interacting with others during activities is an appropriate goal to help the patient not feel so alone. Cognitive exercise is a goal for a patient with disturbed thought processes. Communication of basic needs through the use of photos is a goal for a patient with a diagnosis of impaired verbal communication and remaining in the unit is appropriate for chronic confusion.

The nurse identifies medication administration to be what type of nursing intervention? a. Independent b. Dependent c. Collaborative d. Interdisciplinary

ANS: B Interventions originating from a provider's order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Collaborative interventions require cooperation among a few or many members of the interdisciplinary health care team.

The student nurse learns that which item is the most important symbolic aspect of culture? a. Flags b. Language c. Art d. Music

ANS: B Language is the most extensively used set of symbols in a culture. The other items are important symbols but are not as important as language because words are used to represent objects and ideas.

The nurse correctly defines leadership when making which statement? a. "Leadership is coordinating others toward a common goal." b. "Leadership is the ability to influence others." c. "Leadership focuses on the task at hand." d. "Leadership is based in formal authority."

ANS: B Leaders have the ability influence and motivate others while maintaining relationships to accomplish a goal. Management is the process of coordinating others and directing them toward a common goal. Management is focused on the task at hand. A manager holds a formal position of authority in an organization; that position includes accountability and responsibility for accomplishing the tasks within the work environment. Managers demonstrate accountability when they are answerable for their own actions and the actions of those under their direction.

5. 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.

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.

The student nurse is planning care for a patient who believes that Western medicine is effective but not always accurate and recognizes which nursing theory would best explain the patient's health practices? a. Nursing: Human Science and Human Care b. Theory of Cultural Care Diversity and c. Theory of Nursing as Caring d. Five caring processes

ANS: B Leininger describes patient care and its relationship to cultural diversity. Swanson's five caring processes include maintaining belief, knowing, being with, doing for, and enabling. In the Theory of Nursing as Caring, Boykin & Schoenhofer, note that caring is defined as "the intentional and authentic presence of the nurse with another who is recognized as person living caring and growing in caring." Watson's Theory of Human Science and Human Care impacts both the person and the universe and is built upon 10 caritas processes.

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.

A nurse is interested in epidemiology. What work activity would best fit this role? a. Studying census data to determine common causes of death b. Researching population variables that contribute to disease c. Developing sanitary measures to prevent foodborne illness d. Designing research to determine the connection between pollution and cancer

ANS: B The epidemiologist works to develop programs to prevent the development and spread of disease. Studying census data, researching population variables, and designing studies do not fall in this field.

The nurse is preparing to discharge a patient admitted with fever of unknown origin. The patient states, "I never got past the fifth grade in school. Don't read much. Never saw much sense in it. But I do OK. I can read most stuff. But my doctor explains things good and doesn't think that my sickness is serious." Considering this patient response, what action should the nurse carry out? a. Provide discharge medication information from a professional source to provide the most information. b. Expect that the patient may return to the hospital if the discharge process is poorly done. NURSINGTB.COM c. Assume that the physician and the patient have a good rapport and that the physician will clarify everything. d. Defer offering the patient the opportunity to sign up for wellness classes due to the low literacy rate.

ANS: B Low health literacy is associated with increased hospitalization, greater emergency care use, lower use of mammography, and lower receipt of influenza vaccine. A goal of patient education by the nurse is to inform patients and deliver information that is understandable by examining their level of health literacy. The more understandable health information is for patients, the closer the care is coordinated with need.

A nurse works full time on the oncology unit at the hospital and works part time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. b. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital. c. As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will cover the nurse. d. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need.

ANS: B Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this. The hospital policy would not provide coverage even if the nurse followed all procedures and policies or had never been sued. It will not provide 50% of coverage.

26. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? a. Monitor for specific symptoms. b. Manage all patients using standard precautions. c. Transport patients quickly and efficiently through the elevators. d. Prepare for post-traumatic stress associated with this bioterrorism attack.

ANS: B Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.

After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. What is the framework that provides the most holistic view of the patient's condition? a. Head-to-toe pattern b. Functional Health Patterns c. Cephalic-caudal pattern d. Body systems model

ANS: B Marjory Gordon developed the Functional Health Patterns to help nurses focus on patient strengths and related but sometimes overlooked data relationships. This method of organizing patient data is a more holistic approach than the others because it includes data such as values, beliefs, and roles in addition to physical data. Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of concern are addressed as the nurse performs an assessment covering the entire body. The body systems model organizes data on the basis of each system of the body: integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune systems. It follows a sequence similar to the medical model for physical examination. The body systems model for data organization tends to focus on the physical aspects of a patient's condition rather than a more holistic view.

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.

18. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take? a. Remove elastic stockings every 4 hours. b. Measure the calf circumference of both legs. c. Lightly rub the lower leg for redness and tenderness. d. Dorsiflex the foot while assessing for patient discomfort.

ANS: B Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral increases in calf circumference are an early indication of thrombosis. Homan's sign, or calf pain on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus.

23. During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? a. The patient is oriented. b. The patient takes a hypnotic. c. The patient walks 2 miles a day. d. The patient recently became widowed.

ANS: B Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics. Being oriented will decrease risk for falls while disorientation will increase the risk of falling. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not a great risk.

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.

A newly licensed registered nurse is curious about the scope of care that he or she has in caring for patients undergoing conscious sedation. Which would be the best source of information for this nurse? a. National Student Nurses Association b. Nurse Practice Act c. ANA Standards of Professional Performance d. National League for Nursing

ANS: B Nurse practice acts provide the scope of practice defined by each state or jurisdiction and set forth the legal limits of nursing practice. Nursing organizations enable the nurse to have access to current information aUnd rSesoNurceTs as weOll as a voice in the profession. Nursing organizations include the ANA, the NLN, the ICN, Sigma Theta Tau International Honor Society of Nursing, and the National Student Nurses Association (NSNA).

A charge nurse works on an inpatient unit in a diverse city. To provide culturally congruent care to the patient, which action by the nurse would be most appropriate? a. Using puns and sarcasm to help draw the patient into sharing information b. Working to understand the socioeconomic status of the patient so teaching is culturally sensitive and appropriate c. Assuming a patient from a minority population does not have the economic means to pay for home care follow-up d. Admonishing a Hispanic patient for showing up for a preoperative teaching class 15 minutes late

ANS: B Nurses need to be cognizant of the impact of a patient's socioeconomic status to health care practices. The use of puns, sarcasm, and colloquialisms are not easily comprehended or interpreted by those who speak a different primary language. While the level of poverty in minority populations within all cultures is disproportionally higher, it is inappropriate to base an action on an assumption. According to research, some Hispanics believe that time is flexible and events will begin when they arrive. However, admonishment is not the best approach to dealing with this behavior.

A home health care nurse is visiting the home of a patient whose culture is totally unfamiliar to the nurse. What action by the nurse is best? a. Perform nursing care with a high degree of professionalism. b. Watch family interaction patterns closely and try to copy them. c. Tell the family you need to learn about their culture. d. Apologize after performing tasks that make the patient uncomfortable.

ANS: B Nurses should observe family dynamics carefully, including communication, and try to copy them as much as possible. For instance, if the family does not make eye contact with the nurse, he/she should avoid trying to make direct eye contact with the family. The other options are reasonable, although telling the family you need to learn about their culture may place the burden of educating the nurse on them.

Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who 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.

A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess? a. Presence of grocery stores nearby b. Safety concerns within the home c. Number and kind of pets d. Proximity to a health care facility

ANS: B OASIS (Outcomes and Assessment Information Set) is a data set of outcome measures for adult home health care clients that is used to track outcome-based quality improvement. Factors that could potentially affect patient safety in the home are particularly important. The other options are not included in this assessment.

A nurse has referred a patient to a community agency. When talking to the patient later, he states that he did not find the agency helpful. What action by the nurse is best? a. Determine what the patient would find helpful b. Review the agency's mission and scope. c. Make another appointment with the agency. d. Warn the patient that nonadherence affects payment.

ANS: B One of the most important aspects of a community health nurse's role is to be familiar with referral agencies. Awareness of the scope of an agency's influence and services helps the community nurse to pinpoint which agencies are best able to address specific needs. The nurse may have sent this patient to an agency that did not meet his needs. The nurse should ask the patient's opinion about what services are needed. Making another appointment without ensuring that this is the right agency for the patient will not solve the problem. Telling the patient that payment might not be ensured for nonadherence is not therapeutic communication.

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.

The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery. The nurse sees the visitor push the PCA button while the patient is sleeping quietly. What is the best response of the nurse? a. "Thank you for pushing the button for her to help keep her comfortable after surgery." b. "Please do not push the button for the patient—she could receive more medication than she needs." c. "You can push the button for her now, but please have her do it herself when she awakens." d. "PCA pumps are great because she doesn't have to wait for me to administer her pain medication."

ANS: B Only the patient should operate the PCA and push the administration button. Family members and visitors should never activate the PCA pump for the patient because too much medication could be delivered, resulting in overdose and respiratory suppression.

A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best? a) Have the patient drink room temperature water. b) Return in 30 minutes to take the patient's temperature. c) Take the patient's temperature rectally instead. d) Document that temperature is unable to be obtained.

ANS: B Oral temperatures will be inaccurate if the patient has been drinking or eating hot or cold foods. The nurse instructs the patient not to continue drinking the coffee and returns in 30 minutes to take the temperature. Drinking room temperature water will not "even out" the patient's mouth temperature. The rectal route is not preferred by patients and should not be used in this situation. The nurse needs a temperature and so should not document that it was not obtained.

The nurse is assessing a patient's environment and its impact on outdoor activity and notes that the child rarely plays outside. Which is true regarding the indoor environment? a) Indoor environments protect the patient from toxics chemicals. b) Indoor activity is sometimes a result of unsafe outdoor conditions. c) Indoor activity decreases the risk of respiratory illness. d) Indoor lifestyles reduce the risk for sedentary behaviors.

ANS: B Outdoor environments affect individual health in the areas of sanitation and waste disposal, water quality, air quality, and safety. Children living in areas where there are safety issues related to gang activity, sexual predators, or heavy traffic are less likely to engage in outdoor play activities. Their limited access to safe outdoor play space increases their risk for sedentary behaviors, excessive calorie intake, and obesity. Indoor environments may harbor toxic household cleaning agents, chemicals (e.g., radon, carbon monoxide, unused drugs), tobacco smoke, and energy sources (e.g., microwave ovens). Exposure to mold, household pests (e.g., dust mites, spiders), and unsanitary living conditions in an enclosed space increases the likelihood of respiratory illness and skin disorders.

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

41. The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy? a. After the acute phase of the disease has passed b. As soon as the ability to move is lost c. Once the patient enters the rehab unit d. When the patient requests it

ANS: B Passive ROM exercises should begin as soon as the patient's ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit or the patient requests it, and contractures could form by then.

The hospital has recently implemented computer charting. The nurse knows the computerization of nursing practice has what impact? a) It enhances and increases the time spent on documentation. b) It makes patient data immediately available to the health care team. c) It makes retrieval of data more difficult but safer. d) It is enhanced by limiting the use of point-of-care technology.

ANS: B Patient data collected by a nurse and recorded electronically are immediately available to all members of the health care team. The computerization of nursing practice data enables capture, storage, retrieval, organization, processing, and analysis of information. The information can be used to make a diagnosis, plan for care, provide nursing decision support, enhance documentation, and identify nursing care trends and costs. Systems that support data collection at the point of care can directly enhance patient care by decreasing the time spent on documentation, reducing the potential for errors, and supporting improved assessment and data communication. Computers, tablets, or pocket devices used at the bedside for documentation are examples of point-of-care technology.

The nurse identifies which patient to be best suited for PCA analgesia? a. A patient who is confused after a head injury b. A patient recovering from total hysterectomy surgery c. A patient who has severe psychogenic pain d. A patient with arthritis who is unable to push the nurse call button

ANS: B Patients recuperating from surgery are often good candidates for PCA analgesia. Confusion, inability to push the PCA button, and psychogenic pain are all contraindications for PCA analgesia.

15. The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

ANS: B Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis of impaired mobility a. Patient will interact with others. b. Patient will ambulate to the bathroom with assistance. c. Patient will have no skin breakdown. d. Patient will have a physical therapy consult.

ANS: B Patients with a diagnosis of Impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.

The nurse is performing an assessment of a patient's right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient's reaction. Which assessment technique is the nurse using? a. Inspection b. Percussion c. Palpation d. Auscultation

ANS: B Percussion involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.

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.

The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, "I have never had sugar problems before. My doctor says it is because I am getting this IV." These types of data are considered to be which type? a. Primary, objective data b. Primary, subjective data c. Secondary, objective data d. Secondary, subjective data

ANS: B Primary data come directly from the patient. Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data. Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.

The nurse identifies what measurement to be an acceptable personal space distance for most English-speaking persons? a. 14 inches b. 18 inches c. 21 inches d. 24 inches

ANS: B Proxemics refers to the amount of space or distance acceptable to two or more individuals based on cultural standards and personal preferences. Most English-speaking persons consider 18 inches to be an acceptable distance for communication. In general, intimate space is 0 to 1.5 feet; personal space is 1.5 to 4 feet; social space is 4 to 12 feet; and public space is 12 to 25 feet or more.

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. 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.

What does the nursing student learn about race? a. It is biologically based. b. It is a social construct. c. It is chosen by the person. d. It helps establish superiority.

ANS: B Race is often thought to be inherited and biologically based, but this is not true. Race is a social construct that is used to group people together based on common physical characteristics, heredity, or common descent. People are placed into racial categories by the larger society. One race is not superior to any other.

The nurse recognizes which topic is appropriate teaching content for the patient who is returning from surgery? a. Signs and symptoms of infection b. Use of patient-controlled analgesia c. Activity limitations upon discharge d. Physical therapy

ANS: B Readiness to learn is an important consideration. For example, when a patient returns from surgery, it is essential that some information be reviewed (e.g., how to use the patient-controlled analgesia pump and incentive spirometer) but completing all discharge teaching at this time would not be effective. At other times, teaching is more formalized, such as discharge teaching, signs of infection and physical therapy.

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

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

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.

8. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal calculi c. Pressure ulcers d. Thrombus formation

ANS: B Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis or pooling of secretions. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.

7. The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? a. Do nothing, no harm has occurred. b. Notify the health care provider. c. Complete an incident report. d. Assess the patient.

ANS: B Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

The nurse identifies which instruction to be appropriate to delegate to the UAP (Unlicensed assistive personnel)? a. Assess the patient's skin during a bath. b. Reposition the patient using the trapeze. c. Assess the patient's ability to perform range-of-motion exercises. d. Notify the health care provider of any changes.

ANS: B Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the health care provider).

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.

The nurse is teaching a student nurse about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints? a. "Having all four side rails up on the bed is considered a restraint." b. "The use of restraints has been shown to decrease fall-related injuries." c. "Death has been associated with the use of restraints." d. "Medications administered to control behavior are considered a chemical restraint."

ANS: B Restraints may be physical or chemical. A physical restraint is a mechanical or physical device, such as material or equipment attached or adjacent to the patient's body, used to restrict movement. Examples of physical restraints are wrist or ankle restraints, a jacket or vest, and side rails. A medication that is administered to a patient to control behavior is a chemical restraint. The use of restraints has been associated with patient injury including death and does not prevent patient falls.

The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority Nursing diagnosis for this patient? a. Risk for imbalanced body temperature b. Risk for aspiration c. Risk for perioperative positioning injury d. Risk for delayed surgical recovery

ANS: B Risk for aspiration is the highest priority because the patient has not been NPO and his stomach is filled with food after lunching with his colleagues. The patient may easily aspirate stomach contents into the airway when general anesthesia is administered, so precautions must be taken to prevent this from happening. The other Nursing diagnoses certainly apply but are not as important as risk for aspiration.

A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend? a. Stroke rehabilitation support group b. Blood pressure screening at the mall c. Bicycle safety class at the elementary school d. Drop by nutrition station at the grocery store

ANS: B Secondary prevention activities are aimed at early diagnosis and prompt intervention. Blood pressure screening events are a good example. Stroke rehabilitation is tertiary prevention. Bicycle safety classes and nutrition education are examples of primary prevention.

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.

The nurse knows the one theory explaining the variation in response to stress among individuals is identified by which term? a. Stress appraisal b. Sense of coherence c. Allostasis d. Homeostasis

ANS: B Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious assessment of a demand or stressor. Allostasis is an alternative term for the stress response. Homeostasis is the tendency of the body to seek and maintain a condition of balance or equilibrium.

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

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 is preparing to teach indwelling urinary catheter insertion techniques to a group of graduate nurses. Which teaching-learning strategy would the nurse find most useful in teaching this skill? a. Concept mapping b. Simulation c. Role playing d. Literature review

ANS: B Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence in providing direct nursing care. The concept map as a way to organize and visualize data to identify relationships and solve problems. Role-play strategies involve assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role playing, and then all are involved in the debriefing or discussion of the scenario. As with simulation, this approach allows learners to interact in a safe, controlled environment. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits.

The nurse recognizes which situation to be inappropriate to use alcohol-based hand sanitizer? a. Patient with pneumonia b. Patient with Clostridium difficile c. Status post-appendectomy d. Patient with HIV

ANS: B Soap and water must be used to thoroughly clean hands if there is any visible soiling or dirt and with certain infections such as Clostridium difficile and vancomycin-resistant enterococci when preparing for a sterile or surgical procedure, before and after eating, and after using the restroom. In the other situations, a hand sanitizer is as effective as soap and water.

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

ANS: B Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment orders are located under the Orderssection in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

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.

The nurse recognizes that a patient is using a portable generator in the house as a power source. What source of poisoning does the nurse appropriately identify? a. Lead b. Carbon monoxide c. Antifreeze d. Pesticide

ANS: B Sources of carbon monoxide include automobiles, stoves, gas ranges, portable generators, lanterns, the burning of charcoal and wood, and heating systems. Lead is found in lead-based paints in toys, buildings, and ceramic dishes; sources of lead include water from lead pipes or pipes soldered with lead, gasoline or soil contaminated by gasoline, and household dust that may contain paint chips or soil, antifreeze and pesticides are liquids.

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include? a. A pressure ulcer that involves exposure of bone and connective tissue. b. A pressure ulcer that does not extend through the fascia. c. A pressure ulcer that does not include tunneling. d. A partial-thick wound that involves the epidermis.

ANS: B Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

The nurse understands state legislatures give authority to administrative bodies, such as state boards of nursing, to carry out what action? a. Create statutory laws. b. Establish regulatory laws. c. Try case law cases. d. Create laws based on social mores

ANS: B Statutory law is created by legislative bodies such as the U.S. Congress and state legislatures. Statutory laws are often referred to as statutes. State legislatures give authority to administrative bodies, such as state boards of nursing, to establish regulatory law, which outlines how the requirements of statutory law will be met. Judicial decisions from individual court cases determine case law. Case law was historically referred to as common law because it originally was determined by customs or social mores that were common at the time.

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.

20. A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? a. As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order. b. At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. c. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. d. A nurse reads an order correctly as written by the health care provider in the patient's medical record.

ANS: B Telephone orders and verbal orders (VO) usually occur at night or during emergencies (blood pressure dropping); they should be used only when absolutely necessary and not for the sake of convenience. Because the time is 1 AM (0100 military time) and the health care provider is not present, the nurse will need to call the health care provider for a telephone order. A VO involves the health care provider giving orders to a nurse while they are standing in proximity to one another. Just reading an order that is correctly written in the chart does not require a telephone order.

During a shift report, the nurse briefly describes the history of a patient admitted with chronic gastrointestinal bleeding. In which SBAR topical area would this information be presented? a. Situation b. Background c. Assessment d. Recommendation

ANS: B The "B" in SBAR stands for "Background," or what led up to the current situation. The "S" stands for Situation or what is happening right now. The "A" stands for "Assessment," or what is the identified problem, concern, or need. The "R" stands for "Recommendation," or what actions or interventions should be initiated to alleviate the problem.

The American Nurses Association (ANA) standards of professional performance require nurses to use research findings in practice. How do these standards impact nurses in the workplace? a. Nurses need to regulate their practice according to the latest journal articles. b. Nurses need to use the best available evidence to guide practice decisions. c. Nurses only need to participate in research while in advanced practice. d. Nurses may use evidence-based practice to develop procedures but not policies.

ANS: B The American Nurses Association (ANA) standards of professional performance require nurses to use research findings in practice. Two criteria are measured. The first criterion is that nurses need to use the best available evidence, which includes research findings, to guide their practice decisions (ANA, 2015). The second criterion is that nurses participate in research activities that are appropriate for their position and level of education. Activities may include identifying problems in the clinical setting that may be researched; participating in data collection; participating as a member of a research committee or a research program; sharing research findings the nurse has found with others; conducting research; critiquing research that may be used in practice; using research findings to develop policies, procedures, and standards for patient care at health care facilities; and incorporating research as part of ongoing learning as a nurse. Nurses may participate in one or more of these activities during their careers. The ANA (2017) Research Toolkit was developed to help nurses to provide evidence-based care that improves patient outcomes. The ANA (2017) Research Toolkit was developed to help nurses to provide evidence-based care that improves patient outcomes.

During a staff meeting, the nurse manager announces that the hospital will be seeking Magnet status. To explain the requirements for this award, the nurse manager will contact which organization? a. American Nurses Association (ANA) b. American Nurses Credentialing Center (ANCC) c. National League for Nursing (NLN) d. Joint Commission

ANS: B The American Nurses Credentialing Center (ANCC) awards Magnet Recognition to hospitals that have shown excellence and innovation in nursing. The ANA is a professional organization that provides standards of nursing practice. The National League for Nursing (NLN) outlines and updates competencies for practical, associate, baccalaureate, and graduate nursing education programs. The Joint Commission is the accrediting organization for health care facilities in the United States.

6. The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. No blood incompatibility occurs with a blood transfusion. b. A surgical sponge is left in the patient's incision. c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

ANS: B The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient's incision is a Never Event. No blood incompatibility reaction is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.

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. Making sure the patients are disease free b. Making sure to involve the whole person c. Making sure care is strictly personal in nature d. Making sure to 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.

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.

The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessmentUfindSingNbesTt indicaOtes to the nurse that the pain medication was effective? a. The patient is sleeping quietly. b. The patient states a reduction of the pain. c. The patient's respirations are slow and regular. d. The patient's blood pressure has returned to baseline.

ANS: B The best way for the nurse to determine that the pain medication was effective is for the patient to state a reduction of the pain. The other assessment findings cannot definitively determine whether the patient is still in pain.

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best? a) "The patient's metabolic rate is increased from being ill." b) "The lungs are trying to rid the body of extra carbon dioxide." c) "The patient is trying to reduce his temperature through panting." d) "Patients who are acutely ill often have abnormal vital signs."

ANS: B The body tries to compensate for excess carbon dioxide (seen in acidosis) by increasing the rate and depth of respirations to "blow off" the carbon dioxide.

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.

A nurse is a case manager for a home health care agency. The nurse often orders supplies for patients seen by the agency. What action by the nurse is best? a. Negotiate for cheaper prices from suppliers. b. Investigate what each patient's insurance will cover. c. Refer the patient to the closest supply source. d. Use the same supplier for all patients' needs.

ANS: B The case manager in home health care must be a well-versed financial steward and understand what each patient's insurance will cover to maximize the patient's benefit. The home health care nurse serves as a case manager (coordinator) of client care, needed services, and needed supplies in the home settingThe nurse must be well versed as a financial resource manager, who needs to be aware of what is or is not covered on the client's insurance plan.

The nurse identifies that The Code of Ethics for Nurses is defined in which terms? a. Like the Constitution and not revisable b. A succinct statement of ethical obligations c. Required by entry level nurses only d. A negotiable document dependent on individual conscience

ANS: B The current nursing code, the Code of Ethics for Nurses with interpretive statements, was published in 2015. The Code of Ethics for Nurses is "a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession," the profession's "nonnegotiable ethical standard," and "an expression of nursing's own understanding of its commitment to society."

