Overall Quiz Questions

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

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

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B. Beneficence

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

B. Evaluate whether patient goals and outcomes have been met.

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

C. Diagnostic reasoning

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

C. Electronic communication to assess a patient in another city

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.

C. Establish a rapport

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

C. Implementation

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

C. Reassess the patient's pain level in 30 minutes.

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.

C. Refer to an ostomy specialist.

A nurse is emphasizing the use of touch to decrease "skin hunger" in caring for patients. Which age group is the nurse primarily describing? A. Infants B. Children C. Middle age D. Older adults

D. Older adults

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

A. Determines whether an intervention is correct and appropriate for the given situation

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.

A. Let the patient touch and use the exercise equipment.

A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? A. Meditation B. Acupuncture C. Ayurvedic herbs D. Chiropractic care

A. Meditation

Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system? A. Patient safety B. Evidence-based practice C. Patient satisfaction D. Maintenance of competency

A. Patient safety

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

A. Patient will increase activity level this shift.

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

A. Preinteraction

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

A. Preinteraction

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

A. Primary prevention

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

A. Promotes support for a local health charity

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

A. Public

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

A. Reassess the patient and situation.

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.

A. Reassess the patient.

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. Self-efficacy

A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? A. Shaman B. Vitalist C. Ayurvedic D. Curanderismo

A. Shaman

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

A. Social acknowledgment

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

A. States feels better after talking with family and friends

A patient is proficient at meditation from long-time use of the technique. Which finding in the medication history will cause the nurse to follow up? A. Takes thyroid-regulating medication B. Takes corticosteroid medication C. Takes loop diuretic medication D. Takes anticoagulant medication

A. Takes thyroid-regulating medication

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.

A. The CPR procedure was done incorrectly.

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.

A. The nursing assistive personnel is calling the older-adult patient "honey."

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.

A. The patient will walk to the bathroom and back to bed using a cane.

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

C. Health promotion

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

C. History of angina

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.

C. If a nurse has computer competency, the nurse is competent in informatics.

A nurse is using the holistic approach to care. Which goal is the priority? A. Integrate spiritual treatments. B. Join physical care with a vegan diet. C. Incorporate the mind-body-spirit connection. D. Use complementary and alternative therapies.

C. Incorporate the mind-body-spirit connection.

A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? A. It is probably an ayurvedic clinic. B. It is probably a homeopathic clinic. C. It is probably an integrative medical clinic. D. It is probably a naturopathic medical clinic.

C. It is probably an integrative medical clinic.

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.

C. Left knee incision 1 inch without redness, drainage,or edema

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

C. Measure the wound and observe for redness, swelling, or drainage.

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

C. Mode of transportation

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

C. Mutuality

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? A. Nurses understand the principle of autonomy to guide respect for a patient's self-worth. B. Nurses have a scope of practice that encourages their presence during ethical discussions. C. Nurses develop a relationship with the patient that is unique among all professional health care providers. D. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

C. Nurses develop a relationship with the patient that is unique among all professional health care providers.

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.

C. Observe wound appearance and edges.

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.

C. Perform a thorough nursing health history.

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? A. Discussing patient conditions in the nursing report room at the change of shift B. Allowing nursing students to review patient charts before caring for patients to whom they are assigned C. Posting medical information about the patient on a message board in the patient's room D. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

C. Posting medical information about the patient on a message board in the patient's room

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.

C. Provide assistance while the patient walks in the hallway twice this shift with crutches.

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.

B. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.

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

B. Revise the plan of care and change the dressing now.

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

C. Provide specific information about strokes in short, small amounts.

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

C. Psychomotor

Which of the following categories of shared theories would be most appropriate for a patient who is grieving the loss of a spouse? A. Biomedical B. Leadership C. Psychosocial D. Developmental

C. Psychosocial

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.

C. Review the patient's activity orders.

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. Check the policy and procedure manual for the facility's method.

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

D. Coping with impaired functions

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.