22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobilityfor a care plan? a. A patient who is completely immobile b. A patient who is not completely immobile c. A patient at risk for single-system involvement d. A patient who is at risk for multisystem problems

ANS: B The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene? a) Assessing apical pulse between the fifth and sixth intercostal spaces b) Assessing the dorsalis pedis pulse by palpating behind the patient's knee c) Assessing the radial pulse on the patient's wrist d) Assessing the brachial pulse on the patient's inner elbow

ANS: B The dorsalis pedis pulse is palpated on the top of the foot. The other assessment locations and pulses are correct.

A patient calls the nurse to report the smell of cigarette smoke in the bathroom. The nurse recognizes that this component of the communication process is identified by which term? a. Channel b. Referent c. Message d. Feedback

ANS: B The elements of the communication process include a referent (i.e., event or thought initiating the communication), a sender (i.e., person who initiates and encodes the communication), a receiver (i.e., person who receives and decodes, or interprets, the communication), the message (i.e., information that is communicated), the channel (i.e., method of communication), and feedback (i.e., response of the receiver).

The family of a patient who was in a motor vehicle accident tells the nurse "I'm just not the person I was before the crash" The nurse recognizes this is likely because of the injury to what area of brain? a. Parietal lobes b. Frontal lobes c. Occipital lobes d. Temporal lobes

ANS: B The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell. The occipital lobes process visual information.

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.

The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient? a. "Do you have a headache or any dizziness?" b. "Do you have any chest pain or shortness of breath?" c. "When did you first notice the swelling and redness in your leg?" d. "Do you have any cramping or muscle spasms in your leg?"

ANS: B The highest risk of a DVT is the potential for the clot to break free and travel through the bloodstream to cause a pulmonary embolus (PE). The nurse should ask the patient about chest pain or shortness of breath to assess if a PE may have occurred.

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.

14. 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

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.

A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate? a) Offer the patient a small pillow for under his/her head. b) Provide a method for ensuring the patient stays warm. c) Raise the head of the bed to about 30 degrees. d) Ensure there is enough lighting for an adequate examination.

ANS: B The important fact in this question is that the patient is partly undressed, and the nurse provides a means to keep the patient warm. All answers are appropriate for any examination but keeping the patient warm is specific to this situation.

10. The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing? a. Young infant b. Toddler c. Preschooler d. Adolescent

ANS: B The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.

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.

Which patient assessment result would require the nurse to assess that patient further? a) A 40-year-old woman with a radial pulse of 68 b) A 65-year-old man with a respiratory rate of 10 c) A 12-year-old with a pulse of 92 after ambulating in the hallway d) A 50-year-old man with a BP of 112/60 upon awakening in the morning

ANS: B The normal respiratory rate is 12 to 20 breaths/min for an adult, so a rate of 10 would require further assessment. The other options are all within normal limits.

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.

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

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

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.

The nurse is planning care for a group of patients and recognizes which activity may be delegated to unlicensed assistive personnel? a. Analysis of the patient's physical condition b. Morning vital signs, height, and weight c. Evaluation of whether colostomy drainage is normal d. Determining patient readiness for post surgical nursing

ANS: B The nurse often works with unlicensed assistive personnel (UAP) to collect relevant data on height and weight, intake and output, and vital signs. The registered nurse uses critical thinking to guide decisions related to delegation of assignments and tasks. Before delegation of a task, the nurse must be knowledgeable about the role, scope of practice, and competency of the recipient of the delegated task. Analysis and evaluation of patient conditions and readiness for teaching require critical thinking and are nursing functions.

13. 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.

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

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

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

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

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first? a. Hands b. Eyes c. Face d. Arms

ANS: B The nurse should start washing the patient's eye area, using a washcloth without soap, followed by the patient's face, hands, and arms.

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

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

33. Which patient will the nurse see first? a. A 56-year-old patient with oxygen with a lighter on the bedside table b. A 56-year-old patient with oxygen using an electric razor for grooming c. A 1-month-old infant looking at a shiny, round battery just out of arm's reach d. A 1-month-old infant with a pacifier that has no string around the baby's neck

ANS: B The nurse will see the patient shaving with an electric razor first as this is an actual problem. Do not use oxygen around electrical equipment or flammable products. A lighter on the bedside table and a shiny, round battery are potential problems, not actual. Plus, it would be hard, almost impossible, for a 1 month old to actually grab the battery when it is out of arm's reach. A baby should use a pacifier without strings.

What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation? a. They are chronologic. b. They are examples of problem-oriented charting. c. They are narrative charting. d. They are forms of "charting by exception."

ANS: B The nurse's notes may be in a narrative format or in a problem-oriented structure such as the PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format. Narrative charting is chronologic, charting by exception (CBE) is documentation that records only abnormal or significant data.

The nurse identifies that the nursing process is an attempt to meet patient needs, including which concept? a. Nursing process is linear in nature. b. Nursing process is dynamic and cyclic. c. Nursing process requires occasional care plan re-evaluation. d. Nursing process does not allow care plan modification.

ANS: B The nursing process is ongoing in an attempt to meet patient needs. The nursing process is not linear in nature but is dynamic and cyclic, constantly adapting to a patient's health status. Care plan modifications may be necessitated due to deterioration or improvement of a patient's condition. The Joint Commission requires patient care plans to be evaluated on a continual basis.

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.

The nurse manager is considered a "great communicator." She can be found on the unit talking with staff, keeping them informed and asking their opinions. She believes that nurses are motivated by internal means and that they want to participate in making decisions about the unit although the final decision always rests with her. The nurses recognize that this nurse manager is what type of leader? a. Autocratic b. Democratic c. Bureaucratic d. Laissez-faire

ANS: B The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. The authoritarian or autocratic leader exercises strong control over subordinates. Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules. Like the democratic leader, the permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own decisions.

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

A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. 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 the pain is, 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 identifies which nurse established the American Red Cross during the Civil War? a. Dorothea Dix b. Linda Richards c. Lena Higbee d. Clara Barton

ANS: D Clara Barton practiced nursing in the Civil War and established the American Red Cross. Dorothea Dix was the head of the U.S. Sanitary Commission, which was a forerunner of the Army Nurse Corps. Linda Richards was America's first trained nurse, graduating from Boston's Women's Hospital in 1873, and Lena Higbee, superintendent of the U.S. Navy Nurse Corps, was awarded the Navy Cross in 1918.

29. The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care? a. Risk for falls b. Deficient knowledge c. Risk for suffocation d. Impaired physical mobility

ANS: B The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for falls, impaired physical mobility, or suffocation.

A nurse assesses a patient's lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best? a) Prepare to treat the patient for asthma. b) Prepare to treat the patient for pneumonia. c) Teach the parent how to prevent croup. d) Assess the patient for heart failure.

ANS: B The patient has rhonchi. Rhonchi are caused by increased secretions in large airways and can be seen in pneumonia or in other conditions, leading to increased mucus production. The nurse prepares to treat the patient for pneumonia. Asthma would manifest with wheezing, croup with stridor, and heart failure with rales or crackles.

The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of a patient interview, the nurse carries out what action? a. Obtain demographic data using open-ended questions. b. Establish the name by which the patient prefers to be addressed. c. Gather general information using closed-ended questions. d. Stand by the bedside to ask the needed questions.

ANS: B The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should establish the name by which the patient prefers to be addressed. Some individuals prefer formal titles of respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable with less formality. How a patient is addressed is the patient's choice. Demographic data should be collected by asking focused or closed-ended questions. More general information can be gathered by open-ended communication techniques. When feasible, the nurse and the patient should be seated at eye level with each other. In this way, the interaction between the nurse and the patient is horizontal instead of vertical. Standing over someone implies control, power, and authority. The implication of power can result in less-than-optimal data collection and a potential conflict as the patient strives to regain control over the situation.

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

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 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.

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

ANS: B The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons.

A nurse is caring for a homeless patient and tells the manager, "I will make sure he doesn't steal food from our nourishment center." What action by the manager is best? a. Tell the nurse she is right to monitor the patient's activity. b. Inform the nurse that not all homeless people will steal. c. Educate the nurse that hunger might make the patient steal. d. Remind the nurse to initiate a social work consultation.

ANS: B This nurse is guilty of being prejudiced against the patient, who is a member of the homeless culture. Although hunger might drive a homeless person to steal, prejudice leads the nurse to believe that all homeless people steal. The manager informs the nurse of this information, gently pointing out the nurse's bias. A social work consultation may be a good idea for the patient but does not address the prejudiced nurse.

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.

The nurse recognizes which term to identify the second line of defense that leads to local capillary dilation and leukocyte infiltration? a. Normal flora b. Inflammatory response c. Immune response d. Humoral immunity

ANS: B The second line of defense is the inflammatory response. Inflammation is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Normal flora is the body's first line of defense. The immune response is the body's attempt to protect itself from foreign and harmful substances. Humoral immunity is a defense system that involves white blood cells (B lymphocytes) that produce antibodies

5. A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation

ANS: B The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient's level of comfort and for any hazards of immobility and assessing circulation.

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.

4. A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

ANS: B The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.

8. 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 find? 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 patient arrives at the urgent care clinic and complains of vague pains in the legs and the nurse asks the patient to describe this pain in greater depth. The nurse knows this is a critical-thinking skill and can be developed in which context? a. Critical thinking is used to avoid repetition in providing care. b. Critical thinking can be enhanced through practice. c. Critical thinking should be based in thought and not spontaneity. d. Critical-thinking skills become dull when used routinely.

ANS: B The ultimate goal is for these questions to become so spontaneous in thinking that they form a natural part of our inner voice, guiding us to better reasoning. As with any skill, critical thinking can be enhanced through practice. The routine use of these questions should promote critical thought.

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 nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best? a) Avoid palpating this patient's abdomen. b) Document the findings in the patient's chart. c) Have another nurse verify the findings. d) Ask the patient when the last food intake was.

ANS: B These findings are normal; it may take up to 30 seconds of listening to hear bowel sounds. The nurse documents the findings; no other action is needed.

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).

The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best? a) Diseased eye first because it is the priority. b) Healthy eye first to prevent spread of disease c) It does not matter if both eyes are examined d) Start with the eye the patient wants you to start with

ANS: B To prevent cross contamination, the healthy eye is examined before the diseased eye.

7. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a. Maintain a narrow base of support. b. Dangle the patient at the bedside. c. Encourage isometric exercises. d. Suggest a high-calcium diet.

ANS: B To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.

The nurse is caring for a patiNen Ut Rwi SthIs NevGeTreBc.hrCon OicMpain and applied the first 50 mcg transdermal fetanyl (Duragesic) patch 2 hours ago. The patient states that the pain is presently rated at 9 on a 1 to 10 scale. What is the nurse's best action? a. Instruct the patient that the fentanyl patch will start to work soon. b. Check the provider's orders for a short-acting narcotic medication to administer for breakthrough pain. c. Give the patient a gentle back rub and encourage guided imagery. d. Apply a second 25-mcg transdermal fentanyl patch now.

ANS: B Transdermal administration of medication does not become effective for 12 to 16 hours after application. Short-acting narcotic medication should be given in the meantime to make the patient comfortable.

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which patient would the nurse consider as having the highest priority? a. A 68-year-old patient suffering from dehydration and disorientation b. A 14-year-old patient having respiratory distress and increasing anxiety c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities d. A 38-year-old patient with a broken right hip and in severe pain

ANS: B Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a five-tier triage system. The five-tier system classifies patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain. Level 3 is considered urgent: potentially life-threatening conditions that require care within 30 to 60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered semi-urgent, stable health conditions that require care within 60 to 120 minutes, such as a twisted ankle. Level 5 conditions are non-urgent and lower risk such as cold symptoms.

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.

The nurse identifies which goal is written correctly for the Nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand? a. Patient will walk 1 mile without shortness of breath. b. Patient will ambulate 100 feet with no shortness of breath on third day after treatment. c. Patient will climb stairs without shortness of breath by day 2 of hospital stay. d. Patient will tolerate activity.

ANS: B Useful and effective goals have certain characteristics. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient's capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation. In option A, there is no time frame to gauge expectations, so the diagnosis is not measurable. In option C, the number of stairs is not specified and so is not measurable. In option D, the type of activity is not mentioned, so it is not specific and there is no measurable criterion.

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.

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.

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 excess 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.

The student studying community health nursing learns that vulnerable populations can be best assisted by which activity? a. Researching their genetic risk for health problems b. Working with the community to decrease health risks c. Studying vital statistics to determine their causes of death d. Making sure the population maintains immunizations

ANS: B Vulnerable populations have some characteristic that puts them at higher risk for identified health problems. The nurse can best assist vulnerable populations by identifying and working with them to decrease their risks. Researching genetic risks, studying vital statistics, and improving immunizations are all part of the solution, but the overarching priority action is to help the community decrease its risks.

11. The nurse is preparing to lift a patient. Which action will the nurse take first? a. Position a drawsheet under the patient. b. Assess weight and determine assistance needs. c. Delegate the task to a nursing assistive personnel. d. Attempt to manually lift the patient alone before asking for assistance.

ANS: B When lifting, assess the weight you will lift, and determine the assistance you will need. The nurse has to assess before positioning a drawsheet or delegating the task. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient's weight; most facilities have a no-lift policy.

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

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

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.

The nurse recognizes that a vital aspect of providing effective and appropriate nursing care is being able to actively listen to a patient and then demonstrates this concept when carrying out which activity? a. Pays attention as if in a social conversation with the patient. b. Practices and develops this skill over many years. c. Focuses on what the patient is saying. d. Passively listens with the ears.

ANS: B listen to a patient in a way that conveys understanding, sensitivity, and compassion. Caring involves interpersonal relationships and communication skills that require paying more attention to the details of communication than would be necessary in a social conversation. This type of listening is a highly developed skill that usually takes a great deal of time and many years of experience to acquire. It can be learned with practice and enhanced with sensitivity and attention to the feedback that is received during each interaction. In a caring nurse-patient relationship, the nurse takes responsibility for establishing trust, making sure that the lines of communication are open and that the nurse accurately understands not only what the patient is saying, but also that the nurse is clearly understood. Active listening means paying careful attention and using all of the senses to listen rather than just passively listening with the ears. It requires energy and concentration and involves hearing the entire message— what the patient means as well as what the patient says. This type of listening focuses solely on the patient and conveys respect and interest.

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene? a) Student washes hands prior to patient contact. b) Student pulls the pinna of the patient's ear down and back. c) Student explains the procedure to the patient. d) Student pulls the pinna of the patient's ear up and back.

ANS: B For an adult, the correct procedure for taking a tympanic temperature includes pulling the pinna of the patient's ear up and back. Children's pinnae are pulled down and back. Washing hands and explaining the procedure are appropriate.

The nurse knows which statements would be considered objective data? (Select all that apply.) a. "I'm short of breath." b. "Blood pressure 90/68, apical pulse 102, skin pale and moist." c. "Lung sounds clear bilaterally, diminished in right lower lobe." d. "I feel weak all over when I exert myself." e. "My pain level is down to 2. It was 8."

ANS: B, C Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured.

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. What actions by the nurse will assist in validating this suspicion? (Select all that apply.) a. Determine the patient's cognitive ability and potential language barriers. b. Gather information about what the patient already knows about diabetes. c. Have the patient demonstrate checking a blood glucose level. d. Formulate the patient's plan of care using a standard protocol. e. Prepare to teach the patient using materials written at a third-grade level.

ANS: B, C Data that would validate the nurse's suspicion that the patient needs further education include determining what the patient already knows about diabetes and having the patient demonstrate the technique of blood glucose monitoring. If the nurse is correct, further education is needed. Before further education can occur however; the nurse should determine if the patient has cognitive difficulties or a language barrier which would all contribute to an individualized plan of care. Reading material should typically be written at a fifth-grade level, but the nurse should not assume the patient needs third-grade level material.

The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. The nurse identifies which abbreviations to be unacceptable? (Select all that apply.) a. prn b. QD c. qod d. 0.X mg e. X mg

ANS: B, C Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission (2018) has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. QD, Q.D., qd, q.d. (daily), QOD, Q.O.D., qod, and q.o.d. (every other day) can be mistaken for each other. Periods after Q can be mistaken for I, and the O mistaken for I. Write daily or every other day. Trailing zero (X.0 mg) or a lack of leading zero (.X mg) can be confusing. Write as X mg or 0.X mg.

The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.) a. The belt is placed around the patient's hips. b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. d. The nurse holds the belt on the side of the patient. e. The nurse stands behind the patient while ambulating

ANS: B, C Transfer belts are used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient's waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient's waist while ambulating.

The nurse notes that a trauma patient has multiple tangles in the hair. Which actions taken by the nurse are appropriate? (Select all that apply.) a. Work the tangles to the ends of the hair, then trim with scissors. b. Apply warm water and conditioner. c. Apply detangler as available. d. Use a comb or fingers to work through tangles. e. Cut the tangles out if working on them agitates the patient.

ANS: B, C, D Apply warm water and a conditioner or a detangler, if available, to release tangles and avoid injury to the scalp. Use a comb and/or fingers to work through the tangles individually before shampooing. The nurse avoids cutting the patient's hair unless first asking the patient's permission.

The nurse is performing a morning assessment and notes the patient to be experiencing dyspnea. Which patient assessment findings would most indicate this respiratory condition? (Select all that apply.) a) Occasional productive cough b) Pulse oximetry 89% c) Patient in orthopneic position d) Respirations 26 & shallow e) Temperature 100.1 °F

ANS: B, C, D Dyspnea is difficult, labored breathing, usually with a rapid, shallow pattern, that may be painful. Anxiety usually is present as well. Accessory muscles in the chest and neck are used in dyspneic breathing. Many patients experiencing dyspnea find it easier to breath in an upright position. Difficulty breathing experienced in positions other than sitting or standing is termed orthopnea. Occasional productive cough and slight temperature elevation are not indicators of dyspnea.

The nurse is providing education to a cardiac patient who has multiple life stressors that are impacting the patient's health. Which statements by the patient indicate a good understanding of actions that can be taken to reduce stressors? (Select all that apply.) a. "I should change my job." b. "I should plan some downtime." c. "I should meet with a financial counselor." d. "I should talk with my family about my situation." e. "I should make my family go to counseling with me."

ANS: B, C, D In adulthood, life stressors such as financial concerns, work-related demands, and efforts to balance work with family life are common challenges that can take a physical toll on the body. Individuals should plan relaxation periods or vacations. Meeting with financial counselors and talking with family can help to achieve that balance. Changing jobs may be beneficial but could also create more stress and forcing family to go to counseling may also not be a wise choice.

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.

Touch is the intentional physical contact between two or more people and it is deemed to be an essential and universal component of nursing care. The nurse knows that task-oriented touch occurs during which activities? (Select all that apply.) a. Holding the patient's hand during a painful procedure b. Giving the patient an injection to treat discomfort c. Starting an intravenous (IV) line for fluid administration d. Inserting a nasogastric tube to decompress the patient's stomach e. Shaking the patient's hand in order to establish rapport

ANS: B, C, D Task-oriented touch includes performing nursing interventions such as giving treatments, changing dressings, suctioning an endotracheal tube, giving an injection, starting an IV line, or inserting an NG tube. Task-oriented touch should be done gently, skillfully, and in a way that conveys competence. Patients become alarmed when they detect that their nurse is unfamiliar with a procedure. It is best to seek assistance with any procedure or skill that the nurse cannot safely accomplish alone. Every task-oriented procedure should be explained to a patient, followed by feedback indicating patient understanding, before care is initiated. Caring touch is considered by most people to be a valuable means of nonverbal communication. In today's highly technical world of nursing, caring touch is an essential aspect of patient-centered care. Caring touch can be used to soothe, comfort, establish rapport, and create a bond between the nurse and the patient. Care may be conveyed by holding the hand of a patient during a painful or frightening procedure or when delivering bad news. This is an important way nurses let patients know that they are not alone and that another human being cares.

The nurse is demonstrating cultural sensitivity in performing perineal care when carrying out which actions? (Select all that apply.) a. The male nurse delegates perineal care of a female patient to the female UAP. b. The male nurse asks a female patient if she would prefer a female to perform care. c. The nurse approaches the care in a sensitive, professional manner. d. The nurse assesses cultural preferences of the patient prior care e. The nurse provides care quickly and in a matter of fact manner.

ANS: B, C, D The nurse assesses patient backgrounds and provides hygienic care in a manner that is sensitive to the differences in habits and customs. This includes asking the patient about their preferences and not assuming what their preferences will be. A female patient may be comfortable with a male nurse performing perineal care. The nurse should not perform the care without asking first and should not preform the task quickly.

The nurse is explaining the National Patient Safety Goals (NPSG) to the student nurse. Which answers indicate that the student has a good understanding of these goals? (Select all that apply.) a. The NPSG's focus on treating chronic infections quickly b. The NPGS's focus on improving staff communication c. The NPGS's focus on using medications safely d. The NPGS's focus on identifying patients correctly

ANS: B, C, D The NPSG focus on specific goals each year. The goals for 2018 included: identify patients correctly, improve staff communication, improve the safety of using medications, reduce harm associated with clinical alarm systems, reduce risk of health care-associated infections and the hospital identifies safety risks inherent in its patient population. Although treating chronic infections quickly is important, it is not an NPSG.

The nurse is providing education to the family of a patient being discharged with dementia. Which statement by the family indicates an appropriate level of understanding of dementia? (Select all that apply.) a. "The condition is permanent and has an acute onset." b. "Alzheimer is the most common type of dementia." c. "The condition worsens over time." d. "I should observe for wandering behavior." e. "Agitation can be worse in the evening."

ANS: B, C, D, E Dementia, which is a permanent decline in mental function, has a subtle onset. The most common type of dementia is Alzheimer disease. Dementia is not reversible and worsens over time. Behavioral problems that arise in dementia patients include wandering, agitation, repetitive behaviors, and sundowning, or worsening of agitation and confusion in the evening.

The nurse knows that which areas of the patient's body are at increased risk of excoriation? (Select all that apply.) a. Exposed areas such as the face b. Areas exposed to stool c. Skin on skin areas d. Area under pendulous breasts e. Under an abdominal fold

ANS: B, C, D, E Excoriation (red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices. Excoriation also occurs in areas where skin rests on skin, such as in the axilla (armpit); under large, pendulous breasts; or in abdominal folds. Exposed areas are more likely to become sun burned or wind burned.

4. The nurse is bathing a patient and notes reddened skin above the coccyx. Which actions by the nurse are appropriate? (Select all that apply.) a. Apply a barrier cream and massage the area. b. Document the findings. c. Position the patient to relieve pressure on coccyx. d. Report the area to the charge nurse. e. Report the new finding to the provider.

ANS: B, C, D, E Gently wash any reddened or swollen areas and pat them dry. Use clean, nonsterile gloves as needed to comply with standard precautions. Document the findings from the assessment and report them to the provider, charge nurse, or other appropriate personnel per agency policies. Avoid massaging reddened areas on the skin during the bath. Further tissue breakdown can occur if reddened areas are massaged.

The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report? (Select all that apply.) a. Patient is an 84-year-old female with a history of hypertension: S b. Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S c. Patient is hemorrhaging with four saturated dressings in an hour: A d. The patient took an overdose of antidepressants three days ago: B e. By policy, the patient needs transferred to the ICU; please come write the orders: R

ANS: B, C, D, E SBAR stands for situation (what is happening the current time), background (circumstances leading up to this situation), assessment (what the nurse thinks the problem is), and recommendation (what needs to be done to correct the situation). A history of hypertension would be background (if it were related to the current issue).

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.) a) "Let me know if Mr. Smith's blood pressure is low." b) "Take Mrs. Jones' blood pressure every 15 minutes." c) "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg." d) "Do you want me to demonstrate using the electronic blood pressure cuff?" e) "I'll take Mr. Derby's blood pressure since he is not stable."

ANS: B, C, D, E The nurse can delegate measuring vital signs to UAPs if the patient is stable. The nurse must ensure the UAP knows the proper technique for taking vital signs and knows which readings must be reported. Telling the UAP to report a blood pressure that is "too low" is too vague.

The nurse has been practicing for several years and has become an unofficial leader, with newer nurses asking for advice about patient care. They are amazed at how much the older nurse "thinks like a nurse." To "think like a nurse," the nurse must carry out which actions? (Select all that apply.) a. Be a nurse for several years. b. Be able to apply knowledge in making clinical decisions. c. Actively participate in the process. d. Accept procedures that have been in place for years as right. e. Develop a questioning attitude.

ANS: B, C, E Because nursing requires the application of knowledge to make clinical decisions and guide care, it involves active participation by the nurse. The application of knowledge requires development of a questioning attitude. This process is sometimes referred to as thinking like a nurse. "Several years" is vague, and nurses develop critical thinking abilities at different rates. A questioning attitude does not accept doing things because they have been done that way for a long time.

The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding? (Select all that apply.) a. The patient's urinary output increased to 40 mL/hr. b. The patient's pulse has risen from 76 to 112 beats/min. c. The patient states that his abdominal pain is worse than yesterday. d. The patient complains of generalized itching. e. The patient's hematocrit dropped from 14.6 to 11.0 g/dL. f. The patient has not been able to have a bowel movement since before surgery.

ANS: B, C, E Signs of internal bleeding include tachycardia, increased abdominal pain and a drop in hematocrit/hemoglobin. Urinary output would decrease with internal bleeding because the kidneys work to conserve fluids. Itching and constipation are not signs of internal bleeding.

The nurse recognizes barriers to the use of evidence-based practice (EBP) include what points? (Select all that apply.) a. Nurses critiquing research b. Difficulty communicating how to conduct EBP c. Copious amount of literature available d. Short time between research and practice e. Reluctance of organizations to fund research

ANS: B, C, E To adequately integrate EBP into patient care, nurses must critique research to differentiate between opinion and evidence and must regularly read current professional journals. Some barriers are common to research use and EBP, including the difficulty of communicating how to conduct EBP and the individual nurse's skills in determining the quality of research available for review. Another limitation is the reluctance of organizations to fund research and subsequently make potentially costly practice changes based on the best evidence. Because of the copious amount of literature on a specific topic, it is difficult to analyze the literature in an efficient and effective manner. Health care literature with clinically applicable findings is published at a rate that is impossible for individual health care professionals to keep up with. There are delays of approximately 17 years for implementation of clinical research into practice.

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform? (Select all that apply.) a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. d. Secure the device to the patient's gown above the level of the wound. e. Check for kinks in the tubing.

ANS: B, C, E Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

2. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.) a. Water outdoor plants with a nozzle and hose. b. Walk to the mailbox in the summer. c. Encourage yearly eye examinations. d. Use bathtubs without safety strips. e. Keep pathways clutter free.

ANS: B, C, E Walking to the mailbox in summer provides exercise when pathways are not icy and slick. Encourage annual vision and hearing examinations. Pathways that are clutter free reduce fall risk. Using a hose to water plants and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home.

8. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.) a. One family member has gone to lunch. b. Patient is placed in bilateral wrist restraints at 0815. c. Bilateral radial pulses present, 2+, hands warm to touch d. Straps with quick-release buckle attached to bed side rails e. Attempts to distract the patient with television are unsuccessful. f. Released from restraints, active range-of-motion exercises completed

ANS: B, C, E, F Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses' notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses' notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.

The nurse knows which findings indicate orthostatic hypotension? (Select all that apply.) a. A decrease in systolic blood pressure by 30 mm Hg b. A decrease in diastolic blood pressure by 10 mm Hg c. An increase in heart rate by 30 beats/min d. An increase in systolic blood pressure by 20 mm Hg e. A decrease in heart rate by 20 beats/min

ANS: B, D A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

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.

The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which Nursing diagnosis indicates an understanding of a Nursing diagnostic statement? (Select all that apply.) a. Impaired breathing related to drug effect on the respiratory center b. Risk for injury related to hallucinations c. Insomnia d. Impaired socialization related to excessive stimulation of nervous system as evidenced by unintelligible speech. e. Powerlessness

ANS: B, D Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics.Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The first statement needs defining characteristics. Insomnia is a medical diagnosis. The last statement needs etiology and manifestations.

The nurse considers which skills to be invasive procedures? (Select all that apply.) a. Administering oral medications b. Starting an intravenous (IV) line c. Repositioning the patient d. Inserting a urinary catheter

ANS: B, D Many interventions focus on physical care that is performed when treating patients. These interventions may include invasive procedures, such as starting an intravenous line or inserting a catheter, or they may be noninvasive, such as administering oral medications and repositioning.

The nurse is caring for a patient who has severe burning pain in the right arm caused by a compressed nerve in the neck. Which medications can be used along with a narcotic pain reliever to relieve the patient N's pRain u Inti Gl sur Bg.er Cy ca Mn be performed to release the nerve? (Select all that apply.) a. Diphenhydramine (Benadryl) 50 mg PO daily b. Amitriptyline (Elavil) 50 mg PO BID c. Ondansetron (Zofran) 8 mg PO q 4 hours PRN d. Gabapentin (Neurontin) 400 mg PO BID e. Senna (Senokot) 8.6 mg PO daily f. Naloxone (Narcan) 0.4 mg IV now, may repeat in 1 hour PRN

ANS: B, D Tricyclic antidepressants like amitriptyline and anticonvulsants like gabapentin are often used to treat neuropathic pain because they work directly on the nervous system. They may be given along with narcotic pain medication to make the patient comfortable. Senna will relieve constipation and diphenhydramine will relieve itching. Ondansetron is used to relieve nausea and vomiting, whereas naloxone will reverse narcotic-induced respiratory suppression.

The nurse manager knows a Magnet hospital is characterized by which? (Select all that apply.) a. Excellent medical outcomes b. A high level of nursing job satisfaction c. A low number of grievances d. Nursing care leading excellent patient outcomes e. Evidence-based environment support

ANS: B, D, E A Magnet hospital is characterized by excellent patient outcomes resulting from nursing, a high level of nursing job satisfaction with a low nurse turnover rate, and appropriate resolution of any grievances. The Magnet Recognition Program supports an evidence-based environment, which includes the nurses' autonomy to improve quality of care through research utilization (ANCC, 2018). Research and EBP must, therefore, become a part of the nurses' care of the patients.

3. A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.) a. Health care provider orders restraints prn (as needed). b. Health care provider writes the type and location of the restraint. c. Health care provider renews orders for restraints every 24 hours. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used.

ANS: B, D, E A physician's/health care provider's order is required, based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9. Restraints are not to be ordered prn (as needed).

The nursing student learns that which are correct regarding acculturation and assimilation? (Select all that apply.) a. Assimilation is forced entry into a different culture. b. Acculturation depends on first-hand contact between groups. c. Acculturation results in changes to the minority culture only. d. Assimilation can occur at the group or individual level. e. Assimilation causes a minority group member to blend into the majority group.

ANS: B, D, E Acculturation occurs from first-hand contact between a minority group and the majority cultural group and can result in changes to one or both cultures. Assimilation occurs when members of a minority group blend into the majority group and can occur at the group or individual level. Assimilation is not a forced change.

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

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.

When administering a bath to a hearing-impaired patient, what actions should the nurse carry out? (Select all that apply.) a. Speak very loudly into the patient's right ear. b. Control background noise as much as possible. c. Turn away when responding to a question. d. Adjust the lighting in the room. e. Be wary of consistent affirmative answers.

ANS: B, D, E When communicating with a hearing-impaired patient, the nurse should make sure that the area is well lit with as little background noise as possible. Hearing aids amplify all sounds, making noisy environments confusing and frustrating. Raising the voice level slightly, speaking clearly, and making sure that the patient can see the nurse's face helps to facilitate communication. Adequate lighting enhances the patient's ability to see the speaker's mouth and face and interpret nonverbal communication. Consistent affirmative answers to the nurse's questions may be an indication that the patient is not hearing the information being shared. Care should be taken to verify that patients truly understand the content of verbal interaction. Extra patience may be required by the nurse to demonstrate caring while communicating with hearing-impaired patients.

3. 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 patient and the patient's family about self-care measures for hypertension. Which topics should the nurse include? (Select all that apply.) a) Increase exercise on most days. b) Maintain a normal body weight. c) Abstain from any alcohol. d) Reduce dietary sodium to 2.4 g/day. e) Follow the DASH diet.

ANS: B, D, ESelf-care measures for hypertension include 30 minutes of aerobic exercise on most days of the week, maintaining a normal body weight, limiting alcohol to two drinks/day for men and one drink/day for women, reducing sodium intake to 2.4 g/day, and following the DASH diet.

The nurse is working with a nursing assistant to care for several postoperative patients. Which interventions can the nurse delegate to the assistant for completion? (Select all that apply.) a. Assess patients' comfort levels and need for pain medication. b. Empty urinary catheter bags and record urine output. c. Teach patients how to use incentive spirometers hourly. d. Provide ice chips and juice to patients who are no longer NPO. e. Monitor incisions for signs of infection. f. Apply TED hose and assist with oral care.

ANS: B, D, F Basic patient care tasks that do not require assessment or critical thinking may be assigned to the nursing assistant for completion. These include emptying drainage bags, providing ice chips to patients who are allowed oral intake, and applying TED hose. Teaching, monitoring, and assessing patients are done by the nurse.

The nurse is educating the patient about the effects of immobility on the body. Which statements by the patient indicate a need for further education? (Select all that apply.) a. "I can become very weak." b. "I will gain weight." c. "I will lose muscle tone." d. "I can get bed sores." e. "I won't have any lung problems."

ANS: B, E Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, DVTs, pulmonary embolism, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient's risk and recognize signs of impending complications.

The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. The nurse knows which statements about screening examinations to be true? (Select all that apply.) a) Free or low-cost screening ensures patient screening. b) People may not screen due to fear of testing positive. c) Early screening ensures minimal treatment costs. d) Employment stability is enhanced by early screening. e) Treatment of disorders often means lost wages.

ANS: B, E The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. Even if screening is free or low cost, the patient or family members may decline because of the potential for testing positive for a disease. Treatment of a disorder often requires time spent away from work, lost wages, and expensive drug therapies and diagnostic tests. The financial impact can be devastating to families or individuals who have a limited or fixed income and fear that employment stability may be compromised.

The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best to hear the murmur? a) Ensure that the room is extremely quiet. b) Use a specialized stethoscope with amplification. c) Auscultate the patient's chest with a stethoscope. d) Place the stethoscope diaphragm on the patient's back.

ANS: C A Grade 3 murmur should be readily heard with a regular stethoscope. Although the room should be quiet for all auscultation tasks, an "extremely" quiet room and an amplification stethoscope should not be necessary. The bell of the stethoscope is usually used to listen to heart murmurs, but the stethoscope needs to be on the patient's chest.

6. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a. Thermometer b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices

ANS: C A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light- headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position. A thermometer is used to assess for fever. Elastic stockings and sequential compression devices are used to prevent thrombus.

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

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

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

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 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 patient who is hospitalized for pneumonia. Which Nursing diagnosis has the highest priority? a. Activity intolerance r/t generalized weakness and hypoxemia b. Impaired nutritional intake r/t poor appetite and increased metabolic needs c. Impaired airway clearance r/t thick secretions in trachea and bronchi d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators

ANS: C Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient's airway is kept patent.

Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document? a. Flow sheet b. Kardex c. MAR d. Admission summary

ANS: C A medication administration record (MAR) is a list of ordered medications, along with dosages and times of administration, on which the nurse initials medications given or not given. A paper MAR usually includes a signature section in which the nurse is identified by linking the initials used with a full signature. The EHR includes an electronic medication administration record (eMAR). Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, and intake and output measurements. Data collected on flow sheets may be converted to a graph, which pictorially reflects patient data. Originally, the Kardex was a nonpermanent filing system for nursing records, orders, and patient information that was held centrally on the unit. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station. An admission summary includes the patient's history.

The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate? a) Auscultate the patient's bowel sounds. b) Test the cranial nerves for sensory function. c) Inspect the patient's nails and surrounding skin. d) Inspect the skin using the ABCDE mnemonic.

ANS: C A paronychia is inflammation at the base of the nail, so the nurse assesses the patient's nails and the surrounding skin. The other assessments are not related to this diagnosis.

The student learns that which is the best definition of a public health nurse? a. Works with the public. b. Works in public areas. c. Works with the greater community. d. Works with public funding.

ANS: C A public health nurse works with communities as a larger whole and is concerned with specific target or vulnerable groups within that community. The other options are inaccurate.

The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first? a) Pulse oximetry 96% b) Blood pressure 102/62 mm Hg c) Pulse 42 beats/min d) Respiratory rate 18 breaths/min

ANS: C A pulse of 42 beats/min is considered bradycardia and the patient should be assessed first because perfusion could be compromised. The blood pressure, pulse oximetry, and respiratory rate are normal.

The nurse is taking an advanced cardiac life support (ACLS) recertification class. As part of that class, the nurse and other nurses in the group rotate responsibilities during multiple mock code exercises simulating cardiac arrest scenarios. The nurse recognizes what process is assigning the nurses to these different responsibilities? a. Concept mapping b. Simulation c. Role playing d. Literature review

ANS: C A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role playing, and then all are involved in the debriefing or discussion of the scenario. As with simulation, this approach allows learners to interact in a safe controlled environment. The concept map is a way to organize and visualize data to identify relationships and solve problems. Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence in providing direct nursing care. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits.

A group of nursing students are discussing the history of nursing to a staff nurse. When a student states, "Yeah, nurses uUsed Sto bNe caTlled theOdoctors' handmaidens." the staff nurse recognizes that this comment is identified by which term? a. Prejudice b. Generalization c. Stereotype d. Belief

ANS: C A stereotype is a belief about a person, a group, or an event that is thought to be typical of all others in that category. A prejudice is a preformed opinion, usually an unfavorable one, about an entire group of people that is based on insufficient knowledge, irrational feelings, or inaccurate stereotypes. In the process of learning, people form generalizations (general statements or ideas about people or things) to relate new information to what is already known and to categorize the new information, making it easier to remember or understand. A belief is a mental representation of reality or a person's perceptions about what is right (correct), true, or real, or what the person expects to happen in a given situation.

34. The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation? a. Hand rolls b. A trapeze bar c. A trochanter roll d. Hand-wrist splints

ANS: C A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist splints are individually molded for the patient to maintain proper alignment of the thumb and the wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

11. 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.

The nurse is caring for patients on a unit that uses electronic health records (EHRs). What action by the nurse protects personal health information? a. The nurse should allow only nurses that he/she knows and trusts to use his/her verification code. b. The nurse should not worry about mistakes since the information cannot be tracked. c. The nurse should never share any password with anyone. d. The nurse should be aware that the EHR is sophisticated and immune to failure.

ANS: C Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords and verification codes should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information. Disadvantages of use of computers for documentation include computer and software failure and problems if there is a power outage.

28. 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.

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.

The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart rate in preparation to write a care plan. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells. Vital signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/min. Oxygen saturation is 88%. Which action does the nurse perform next? a. Exclude all subjective data in favor of objective data. b. Focus on data gathered during the physical assessment. c. Evaluate the data looking for patterns and related data. d. Dismiss family members input as "hearsay."

ANS: C After collecting and reviewing all of the assessment data, the nurse looks for patterns and related data to support specific Nursing diagnoses. This process is referred to as clustering data. Clustering involves organizing patient assessment data into groupings with similar underlying causes. All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians' orders, and documentation from health care providers. Verifying specific Nursing diagnoses for a patient or situation follows accurate analysis and clustering of data.

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.

When the nurse manager on a medical-surgical floor has met education and experience requirements in nursing informatics, hospital administration may request the nurse to pursue what additional verification of competence in this area? a) Technical competencies b) Utility competencies c) Certification from ANCC d) Leadership competencies

ANS: C After meeting the educational and experience requirements, the nurse can receive certification in nursing informatics from the Health Care Information and Management Systems Society (HIMSS) and through the American Nurses Credentialing Center (ANCC). Technical competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. Utility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making. Leadership competencies address the ethical and management issues related to using IT in nursing practice, education, research, and administration. Specific leadership competencies include the application of accountability, maintenance of privacy and confidentiality, and quality assurance. Technical, utility, and leadership competencies can be achieved without certification.

The nurse is preparing to administer medications to a patient. When the patient reports new shortness of breath, which action by the nurse is most appropriate? a. Provide the patient with oxygen since it does not require a provider order. b. Complete at least three checks to ensure that the proper medication is given. c. Check the provider orders for all forms of prescription medications. d. Document that the 6 rights of medication administration were followed.

ANS: C All forms of prescription medication (i.e., oral, topical, and parenteral) require an order before administration, as does providing oxygen to a patient. The nurse would check for an as needed order for oxygen. Nurses must complete three checks, follow the six rights of medication administration, and document appropriately when administering medications, but those actions are not the priority due to the change in the patient's condition. The nurse must first address the patient's shortness of breath.

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

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.

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.

The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)? a. Handoff is an uncommon occurrence of little importance. b. Handoff occurs only at change of shift and only to oncoming nurses. c. Handoff can lead to patient death if done incorrectly. d. Handoff does not allow for collaboration or problem solving.

ANS: C An ineffective handoff may lead to wrong treatments, wrong medications, or other life-threatening events, increasing the length of stay and causing patient injury or death. Improvement in the hand-off process can increase patient safety and promote positive patient outcomes. The hand-off process can be an opportunity for collaborative problem solving. During an average hospital stay of approximately 4 days, as many as 24 handoffs can occur for just one patient because shifts change every 8 to 12 hours and many individuals are responsible for care.

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.

Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most application for a patient with excessively dry skin? a. Impaired Health Maintenance b. Risk for Injury c. Risk for infection d. Acute pain

ANS: C Any interruption in the skin, which is the body's first line of defense, can potentially lead to infection. Impaired health maintenance could have dry skin as a symptom. Acute pain and risk for injury are not appropriate.

A patient is being discharged from the hospital with wound care dressing changes. The nurse recommends a referral for home health nursing care. The nurse is using which standard of practice? a. Assessment b. Diagnosis c. Planning d. Implementation

ANS: C As a care provider, the nurseNfollRowsItheGnuBrsi.nCg prMocess to assess patient data, prioritize Nursing diagnoses, plan the care of the patient, implement the appropriate interventions, and evaluate care in an ongoing cycle. In recommending a referral, the nurse is, in effect, planning care.

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 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.

The nurse is caring for a patient who refuses two units of packed red blood cells. When the nurse notifies the health care provider of the patient's decision, the nurse is acting in which role? a. Manager b. Change agent c. Advocate d. Educator

ANS: C As the patient's advocate, the nurse interprets information and provides the necessary education. The nurse then accepts and respects the patient's decisions even if they are different from the nurse's own beliefs. The nurse supports the patient's wishes and communicates them to other health care providers. A nurse manages all of the activities and treatments for patients. In the role of change agent, the nurse works with patients to address their health concerns and with staff members to address change in an organization or within a community. The nurse ensures that the patient receives sufficient information on which to base consent for care and related treatment. Education becomes a major focus of discharge planning so that patients will be prepared to handle their own needs at home.

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

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

18. 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.

32. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on count of three shift weight from the front to back leg. a. 1, 4, 5, 6, 3, 2 b. 4, 1, 3, 5, 6, 2 c. 3, 4, 1, 5, 6, 2 d. 5, 6, 3, 1, 4, 2

ANS: C Assisting a patient up in bed with a drawsheet (two or three nurses): (1) Place the patient supine with the head of the bed flat. A nurse stands on each side of the bed. (2) Remove the pillow from under the patient's head and shoulders and place it at the head of the bed. (3) Turn the patient side to side to place the drawsheet under the patient, extending it from shoulders to thighs. (4) Return the patient to the supine position. (5) Fanfold the drawsheet on both sides, with each nurse grasping firmly near the patient. (6) Nurses place their feet apart with a forward-backward stance. Nurses should flex knees and hips. On the count of three, nurses should shift their weight from front to back leg and move the patient and drawsheet to the desired position in the bed.

28. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent? a. Arm b. Hip c. Back d. Ankle

ANS: C Back injuries are often the direct result of improper lifting and bending. The most common back injury is strain on the lumbar muscle group. While arm, hip, and ankle can occur, they are not as common as back.

A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the mostpertinent 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 for the first time. Which action should the nurse take initially? a. Ask for at least two other assistive personnel to come to the room. b. Medicate the patient to alleviate discomfort while ambulating. c. Review the patient's activity orders. d. Offer the patient a walker.

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

The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education? a. "I should make sure the passage ways are wide" b. "I should remove all the throw rugs." c. "I should keep the lights dim." d. "I can use a cane to feel for objects in front of me."

ANS: C Bright lighting in hallways and stairways prevents falls by the patient who has limited vision. Furniture is placed to allow wide passageways. Throw rugs, which are a tripping hazard, are removed. If vision is severely limited, use of a cane or walking stick held slightly in front helps the patient feel objects in his/her path.

The nurse correctly recognizes which one of the following illnesses to trigger the broadest range of emotional and behavioral responses? a) Ear infection b) Mild concussion c) Rheumatoid arthritis d) Influenza

ANS: C Chronic, debilitating disease such as rheumatoid arthritis and severe illness can produce a broad range of emotional or behavioral responses in patients and their families. A short-term, self-limited illness that is not life threatening does not evoke emotions or actions that cause fundamental changes in daily lifestyle. More often, illnesses such as the flu, ear infections, and sore throats are viewed as minor irritations or inconveniences. They usually require a short-term adjustment in daily routines, and treatment of symptoms is the priority so that the individual can continue with normal activities. The emotional and behavioral changes associated with non-life-threatening illness are usually minimal, and the individual quickly returns to the previous baseline level of emotional functioning.

The nurse has been hired for a first job and is nervous about making errors in clinical judgment. It is important for the nurse to realize that clinical reasoning and the ability to make decisions in a clinical setting occurs at which time? a. When it has been instilled in the content covered in nursing school. b. When it is solely based in clinical experience. c. When it develops over time with increased knowledge and expertise. d. When it is an expectation of all nurses regardless of experience.

ANS: C Clinical reasoning uses critical thinking, knowledge, and experience to develop solutions to problems and make decisions in a clinical setting. A nurse's clinical-reasoning skills develop over time with increased knowledge and expertise.

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.

A patient from an unfamiliar culture appears disinterested when the physician is telling her about options for treatment of a new diagnosis. After the physician leaves, the nurse attempts to talk to the patient and notices the same behavior. What action by the nurse is best? a. Give the patient the information in writing to read later. b. Ask the patient about the meaning of the patient's behavior. c. Investigate nonverbal communication patterns of this group. d. Leave the patient alone to come to terms with the diagnosis.

ANS: C Communication differences can lead to misunderstandings and possible medical errors. Many cultural groups have verbal and nonverbal communication patterns that differ from other groups. Variations can occur due to personal or social situations. The nurse should attempt to learn about the cultural group's communication patterns. Giving the patient written material and leaving the patient alone do not help solve this dilemma, and the patient may not have the literacy skills to understand the material. Asking the patient the meaning of behavior is unlikely to elicit useful information because the patient herself may not totally understand it or be able to articulate it. This may be a deeply seated cultural custom that is simply part of who the patient is.

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

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

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 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.

The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism? a. "The patient should be allowed to decide." b. "As your nurse, I'll support your right to refuse." c. "You should do this because many could benefit from it." d. "If this is against your beliefs, you should not do it."

ANS: C Compared with deontology, utilitarianism is on the opposite end of the ethical theory continuum. Utilitarianism maintains that behaviors are determined to be right or wrong solely based on their consequences. Deontology is an ethical theory that stresses the rightness or wrongness of individual behaviors, duties, and obligations without concern for the consequences of specific actions. Meeting the needs of patients while maintaining their right to privacy, confidentiality, autonomy, and dignity is consistent with the tenets of deontology. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. The remaining responses are examples of either deontology or autonomy.