A. Instruct the patient to talk with parents about the desire to donate organs.

The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again .... Notice how it is regular .... Now focus on your left arm .... Notice how relaxed your left arm feels .... Notice the relaxation going down the left arm to the hand." A patient asks the nurse what the group is doing. What is the nurse's best response? A. It is progressive relaxation training. B. It is group biofeedback. C. It is guided imagery. D. It is meditation.

A. It is progressive relaxation training.

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

A. Justice

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) "I am thinking about joining the health committee at my church." "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." "I will go back to school as soon as I finish orientation."

"I am thinking about joining the health committee at my church." "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are defining characteristics that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) "I need to call my sister for support." "I have nothing to live for now." "Why would my God do this to me?" "I need to pray for a miracle." "I want to be more involved in my church."

"I have nothing to live for now." "Why would my God do this to me?"

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.) "Patient education is an essential component of safe, patient-centered care." "Patient education is a standard for professional nursing practice." "Patient teaching falls within the scope of nursing practice." "Patient teaching is documented and part of the chart." "Patient education is not effective with children." "Patient teaching can increase health care costs."

"Patient education is an essential component of safe, patient-centered care." "Patient education is a standard for professional nursing practice." "Patient teaching falls within the scope of nursing practice." "Patient teaching is documented and part of the chart."

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. If you still do not understand, ask again.

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

Uses humility Portrays self-confidence Demonstrates independent attitude

Benner s Skill Acquisition AACN s Synergy Model Mishel s Uncertainty in Illness Kolcaba s Theory of Comfort A. The nurse strives to relieve patients distress. B. The nurse progresses through five stages of expertise. C. The nurse assists the patient to process and find meaning related to his or her illness. D. Matching nurse competencies to patient needs can improve patient outcomes.

B D C A

A nurse is caring for a 78-year-old patient with chronic multiple sclerosis. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patient's trust and wants to assess her life satisfaction. Which of the following questions should the nurse ask? (Select all that apply.) How often are you able to attend your synagogue? What about your family makes you proudest? What does your husband do for you at home? Looking back, what is your greatest accomplishment? How has your illness affected the way you live your life spiritually at home?

What about your family makes you proudest? Looking back, what is your greatest accomplishment?

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

Ambulating a patient Inserting a feeding tube Performing resuscitation Teaching about medications

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

B. Counseling about respite care options

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

B. Personal

Health care agencies often have assessment tools to use in clarifying patient values and assess spirituality. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. F Faith I Importance of spirituality C Community A Interventions to address spiritual needs A. Tell me if you have a higher power or authority that helps you act on your beliefs B. Describe which activities give you comfort spiritually? C. To whom do you go for support in times of difficulty? D. Your illness has kept you from attending church. Is that a problem for you?

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

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? A. Call the nursing supervisor to discuss the situation B. Discuss the problem with a colleague C. Leave the nursing unit and go home D. Say nothing and begin your work

A. Call the nursing supervisor to discuss the situation

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

A. Decreased cardiac output related to altered myocardial contractility.

A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? A. "Biofeedback will help me with my thoughts and physiological responses to stress." B. "Biofeedback will direct my energies in an intentional way when stressed." C. "Biofeedback will allow me to manipulate my stressed out joints." D. "Biofeedback will let me assess and redirect my energy fields."

A. "Biofeedback will help me with my thoughts and physiological responses to stress."

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."

A. "This system can help medical students determine the cost of the care they provide to patients."

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

A. 2, 4, 1, 3

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

A. A minimum data set

Which patient will cause the nurse to question an order for acupuncture? A. A patient with AIDS B. A patient with osteoarthritis C. A patient with low back pain D. A patient with migraine headaches

A. A patient with AIDS

A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? A. Acupuncture B. Naturopathic C. Latin American traditional healing D. Native American traditional healing

A. Acupuncture

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.