The nursing student is admitting a patient with abdominal distention and severe nausea. The provider orders the insertion of a nasogastric tube. The student reviews the procedure, gathers the supplies, and tells the instructor, "I'm ready to begin." Which critical-thinking trait suggests that the student is prepared for the task? a. Risk taking b. Curiosity c. Confidence d. Perseverance

ANS: C Confidence is feeling certain about one's ability to accomplish a goal. The student stating "I'm ready" indicates this. Risk taking involves being willing to try new ideas. Curiosity is being motivated to achieve and asking why. Perseverance is staying determined to work until the goal is achieved.

19. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of fluid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care.

ANS: C Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.

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.

The nurse is educating the family of a patient in the intensive care unit about the patient's cognitive status, including the current problem of delirium. Which statement by the family indicates a need for further education? a. "The delirium can be caused by sensory overload." b. "The delirium is reversible." c. "The delirium is a mood disorder." d. "The delirium is a state of confusion."

ANS: C Delirium is a reversible state of acute confusion. It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition. Delirium may occur in intensive care patients as a result of sensory overload. It is not a mood disorder.

In practice, the nurse has identified an observable phenomenon and wants to conduct research to generate a hypothesis through observation of the situation. The nurse knows what approach to be the best way for the nurse to conduct this type of investigation? a. Correlational research study b. Experimental research study c. Descriptive research study d. Quasi-experimental research study

ANS: C Descriptive research identifies data and characteristics about the population or phenomenon. Correlational research is used to explore a relationship between two variables. Experimental research explores the causal relationships between variables. Experimental research examines whether one variable has a cause-and-effect relationship with another. Quasi-experimental research examines a causal relationship between variables, but it may not meet the strict guidelines of experimental research.

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.

13. 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

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 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 is the nurse 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.

mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't understand! Why can't the doctor find out what is wrong with my child?" The nurse understands that this behavior is most likely an example of which defense mechanism? a. Suppression b. Sublimation c. Displacement d. Rationalization

ANS: C Displacement is an unconscious defense mechanism used to avoid conflict and anxiety by transferring emotions from one object to another object that is less anxiety-producing. The mother is upset that the health care team is not able to determine the cause of her child's illness and expresses her anger by kicking the trashcan. Suppression is the conscious decision to conceal unacceptable or painful thoughts. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities. Rationalization is the act of suggesting a different explanation for one that is painful, negative, or unacceptable.

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)?

What action should the nurse take to correct an error in paper charting? a. Remove the sheet with the error and replace it with a new sheet with the correct entry. b. Scribble out the error and rewrite the entry correctly. c. Draw a single line through the error write "error" above or after the entry, along with the nurse's initials. d. Leave the entry as is and tell the charge nurse.

ANS: C Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.

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 using 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 c. Electronic communication to assess a patient in another city 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. 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.

24. 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.

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

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.

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

ANS: C First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary.

The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates a good understanding of the information? a. "Remove the label from the bottle and throw in the trash." b. "Flush the medication down the disposal." c. "Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the trash." d. "Dissolve the medication in water and pour down the drain."

ANS: C Flushing or pouring the medication down the drain can contaminate the water system. Throwing the medication in the trash poses potential for someone to remove the medication and use it. This can be avoided by mixing it with an undesirable substance like kitty litter or coffee grounds.

A patient has hypertension and is on a very-low-sodium diet. However, the patient is going to celebrate an important religious holiday soon that includes many food items high in sodium. What action by the nurse is best? a. Tell the patient you are so sorry she can't have any of these foods. b. Consult with the prescriber about increasing the blood pressure medications. c. Collaborate with the patient and dietitian to include some of these foods. d. Tell the patient eating these foods once won't hurt her condition.

ANS: C Food has important meaning to many people, especially when they are part of celebrations, religious, or cultural activities. The nurse should collaborate with the patient and dietitian and try to find ways to incorporate some of these items. The nurse should not just tell the patient she can't have them. Increasing the medications or encouraging the patient to be nonadherent could lead to adverse outcomes.

When explaining delegation to student nurses, what statement by the nurse educator aligns to the ANA regarding delegation? a. A transfer of authority to a less-qualified individual b. The nurse transferring accountability to the delegate c. The transfer of tasks by the nurse while retaining accountability d. Transferring responsibility for assessments and planning

ANS: C For patient care to be completed in a safe and timely manner, it is sometimes necessary for the nurse to delegate tasks to other health care providers. The National Council of State Boards of Nursing (NCSBN) offers support in this process. In their joint statement (ANA and NCSBN, 2005), the ANA describes delegation as the transfer of responsibility, and the NCSBN calls it a transfer of authority. This transfer gives a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation. Any significant findings during the care such as alterations in skin integrity, shortness of breath, or changes in a patient's condition should be reported to the nurse. The nurse is then responsible for assessing the alterations and addressing them in the plan of care.

The nurse recognizes that patient goals include which characteristic? a. They are considered short-term if achieved within a month of identification. b. They always have established time parameters, such as "long-term" or "short-term." c. They are mutually acceptable to the nurse, patient, and family. d. They can be vague to facilitate flexibility when evaluating achievement.

ANS: C Goals are broad statements of purpose that describe the aim of nursing care. Goals represent short- or long-term objectives that are determined during the planning step. Some sources establish time parameters for short- and long-term goals, whereas others do not. According to Carpenito, goals that are achievable in less than a week are short-term goals, and goals that take weeks or months to achieve are long-term goals. Useful and effective goals have certain characteristics. They are mutually acceptable to the nurse, patient, and family. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient's capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation.

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.

The nurse recognizes that intentional behaviors to circumvent illness, detect it early, and maintain the best possible level of mental and physiologic function within the boundaries of illness is the definition of which term? a) Health promotion b) Self-actualization c) Health protection d) Self-transcendence

ANS: C Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness. Health promotion is behavior motivated by the desire to increase well-being and optimize health status. Maslow considered self-actualization the highest level of optimal functioning and involves the integration of cognition, consciousness, and physiologic utility in a single entity. In later years, Maslow described a level above self-actualization called self-transcendence. He refers to self-transcendence as a peak experience, in which analysis of reality or thought changes a person's view of the world and his or her position in the greater structure of life.

A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation, several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan? a. Risk b. Actual c. Health-promotion d. Potential

ANS: C Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk (potential) nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication.

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.

The nurse realizes that information technology (IT) can be used to increase patient safety in what way? a) By creating redundancy in orders making them safer b) By removing the need for verification by the nurse c) By analyzing errors to develop prevention strategies d) By eliminating the need for bar codes in medication administration

ANS: C IT can be used to increase patient safety. Errors are analyzed to develop strategies for prevention. Diagnostic test results are available faster to support treatment decisions and avoid redundancy in orders. When technology such as a bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made. After signing into the system or scanning his/her identification (ID) badge, the nurse electronically scans the bar codes of the patient ID, the medication administration record (MAR), and the drug to determine that the right patient is getting the right drug and dose at the right time. An alert signals a potential error, and it is the nurse's responsibility to verify all information before administration.

The ER nurse is triaging a patient with suspected poisoning. Who should the nurse anticipate contacting first? a. Family services b. Radiology c. Poison Control Center d. Respiratory

ANS: C If poisoning is suspected, the National Poison Control Center should be contacted immediately. This information will be needed to determine treatment. Respiratory may be needed, and radiology and family services may also be needed, but that will be determined after the treatment plan is determined.

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first? a. Notify the provider. b. Notify the wound care nurse. c. Stop the procedure. d. Give the patient pain medication.

ANS: C If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

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.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been 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 is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations should be carried out within which parameters? a. They must be done at the end of every shift. b. They should be done at least every 24 hours. c. They depend on intervention and patient condition. d. They are always done at time of discharge.

ANS: C In most cases, goal statements need to include a time for evaluation. The time depends on the intervention and the patient's condition. Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly. The health care setting affects the time of evaluation. If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly. At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan.

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 presents to the clinic for illness, and the sick role is legitimized by the provider. The nurse recognizes this as what stage of illness according to Suchman's Model? a) I b) II c) III d) IV

ANS: C In stage III (Medical care contact), professional advice from health care providers is sought by the individual. A professional health care provider identifies and validates the illness and legitimizes the sick role. During stage II (Assumption of the sick role), the person decides that the illness is genuine and that care is necessary. This stage gives an individual permission to act sick and to be excused temporarily from typical social and personal obligations. During stage I (Symptom experience), a clinical manifestation of disease is experienced, and the person acknowledges that something is wrong and seeks a cure. The outcome of stage I is that the person accepts the reality of symptoms and decides to take action in seeking care. During stage IV (Dependent patient role), the person, who is designated as a patient, usually undergoes treatment. During this stage, patients often feel dependent on others and may experience ambivalent or fearful thoughts that cause them to reject treatment, the advice of health care providers, and the illness.

The nurse is performing an abdominal assessment on a postoperative surgical patient. The nurse notes that the dressing needs to be changed twice a day and discusses when the patient would like to have it done. The nurse then plans to change the dressing at that time. In which phase of the nurse-patient helping relationship would this process occur? a. Introductory phase b. Orientation phase c. Working phase d. Termination phase

ANS: C In the working phase, there is the development of a contract or plan of care to achieve identified patient goals; implementation of the care plan or contract; collaborative work among the nurse, patient, and other health care providers, as needed; enhancement of trust and rapport between the nurse and the patient; reflection by the patient on emotional aspects of illness; and use of therapeutic communication by the nurse to keep interactions focused on the patient. In the orientation phase or introductory phase, introductions are made, establishing professional role boundaries (formally or informally) and expectations, and clarifying the role of the nurse. Identifying the needs and resources of the patient through observing, interviewing, and assessing the patient, followed by validation of perceptions also occur in this phase. Termination involves alerting the patient to impending closure of the relationship, evaluating the outcomes achieved during the interaction, and concluding the relationship and transitioning patient care to another caregiver, as needed.

22. A patient 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 patient 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

The registered nurse is providing an independent nursing intervention when completing which action? a. Administering oral medications b. Administering oxygen c. Providing emotional support d. Administering intravenous medication

ANS: C Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Repositioning a patient in bed, performing oral hygiene, and providing emotional support through active listening are examples of independent nursing interventions. Dependent nursing interventions are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary care provider to be implemented. Administering patient medications or administering oxygen to a patient are examples of common dependent nursing interventions that require clinical judgment before implementation. These interventions are based on a collaborative effort of the nurse and the physician to provide care to patients.

A nurse notes a patient has abnormal vital signs. What action by the nurse is best? a) Document the findings. b) Notify the provider. c) Compare with prior readings. d) Retake the vital signs in 15 minutes.

ANS: C Individual vital signs are not as important as the trends. For instance, a patient may have a blood pressure higher than "normal" that is normal for the patient. Trends give more useful information than a single reading. Documentation is important, but the nurse needs to do more. If the readings are significantly abnormal, the provider should be notified. The nurse may retake the vital signs if he/she is not confident of the first set of measurements, but should not wait for time to pass.

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

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

A patient is admitted to a skilled nursing facility with a closed head injury. The nurse believes that the patient has been pocketing food in his cheeks during the noon meal although she has not found any food pocketed. The nurse refers the patient to the speech therapist for a swallowing evaluation. The nurse is using which critical-thinking component in making this decision? a. Inference b. Deductive reasoning c. Intuition d. Inductive reasoning

ANS: C Intuition is the feeling that you know something without specific evidence. Inferences are intellectual acts that involve a conclusion being made on the basis of something. The accuracy of an inference is directly related to the accuracy of what the inference is based on. Deductive reasoning involves generating factors or details from a major theory, generalization, or premise (from general to specific) Inductive reasoning uses specific facts or details to make conclusions and generalizations; it proceeds from specific to general.

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding of these exercises? a. "An example of this type of exercise is walking." b. "An example of this type of exercise is running." c. "An example of this type of exercise is Kegels." d. "An example of this type of exercise is weight lifting."

ANS: C Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting.

Which assessment made by the nurse should be addressed first? a. Reddened area to coccyx b. Decreased urinary output c. Shortness of breath d. Drainage from surgical incision

ANS: C It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable tool for directing the nurse's thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing. The reddened coccyx, decreased urinary output, and surgical incision drainage are not immediately life threatening.

The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education? a. "I should keep the wheelchair locked unless using it to move Mom." b. "I should leave the bathroom light on as she does at her home." c. "I should leave her slippers by the wheelchair." d. "I should keep her cell phone close to her bed."

ANS: C Leave lights on or off at night, depending on the patient's cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

15. Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. A patient has the ability to grasp and apply the elastic bandage. b. A patient has sufficient upper body strength to move from a bed to a wheelchair. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

The nurse manager of the emergency room believes that efficiency is the expected standard for the department and believes that efficiency lies in following established rules, policies, and guidelines. The only way to change procedures is to changes rules, policies, and guidelines. To run the emergency room with this philosophy, the nurse manager must take on which role? a. Laissez-faire leader b. Democratic leader c. Bureaucratic leader d. Autocratic leader

ANS: C Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules. The permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. The authoritarian or autocratic leader exercises strong control over subordinates.

14. 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.

The nurse is providing care to a patient newly diagnosed with multiple sclerosis. When the patient expresses the desire to communicate with other people living with the disorder, the nurse refers the patient to which source? a) An e-mail list with the patient's contacts b) A social media blog c) A listserv concerning multiple sclerosis d) Facebook, Twitter, and LinkedIn

ANS: C Listservs can be used in health care to connect groups of patients with common problems or to send updated information to large groups. E-mail has become a common means of communication but would not be focused on the patient's issues. Social media include online technologies such as Facebook, Twitter, and LinkedIn that allow people to communicate easily by the Internet to share information and resources, but they are more general than listservs. These technologies enable a potentially massive community of participants to collaborate, providing a mechanism for tapping into collective power in ways previously unachievable. A blog is a social medium that is usually maintained by an individual and has regular entries of commentary, descriptions of events, or other material such as graphics or videos. Most blogs are interactive, allowing visitors to leave comments and message each other. Many blogs focus on health care issues.

The manager of the intensive care unit is accepting an award for excellence and efficiency in the provision of patient care. The manager accepts the award for the unit and cites the contributions of the staff since, without their expertise and dedication, the award may not have been achieved. The staff nurse recognizes the nurse manager is demonstrating which quality? a. Dedication b. Openness c. Magnanimity d. Creativity

ANS: C Magnanimity means giving credit where credit is due. Good leaders reflect the work and success of accomplishing a goal by crediting those who helped reach it. Dedication is the ability to spend the time necessary to accomplish a task. Effective leaders persist in working toward accomplishment of a goal even when doing so is difficult. Openness refers to the leader's ability to listen to other points of view without prejudging or discouraging them. An effective leader considers others' opinions with an open mind because a wider variety of solutions to problems is offered. Openness by the nurse leader encourages creative solutions by providing an environment in which people feel comfortable "thinking outside the box." Creativity is the ability to think differently. A creative leader examines all possible solutions to a problem even if at first glance they appear to be unrealistic or outside the norm. This ability allows the nurse leader to inspire followers to consider broader visions and goals.

A patient admitted after abdominal surgery has a Nursing diagnosis of risk for infection. The nurse identifies which goal to be most appropriate? a. Patient will ambulate length of hallway this shift. b. Patient will consume 20% of meals by the end of the week. c. Patient's incision will be without signs or symptoms of infection at discharge. d. Patient will verbalize need to stop antibiotics medication when symptom free.

ANS: C Maintaining skin integrity is an appropriate goal for this patient to ensure the patient does not develop a wound infection. breakdown be getting the patient out of bed, but it is not the priority goal for a patient with an incision. Consuming only 20% of meals will not ensure adequate nutrition and verbalizing the end of antibiotic administration to be when symptoms end is inappropriate. Antibiotics should be taken until the prescription is complete.

A group of nursing students are discussing the impact of nonnursing theories in clinical practice. The students would be correct if they chose which theory to prioritize patient care? a. Erikson's Psychosocial Theory b. Paul's Critical-Thinking Theory c. Maslow's Hierarchy of Needs d. Rosenstock's Health Belief Model

ANS: C Maslow's hierarchy of needs specifies the psychological and physiologic factors that affect each person's physical and mental health. The nurse's understanding of these factors helps with formulating Nursing diagnoses that address the patient's needs and values to prioritize care. Erikson's Psychosocial Theory of Development and Socialization is based on individuals' interacting and learning about their world. Nurses use concepts of developmental theory to critically think in providing care for their patients at various stages of their lives. Rosenstock (1974) developed the psychological Health Belief Model. The model addresses possible reasons for why a patient may not comply with recommended health promotion behaviors. This model is especially useful to nurses as they educate patients.

Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. A patient has the ability to grasp and apply the elastic bandage. b. A patient has sufficient upper body strength to move from a bed to a wheelchair. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

ANS: C 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 is caring for a patient who is complaining of tingling in the hands and fingers. The nurse knows this is a sign of what electrolyte imbalance? a. Hyponatremia b. Hypernatremia c. Hypocalcemia d. Hypercalcemia

ANS: C NURSINGTB.COM Tactile disturbances, such as tingling and numbness around the mouth and in the fingers, are signs of hypocalcemia. Mental changes are associated with both hypercalcemia and hypocalcemia. Both hypernatremia and hyponatremia have symptoms of central nervous system disorder.

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 from 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 nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse carries out which action? a. Avoid eye contact to appear less threatening. b. Demonstrate professionalism by not smiling. c. Sit close and leans in slightly toward the patient. d. Speaks in a slow rate of speech and low tone.

ANS: C Nonverbal behaviors of the nurse can influence the information obtained from the patient. Negative nonverbal cues such as distracting gestures (e.g., tapping a pen, swinging a foot, looking at a watch), inappropriate facial expressions, and lack of eye contact communicate disinterest. To establish a trusting relationship with the patient before the physical examination is conducted, the nurse should communicate professionally, sit close and lean in slightly toward the patient, listen attentively and demonstrate appropriate eye contact, smile, and use a moderate rate of speech and tone of voice.

The nurse needs to consider which approach when caring for patients with chronic illness? a) Help the patient face the reality that he will not get better. b) Emphasize to the patient that the illness is not his fault. c) Focus on improving quality of life through preventive behaviors. d. Acknowledge the limitations placed on the patient by his suffering.

ANS: C Nurses can help patients establish a daily routine of care by educating them about how to manage their care and the symptoms associated with the condition, including emergency or life-threatening situations. Emphasis is on improving quality of life through preventive behaviors. The attitude of being a victim, suffering with, or being afflicted by a chronic illness is viewed by nurses as a counterproductive behavior that needs positive intervention. Nurses can assist patients with strategies that help them cope with their chronic conditions and associated feelings of anger, frustration, and depression. Encouragement and positive support from a professional nurse can help individuals gain control over the alternating periods of health and illness and improve their quality of life.

Collaborating effectively with patients to find treatment methods that are congruent with the patients' belief systems and that promote healthy outcomes is an approach that requires the nurse to include which activity? a. Focus on patient values only and disregard family desires in setting goals. b. Rely more and more on their scientific background. c. Listen carefully to how the patient's beliefs impact their health beliefs. d. Understand that the nurse's beliefs are the most important.

ANS: C Nurses must collaborate effectively with patients to find treatment methods that are congruent with the patients' belief systems and that promote healthy outcomes. This approach requires excellent assessment skills and a willingness to listen carefully to determine how patients' personal beliefs impact their health beliefs. Failure to consider the patient's belief systems may result in ineffective implementation of the plan of care.

17. A nurse is charting. Which information 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, Lortab. d. The family is poor and had to go on welfare.

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 is preparing to administer an anticoagulant when the patient says, "Why do I have these bruises on my arms?" The nurse reviews the patient's blood tests and notes an abnormal bleeding time. When the nurse then decides to hold the medication and notify the health care provider, the nurse recognizes this to be an example of which action? a. Thinking aloud b. Reviewing the literature c. Applying knowledge d. Role playing

ANS: C Nursing practice is based on the application of knowledge to address patient problems. In this case, the nurse is able to connect the medication, physical signs and laboratory data to determine a course of action. Nurses may "think aloud" as an inner dialogue to examine their thinking. The literature review is used to address knowledge gaps through the review of scholarly journals. A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role playing, and then all are involved in the debriefing or discussion of the scenario.

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

ANS: C Objective data are observations or measurements of a patient's health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States "doesn't feel good," reports a headache, and nausea are all subjective data. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition.

The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint? a. Objective data from a primary source b. Objective data from a secondary source c. Subjective data from a primary source d. Subjective data from a secondary source

ANS: C Objective data consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.

The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding? a. "Occlusive dressings are used for autolytic debridement." b. "Hydrocolloids are a type of occlusive dressing." c. "Occlusive dressings can be used on infected wounds." d. "Occlusive dressings support the most comfortable form of debridement."

ANS: C Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

When the nurse is wearing sterile gloves, which action would result in the gloves becoming nonsterile? a. Fold gloved hands until procedure begins. b. Change a dressing using aseptic technique. c. Place sterile gloved hands below waist. d. Use correct protocol when donning sterile gloves.

ANS: C Once the hands have been placed below the waist, they can longer be considered sterile or free from organisms. Asepsis refers to freedom from disease-causing contamination. All other choices maintain asepsis.

23. 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 acronym PICO assists in remembering the steps to constructing a good research question and the nurse identifies that the "O" in the acronym refers to what term? a. Objectivity b. Ordinal approach c. Outcome d. Observer

ANS: C One method of formulating a research question is identified by the acronym PICO (i.e., patient, population, or problem; intervention; comparison intervention; and outcomes).

22. A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? a. Identifies patient with one identifier before transporting to x-ray department b. Initiates an intravenous (IV) catheter using clean technique on the first try c. Uses medication bar coding when administering medications d. Obtains vital signs to place on a surgical patient's chart

ANS: C One of the National Patient Safety Goals is to use medicines safely. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" intravenous (IV) pumps reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent infection; starting an IV should be a sterile technique, not a clean technique. While obtaining vital signs is a component of safe care, it does not meet a national patient safety goal.

The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. What should the nurse write as a problem statement for the Nursing diagnosis? a. Gastritis related to inflammation. b. Alterations in comfort and ability to void. c. Abdominal pain and nausea related to inflammation. d. Alteration in comfort related to restless leg syndrome and inflammation.

ANS: C One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. Abdominal pain, nausea, and inflammation (of the intestines) are clustered together.

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which technique would the nurse use to collect this data? a. Inspection b. Percussion c. Palpation d. Auscultation

ANS: C Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility? a. Patient will remain free of wound infections during the hospitalization. b. Patient will report pain management strategies and reduce pain to a tolerable level. c. Patient will be able to assist with position changes using over bed trapeze within 1 week. d. Patient will consume adequate nutrition to meet nutritional requirements within 1 week.

ANS: C Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

A patient wishes to review his medical record. What response by the nurse is best? a) "I'm sorry, we don't allow you to look at your chart." b) "Let me check to see if we can allow you to do that." c) "Yes, I can sit with you while you look at it, so you can ask questions." D). "Yes, all patients can review their charts at any time they wish."

ANS: C Patients have the right to look at their records. It is best if a health care provider is present to answer any questions the patient may have or to help interpret any information found within the record.

The nurse is preparing to assist the patient to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware? a. Constipation b. Depression c. Dizziness d. Pain relief

ANS: C Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse's ability to safely ambulate the patient.

The nurse knows practicing nursing without a license is what wrongdoing? a. Misdemeanor b. Statute c. Felony d. Tort

ANS: C Practicing nursing without a license is a felony. A misdemeanor is a minor crime, such as stealing an item from a patient that does not have much value. A statute is a law created by legislative bodies. Torts are crimes committed against another person. An intentional tort example is assault and battery. Negligence and malpractice are examples of unintentional torts.

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.

The nurse understands that based on a patient's perception of professional competence and caring, the nurse should wear which item? a. Large, dangling, hoop earrings b. Bright, multicolored acrylic fingernails c. Clean, neatly pressed uniform d. Offensive tattoos that cannot be covered

ANS: C Professional symbolic expressions often communicate self-worth and pride. A clean uniform demonstrates a competent and caring demeanor. Patients consistently judge health care professionals by their appearance. The use of large amounts of jewelry, fake fingernails, and visible body markings, including body piercings, are generally not considered appropriate attire in the nursing profession.

The nurse understands which rationale to be appropriate for drying a wound after irrigation? a. Ensure the new dressing adheres to the wound. b. Ensure the new dressing remains occlusive. c. Prevent skin breakdown from moisture. d. Prevent infection from irrigate solution.

ANS: C Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

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.

The nurse is caring for a patient who has been belligerent and is in 4-point "leather" restraints. When the patient continues to be verbally abusive and still tries to kick and punch staff even though he is restrained, the nurse should carry out which action? a. Do not attempt to meet patient needs until the patient has calmed down. b. Only provide care while security is in the room. c. Continue to attempt to meet the patient's needs. d. Inform the patient the police will be called if the patient's behavior does not stop.

ANS: C Provision 1.5 (of the Nursing Code of Ethics) states, "The principle of respect for persons extends to all individuals witNh whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict. The nurse should make all attempts to provide for the patient's needs. It is unrealistic to only provide care if security is present. Telling the patient that the police will be called is threatening.

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 nursing instructor asks the student nurse to identify what Robert Wood Johnson Foundation funded project that focuses on nurses' increased attention to patient safety? a. OSHA (Occupational Safety and Health Agency) b. MSDS (material safety data sheets) c. QSEN (Quality and Safety Education for Nurses) d. ADA (Americans with Disability Act)

ANS: C QSEN, or the Quality and Safety Education for Nurses, was funded by the RWJ to focus on preparing nurses of the future with the knowledge, skills, and attitudes to advance quality and safety on the job. MSDS are material safety data sheets, OSHA is the Occupational Safety and Health Agency, and ADA is the Americans with Disability Act.

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.

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

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

27. A patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse's next action? a. Refer to a mental health specialist. b. Refer to a wound care specialist. c. Refer to an ostomy specialist. d. Refer to 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 patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse's next action? a. Refer to a mental health specialist. b. Refer to a wound care specialist. c. Refer to an ostomy specialist. d. Refer to a dietitian.

16. The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? a. The patient continues to get up from the chair at the nurses' station. b. The patient gets restless when the sitter leaves for lunch. c. The patient folds three washcloths over and over. d. The patient apologizes for being "such a bother."

ANS: C Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding washcloths. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Getting restless when the sitter leaves indicates the alternative is not working.

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

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

What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system? a. Muscle weakness b. Muscle wasting c. Joint inflammation d. Joint spasticity

ANS: C Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range of motion (ROM) and abnormal movement patterns.

A nurse is caring for a patient who lost a large amount of blood during childbirth. The nurse provides the opportunity for the patient to maintain her activity level while providing adequate periods of rest and encouragement. Which nursing theory would the nurse most likely choose as a framework for addressing the fatigue associated with the low blood count? a. Watson Human Caring Theory b. Parse's Theory of Human Becoming c. Roy's Adaptation Model d. Rogers' Science of Unitary Human Beings

ANS: C Roy's Adaptation Model is based on the human being as an adaptive open system. The person adapts by meeting physiologic-physical needs, developing a positive self-concept-group identity, performing social role functions, and balancing dependence and independence. Stressors result in illness by disrupting the equilibrium. Nursing care is directed at altering stimuli that are stressors to the patient. The nurse helps patients strengthen their abilities to adapt to their illnesses or helps them to develop adaptive behaviors. Watson's theory is based on caring, with nurses dedicated to health and healing. The nurse functions to preserve the dignity and wholeness of humans in health or while peacefully dying. Parse's theory is called the Human Becoming School of Thought. Parse formulated the Theory of Human Becoming by combining concepts from Martha Rogers' Science of Unitary Human Beings with existential-phenomenologic thought. This theory looks at the person as a constantly changing being, and at nursing as a human science. Martha Rogers (1970) developed the Science of Unitary Human Beings. She stated that human beings and their environments are interacting in continuous motion as infinite energy fields.

A 40-year-old patient presents to her provider for a yearly physical. The provider notes a family history of breast cancer in the patient's mother. The provider schedules the patient for a mammogram. The nurse recognizes this as what level of prevention? a) Tertiary b) Primary c) Secondary d) Holistic

ANS: C Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

When planning to change a dressing on an anxious patient, the nurse recognizes which to be the best approach? a. Ask another staff member to perform the task. b. Tell the patient the dressing change will take 30 minutes. c. Schedule a time in collaboration with the patient. d. Review the physician's order prior to the procedure.

ANS: C Setting up a schedule to perform tasks helps to relieve patient anxiety and promotes a sense of security. Explaining the procedure and reviewing physician orders should be completed after establishing a schedule. Asking another staff member to change the dressing may increase patient anxiety.

The nurse recognizes conversations about safe sexual practices, including the consequences of unprotected sex such as pregnancy and sexually transmitted infections, are important to begin in what patient population? a. Adults b. School-aged children c. Adolescents d. Older adults

ANS: C Sexual curiosity and experimentation occur in the adolescent patient population. Conversations about safe sexual practices, including the consequences of unprotected sex, such as pregnancy and sexually transmitted infections, are important. These conversations are also important for adults and older adults but are handled differently in context with their age-related needs. School-aged children may be too young depending on their age and their environment. The nurse must use judgment on when to have the conversation.

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept? a. Protocol b. Clinical pathway c. Standing order d. Care map

ANS: C Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.

A nurse has been told he has many obvious stereotypes about a specific cultural group. What action by the nurse is best? a. Ask to not care for members of this cultural group. b. Ask to take care of as many members of this group as possible. c. Begin to educate himself on aspects of this cultural group. d. Vow to not allow his stereotypes to show when providing care.

ANS: C Stereotypes are fixed ideas, often unfavorable, about groups of people. They occur because of being unwilling to gather all the information needed to make fair determinations. The nurse would benefit most from beginning to learn about this cultural group. Caring or not caring for members of this group will not help him obtain new information. The nurse should not let stereotypes show, but this is not the best option.

The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do? a. Notify the health care provider. b. Hyperextend the joint. c. Stop the range of motion. d. Switch to active range of motion.

ANS: C Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient's joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen later.

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

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

The nurse is caring for a patient with lung disease. The patient tells the nurse that the most important thing to do during the shift is to walk down to the nurses' station and back without having shortness of breath. The patient's request is an example of which nursing theory? a. Leininger's Cultural Care Theory b. Boykin & Schoenhofer's Theory of Nursing as Caring c. Swanson's Theory of Caring d. Watson's Human Science and Human Care Theory

ANS: C Swanson's Theory of Caring is composed of five interrelated caring processes: having faith in the ability of others to have meaningful lives; striving to understand the meaning of events in other's lives; being emotionally present to the other person; doing for others what they would do if possible and facilitating or enabling the capacity of others to help themselves and their families. The patient's goal to walk without breathing problems is an example of the enabling process. Leininger's Cultural Care Theory centers on cultural practices that influence patient care. Boykin & Schoenhofer's theory focuses on the intentional and authentic presence of the nurse with another who is recognized as a person living caring and growing in caring. Watson's theory describes holistic care and focuses on caritas processes such as instilling faith and hope, promoting and accepting positive and negative feelings, and developing a helping-trust relationship.

4. 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 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."

A nurse is orienting to a new job in a home health care agency and is told that most of her patients need tertiary prevention. what activity does the nurse plan to include in the daily routine? a. Household safety checks b. Well-baby checkups c. Antibiotic administration d. Monthly blood pressure assessments

ANS: C Tertiary care is aimed at people who are already experiencing a health alteration, such as those with an infection who need antibiotics. The other options are secondary prevention.

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 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).

The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document? a. Electronic medical record (EMR) b. The computerized provider order entry (CPOE) c. Electronic health record (EHR) d. Primary provider's office notes

ANS: C The EHR is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings. The EMR is a record of one episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department. It does not provide historical data. The primary provider's office notes may not include all the patient's information if the patient has other providers.

The patient asks the nurse about how to evaluate websites and standards used to evaluate Internet health sites. The nurse appropriately refers the patient to which agency? a) The Computer Ethics Commission b) The U.S. Food and Drug Administration c) The Health on the Net Foundation d) The US Federal Trade Commission

ANS: C The Health on the Net Foundation focuses on the promotion and use of reliable online health information. The Computer Ethics Institute (CEI) was founded in 1985 to serve as a forum and resource for identifying, assessing, and responding to ethical issues associated with the advancement of information technologies and to facilitate the recognition of ethics in the development and use of computer technologies. The World Health Organization, the U.S. Food and Drug Administration, and the U.S. Federal Trade Commission are organizations that are consulted on efforts to promote credible online health care information and combat online health fraud.

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.

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out? a. The drain must be compressed after emptying to work properly. b. The drain must be connected to suction if ordered. c. The drain is not sutured in place so care is taken to not dislodge it. d. The suction pulls drainage away from the wound as it re-expands.

ANS: C The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

Which statement by the nurse correctly identifies the UAP role in patient restraint use? a. "The UAP can perform initial assessment." b. "The UAP can apply a restraint." c. "The UAP can assist with applying and monitoring of a physical restraint." d. "The UAP can contact the health care provider and request an order for restraints."

ANS: C The UAP cannot perform the initial assessment, and most facilities require that a registered nurse or licensed practical nurse. Applying a restraint. The health care provider should be contacted by the nurse, not the UAP. The UAP can assist with applying the restraint and can perform monitoring checks under the direction of a Registered Nursing.

The nurse knows the World Health Organization defines health in which of the following terms? a) The absence of disease b) The lack of infirmity c) Complete well-being d) Being independent of fiscal responsibility

ANS: C The World Health Organization offers a definition for health: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Nurses are responsible for helping patients reach their optimal levels of physiologic and mental health, but they also must provide health care in a system that requires cost containment and fiscal responsibility.

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.

During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which framework would the nurse most likely choose to document this data? a. Head-to-toe model b. Gordon's Functional Health Patterns c. Body systems model d. Cephalic-caudal model

ANS: C The body systems model organizes data on the basis of each system of the body. As this patient report is confined to the patient's leg pain, the nurse would document the data according to this model. Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of the body are assessed, including vital signs and other data not pertinent to this report by the patient. Gordon's Health Patterns allow the nurse to organize data in a holistic manner and reveals relationships between data. The cephalic-caudal model allows for a head to toe assessment.

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member? a) Counts pulse for 30 seconds and multiplies by two. b) Performs hand hygiene prior to patient contact. c) Compares pulses in both carotid arteries at the same time. d) Assesses pulse on one side then assesses the other side.

ANS: C The carotid arteries are the main supply route of blood to the brain. Compressing both sides of the carotid arteries at the same time can lead to ischemia. The other actions are appropriate.

A new 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 this 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 student nurse is preparing to auscultate a patient's lungs. What action by the student leads the instructor to intervene? a) Student asks to turn the television volume down. b) Student warms the bell of the stethoscope before use. c) Student uses the stethoscope bell to listen to bowel sounds. d) Student places the stethoscope diaphragm on the patient's skin.

ANS: C The diaphragm is used to listen to bowel sounds. The other actions are appropriate.

While the nurse is assisting with morning care, the patient has a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: C The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing? a. Assessment b. Diagnosis c. Implementation d. Evaluation

ANS: C The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

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

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

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 that color. It makes my hips stick out." c. "I'll wear the blue dress. It matches my eyes." d. "I will go to the pool next summer."

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.

21. 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.

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

ANS: C The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

25. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility? a. Delegates assessment of lung sounds to nursing assistive personnel b. Becomes solely responsible for modifying activities of daily living c. Consults physical therapy for strengthening exercises in the extremities d. Involves respiratory therapy for altered breathing from severe anxiety levels

ANS: C The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs. For example, physical therapists are a resource for planning ROM or strengthening exercises. Nurses often delegate some interventions to nursing assistive personnel, but assessment of lung sounds is the nurse's responsibility. Nursing assistive personnel may turn and position patients, apply elastic stockings, help patients use the incentive spirometer, etc. Occupational therapists are a resource for planning activities of daily living that patients need to modify or relearn. A mental health advanced practice nurse or psychologist should be used for severe anxiety.

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

ANS: C The nursing health history also includes a description of a patient's habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the patient's habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.

The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from local fast-food restaurants and plans a nutrition workshop. The nurse is applying which characteristic of the nursing process? a. Organization b. Dynamics c. Adaptability d. Collaboration

ANS: C The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse has planned actions based on the needs of this specific population. Organization is another key concept, however; there is no information in the stem on organization. A care plan should be dynamic, changing over time to meet changing needs. The nurse may or may not have to collaborate with other providers in planning and conducting the seminar, but that is another characteristic of a good nursing care plan.

Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient's condition changes the nurse should anticipate what concept? a. The nurse's thought processes do not have to vary. b. Plans of care are easier to use and do not need modification. c. The accuracy and effectiveness of thought processes must be considered. d. Reflective thought is not necessary since issues tend to be repetitive.

ANS: C The nursing process is cyclic rather than linear. As an individual patient's condition changes, so does the way a professional nurse thinks about that patient's needs, forcing modification of earlier plans of care. At each step of the nursing process, nurses must consider the accuracy and effectiveness of their thought process. This form of reflective thought is an essential aspect of critical thinking. The evolutionary nature of the nursing process allows nurses to adjust to changing patient needs. Plans of care must evolve as patients' needs change.

A nurse is caring for a patient with a stroke that has altered her ability to see. The nurse knows which area of the brain was likely impacted by the stroke that is responsible for visual function? a. Parietal lobes b. Frontal lobes c. Occipital lobes d. Temporal lobes

ANS: C The occipital lobes process visual information. The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell.

The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis impaired skin integrity? a. Patient will ambulate twice a day. b. Patient will eat 50% of meals. c. Patient will have no further skin breakdown. d. Patient will interact with others.

ANS: C The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

The nurse identifies which goal to be most appropriate for the Nursing diagnosis of acute confusion? a. The patient will use the call light before getting out of bed within 48 hours. b. The patient will use a calendar to remember the date within 48 hours. c. The patient will respond appropriately to questions about place within 48 hours. d. The patient will remain within the unit while in long-term care.

ANS: C The patient has acute confusion and therefore an appropriate early goal as the confusion resolves is to remember where they are. Remembering to use a call light would be appropriate for risk for falls. Using a calendar is appropriate for impaired memory and remaining in the unit is appropriate for chronic confusion.

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.

21. A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident? a. Pathogenic asepsis b. Medical asepsis c. Surgical asepsis d. Clean asepsis

ANS: C The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.

The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.) a. Use simple phrases. b. Speak loudly. c. Use yes/no questions. d. Use a picture board. e. Be patient and unrushed.

ANS: C, D, E If a patient has expressive aphasia, he or she understands language but is unable to answer questions, name common objects. The patient can answer yes/no questions by shaking the head. The patient might be able to point to pictures to express needs. For any type of aphasia, being patient and not rushing will make communication less stressful.

Nursing students are analyzing the following Nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated which response to be the etiology of the patient's problem? a. Patient verbalizations of pain b. Acute pain c. Pressure on lumbar spinal nerves d. Grimacing when walking

ANS: C The second part of the Nursing diagnosis consists of related factors (for actual Nursing diagnoses) and risk factors (for risk Nursing diagnoses). Related factors are the underlying cause or etiology of a patient's problem. Risk factors are environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern. In this case the acute pain is being caused by pressure on the lumbar spinal nerves.

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care? a. High Fowler's b. Prone c. Side-lying d. Low Fowler's

ANS: C The side-lying position should be used to prevent aspiration. The high Fowler's, low Fowler's, and prone position will not prevent aspiration.

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 identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect? a. Stratum germinativum b. Epidermis c. Subcutaneous layer d. Stratum corneum

ANS: C The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The nurse knows which essential step was added in 1991? a. Assessment b. Diagnosis c. Outcome identification d. Evaluation

ANS: C The term nursing process was first used by Lydia Hall in 1955. In 1973, the American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards of Clinical Practice (1991). These five steps—assessment, diagnosis, planning, implementation, and evaluation—define how professional nursing practice is conducted. Outcome identification was added as an essential aspect of the nursing process by the ANA in 1991. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.

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.

When creating a Nursing diagnosis, the nurse knows the related factor is based on what premise? a. It should be based on the medical diagnosis. b. It is unrelated to the pathophysiology causing the problem. c. It is the underlying etiology of the patient's situation. d. It does not reflect the nurse's understanding of pathophysiology.

ANS: C The underlying etiology, or cause of a patient's concern or situation, rather than a medical diagnosis, should be used as a related factor when writing a Nursing diagnosis. By doing so, the nurse articulates an understanding of the pathophysiology or situation with which the patient is faced.

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 bestresponse? 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.

The nursing student is writing a paper about the direct patient care role of advanced practice nurses. Which advanced practice role would the student include in the report? a. Nurse Administrator b. Clinical Nurse Leader c. Clinical Nurse Specialist d. Nurse Educator

ANS: C There are four specialties in which nurses provide direct patient care in advanced practice roles: certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and certified registered nurse anesthetist (CRNA). Four additional advanced practice roles that do not always involve direct patient care are clinical nurse leader (CNL), nurse educator, nurse researcher, and nurse administrator.

A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider? a. Social isolation b. Deficient community resources c. Ineffective community coping d. Deficient community health

ANS: C This diagnosis considers those in a community who may be feeling helpless, hopeless, or frustrated because of an extraordinary event. Financial and physical resources may not be available for rebuilding. Social isolation refers to unacceptable social behavior. Deficient community resources is not an approved diagnosis. Deficient community health may become a problem if sanitary conditions lead to an outbreak of disease.

Which statement by the patient indicates to the nurse a teaching need regarding safety in the home? a. "I will put a night-light in every room." b. "I will not use an extension cord to plug in multiple items." c. "I will wash my throw rugs in the bathroom regularly." d. "I will keep all cleaning supplies out of reach of children."

ANS: C Throw rugs present a fall or tripping hazard. Night-lights help light halls to prevent falls, extension cords can present a trip hazard, and cleaning supplies can contain poisonous materials.

The nurse is caring for a 6-month-old infant who has just undergone surgery. The infant's facial muscles are tight with a furrowed brow and the infant's respirations are shallow and irregular. The infant is mildly fussy and softly crying without muscular rigidity in the arms and legs. What score will the nurse give to the infant on the Neonatal Infant Pain Scale?

ANS: C Tight muscles and furrowed brow = 1 point. Softly crying = 1 point. Shallow, irregular respirations = 1 point. Relaxed arms and legs = 0 points. Mild fussiness = 1 point. Total = 4 points.

The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. The instructor identifies which Nursing diagnostic statement that is written incorrectly? a. Difficulty coping related to inadequate support systems as evidenced by patient's verbalization, "I don't have any friends or family in town. I just moved here a week ago." b. Activity intolerance related to immobility as manifested by shortness of breath and patient's verbalization of fatigue. c. Impaired sleep and lack of knowledge related to stress as evidenced by patient report of difficulty sleeping and lack of energy. d. Impaired self feeding related to upper extremity weakness as manifested by inability to get food onto spoon.

ANS: C To correctly formulate a nursing diagnostic statement, the student needs to cluster related data and choose one diagnosis per statement. In the incorrect example, two nursing diagnoses were combined in one statement.

The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation? a. "I should keep the noise levels low." b. "I should schedule all the care together." c. "I should keep the room well lit." d. "I should allow the family to visit."

ANS: C To prevent or alleviate overload, the nurse reduces sensory stimuli, dimming unnecessary lights and turning down the sound on alarms if possible. Nursing care is planned so that the patient is not constantly disturbed. Visitation by family provides reality orientation and a soothing, recognizable presence for some patients experiencing overload.

The unit charge nurse uses reward and punishment to gain the cooperation of the nurses assigned to the unit. What type of leader is this charge nurse? a. Transformation b. Autocratic c. Transactional d. Situational

ANS: C Transactional leaders use reward and punishment to gain the cooperation of followers. Transformational leaders use methods that inspire people to follow their lead. Transformational leaders work toward transforming an organization with the help of others. The authoritarian or autocratic leader exercises strong control over subordinates. Situational theories suggest that leaders change their approach depending on the situation.

The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education? a. "I should keep the home free of scissors." b. "I should minimize the number of visitors." c. "I should use push-button door locks." d. "24-hour supervision may become necessary."

ANS: C Use of door locks that require a key may be necessary if the patient wanders. Keep the environment free of hazards such as sharp objects and minimize distractions. If the patient is not safe to be left alone, 24-hour supervision may be necessary.

5. 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."

12. A toddler is going to have surgery on the right ear. Which teaching method is mostappropriate 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.

A toddler is going to have surgery on the right ear. Which teaching method is mostappropriate 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.

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 unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. What would be the best response by the nurse? a. "Maybe the patient doesn't think the show is funny." b. "Don't worry about it. The patient's daughter says this is normal." c. "I will go visit her right away and see what is going on." d. "Just document what you observe in your notes."

ANS: C Validating data is making sure that the data are accurate. As patient information is collected, consistency between subjective and objective data must be confirmed. Confirming the validity of collected data often requires verbally checking with the patient to see whether assumptions or conclusions at which the nurse arrived are correct. Crying, a disheveled appearance, and lack of eye contact may be cues of depression. However, conclusions about the underlying cause of the patient's actions cannot be assumed. All cues need to be interpreted and validated to verify the data's accuracy. The nurse cannot assume that this is normal behavior nor ignore the problem by making a joke. The nurse has the responsibility to attempt to determine the real reason for the crying episode.

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

ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

The nurse is discussing the use of a values clarification tool with a patient. The patient asks, "What is the goal of the values clarification tool?" Which is the best response by the nurse? a. "The tool will help change your value system so that you can make the right decision." b. "The tool will dispel your current beliefs and formulate brand new ones." c. "The tool will assist you in prioritizing your value preferences and help you make decisions." d. "The tool allows you to make decisions without the need of self-awareness."

ANS: C Values clarification is a process used to help people reflect on, clarify, and prioritize personal values to increase self-awareness or to make decisions. Nurses can use values clarification to help patients identify the nature of a conflict and reach a decision based on their values.

The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education? a. "I should fill my ice bag 2/3 full of ice." b. "I should use distilled water in my Aqua-K pad." c. "I can warm up my hot pack in the microwave." d. "I should check the order for how long to leave the compress on."

ANS: C Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating. Ice bags are filled two-thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

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.

The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary. The nurse replies, "I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me." The nurse's response is most likely related to which concept? a. Illogical thinking b. Bias c. Closed-mindedness d. Erroneous assumption

ANS: C When relevant information from patients or experts is ignored due to closed-mindedness, nursing care can be compromised. Closed-minded individuals often believe that their way is the best and preferred way. Illogical thinking is characterized by a failure to follow rational, systematic processes when approaching an issue or problem. Often making hasty generalizations and assumptions that do not consider the evidence, the illogical thinker may jump to conclusions. Decisions may be unduly influenced by bias, which is an inclination or tendency to favoritism or partiality. Bias may be related to a preconceived notion or prejudice against a group of people is important for nurses to examine personal biases because they can negatively impact care. Errors in thinking and decision making can result from intentionally overlooking alternatives suggested by others. Assumptions are beliefs that are taken for granted and assumed to be true. Assumptions can be unjustified or justified, depending on whether there are good reasons for them. Erroneous assumptions can lead to safety issues in the clinical setting.

When technology such as a bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made. The nurse knows that the proper procedure when using the BCMA includes which action? a) Signing into the system using the patient's ID number b) Typing in the patient's name and room number. c) Scanning the patient's ID, UMASR, and medication d) Discontinuing the medication if the system signals an error

ANS: C When technology such as a BCMA system is used as part of the process of medication administration, fewer errors are made. After signing into the system or scanning his/her ID badge, the nurse electronically scans the bar codes of the patient ID, the MAR, and the drug to determine that the right patient is getting the right drug and dose at the right time. An alert signals a potential error, and it is the nurse's responsibility to verify all information before administration.

22. 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.

1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reads the patient's plan of care. b. The student nurse reviews the patient's medical record. c. The student nurse shares patient information with a friend. d. The student nurse documents 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.