A. Administer the acetaminophen.

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

A. Advocacy

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

A. Determining the degree to which standards of care are met by reviewing patients' health records

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

A. Developed learning objectives

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

A. Etiology

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

A. Fidelity

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

A. Heart rate 78 beats/min on 12/3

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

A. Home health

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.

A. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

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

A. Identify factors interfering with goal achievement.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following best describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. B. To study the literature on current research about the possible clinical interventions available for the patient in question. C. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal opinion. D. To allow the patient and the physician to resolve the dilemma on the basis of ethical principles without regard to personally held values or opinions.

A. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations.

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.

A. Use a picture board

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.

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.

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.) Includes seven domains for level 1 Uses an easy 3-point Likert scale Adds objectivity to judging a patient's progress Allows choice in which interventions to choose Measures nursing care on a national and international level

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

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

B. "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."

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

B. "How many bowel movements a day have you had?"

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."

B. "Let me check with someone here in the hospital who can assist you."

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."

B. "This must be hard news to hear."

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."

B. "You are expected to perform at the level of a professional nurse."

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

B. 2, 1, 5, 4, 3

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma? 1. List the actions that could be taken to resolve the dilemma. 2. Agree on a statement of the problem or dilemma that you are trying to resolve. 3. Agree on a plan to evaluate the action over time. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. 5. Take time to clarify values and distinguish between facts and opinions your own and those of others involved. 6. Negotiate a plan. A. 4, 5, 2, 6, 1, 3 B. 4, 5, 2, 1, 6, 3 C. 5, 4, 2, 1, 3, 6 D. 4, 5, 1, 2, 3, 6

B. 4, 5, 2, 1, 6, 3

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? A. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C. The patient cannot make changes in the advance directive once admitted to the hospital. D. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

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.

B. A patient demonstrates how to inject insulin.

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

B. A well-lit, ventilated room

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? A. Sore throat B. Acute pain C. Sleep apnea D. Heart failure

B. Acute pain

A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? A. Complementary B. Allopathic C. Alternative D. Mind-body

B. Allopathic

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.

B. Allow the patient to reminisce

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.

B. Ask the patient to return to the room, so the nurse can inspect the abdomen.

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.

B. Assess the patient's health literacy.

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.

B. At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.

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

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

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

B. Community resources

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

B. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

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.

B. Determine patient acuity and care the nurse can safely provide.

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.

B. Develop good communication skills.

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

B. Electric health record

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

B. Health Behavior

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

B. Hemorrhage

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? A. Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. B. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. C. Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. D. Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.

B. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism.

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

B. Interpersonal

A nurse is caring for a patient with a seriously advanced infection who asks to have a spiritual care provider come who can offer Blessingway, a practice that attempts to remove ill health. This patient is likely a member of which religion or culture? A. Hinduism B. Navajo C. Sikhism D. Judaism

B. Navajo

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

B. Nonverbal

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. You have cared for her for only 2 hours but have a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time? A. Make a referral to a professional spiritual care advisor B. Sit down and talk with the patient; have her discuss her feelings and listen attentively C. Move the patient's bible from her bedside cabinet drawer to the top of the over-bed table D. Ask the patient if she would like to learn more about the implications of having this type of tumor

B. Sit down and talk with the patient; have her discuss her feelings and listen attentively

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

B. So different perspectives are respected

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? A. Family member B. Surgeon C. Nurse D. Nurse manager

B. Surgeon

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.

B. Tell the cameraman where the hospital's public relations department is located.

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.

B. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital.

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.

B. The new nurse charts consecutively on every other line.

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

B. The patient is able to ambulate in the hallway with crutches.

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

B. To distinguish the nurse's role from the physician's role

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.

B. Turn off the television.

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

B.Role play

A patient who is recovering from a bilateral amputation of the legs below the knee shows transcendence when she states: A. "My pain medicine helps me feel better." B. "I know I'll get better if I just keep trying." C. "I see God's grace and become relaxed when I watch the sun set at night." D. "I have had a great life and a good marriage. My husband has been so helpful in my healing."