The nurse understands that which set of vital signs most likely indicates infection? a. T: 98.6 °F (37.0 °C), P: 75 beats/min, R: 18 breaths/min, BP 120/80 mm Hg b. T: 99 °F (37.2 °C), P: 80 beats/min, R: 18 breaths/min, BP: 110/70 mm Hg c. T: 100.5 °F (38 °C), P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg d. T: 98.9 °F (37.1 °C), P: 66 beats/min, R: 18 breaths/min, BP: 98/62 mm Hg

ANS: C With infection, temperature will rise and blood pressure will increase along with pulse and respiratory rate.

25. A nurse is teaching an older-adult patient about strokes. Which teaching technique is mostappropriate 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.

A nurse is teaching an older-adult patient about strokes. Which teaching technique is mostappropriate 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.

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication? a. A wound infection b. The stitches came loose c. Wound dehiscence d. Wound crepitus

ANS: C Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

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

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.

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

ANS: C You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests.

The nurse has assisted the patient to wash the hands, face, axillae, and perineal area. What type of bath does the nurse chart? a. Sink bath b. Complete bed bath c. Partial bed bath d. Shower

ANS: C A partial bed bath is performed when only part of the body is washed. A complete bed bath is for patients who are completely bedridden or are totally dependent on others for care. A shower is usually for patients who are strong enough to shower independently. A sink bath is when the patient washes while standing or sitting in front of a bath basin or sink.

The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first? a. A patient who is waiting for discharge teaching before going home. b. A patient who needs to be ambulated for the first time postoperatively. c. A patient who has not voided since the catheter was removed 8 hours ago. d. A patient who requires a daily dressing change to the surgical incision.

ANS: C urinary retention common after catheter removal and must be addressed promptly.

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.

The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities? (Select all that apply.) a. The top of the cane is level with the patient's bent elbow. b. The patient holds the cane on his/her weaker side. c. The patient moves the cane forward first. d. The patient's arm is comfortably bent when walking. e. The patient moves the strong leg forward first.

ANS: C, D The top of the cane should be level with the hip joint, and the patient's arm should be comfortably bent when the patient is walking. The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg. This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to one side or looking down can jeopardize safety and cause poor posture.

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.

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.

The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions would be included? (Select all that apply.) a. Verify bath water temperature is approximately 39.5 °C. b. Do not use hot or cold therapy on any extremity. c. Use sturdy shoes when walking outside or on hard surfaces. d. Report any changes in skin color on your legs to your health care provider. e. Set your water heater so that scalding is not possible.

ANS: C, D, E Bath water temperature should be approximately 37.8 °C (100 °F), so 39.5 (103.1 °F) is too hot. Hot and cold therapy should not be used on the affected extremities, although it can be used on other areas of the body. Sturdy shoes can prevent foot injuries when there is decreased sensation in the lower extremities. Any decrease in sensation, change in the color of the skin, or wounds are reported to the health care provider. Water heaters are set so that scalding is not possible.

The nurse understands that the five rights of delegation include which components? (Select all that apply.) a. Right patient b. Right time c. Right person d. Right supervision e. Right task

ANS: C, D, E Delegation principles focus on the appropriate intervention (task) being performed under the correct circumstances, by the correct personnel, and with the correct direction and supervision. The right patient and the right time refer to components of the "6 Rights" of medication administration.

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.

The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply.) a. Puts a picture board in the room to communicate with the patient. b. Places the call light on the patient's left side. c. Leaves a light on in the bathroom at night for good visibility. d. Places the call light on the patient's right side. e. Makes sure there are no trip hazards in the patient's room.

ANS: C, D, E If the damage is on the right side of the brain, there is loss of sensation and motor function in the extremities on the left side of the body and visual-spatial problems occur. Therefore, placing the call light on the side where the patient is likely to be strong is important. The patient will not necessarily have communication problems but might have visual problems, so the bathroom light is helpful. If the damage is on the left side of the brain, there is loss of sensation and motor function in the extremities on the right side of the body and problems with speech occur.

The nurse identifies what decisional roles that are included in Mintzburg's description of management in terms of behavior? (Select all that apply.) a. Figurehead b. Spokesperson c. Entrepreneur d. Resource allocator e. Negotiator

ANS: C, D, E Mintzberg described management in terms of behaviors. Underlying his descriptions were two assumptions: much of a manager's time is spent in human relations, and managers are more reactive than proactive. These assumptions provided the basis for three categories of behaviors: interpersonal roles, informational roles, and decisional roles. Mintzberg described three interpersonal roles: figurehead, leader, and liaison. The three informational roles he described are monitor, disseminator, and spokesperson. The third category of Mintzberg's behavioral roles comprises the four decisional roles: entrepreneur, disturbance handler, resource allocator, and negotiator.

The student nurse learns the ANA's Scope and Standards of Practice for public health nursing include components? (Select all that apply.) a. Team membership b. Developing research c. Ethical behavior d. Responsible resource use e. Advocacy

ANS: C, D, E The ANA's Scope and Standards of Practice for public health nursing requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy like the standards of practice for all nurses. Team membership and developing one's own research are not included.

4. The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take? (Select all that apply.) a. Ranks a patient as high risk for falls after patients takes 18 seconds to complete b. Teaches patient to rise from straight back chair using arms for support c. Instructs the patient to walk 10 feet as quickly and safely as possible d. Observes for unsteadiness in patient's gait e. Begins counting after the instructions f. Allows the patient a practice trial

ANS: C, D, F The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for unsteadiness in the patient's gait. For accuracy, a patient should have one practice trial that is not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

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.

The patient is on protective precautions. The nurse knows which statements are true regarding these precautions? (Select all that apply.) a. A positive-pressure room with a HEPA filtration system is required. b. Special respirator masks should be available and one size fits all. c. No live plants are allowed in the room. d. The patient may eat any foods desired. e. Everyone entering the room wears a mask.

ANS: C, E Protective precautions may require a positive-pressure room. No live plants, fresh flowers, fresh raw fruit or vegetables, sushi, or blue cheese may be brought into the room because they may harbor bacteria and fungi. The patient cannot eat just any foods because some are restricted. A mask is required for anyone entering the room and for the patient if leaving the room.

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

ANS: C, E Subjective data include patient's feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

The community health nurse knows that which are standards of professional performance for home care nurses according to the ANA? (Select all that apply.) a. Collegiality b. Performance appraisal c. Ethical behavior d. Outcome identification e. Resource utilization

ANS: C, E The ANA's Public Health Nursing: Scope and Standards of Practice (2013) requires participation in research, responsible resource utilization, ethical behavior, leadership, and advocacy similar to the standards of practice for all nurses.

When making rounds, the nurse finds a patient who is not able to sleep because of 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.

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

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

The nurse identifies which syringe to use when irrigating a patient's deep wound? a. 5-mL syringe b. 10-mL syringe c. 3-mL syringe d. 30-mL syringe

ANS: D A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.

4. 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."

20. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all four side rails in the "up" position. d. Keep the patient on fall risk until discharge.

ANS: D A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient's discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

The nurse correctly identifies which referral as an inappropriate nursing referral? a. Music therapist b. Community agencies c. Adaptive care services d. Dermatologist

ANS: D A primary care provider (PCP) may refer a patient to a medical or surgical specialist for further assessment, testing, or treatment. Nurses are often instrumental in initiating these types of referrals but do not complete the actual referral. Referral to a community agency is usually a collaborative action. Obtaining adaptive services and music therapy are independent nursing actions.

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 nurse identifies a clinical problem with pressure ulcers. 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.

The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the Nursing diagnostic label? a. Blood pressure, pulse rate b. Blood pressure, pulse rate, blood volume c. Blood pressure, pulse rate, blood volume, mental status d. Blood pressure, pulse rate, blood volume, mental status, dehydration

ANS: D All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians' orders, and documentation from health care providers. Verifying specific Nursing diagnoses for a particular patient or situation follows accurate analysis and clustering of data.

The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to be most important? a. Patient will ambulate twice a day. b. Patient will have no symptoms of infection. c. Patient will perform activities of daily living. d. Patient will have no injuries during hospital stay.

ANS: D All the goals except lack of infection are appropriate for a patient with a Risk for Falls diagnosis; however, the most important goal is for the patient to have no injuries during the hospitalization.

The nurse understands an institutional review board (IRB) is a review committee established to carry out what task? a. Approve research involving animal subjects. b. Approve research that is not government funded. c. Function differently than scholarly journals do. d. Protect the rights of human research subjects.

ANS: D An institutional review board (IRB) is a review committee established to help protect the rights and welfare of human research subjects. Regulations require IRB review and approval for research involving human subjects if it is funded or regulated by the federal government. Most research institutions, professional organizations, and scholarly journals apply the same requirements to all human research. The IRB must approve the research and procedure for data collection from human subjects.

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 skills

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.

The nurse is explaining to the patient why antibiotics are being administered. The answer would be correct if the nurse stated antibiotics are effective against which microorganism? a. Viruses b. Fungi c. Parasites d. Bacteria

ANS: D Antibiotics are effective against bacteria, and exact antibiotic sensitivity is tested so that appropriate antibiotics are prescribed. Infections that are caused by fungi are treated with antifungal medications. Certain antiviral medications are used to manage the symptoms of a viral infection. These medications, if given during the early phases of illness, can decrease the amount of time that the patient has viral symptoms. Treatment for parasitic infections varies depending on type of parasite.

The nurse is caring for a diabetic patient who has painful foot neuropathy. The patient asks why the nurse is administering gabapentin (Neurontin) when there is no history of seizure disorder. What is the nurse's best response? a. "Gabapentin will help you sleep at night so you can deal with the pain more effectively." b. "Long-term diabetes can put patients at risk for certain type of seizures." c. "This medication can help relieve your anxiety from being admitted to the hospital." d. "Gabapentin works on the nervous system to help relieve the burning pain in your feet"

ANS: D Anticonvulsant medication like gabapentin and tricyclic antidepressants are often used to relieve neuropathic pain as they work directly on the nervous system. The other statements do not correctly indicate why the patient is receiving this medication.

The nurse researcher audiotaped interviews with subjects and would like to play these tapes during dissemination. The nurse identifies what steps that may be required to play the tapes? a. Inform the participants that they cannot hear the tapes beforehand. b. None, if the tape is of a group, since there is no expectation of anonymity. c. None, since the tape is a direct "quote" and voice recognition is not controllable. d. A release will need to be obtained from the subjects.

ANS: D Any videos, photos, or audiotapes require releases if they are to be shown in the dissemination of research findings. The participantIs have the right to review these tapes before allowing them to be used for research. If subjects are involved in a group, they should be reminded that their exchange of information and identities must remain confidential. Participants' permission is needed if the data include quotations or can reveal the subject's identity.

2. 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 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

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).

When considering factors influencing health and the impact of illness, specifically age, the nurse would correctly identify which patient as having the greatest risk? a) 10-year-old girl b) 23-year-old woman c) 47-year-old man d) 85-year-old woman

ANS: D Assessment of the patient begins witIh risk factors that take into account the person's age and the associated level of immune system function. The very young, especially neonates and infants born prematurely, are more susceptible to infections because of the immaturity of their immune systems. Likewise, older adults have decreased immune system function because of the aging process. Older patients are at risk for opportunistic infections resulting from harmless organisms that become pathogenic and illness from the spread of community-acquired disease. Complications from comorbidities of chronic disease may also increase suffering in the aged population.

The nurse has received advanced orders for a patient who is being admitted from the emergency department (ED). The patient's name is Mr. Herman Goldstein. Trying to get ahead, of tasks, the nurse changes the patient's diet from "Regular" to "Kosher." When the patient reaches the unit, the nurse discovers that the patient is Catholic even though his father is Jewish. The nurse is guilty of giving in to which concept? a. Illogical thinking b. Bias c. Closed-mindedness d. Erroneous assumption

ANS: D Assumptions are beliefs that are taken for granted and assumed to be true. Assumptions can be unjustified or justified, depending on whether there are good reasons for them. Erroneous assumptions can lead to safety issues in the clinical setting. Illogical thinking is characterized by a failure to follow rational, systematic processes when approaching an issue or problem. Often making hasty generalizations and assumptions that do not consider the evidence, the illogical thinker may jump to conclusions. Decisions may be unduly influenced by bias, which is an inclination or tendency to favoritism or partiality. Bias may be related to a preconceived notion or prejudice against a group of people. It is important for nurses to examine personal biases because they can negatively impact care. Errors in thinking and decision making can result from intentionally overlooking alternatives suggested by others. When relevant information from patients or experts is ignored due to closed-mindedness, nursing care can be compromised. Closed-minded individuals often believe that their way is the best and preferred way.

The nurse is using a stethoscope to assess a patient's cardiac status. Which assessment technique is the nurse using? a. Inspection b. Percussion c. Palpation d. Auscultation

ANS: D Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound. Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.

Patients frequently seek sources for health information online, and nurses, as advocates, need to be prepared to help patients evaluate online sources. To do this, the nurse asks who sponsors the site, is the author listed, and the author's credentials. The nurse is evaluating what concept? a) Purpose b) Coverage c) Currency d) Authority

ANS: D Authority involves knowing who the sponsor or publisher is. Is this a personal page? Where does it come from? Is the author or organization listed? What are the author's credentials? Purpose is determining to focus of the site. Does the site inform? Explain? Share? Disclose? Sell? What is the intended audience? Coverage tries to determine if citations are correct. Is there a balance of text and images? Currency refers to when the site was created. How often is it updated?

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.

The nurse will be caring for a patient who has just arrived on the medical-surgical unit following surgical repair of his fractured right ankle. Which is the priority action of the nurse when the patient arrives on the unit? a. Instruct the patient how to call for assistance using the call light. b. Assess the color and warmth of the toes on the patient's right foot. c. Determine when the patient's next pain medication is due. d. Check pulse oximetry and obtain a full set of vital signs.

ANS: D Checking pulse oximetry and vital signs is the priority action when the patient first arrives on the medical-surgical unit from the postoperative area. The other actions can wait until the vital signs have been obtained.

The nurse is learning to identify readiness to learn in patients. Which patient would the nurse identify correctly as ready to learn? a. The patient requesting pain medication for treatment of severe discomfort b. The patient reporting nausea and vomiting c. The patient who was just told the diagnosis of cancer of the pancreas d. The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days

ANS: D Choosing opportunities when the patient's condition and environment are most conducive to learning is recommended when attempting to teach patients. Patients who are in pain, are nauseated, or who have been given recent traumatic diagnoses are not psychologically able to retain information.

The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain. Which nursing diagnosis is the highest priority for this patient? a. Impaired mobility r/t patient's need to use a cane or walker with ambulation b. Impaired health maintenance r/t sedentary lifestyle and poor physical condition c. Anxiety r/t mistrust of health care personnel d. Chronic pain r/t ongoing inflammatory tissue damage and joint destruction

ANS: D Chronic pain is the highest priority diagnosis for this patient because it is severe. The other diagnoses may be addressed once the patient's pain is controlled.

The nurse is reviewing data obtained through the health history interview and physical assessment of an assigned patient. Data collected include dry skin, brittle nails, weight gain, thinning hair, constipation, prolonged menstruation, and the patient's complaints of feeling tired and cold. The nurse recognizes which statement represents an appropriate data cluster? a. Prolonged menstruation, constipation b. Dry skin, brittle nails, weight gain c. Tired, cold, thinning hair d. Constipation, weight gain

ANS: D Clustering involves organizing patient assessment data into groupings with similar underlying causes. The nurse looks for cues among the data that support the diagnosis of a problem. One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. A person who has not had a bowel movement may experience weight gain. Skin, nails, and hair are components of the integumentary system. The subjective feelings of tired and cold are related and prolonged menstruation, as part of the reproductive system, is in a group by itself.

The patient asks the nurse to explain collaborative health care partnerships. The nurse gives a correct description when making which statement regarding collaborative care? a) Does not require participation of the patient. b) Is individual and cannot be mandated or legislated. c) Education needs are delegated to assistive personnel. d) Is designed to provide care to the patient as a whole.

ANS: D Collaborative health care partnerships are designed to deliver well-balanced care to the patient as a whole, rather than rendering fragmented care involving a single element of a disease process. Prevention is not solely the responsibility of the nurse; it involves active participation by the individual and the combined services of practitioners in a spectrum of health care disciplines as varied as nutrition, physical therapy, exercise physiology, and pharmacy. Collaborative preventive care can be mandated in the form of health care legislation, with rates for reimbursement of practitioners determined by the individual provider's ability to collaborate and develop innovative methods for delivering high-quality, cost-effective health care services. The role of the professional nurse is to collaborate and communicate health education to the patient and family, care provider, or surrogate. Patient education responsibilities are not delegated to assistive personnel or other members of the health care team and are considered a cornerstone of nursing care.

When providing the patient with routine hygienic care, which action would the nurse omit? a. Massage the back with lotion b. Oral care with a toothbrush c. Shaving with a disposable razor d. Ear hygiene with cotton-tipped applicators

ANS: D Cotton-tipped swabs or us Med in the ears for cleaning because this can push wax farther into the ears. A back massage may be given as part of a complete bed bath. Oral care is an essential nursing intervention that provides patient comfort, removes plaque and bacteria, reduces the risk of tooth decay, and decreases halitosis. Oral care includes brushing the teeth and tongue, flossing, rinsing the mouth, and cleaning dentures. Shaving a patient may be part of hygienic care and can be done with a disposable or electric razor.

7. 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.

The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient "wants his drugs," and is "non-compliant" at home with diabetic therapy. To reduce the risk of slander against this patient, the nurse should carry out which action? a. Write opinions in the medical record only. b. Never share observations. c. Make judgmental statements in private. d. Avoid making judgmental statements.

ANS: D Defamation of character occurs when a public statement is made that is false and injurious to another person. Oral defamation of character is slander. Slander is spoken information that is untrue, causing prejudice against someone or jeopardizing that person's reputation. The nurse should not make opinionated, slanderous comments about patients, orally or in writing. Written forms of defamation of character are considered libel.

The nurse frequently cares for patients who are nearing the end of life. The nurse identifies what strategy that is designed to prolong the time of death rather than restoring life? a. Establishing a do-not-resuscitate (DNR) order b. Adherence to living will requests c. Removal of extraordinary measures already in place d. Continuance of futile care

ANS: D Ethical dilemmas in end-of-life care exist regarding the establishment of do-not-resuscitate (DNR) orders, adherence to living will and organ donation requests, removal of extraordinary measures already initiated, and continuance of futile care (i.e., care that is useless and prolongs the time until death rather than restoring life).

The nurse recognizes which action to be a dependent nursing intervention? a. Utilizing heel protectors b. Preadmission teaching c. Medication reconciliation d. Oxygen administration via mask

ANS: D Dependent nursing interventions originate from health care provider orders. These interventions include orders for oxygen administration, dietary requirements, medications and diagnostic tests. The nurse incorporates these orders into the patient's overall care enact independent interventions has expanded in recent years, allowing nurses to initiate care that they recognize as essential in meeting patient needs or preventing complications. Utilizing heel protectors for patients susceptible to skin breakdown and initiating preventive measures (e.g., activity regimens, consultations with social workers, preadmission teaching) are often independent, nurse-initiated interventions. Collaborative interventions require cooperation among several health care professionals and unlicensed assistive personnel (UAP). Collaborative interventions include activities such as physical therapy, home health care, personal care, spiritual counseling, medication reconciliation, and palliative or hospice care.

25. 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. Call bell 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 prospective student is considering options for beginning a career in nursing. Which degree would best match the student's desire to conduct research at the university level? a. Associate Degree in Nursing (ADN) b. Bachelor of Science in Nursing (BSN) c. Doctor of Nursing Practice (DNP) d. Doctor of Philosophy in Nursing (PhD)

ANS: D Doctoral nursing education can result in a Doctor of Philosophy (PhD) degree. This degree prepares nurses for leadership roles in research, teaching, and administration that are essential to advancing nursing as a profession. Associate Degree in Nursing (ADN) programs usually are conducted in a community college setting. The nursing curriculum focuses on adult acute and chronic disease; maternal/child health; pediatrics; and psychiatric/mental health nursing. ADN RNs may return to school to earn a bachelor's degree or higher in an RN-to-BSN or RN-to-MSN program. Bachelor's degree programs include community health and management courses beyond thUoseSproNvidTed in an associate degree program. A newer practice-focused doctoral degree is the Doctor of Nursing practice (DNP), which concentrates on the clinical aspects of nursing. DNP specialties include the four advanced practice roles of NP, CNS, CNM, and CRNA.

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which Nursing diagnoses written on the care plan indicate a need for further instruction in constructing the diagnostic statement? a. Constipation related to immobility as manifested patient passing hard, dry stool with difficulty b. Activity intolerance related to weakness as evidenced by verbal report of fatigue. c. Impaired self feeding related to fatigue as manifested by inability to open containers and bring food to the mouth. d. Impaired airway clearance related to muscle weakness.

ANS: D Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The impaired airway clearance label is missing the defining characteristics.

The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The admitting provider orders bed rest. The patient tells the nurse, "I usually exercise three times a week. It helps me go to the bathroom." The nurse determines that the patient may have difficulty with bowel movements. Which Nursing diagnosis statement accurately reflects the nurse's concern? a. Constipation related to bed rest as manifested by hard, dry stools. b. Constipation resulting from reduced peripheral circulation manifested by patient's anxiety. c. Risk for constipation related to immobility as manifested by verbal complaint. d. Risk for constipation related to insufficient physical activity.

ANS: D Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. There are no data suggesting the patient is constipated at this time.

A nursing student wants to observe enculturation practices of an ethnic minority community. What action by the student is best? a. Attend a community dance. b. Learn to cook an ethnic meal. c. Visit the group's worship service. d. Observe a grandmother teaching a child.

ANS: D Enculturation is the process of passing a culture down from generation to generation. Culture can be taught directly, for instance, with the grandmother teaching the child. Culture can also be taught indirectly as when a child observes a role in the community. The student observing the grandmother teaching a child is the best example of enculturation.

When the nurse is charting in the paper medical record, what action does the nurse carry out? a. Print his/her name since signatures are often not readable. b. Omit nursing credentials since only the nurses chart c. Skip a line between entries so that it looks neat. d. Use black ink unless the facility allows a different color.

ANS: D Entries into paper medical records are traditionally made with black ink to enable copying or scanning, unless a facility requires or allows a different color. The date, time, and signature, with credentials of the person writing the entry, are included in the entry. No blank spaces are left between entries because they could allow someone to add a note out of sequence.

The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head "yes" when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication but uses herbs for treatment. What action by the nurse is best? a. Warn the patient of the consequences on noncompliance. b. Tell the patient how the medication will help the condition. c. Ask the patient why herbal preparations are preferred. d. Ask the patient to explain the meaning of the herbal products.

ANS: D Ethnocentrism is the belief that one's cultural beliefs are superior to others. To avoid practicing in an ethnocentric manner, the nurse needs to understand the meaning of the herbal preparation to the patient. Warning the patient of bad outcomes will not achieve the desired results if the herbs are culturally important and meaningful to her. Patient education is always important but is not the best answer because it does not allow the nurse to learn from the patient. Asking "why" question is a communication barrier likely to put the patient on the defensive.

The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should complete which next action? a. Ignore the patient's concern in evaluating goal attainment. b. Document the patient's unwillingness to continue the plan of care. c. Continue the plan of care as originally agreed upon. d. Modify the care plan in response to the patient's condition and wishes.

ANS: D Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. If a goal was not met, the care plan needs to be modified to avoid simply repeating the same actions. Ignoring the patient is not a therapeutic response. The nurse should respect the patient's fear and assess further without simply documenting that the patient is unwilling.

The nurse knows what fact to be the focus of evaluation, the final phase of the nursing process? a. The focus is recording the care that was implemented. b. The focus is medical and nursing goals for the welfare of the patient. c. The focus is long-term goals only. d. The focus is patient responses to interventions and outcomes.

ANS: D Evaluation is the final step in the nursing process. Evaluation focuses on the patient and the patient's response to nursingNinteRrveIntioGns aBnd.oCutcMome attainment. Evaluation is not a record of care that was implemented. Patient outcomes serve as the criteria against which the success of a nursing intervention is judged. During the evaluation phase, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and whether desired outcomes were achieved. Monitoring whether the patient's goals were attained is collaborative, involving the patient in the decision-making process.

A patient has been instructed in self-administration of insulin injections. The nurse observes the patient attempting to recap the needle and realizes that further teaching is needed. The nurse is applying which critical-thinking skill of the nursing process? a. Interpretation b. Analysis c. Inference d. Evaluation

ANS: D Evaluation occurs when information, including the reliability, credibility, and bias of the source, is assessed. Nurses also evaluate when determining whether the desired outcome for an intervention was achieved. Recapping the needle is not part of the desired outcome. Analysis includes investigating plans of action on the basis of examination of subjective and objective data. Interpretation is used to understand and explain the meaning

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.

2. A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a. Moves patient's arm in a full circle b. Moves patient's arm cross the body as far as possible c. Moves patient's arm behind body, keeping elbow straight d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed

ANS: D External rotation: With elbow flexed, move arm until thumb is upward and lateral to head. Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball- and-socket joint.) Adduction: Lower arm sideways and across body as far as possible. Hyperextension: Move arm behind body, keeping elbow straight.

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.

10. A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider? a. Loss of bone mass b. Loss of strength c. Loss of weight d. Loss of hope

ANS: D Loss of hope is a psychosocial aspect. Patients with restricted mobility may have some depression. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. All the rest are physiological aspects: bone mass, strength, and weight.

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

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 understands "First, do no harm" defines what ethical principle? a. Beneficence b. Justice c. Fidelity d. Nonmaleficence

ANS: D First, do no harm is the colloquial definition of nonmaleficence. Unlike beneficence, which requires actively doing good, nonmaleficence requires only the avoidance of harm. In its simplest form, beneficence can be defined as doing good. To do justice is to act fairly and equitably. Keeping promises or agreements made with others constitutes fidelity.

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.

42. The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for "ROM as needed." What should the nurse do next? a. Restrict patient's mobility as much as possible. b. Realize the patient is unable to move extremities. c. Move all the patient's extremities. d. Further assess the patient.

ANS: D Further assessment of the patient is needed to determine what the patient is able to perform. Some patients are able to move some joints actively, whereas the nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.

13. The nurse is observing the way a patient walks. Which aspect is the nurse assessing? a. Activity tolerance b. Body alignment c. Range of motion d. Gait

ANS: D Gait describes a particular manner or style of walking. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Body alignment refers to the position of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse.

4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action? a. Prevention of atelectasis b. Prevention of renal calculi c. Prevention of pressure ulcers d. Prevention of joint contractures

ANS: D Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM. ROM exercises reduce the risk of contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises reduced contractures and improved active range of joint motion in affected lower extremities. Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices to relieve pressure.

What response would the nurse provide to correctly identify the most effective method to prevent hospital-acquired infections? a. Use of sterile technique b. Isolation protocols c. Antibiotic use d. Handwashing

ANS: D Handwashing is the most effective method to prevent hospital-acquired infections. Sterile technique is only used for certain procedures and isolation protocols are used for patients already infected or for protective isolation in immune-compromised patients and are not used for every patient. Antibiotics are used to treat infections.

The nurse is assessing the patient's ability to hear and knows which is the correct procedure for the doing this? a. The nurse whispers to the patient while standing on each side of the patient. b. The nurse speaks in a normal voice while standing on each side of the patient. c. The nurse speaks in a normal voice while standing directly in front of the patient. d. The nurse speaks in a normal voice while standing slightly behind the patient.

ANS: D Hearing ability can be determined by observing the patient's conversation and responses and by talking with the patient in a normal conversational tone while standing slightly behind the patient. If the patient does not respond appropriately, a hearing impairment may exist. Standing in front of the patient allows the patient to read your lips and will not detect a hearing loss. A whispered voice will also give a false reading.

The nurse displays an understanding of high-risk populations for MRSA when identifying which group as the lowest risk? a. Prison inmates b. College dorm residents c. Team athletes d. Food service workers

ANS: D High-risk populations for MRSA include those living in close quarters or those who have frequent skin-to-skin contact, including prison inmates, college dorm residents, and team athletes. Food service workers work together but do not generally live in close quarters or have skin-to-skin contact frequently.

The nurse recognizes which nursing theorist who described the relationship between the nurse and the patient as an interpersonal and therapeutic process? a. Virginia Henderson b. Betty Neuman c. Imogene King d. Hildegard Peplau

ANS: D Hildegard Peplau focused on the roles played by the nurse and the interpersonal process between a nurse and a patient. The interpersonal process occurs in overlapping phases: (1) orientation, (2) working, consisting of two subphases: identification and exploitation, and (3) resolution. Betty Neuman's Systems Model includes a holistic concept and an open-system approach. The model identifies energy resources that provide for basic survival, with lines of resistance that are activated when a stressor invades the system. Virginia Henderson described the nurse's role as substitutive (doing for the person), supplementary (helping the person), or complementary (working with the person), with the ultimate goal of independence for the patient. Imogene King developed a general systems framework that incorporates three levels of systems: (1) individual or personal, (2) group or interpersonal, and (3) society or social. The theory of goal attainment discusses the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space. In this theory, both the nurse and the patient work together to achieve the goals in the continuous adjustment to stressors.

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound? a. A wound with a large amount of drainage b. A wound that is tunneling c. A postsurgical incision with staples d. A wound with a moderate amount of drainage

ANS: D Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, "I just don't feel good. I'm so hot and I feel sick to my stomach. Can you ask me those questions later?" What would be the best response by the nurse? a. "It will not take too long. I can hurry." b. "We need the information to complete your admission paperwork." c. "I will come back in a few minutes and we can start over." d. "Let me see if you can have something for the nausea and then talk later."

ANS: D If a patient being admitted to the hospital is too ill to interact for an extended period, the interview can be broken into smaller segments. Interviews with patients already hospitalized or established in the health care system are less extensive and more focused on newly identified patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority and often takes prior thought and planning by the nurse.

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline.

ANS: D If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

9. A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Altered nutrient metabolism

ANS: D Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis, leading to constipation.

The nurse knows changes in which body system affect overall mobility increasing the propensity of falling? a. Neurologic b. Hepatic c. Cardiopulmonary d. Musculoskeletal

ANS: D Impairments in the musculoskeletal system can impact mobility through restrictions of range of motion and strength, increasing the chances of falling. Changes to the neurologic system can impair cognitive functioning, changes to the hepatic system can affect mental status, and changes to the cardiopulmonary system can affect activity tolerance.

While conducting a controlled research study, the nurse wants greater assurance that the result is due to treatment itself and not another factor. For this purpose, the researcher should include what other component? a. A treatment group b. An independent variable c. A dependent variable d. A control group

ANS: D In a controlled study, some of the participants are assigned to the treatment group, and others are assigned to the control group by a random process. The control group does not receive the treatment. In the clinical trial of a medication, the control group receives a placebo. The purpose of a control group is to prevent bias and ensure that the outcome results from the treatment rather than some other factor. An independent variable is a concept or idea whose value determines the value of other (dependent) variables. In research, the independent variable comprises the experimental treatment or intervention, and it is manipulated by the researcher to yield various outcomes. The dependent variable is the outcome that is affected by manipulation of the independent variable.

The nurse identifies which nursing theorist/theorists who describes/describe the nurse-patient relationship as a situation in which the nurse and patient share the lived experience of caring? a. Kristen Swanson b. Jean Watson c. Madeleine Leininger d. Anne Boykin & Savina Schoenhofer

ANS: D In the Theory of Nursing as Caring (Boykin & Schoenhofer, 2015), caring is defined as "the intentional and authentic presence of the nurse with another who is recognized as person living caring and growing in caring" (Boykin & Schoenhofer, 2001, p. 13), and "the general intention of nursing as a practiced discipline is nurturing persons living caring and growing in caring" (Boykin & Schoenhofer, 2015, p. 343). One of the major concepts of the theory is the nursing situation in which theNnUuRrsSeIanNdGpTatBien.tCshOaMre the lived experience of caring. It is in this nursing situation that nursing is created and can best be understood. The model has been used in a variety of settings to guide practice, education, and research. Leininger describes patient care and its relationship to cultural diversity. Swanson's five caring processes include maintaining belief, knowing, being with, doing for, and enabling. Watson's Theory of Human Science and Human Care impacts both the person and the universe and is built upon 10 caritas processes.

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.

23. A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. 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 nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. Which technique is mostappropriate 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.

15. 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.

The nurse understands who is ultimately responsible for explaining the content of the informed consent? a. The registered nurse b. The hospital social worker c. Educated family members d. The provider of the procedure

ANS: D Informed consent is permission granted by a patient after discussing each of the following topics with the physician, surgeon, or advanced practice nurse who will perform the surgery or procedure: (1) exact details of the treatment, (2) necessity of the treatment, (3) all known benefits and risks involved, (4) available alternatives, and (5) risks of treatment refusal.

3. 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.

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 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

Which patient issue should the nurse address first? a. Pain b. Hunger c. Decreased self-esteem d. Absence of pulse

ANS: D It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable tool for directing the nurse's thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. In this situation, the patient needs CPR immediately dueIto the absence of a pulse. Pain, hunger, and decreased self-esteem are not life-threatening issues. Although the nurse must address them, pulselessness is the priority.

Which assessment of a patient who is 1 day postsurgery to 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.

The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and promptly administers the ordered anaIgesics as promised to the patient. This nurse has applied what concept? a. Autonomy b. Accountability c. Confidentiality d. Fidelity

ANS: D Keeping promises or agreements made with others constitutes fidelity. In nursing, fidelity is essential for building trusting relationships with patients and their families. Following through on promises is a critical factor in establishing strong professional relationships with patients and their families. Autonomy, or self-determination, is the freedom to make decisions supported by knowledge and self-confidence. Accountability is the willingness to accept responsibility for one's actions. Confidentiality is the ethical concept that limits sharing private patient information.

The nurse is determining the patient care assignments for a nursing unit. The nurse knows which responsibility may be delegated to the licensed practical nurse? a. Initiating the nursing care plans b. Formulating Nursing diagnoses c. Assessing a newly admitted patient d. Administering oral medications

ANS: D LPNs, or LVNs in California and Texas, are not RNs. They complete an educational program consisting of 12 to 18 months of training, and then they must pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) to practice as an LPN/LVN. They are under the supervision of an RN in most institutions and are able to collect data but cannot perform an assessment requiring decision making, cannot formulate a Nursing diagnosis, and cannot initiate a care plan. They may update care plans and administer medications except for certain IV medications.

After studying legal issues important to nursing, the student shows appropriate understanding with which statement? a. Laws change often, creating liability issues for nurses. b. Licensure laws are devised to protect the nurse. c. The nurse is not responsible for other disciplines' mistakes. d. Keeping current with changing laws can protect the nurse.

ANS: D Laws delineate acceptable nursing practice, provide a basis on which many health care decisions are determined, and protect nurses from liability in cases in which safe practice is maintained. Each state has a nurse practice act that establishes the standards of care required for legal nursing practice. Licensure, laws, rules, and regulations governing nursing practice are enforced to protect the public from harm. In many cases, the nurse is the last line of defense to prevent an error in medication administration or other types of patient care. Keeping current with changing laws related to nursing practice and technology can ensure safety for nurses and their patients.

The nurse has made patient care assignments and expects all team members to set their own goals for the day and manage their time to meet their goals. The nurse is implementing what style of leadership? a. Autocratic b. Democratic c. Bureaucratic d. Laissez-faire

ANS: D Like the democratic leader, the permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own decisions. The authoritarian or autocratic leader exercises strong control over subordinates. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of on established rules.

The nurse recognizes which intervention is not a form of mechanical debridement? a. Wet to dry dressings b. Whirlpool baths c. Wet to damp dressing d. Enzymatic dressing

ANS: D NURSINGTB.COM Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

Which collaborative team member would be most effective in assisting the nurse to identify medication alternatives that are less likely to cause drowsiness and dizziness to reduce the risk of falls in the elderly patient? a. Nursing case manager b. Charge nurse c. Physical therapist d. Pharmacist

ANS: D NURSINGTB.COM The nurse collaborates with the pharmacist and health care provider to identify and implement safe medication alternatives for older adults to minimize side effects such as drowsiness, dizziness, and orthostatic hypotension, which can increase fall risk. Although case managers and charge nurses might have some experience in this area, pharmacists are educated to focus on medication. Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking.

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).

A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by the nurse is most appropriate? a) Document the findings and continue the examination. b) Ask the patient about the use of artificial nails. c) Ask the patient about his/her occupation. d) Assess the patient for signs of hypoxia.

ANS: D Normal capillary refill is 2 to 3 seconds. Prolonged capillary refill can indicate hypoxia, anemia, or circulatory insufficiency. The nurse should document the findings, but further action is not needed. Asking about artificial nails and occupation are not warranted.

9. A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old b. 20/20 vision c. Urinary continence d. Orthostatic hypotension

ANS: D Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).

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

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.

Nurses working surrounded by computers and mobile IT must develop skills in the use of all available technology. At the same time, it is important for nurses to recognize what fact? a) The technology in use today will be the same tomorrow. b) Cell phones are not usually allowed in the acute care setting. c) Most forms of mobile technology are in violation of HIPAA guidelines. d) The technology supports bedside and remote charting.

ANS: D Nurses working surrounded by computers and mobile IT must develop skills in the use of all available technology. At the same time, it is important to recognize that the rapid advancement of IT means that the technology in use today may be entirely different tomorrow. Some facilities have computer access at every bedside, and others have mobile computers, sometimes called workstations on wheels (WOWs), that can be taken to each bedside. Nurses using technology as part of patient care need to work within facility policy and HIPAA guidelines. The technology supports bedside and remote charting. Nurses may use a portable device such as a smartphone or tablet computer to access reference materials, including medical information and vast amounts of drug information. Some facilities issue these devices to staff.

20. Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? 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.

The nurse is preparing to conduct a research study and is interested in exploring the lived experiences of nurses responsible for approaching patients and family members about the donation of organs. Which type of research would this be considered? a. Grounded theory b. Ethnography c. Historical d. Phenomenologic

ANS: D Phenomenologic research explores the reactions of a specific group of people who experienced a similar event in their lives. Grounded theory research derives theories from the data collected in studies. Ethnography focuses on the sociology of meaning through close field observation of a sociocultural phenomenon. The term ethnography is sometimes applied to the field notes or case studies produced from ethnographic research. Historical research studies historical documents to determine an accurate picture of a past event or time period.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? 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.

When applying research to practice, the nurse finds what information? a. It is usually easy to access information at the bedside. b. Research articles are clear in defining nursing practice. c. Bedside care is not directly related to research. d. Nursing research should be used to improve care.

ANS: D One obstacle to applying research to practice is the difficulty in bedside access to information by nurses. Nurses often lack the time to participate in research-related activities. By reading research articles, the nurse may notice discrepancies in what is recommended in current practice and what is found in the literature. Nurses often feel that their bedside nursing care is removed from the research process. However, nurses participate every day in the care of patients, which is based on the nursing process. Nurses should use research to improve the quality of patient care and should understand the research base before initiating nursing interventions.

What statement by the nurse is true regarding oral care of patients on anticoagulants? a. Use an electric toothbrush daily. b. Avoid oral care. c. Use mouthwash only. d. Use a soft-bristled toothbrush.

ANS: D Oral care is important regardless of medication, but a soft-bristled toothbrush should be used related to increased risk of bleeding for any patient on an anticoagulant. An electric toothbrush is too aggressive

3. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? a. Each movement is repeated 5 times by the patient. b. Each movement is performed until the patient experiences pain. c. Each movement is completed quickly and smoothly by the nurse. d. Each movement is moved just to the point of resistance by the nurse.

ANS: D Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated 5 times during the session. The patient moves all joints through ROM unassisted in active ROM.

The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. The nurse recognizes which characteristic of the nursing process most represents this decision? a. Organization b. Dynamics c. Adaptability d. Outcome orientation

ANS: D Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population.

The nurse is caring for a patient who has had abdominal surgery and has developed a slight temperature. The nurse identifies which statement to be a patient-centered goal? a. The patient's temperature will return to normal within 24 hours. b. The nurse will medicate the patient for elevated temperature every 4 hours as needed. c. Skin integrity will be maintained until the patient is ambulatory. d. The patient will ambulate 10 feet by postoperative day 2.

ANS: D Patient-centered goals are written specifically for the patient. The goal should specify the activity the patient is to exhibit or demonstrate to indicate goal attainment. These goals are written to reflect patient, not nursing, activities. Instead of focusing on the patient, the incorrect answers focus on the patient's temperature, the nurse medicating the patient, and the patient's skin integrity. Only option D focuses on the patient.

The nurse is asked to shave a patient who is taking warfarin (Coumadin). What is the most appropriate action? a. Refuse to shave the patient because he is on an anticoagulant. b. Shave as usual with a safety razor. c. Offer to wax rather than shave the patient. d. Use an electric razor.

ANS: D Patients on anticoagulants should use an electric razor for shaving to avoid bleeding complications. Patients should have the option of shaving if they would like to shave. Waxing may not be an option.

Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient? a. Nurse b. Physical therapist c. Occupational therapist d. Podiatrist

ANS: D Patients with diabetes are usually seen by a podiatrist or diabetic specialist for foot care needs. Nurses can trim toenails of patients not at risk for infection. Physical therapists provide services that restore function and mobility. Occupational therapists use treatments to maintain or restore daily living and work skills.

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing? a. Patient with asthma b. Patient with attention deficit hyperactivity disorder c. Patient with a stroke d. Patient with diabetes

ANS: D Patients with neurologic deficits such as peripheral neuropathy resulting from diabetes may not be able to identify extremes of hot and cold. Patients with attention deficit hyperactivity disorder and asthma are not likely to be injured by temperature extremes. Patients with a stroke may have some alteration in sensation on one side of their body but can compensate by using the other side, and they are at less risk than a patient with diabetes.

The nurse is reviewing the last 3 days of a patient's pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the provider for furtherUordSers.NIn Tthis scenOario, which process is the nurse is using? a. Decision making b. Reasoning c. Problem solving d. Judgment

ANS: D Processes dependent on critical thinking include problem solving, decision making, reasoning, and judgment. Judgment is the process of forming an opinion by comparing solutions through reasoning. The nurse observes that the patient's pain level is not decreasing and further assesses the pain level through discussions with the patient. The nurse concludes that the patient's pain should be further addressed and contacts the provider. Decision making requires choosing a solution to a problem. The student is making a decision by reviewing two pertinent resources related to the removal of staples. Reasoning is the process by which a nurse links thoughts, ideas and facts together in a logical way. A systematic approach in finding solutions is termed problem solving.

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

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

The nurse is reviewing a research study that includes data in the form of numbers and recognizes that this is likely to be what type of study? a. Qualitative b. Experimental c. Quasi-experimental d. Quantitative

ANS: D Quantitative research usually produces data in the form of numbers. Experimental research explores the causal relationships between variables. Experimental research examines whether one variable has a cause-and-effect relationship with another. Quasi-experimental research examines a causal relationship between variables, but it may not meet the strict guidelines of experimental research. Qualitative research is based on a constructivist philosophy, which assumes that reality is composed of multiple socially constructed realities of each person or group and is therefore value laden, focusing on personal beliefs, thoughts, and feelings.

The nurse has finished a shift and is on the way home. During the shift, one of the patients attempted to climb out of bed and fell. When the nurse is returning home and is thinking about what could have been done differently to be prevent the fall, this would be an example of what concept? a. Evidence b. Standards c. Attributes or traits d. Reflection

ANS: D Reflection is an effective tool that enables students and nurses to think about how best to improve their future caregiving in similar situations. The results of deliberate thinking are used to guide further thinking. Identification and use of evidence is necessary to guide analysis of situations and decision making. Nursing practice must be based on evidence gained through research and review of findings. Some personal characteristics are associated with critical thinking. Critical thinking needs to be assessed and evaluated according to standards to ensure the quality of thinking. Nursing practice is based on standards established by the American Nurses Association in areas such as the nursing process, ethics, education, research, communication, leadership, and collaboration.

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.

The nurse is caring for an adult patient with a recent below-the-knee amputation. During shift report, the nurse reports that the patient has urinated in the bed multiple times since the surgery. The nurse knows which defense mechanism best describes this behavior? a. Compensation b. Denial c. Rationalization d. Regression

ANS: D Regression is the return to an earlier developmental stage as a means of avoiding unpleasant or unacceptable thoughts. The adult patient recently lost a limb and reverted to bedwetting as a coping mechanism. Compensation refers to a strategy that uses a personal strength to counterbalance a weakness or a feeling of inadequacy. Refusing to accept a fact or reality as truth is termed denial. Rationalization is the act of suggesting a different explanation for one that is painful, negative, or unacceptable.

The nurse is caring for a patient scheduled for a heart catheterization. During shift report, the nurse describes an overheard telephone conversation regarding the patient's HIV-positive son-in-law. The nurse recognizes that this information should be evaluated for which characteristic? a. Accuracy b. Depth c. Breadth d. Relevance

ANS: D Relevance is focusing on facts and ideas directly related and pertinent to a topic—how is this related to the question? The son-in-law's HIV status has no bearing on the patient's care. Accuracy involves representing something in a true and correct way. Depth is getting beneath the surface of the topic or problem to identify and manage related complexities, whereas breadth involves considering a topic, problem, or issue from every relevant viewpoint.

A patient complains that several staff members entered the room during the morning bath without knocking. Which component of professional nursing communication has been violated in this scenario? a. Collaboration b. Advocacy c. Assertiveness d. Respect

ANS: D Respect for the patient includes providing privacy during procedures such as a bath. It is considered respectful to knock on a patient's door prior to entering the room. Assertive communication allows for the expressions of feelings and ideas without hurting or judging. Collaboration refers to the interactions with patients and health care workers to accomplish mutually acceptable goals. Advocacy involves defending the rights of others, especially those who are vulnerable or unable to make decisions independently.

The nurse knows which method to be an appropriate way to tie restraints? a. Knot tied to the bed frame b. Quick-release knot tied to the side rail c. Bow tied to the bed rail d. Quick-release ties attached to the bed frame

ANS: D Restraints should never be tied in a knot because the knot may prohibit a quick exit in the event of an emergency requiring evacuation. Instead, use quick-release ties or mechanisms such as buckles. Restraints are never be tied to side rails because injuries may result when they are raised or lowered. They should be tied to a stable part of the bed such as the frame.

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 observes a confused patient pacing back and forth in the dining room. The patient yells, "The doctor is going to make us all drink poison!" The most appropriate intervention by the nurse at this time would be to take what action? a. Ask the patient why he would say something like that. b. Change the subject to disrupt the patient's thought process. c. Tell the patient that he should probably think of something else. d. Quietly ask the patient to explain the statement.

ANS: D Seeking clarification encourages the patient to expand on a topic that may be confusing or that seems contradictory. Asking "why" questions implies criticism, may make the patient defensive, tends to limit conversation, requires justification of actions, and focuses on a problem rather than a possible solution. Changing the subject avoids exploration of the topic raised by the patient and demonstrates the nurse's discomfort with the topic introduced by the patient. Giving advice implies a lack of confidence in the patient to make a healthy decision.

Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. Which additional point does the nurse the nurse recognize as part of the definition of self-concept? a) If negative, self-concept will allow the patient to compensate for weaknesses. b) If positive, self-concept will cause the patient to see challenges as devastating. c) Self-concept is a concept that is derived from the patient internally. d) Self-concept depends on relationships with family and friends.

ANS: D Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. It is a mental image of self in relation to others and the surroundings. If the image is positive, the person will develop strengths, compensate for weaknesses, and experience life in a healthy way. If the image is negative (e.g., frail), the person will find life's challenges devastating and sometimes insurmountable. The impact of illness on the self-concept of a patient and the patient's family members depends on how secure the parties' relationships are with one another.

The nurse is providing care for a patient of the Jehovah's Witness faith. Based on the nurse's knowledge of the patient's religious beliefs, the nurse would question which order? a. Obtain vital signs every shift. b. Regular diet as tolerated. c. Activity as tolerated. d. Infuse 1 unit packed red blood cells.