C. "I see God's grace and become relaxed when I watch the sun set at night."

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

C. "I'll wear the blue dress. It matches my eyes."

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

C. "Nurses use evaluation to determine the effectiveness of nursing care."

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."

C. "Teaching is most effective when it responds to the learner's needs."

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."

C. "You will need your mother's permission."

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.

C. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

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

C. Abilities of disabled persons

A patient states that he does not believe in a higher power but instead believes that people bring meaning to what they do. This patient most likely is an: A. Academic. B. Atheist. C. Agnostic. D. Anarchist.

C. Agnostic

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 first action? A. Follow the clinical protocol for a stroke. B. Review the most recent lab results for the patient's potassium level. C. Assess the patient for other symptoms or problems, and then notify the health care provider. D. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

C. Assess the patient for other symptoms or problems, and then notify the health care provider.

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

C. Assesses the patient's readiness for the procedure

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

C. At lunchtime, while the nurse is preparing the food tray

You are caring for a hospitalized patient who is Muslim and has diabetes. Which of the following items do you need to remove from the meal tray when it is delivered to the patient? A. Small container of vanilla ice cream B. A dozen red grapes C. Bacon and eggs D. Garden salad with ranch dressing

C. Bacon and eggs

A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? A. Aloe B. Garlic C. Chamomile D. Saw palmetto

C. Chamomile

A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse's evaluation that the therapy is effective? A. Dilated pupils B. Increased blood sugar C. Decreased heart rate D. Elevated blood pressure

C. Decreased heart rate

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

C. Developmental capabilities and physical capabilities

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

C. Disruption of tissue integrity

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? A. Patient Protection and Affordable Care Act (PPACA) B. Patient Self-Determination Act (PSDA) C. Health Insurance Portability and Accountability Act (HIPAA) D. Emergency Medical Treatment and Active Labor Act

C. Health Insurance Portability and Accountability Act (HIPAA)

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A. The nurse's automobile insurance B. The nurse's homeowner's insurance C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence D. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence

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.

C. The nurse took actions beyond those that are standard and appropriate.

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

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

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.

C. The patient will verbalize the value of eating healthy.

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.

C. The patient's affect is inappropriate.

An older-adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low-dose aspirin, ginkgo biloba, and echinacea. Which potential interaction will cause the nurse to notify the patient's health care provider? A. Echinacea and warfarin B. Lisinopril and echinacea C. Warfarin and ginkgo biloba D. Lisinopril and hydrochlorothiazide

C. Warfarin and ginkgo biloba

Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of a nurse's care plan, which of the following questions is most appropriate to evaluate its efficacy? A. Do you feel the need to forgive your wife over your loss? B. What can I do to help you feel more at peace? C. Were prayer or meditation helpful to you? D. Should we plan on having your family try to visit you more often in the hospital?

C. Were prayer or meditation helpful to you?

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

C. Wrap a bandage around a stuffed animal's ear.

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? A. Dependent B. Independent C.Interdependent D. Physician-initiated

C.Interdependent

Which of the following examples are steps of nursing assessment? (Select all that apply.) Collection of information from patient's family members Recognition that further observations are needed to clarify information Comparison of data with another source to determine data accuracy Complete documentation of observational information Determining which medications to administer based on a patient's assessment data

Collection of information from patient's family members Recognition that further observations are needed to clarify information Comparison of data with another source to determine data accuracy

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

Communication Legal documentation Reimbursement Research Education

A nurse is describing the therapeutic effects of imagery. Which information should the nurse include in the teaching session? (Select all that apply.) Controls pain Decreases nightmares Improves social anxiety disorders Helps with irritable bowel syndrome Reduces relapses in alcohol treatment

Controls pain Decreases nightmares Helps with irritable bowel syndrome

Preferred provider organization Managed care organization Medicaid Medicare A. Insurance for low-income families B. Federal insurance for people aged 65 and older C. Health maintenance focus to specific group of voluntarily enrolled people D. Services at a discount for companies under contract

D C A B

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?"