ANS: D Some interventions may be declined because of religious affiliation (e.g., blood transfusion for a Jehovah's Witness, pork-based insulin for a Muslim patient).

18. The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Dirty floors, hallways blocked, medication room locked, and alarms set c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

ANS: D Specific risks to a patient's safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient- inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly.

A nurse is told in hand-off report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient's Glasgow Coma Scale to be? a) 7 b) 9 c) 11 d) 13

ANS: D This patient's eye opening would be scored 4, verbal response would be 4, and motor response would be scored at 5; this equals a score of 13.

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 patient is transported to the emergency department from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient's son for additional health history information. Information provided by the son would be considered which type of data? a. Primary, objective data b. Primary, subjective data c. Secondary, objective data d. Secondary, subjective data

ANS: D Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data. Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Primary data come directly from the patient.

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.

1. 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

The nurse identifies which statement to be true regarding nursing documentation? a. Standards for documentation are established by a national commission. b. Medical records should be accessible to everyone. c. Documentation should not include the patient's diagnosis. d. High-quality nursing documentation reflects the nursing process.

ANS: D The ANA's model for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards for documentation are established by each health care organization's policies and procedures. They should be in agreement with The Joint Commission's standards and elements of performance, including having a medical record for each patient that is accessed only by authorized personnel. General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2017) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment.

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. 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.

The nurse is preparing a patient teaching plan and is seeking a way to determine the patient's readiness and motivation to act regarding lifestyle changes to best manage diabetes mellitus. Which model would be useful for this nurse? a) Maslow's hierarchy of needs b) Holistic Health Model c) Health Promotion Model d) Health Belief Model

ANS: D The Health Belief Model was developed by psychologists Hochbaum, Rosenstock, and Kegels. It explores how patients' attitudes and beliefs predict health behavior. Maslow's hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development. The model is most often presented as a pyramid consisting of five levels. The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity. Holistic Health Models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment. Holistic care is an approach to applying healing therapies. Holistic models focus on the interrelatedness of body and mind. The Health Promotion Model, developed by Pender and colleagues, defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state.

The nurse manager would counsel the staff nurse for delegating which task to the UAP? a. Personal hygiene b. Assistance with eating breakfast c. Assistance with toileting d. Interpretation of abnormal vital signs

ANS: D The RN must remember to delegate tasks that do not require nursing judgment. Interpretation of abnormal vital signs requires assessment skills possessed by the RN only. Only tasks that are routine and do not require variation from a standardized procedure, such as providing hygiene, assisting with eating, and toileting, should be delegated.

The nurse is delegating frequent blood pressure (BP) measurements for a patient admitted with a gunshot wound to a licensed practical nurse (LPN). When delegating, the nurse understands which fact? a. He/she may assume that the LPN is able to perform this task appropriately. b. The LPN is ultimately responsible for the patient findings and assessment. c. The LPN may perform the tasks assigned without further supervision. d. He/she retains ultimate responsibility for patient care and supervision is needed.

ANS: D The RN retains ultimate responsibility for patient care, which requires supervision of those to whom patient care is delegated. In the process of collaboration, the nurse delegates certain activities to other health care personnel. The RN needs to know the scope of practice or capabilities of each health care member for delegation to be effective and safe.

31. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

ANS: D The administration of ipecac syrup or induction of vomiting is no longer recommended for routine home treatment of poisoning. The nurse must intervene to provide additional teaching. All the rest are correct and do not require follow up. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the substance is eliminated. Loss of consciousness associated with poisoning requires calling 911.

24. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? a. Determining the need for restraints b. Assessing the patient's orientation c. Obtaining an order for a restraint d. Applying the restraint

ANS: D The application and routine checking of a restraint can be delegated to nursing assistive personnel. The skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. A nurse must obtain an order from a health care provider.

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

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

23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures.

ANS: D The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more able to move. Pain must be controlled so the patient will not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM.

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

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

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

The nurse understands that the focus of nursing informatics is which concept? a) Direct patient care b) Increasing documentation time c) The introduction of different EHRs d) How patient care can be improved

ANS: D The focus of nursing informatics is not on direct patient care but on how the process of patient care can be improved and patient safety ensured. Documentation time has decreased by using informatics. Different EHRs are used in different facilities.

The nurse is performing perineal care for the uncircumcised patient. Which action does the nurse take? a. Does not move the foreskin. b. Retracts the foreskin, pulling it away from the body. c. Leaves the foreskin retracted, allowing it to return to position naturally after care. d. Retracts the foreskin and returns it to its natural position after cleaning, rinsing, and drying.

ANS: D The foreskin must be returned to its normal position after cleaning to prevent contraction and swelling. It is okay to move the foreskin to clean the penis. To retract the foreskin, gently push it toward the body. It should be returned to its position by the nurse, not left to return on its own.

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

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.

The nurse has implemented a community-wide immunization program for seasonal influenza. Once the program has ended, what action by the nurse is best? a. Begin planning for next year's program. b. Send mail surveys to participants. c. Determine financial gains or losses. d. Evaluate the program and outcomes.

ANS: D The last step of the nursing process is evaluation. The nurse should evaluate the program to see if interventions had the desired effect. Evaluation could include surveys or looking at financial outcomes, but those are only limited aspects of the process. Planning for next year's event should not occur until after evaluation has been completed.

What fact is the nurse aware of when charting using paper nursing notes? a. Use red ink so the nursing entries stand out. b. When mistakes are made in documentation, the nurse should white out the entry. c. Only one nurse should document on a sheet so that it can be removed in case of error. d. The medical record, in any format, is the most reliable source of information in a legal action.

ANS: D The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Ink color is usually black, blue or other as designated by the facility. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.

The nurse identifies which true statement regarding the medical record? a. It serves as a major communication tool but is not a legal document. b. It cannot be used to assess quality of care issues. c. It is not used to determine reimbursement claims. d. It can be used as a tool for biomedical research and provide education.

ANS: D The medical record promotes continuity of care and ensures that patients receive appropriate health care services. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters. It is a clinical data archive. The medical record serves as a tool for biomedical research and provider education, collection of statistical data for government and other agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and regulations for standards of care. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters.

The nurse is caring for a patient who is unable to take oral medications because of persistent nausea and vomiting. When the nurse decides to call the primary care physician and ask for a different medication administration route, this is a demonstration of what act? a. Collaboration b. Delegation c. Assertiveness d. Advocacy

ANS: D The nurse acts as a patient advocate by promoting what is best for the patient and ensuring that the patient's needs are met. Since the patient is unable to take medications by mouth, it is the nurse's responsibility to inform the physician and obtain alternative medication routes, as appropriate. Assertive communication allows for the expressions of feelings and ideas without hurting or judging. Collaboration refers to the interactions with patients and health care workers to accomplish mutually acceptable goals. Delegation is the art of transferring responsibility of an assigned task to another while at the same time retaining accountability for the outcome.

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

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question.

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

ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's report of a problem or postpone it till the next shift.

The nurse is assessing a patient's alcohol intake. What question is most appropriate? a) "Do you drink alcohol at all?" b) "You don't drink much do you?" c) "When was your last drink?" d) "How much alcohol do you drink daily?"

ANS: D The nurse needs to be nonjudgmental when inquiring about topics that might be sensitive, such as alcohol or drug use. The nurse asks a neutral, objective question such as "How much alcohol do you drink daily?" that allows the patient to quantify the intake. Avoid yes/no questions because they are closed ended and do not lead to further discussion or disclosure. Avoid a negatively charged question such as, "You don't drink much, do you?"; this demonstrates the nurse's displeasure with drinking. Asking when the last drink was is not as important in a general survey as quantifying the amount of intake.

The nurse is concerned about helping the patient find resources to obtain assistive equipment to be used in the home. Which team member should the nurse contact first? a. Occupational therapist b. Physical therapist c. Health care provider d. Social worker

ANS: D The nurse should collaborate with the social worker to identify community resources for obtaining assistive equipment. The social worker facilitates contact with insurance companies or other agencies to assist with the financing of recommended therapeutic assistive and specialty devices. Occupational therapists evaluate the patient for safe performance of activities of daily living (ADLs) such as bathing, dressing, and grooming, and they make recommendations to enhance safe performance of these activities, such as the use of specialty equipment (e.g., grippers for pants, oversized shoehorns). Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking. They make recommendations for assistive devices such as canes and walkers to promote safe performance of these activities. Health care providers order the equipment.

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dNropRpedIfroGm 1B32./8C2 mMm Hg an hour ago to 90/66 mm Hg. What priority action by the nurse is most appropriate? a) Take the vital signs again in another hour. b) Document the findings in the patient's chart. c) Have another nurse recheck the vital signs. d) Plan to take the vital signs more often.

ANS: D The nurse uses clinical judgment to determine how often the patient's vital signs should be checked when there is a change in patient condition. The nurse should plan to assess vital signs more often in this patient. Since this is a significant change, the nurse should not wait another hour even though this is what the provider prescribed. It is not necessary for another nurse to double-check the vital signs. Documentation needs to occur, but the priority is to plan to take the vitals more often.

The nurse anticipates correctly that what medication category would be ordered to treat athlete's foot? a. Antiviral b. Antibiotic c. Antihelminth d. Antifungal

ANS: D The nurse would expect to treat athlete's foot with an antifungal because it is a fungal infection. An antibiotic treats bacterial infections, antivirals treat viral infections, and antihelminth treats parasitic worms.

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

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

The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" When demonstrating the adaptability of the nursing process, the nurse should carry out which task? a. Adjust the patient's care plan so that nursing goals can be met. b. Consult the care provider about extending the patient's hospitalization. c. Abandon the plan of care as not able to be done. d. Contact the social worker about community services.

ANS: D The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse would adjust planning to contact the social worker for community resources so the patient can maintain as much independence as possible. The care plan focuses on the patient's goals. The provider may or may not be able to extend the hospital stay, but even if that were possible, the patient would not be able to stay until all function returned. The nurse does not simply abandon the care plan; the nurse looks for options and adaptations.

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.

The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, "I'm sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine." The nurse recognizes that the patient is using which defense mechanism to cope with the medical diagnosis? a. Suppression b. Sublimation c. Displacement d. Denial

ANS: D The patient is refusing to admit that the breast has to be removed because of cancer. This inability to accept the truth is termed denial. Displacement is an unconscious defense mechanism used to avoid conflict and anxiety by transferring emotions from one object to another object that is less anxiety producing. Suppression is the conscious decision to conceal unacceptable or painful thoughts. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities.

A student nurse is caring for a patient who is a refugee. The patient will take his own blood glucose readings and will self-administer a set dose of insulin but will not follow a sliding scale regimen in which the patient has to choose what dose of insulin to give. What action by the student nurse is best? a. Ask the provider to prescribe only a set insulin regimen. b. Instruct the patient on the benefits of sliding scale insulin. c. Teach the patient that strict carbohydrate limits are needed. d. Ask the patient to explain the meaning of making this decision.

ANS: D The patient may have a more fantastic world view is common in Western societies. The patient may follow "orders" from an authority figure but may feel like it is not his place to determine his insulin dose, or the patient may not feel competent in making that decision. Many explanations are possible. The student needs to determine what the patient feels related to this type of decision making before doing anything else.

The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of Impaired health maintenance. Which goal is most appropriate on day one? a. Patient will ambulate independent b. Patient will perform all own ADLs. c. Patient will consume 75% of all meals. d. Patient will begin to perform 25% of own ADLs.

ANS: D The patient needs to work toward achieving as much independence in self-care as possible; starting with 25% in a post-stroke patient on day one is more achievable than 100%. Ambulating and eating meals are not goals for a problem with self-care.

27. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

ANS: D The patient's behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance.

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.

The nurse correctly teaches the patient to rise from a chair using crutches when which intervention is used? a. Patient starts from the back of the chair. b. The weak leg is closest to the chair. c. The hand on the strong side holds the hand bar of the crutch. d. The strong leg is closest to the chair.

ANS: D The patient's strongest leg needs to be closest to the chair. The patient's hand on the weak side holds the hand bar of the crutches, and the hand on the patient's strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.

The nurse is acting in the planning function as a manager. The nurse knows which stage should be completed first? a. Set the plan. b. Assess the situation and future trends. c. Convert plan into action statement. d. Set the goals.

ANS: D The planning function of a manager is comparable to the assessment, diagnosis, and planning portions of the nursing process. It includes four stages: (1) setting goals, (2) assessing the current situation and future trends, (3) setting the plan, and (4) converting the plan into an action statement.

The nurse is conducting a presurgical screening interview with a patient at a local surgical center. When performing a health assessment, the nurse identifies which source should be the primary source of information? a. Spouse b. Medical record c. Close relative d. Patient

ANS: D The primary source from which data are collected is the patient. A secondary source would include a significant other, family members, caregivers, other members of the health team, and medical records.

20. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings? a. These are normal signs of aging. b. These are early signs of dementia. c. These are purely psychological in origin. d. These are common manifestation with UTIs.

ANS: D The primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Acute confusion in older adults is not normal; a thorough nursing assessment is the priority. With the diagnosis of urinary tract infection, these are not early signs of dementia and they are not purely psychological.

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure? a) 28 b) 42 c) 58 d) 66

ANS: D The pulse pressure is the difference between the systolic and diastolic blood pressure readings. In this case, 142 76 = 66.

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.

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

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

The nurse recognizes that the stethoscope most correctly represents which possible link in the chain of infection? a. Source b. Portal of exit c. Portal of entry d. Mode of transmission

ANS: D The stethoscope would be a means for the pathogen to travel from source to host. The source is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir of infection, and the portal of entry is where the microorganism enters the susceptible host.

16. 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? 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 is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority? 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.

The nurse has identified several problems for a patient scheduled for a bone marrow transplant. When formulating the Nursing diagnosis, the nurse includes which key concept? a. The nurse realizes that changes in patient condition do not have to change diagnoses b. The nurse uses a language that is difficult to interpret by legislators. c. The nurse can communicate with other nurses but not other disciplines. d. The nurse facilitates communication of patient needs and promotes accountability.

ANS: D The use of Nursing diagnosis labels facilitates clear communication of patient needs and promotes professional accountability and autonomy by defining and describing the independent area of nursing practice. Nursing diagnostic statements clearly communicate to legislators, consumers, and insurance providers the unique care nurses deliver and the specific nature of the health conditions they treat. Use of a unified language classification system, or taxonomy, is an effective vehicle for communication among nurses and other health care professionals.

A patient with terminal cancer says to the nurse, "I just don't know if I should allow CPR in the event I quit breathing. What do you think?" Which statement by the nurse would be most beneficial to the patient? a. "If it were me, I would want to live no matter what." b. "Don't worry. You have plenty of time to decide that later on." c. "It's totally up to you. Have you discussed this with your family?" d. "Let's talk about what CPR means to you."

ANS: D The use of the value clarification process is helpful when assisting patients in making health care decisions regarding end-of-life care. Giving advice or telling patients what to do is unethical and not recommended. Ignoring a patient concern or changing the subject is inappropriate. Patients should be given factual information in order for them to make their own decisions.

35. The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe? a. Place the pillow under the patient's head and shoulders. b. Do by self if the bed is in the flat position. c. Place the side rails in the up position. d. Use a friction-reducing device.

ANS: D This is not a one-person task. Helping a patient move up in bed without help from other co-workers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient's head against the head of the bed. When pulling a patient up in bed, the bed should be flat to gain gravity assistance, and the side rails should be down.

A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best? a) Only massage the leg with normal assessment findings. b) Massage the front of both legs and avoid the posterior surfaces. c) Perform a Homan's test to both legs prior to massaging either of them. d) Educate the patient on why a massage would be contraindicated.

ANS: D This patient has manifestations of a deep vein thrombosis, and the nurse should not massage the patient's legs. The nurse should inform the patient of why this is contraindicated. The other actions are not warranted.

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

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. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.

When implementing research-based interventions, the nurse realizes which concept? a. Implementing evidence-based care is unique to the nursing profession. b. Evidence-based practice is based entirely in nursing research. c. Evidence-based care is focused on practices and not outcomes. d. Nurses must read recent literature and remain current in practice.

ANS: D To implement research-based interventions, nurses must read recent literature and remain current in practice. Implementation of evidence-based care is not unique to nursing; it involves interventions provided by all members of the interdisciplinary health care team. The best methods for treating patients with a variety of signs and symptoms are researched by nurses with input from the research findings of other disciplines. Nursing care continues to evolve as nursing research provides new knowledge and recognizes best practices to improve patient care and outcomes. Evidence-based practice guidelines and updated information must be included in plans of care.

24. 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.

When providing end-of-life care, the nurse knows it is essential to carry out which action? a. Tell the patient what he might like to hear to relieve anxiety. b. Begin making health care decisions for the patient. c. Provide the patient with the nurse's personal opinions. d. Offer unconditional support for the patient and family.

ANS: D Two major roles of a nurse caring for a dying patient are: (1) providing accurate information regarding the disease process and treatment options and (2) offering support for the patient and family without interjecting personal opinions. An essential ethical concept is autonomy, which underscores the importance of allowing patients to make their own health care decisions. Limiting information to what will relieve anxiety, providing personal opinions, and making decisions for the patient do not demonstrate respect for patient autonomy.

The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of secretions and identifies what PPE (personal protective equipment) should be worn? a. Gloves and eyewear b. Gloves, gown, and mask c. Eyewear and gown d. Eyewear, mask, gown, and gloves

ANS: D Use gloves routinely when blood or body fluid might be present. If splashing is possible, use your nursing judgment about what other PPE might be necessary. Forceful expulsion of secretions would require all PPE—gown, mask, eyewear, and gloves—to provide adequate protection.

1. A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? a. "Every December is the time to change batteries on the carbon monoxide detector." b. "I will schedule an appointment with a chimney inspector next week." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I will use a nonvented furnace."

ANS: D Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.

A patient with an inoperable brain tumor says to the nurse, "I just want to die now. It's going to happen soon anyway." Which would be the most appropriate response? a. "Don't worry about that right now. It'll be OK." b. "I disagree with what you just said!" c. "Honey, now don't you talk like that." d. "Tell me why you are saying that."

ANS: D Using open-ended questions or comments gives the patient the opportunity to share freely on a subject, avoids interjection of feelings or assumptions by the nurse, and provides for patient elaboration on important topics when the nurse wants to collect a breadth of information. Giving false reassurance discounts the patient's feelings, cuts off conversation about legitimate concerns of the patient, and demonstrates a need by the nurse to "fix" something that the patient just wants to discuss. Showing agreement or disagreement discontinues patient reflection on an introduced topic, and implies a lack of value for the thoughts, feelings, or concerns of patients. Using personal terms of endearment, such as "Honey," demonstrates disrespect for the individual, diminishes the dignity of a unique patient, and may indicate that the nurse did not take the time or care enough to learn or remember the patient's name.

The nurse identifies which type of wounds heal by tertiary intention? a. An acute wound in which the patient has sutures placed when it happened. b. A pressure ulcer that was treated with dressing changes and is healed. c. An acute wound in which surgical glue was used to close the wound. d. A wound that was left open initially and closed later with sutures.

ANS: D When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

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.

While helping patients with values clarification and care decisions, the nurse should complete which action? a. Convince the patient to do what the nurse believes is best. b. Give advice about what the nurse would do. c. Tell the patient what the right thing to do is. d. Provide information so the patient can make informed decisions.

ANS: D While helping patients with values clarification and care decisions, nurses must be aware of the potential influence of their professional nursing role on patient decision making. Nurses should be careful to assist patients to clarify their own values in reaching informed decisions. Providing information to patients so that they can make informed decisions is a critical nursing role. Giving advice or telling patients what to do in difficult circumstances is both unethical and ill-advised.

10. A nurse wants to find the daily weights of a patient. Which form will the nurse use? 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.

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

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.

19. A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include? a. The family is a "pain." b. Pupils equal and reactive to light c. Had poor results from the pain medication d. 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 ("pain") 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.

The nurse is collaborating with a patient to determine interventions to ensure compliance with medication administration after the pending discharge. The nurse understands that the goals and nursing interventions would be agreed upon in which phase of the nurse-patient relationship? a. Preinteraction phase b. Orientation phase c. Working phase d. Termination phase

ANS: D NURSINGTB.COM Termination phase involves alerting the patient to impending closure of the relationship, evaluating the outcomes achieved during the interaction, and concluding the relationship and transitioning patient care to another caregiver, as needed. In this case, the "new" caregiver is the patient. The working phase involves the development of a contract or plan of care to achieve identified patient goals; implementation of the care plan or contract; collaborative work among the nurse, patient, and other health care providers, as needed; enhancement of trust and rapport between the nurse and the patient; reflection by the patient on emotional aspects of illness; and use of therapeutic communication by the nurse to keep interactions focused on the patient. In the orientation phase or introductory phase, introductions are made, establishing professional role boundaries (formally or informally) and expectations, and clarifying the role of the nurse. Identifying the needs and resources of the patient through observing, interviewing, and assessing the patient, followed by validation of perceptions also occur in this phase.

5. The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.) a. Demonstrate how to restrain the patient in the event of a seizure. b. Instruct the family to move the patient to a bed during a seizure. c. Teach the family how to insert a tongue depressor during the seizure. d. Discuss with the family steps to take if the seizure does not discontinue. e. Instruct the family to reorient and reassure the patient after consciousness is regained.

ANS: D, E Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. Family should know what to do. Family should reorient and reassure the patient after consciousness is regained. Never force apart a patient's clenched teeth.

1. 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.

The nurse knows that use of seatbelts and airbags in automobiles is an example of which term? a) Secondary prevention b) Tertiary prevention c) Holistic care d) Primary prevention

ANS: DPrimary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Holistic care is an approach to applying healing therapies. Nurses participate in holistic care through the use of natural healing remedies and complementary interventions. These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.

The nurse is admitting a patient with a foul smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language? a. Using hand gestures to enhance verbal communication b. Standing at the end of the bed with arms crossed c. Facial grimacing at the sight of the wound d. Gentle touching of the patient's shoulder

ANS: DTherapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. This is especially true when a patient is undergoing a painful or stressful procedure. Making inappropriate facial expressions may be offensive and hurtful to patients or their family members. The nurse must control his or her facial expressions to avoid communicating disdain or judgmental attitudes in challenging patient care situations. Maintaining a neutral facial expression establishes an environment of caring and openness in which the patient and family members can feel safe to share their innermost concerns. The use of gestures may be challenging to nurses practicing in a multicultural environment. Although they may enhance verbal communication, gestures may be viewed as inappropriate by patients of various cultures. Standing with crossed arms may be indicating a lack of openness or acceptance.

The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. The nurse knows this is applying which characteristic of the nursing process? a. Organization b. Dynamics c. Adaptability d. Collaboration

ANS:B The nursing process is dynamic, reflecting changing conditions and needs of patients. Adjusting the plan of care after an outcome has been met is an example of this. Care plans should be organized. Care plans are adaptable, in that they are useful in multiple settings and with either individual or groups as the patient. Collaboration is a key component of meeting patient outcomes.

The nurse is caring for a patient who is blind. When reviewing the care plan, the nurse would modify which goal? a. The patient will report any drainage from the wound with a foul odor to the primary care provider after discharge. b. The patient will agree to report pain promptly while hospitalized. c. The patient will obtain no injuries while in the hospital. d. The patient will report any purulent wound drainage to the primary care provider after discharge.

ANS:D Interventions must be individualized for each patient and adapted for any limitations (e.g., amputation, learning disability, blindness, deafness). The patient would be able to detect a foul odor, report pain, and remain injury free, but would not be able to tell if drainage is purulent.

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

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.

The nurse knows that manual lifting should only be done in which situation? a. Patients who are less than 150 lb b. Life-threatening situations c. Postsurgical patients d. Patients who are less than 200 lb

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

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.

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

B 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.

2. 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

B, D

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.

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.

The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next? a. Moisten the finger with lens solution and gently touch it to pick it up. b. Moisten the contact lens with tap water and pick it up. c. Pick it up and insert the contact lens. d. Discard the contact lens.

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.

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.

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