D. "It must be difficult not to know what the surgeon will find. What can I do to help?"

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.

D. Chart on computer immediately after care is provided.

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. 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

D. 0830

What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in correct order. 1. Clarify values. 2. Ask the question, Is this an ethical dilemma? 3. Verbalize the problem. 4. Gather information. 5. Identify course of action. 6. Evaluate the plan. 7. Negotiate a plan. A. 2, 4, 1, 5, 3, 7. 6 B. 2, 4, 3, 1, 5, 6, 7 C. 4, 1, 2, 3, 5, 7, 6 D. 2, 4, 1, 3, 5, 7, 6

D. 2, 4, 1, 3, 5, 7, 6

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

D. Absence of skin breakdown

A nurse is providing different types of therapies to a patient with excessive fatigue and cancer. Which technique will cause the nurse manager to intervene? A. Meditation B. Guided imagery C. Passive relaxation D. Active progressive relaxation

D. Active progressive relaxation

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.

D. Administer pain medication.

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? A. Seeking out the nursing supervisor to talk with the patient B. Documenting patient fears in the medical record in a timely manner C. Working to change the hospital environment D. Assessing the patient's point of view and preparing to articulate it

D. Assessing the patient's point of view and preparing to articulate it

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

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

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? A. Give the family the record B. Discuss the issues that concern the family with them C. Call the nursing supervisor D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? A. Health Insurance Portability and Accountability Act (HIPAA) B. Americans with Disabilities Act (ADA) C. Patient Self-Determination Act (PSDA) D. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

D. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

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

D. Evaluation

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

D. Evaluation

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

D. Family elder who is making the decisions for a young-adult female member

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

D. Feminist ethics

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

D. Graphic record and flow sheet

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

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

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

D. Lungs clear to auscultation following use of inhaler

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? A. Obtain a court order to give the blood B. Coerce the husband into giving the blood C. Call security and have the husband removed from the hospital D. More information is needed about the wife's preference and if the husband has her medical power of attorney

D. More information is needed about the wife's preference and if the husband has her medical power of attorney

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

D. Patient correctly states names of family members in the room.

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.

D. Reassess the patient.

A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? A. Prayer and tai chi B. The "zone" and acupressure C. Massage therapy and ayurveda D. Reiki therapy and therapeutic touch

D. Reiki therapy and therapeutic touch

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

D. Reports to third-party payers

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

D. Self-examines personal communication skills

A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her inner self, including her values and principles. The instructor explains that this is an example of: A. Faith. B. Community. C. Interpersonal connection. D. Self-transcendence.

D. Self-transcendence.

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

D. Sharp pain of 8 on a scale of 1 to 10

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

D. Skin pale and cool

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

D. The patient who is dyspneic, anxious, and has a tracheostomy

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.

D. The patient will administer epinephrine.

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

Determine whether outcomes or standards are met. Document results of goal achievement. Use self-reflection and correct errors.

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.) Equipment Safe environment Confidence Asstitive personnel Creativity

Equipment Safe environment Assistive personnel

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? (Select all that apply.) Ethics of care pays attention to the environment in which caring occurs. Ethics of care pays attention to the stories of the people involved in the ethical issue. Ethics of care is used only in nursing practice. Ethics of care focuses only on the code of ethics for nurses Ethics of care focuses only on understanding relationships.

Ethics of care pays attention to the environment in which caring occurs. Ethics of care pays attention to the stories of the people involved in the ethical issue. Ethics of care focuses only on understanding relationships.

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) Encourage family members to participate in the exercise. Have patient identify a quiet room in the home that has minimal interruptions. Suggest use of a quiet fan running in the room. Explain that it is best to meditate about 5 minutes 4 times a day. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

Have patient identify a quiet room in the home that has minimal interruptions. Suggest use of a quiet fan running in the room. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) How is your diabetic diet affecting you and your family? You seem to not want to follow health guidelines. Can you explain why? What worries you the most about having diabetes? What do you expect from us when you do not take your insulin as instructed? What do you believe will help you control your blood sugar?

How is your diabetic diet affecting you and your family? What worries you the most about having diabetes? What do you believe will help you control your blood sugar?

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

Libel Slander

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.) Observations of wound healing Daily blood pressure measurements Findings of respiratory rate and depth Completion of nursing interventions Patient's subjective report of feelings about a new diagnosis of cancer

Observations of wound healing Daily blood pressure measurements Findings of respiratory rate and depth Patient's subjective report of feelings about a new diagnosis of cancer

A student nurse is developing a plan of care for a 74-year-old female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) Older adults do not routinely use complementary medicine to cope with illness. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. Older adults achieve spiritual resilience through frequent expressions of gratitude. Have the patient determine if her husband left a legacy behind. Offer the patient her choice of rituals or participation in exercise.

Older adults achieve spiritual resilience through frequent expressions of gratitude. Have the patient determine if her husband left a legacy behind. Offer the patient her choice of rituals or participation in exercise.

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with their chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) Pay attention to the patient s spiritual identity throughout the course of her illness Select interventions that you know scientifically support spiritual well-being Listen to the patient s story each visit to the clinic and offer a compassionate presence When the patient questions the reason for her long-time suffering, try to provide answers Consult with a spiritual care advisor and have the advisor recommend useful interventions

Pay attention to the patient s spiritual identity throughout the course of her illness Listen to the patient s story each visit to the clinic and offer a compassionate presence

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

Perform dressing changes twice a day as ordered. Teach the patient about signs and symptoms of infection. Instruct the family about how to perform dressing changes. Administer medications to control the patient's blood sugar as ordered.

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) Information provided by the head nurse Policies and procedures of the employing hospital State Nurse Practice Act Regulations identified in The Joint Commission manual The American Nurses Association standards of nursing practice

Policies and procedures of the employing hospital State Nurse Practice Act Regulations identified in The Joint Commission manual The American Nurses Association standards of nursing practice

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

Reposition a patient who is on bed rest. Teach a patient preoperative exercises. Transfer a patient to another hospital unit.

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) Taking or selling controlled substances Refusing to provide health care information to a patient's child Reporting suspected abuse and neglect of children Applying physical restraints without a written physician's order Completing an occurrence report on the unit

Taking or selling controlled substances Applying physical restraints without a written physician's order

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.) Injury did not occur. That duty was breached. Nurse carried out the duty. Duty of care was owed to the patient. Patient understands benefits and risks of a procedure.

That duty was breached. Duty of care was owed to the patient.

Select the three factors that are evident when a healing relationship develops between nurse and patient. The nurse being able to realistically mobilize hope for the patient The patient being able to share fears of loss with significant others Finding an interpretation or understanding of the patient's illness that is acceptable to the patient Understanding your own beliefs about spirituality Helping the patient use spiritual resources that he or she chooses

The nurse being able to realistically mobilize hope for the patient Finding an interpretation or understanding of the patient's illness that is acceptable to the patient Helping the patient use spiritual resources that he or she chooses

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data B. The nurse who measures joint range of motion after the patient reports pain in the left elbow C. The nurse who considers conflicting cues in deciding which diagnostic label to choose D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia

The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) The patient is hurting. The patient is fatigued. The patient is mildly anxious. The patient is asking questions. The patient is febrile (high fever). The patient is in the acceptance phase.

The patient is hurting. The patient is fatigued. The patient is febrile (high fever).

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) The nurse does not need any representation. The patient must prove injury, damage, or loss occurred. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. The patient must prove that a breach in the prevailing standard of care caused an injury. The burden of proof is always the responsibility of the nurse.

The patient must prove injury, damage, or loss occurred. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. The patient must prove that a breach in the prevailing standard of care caused an injury.

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? A. Orientation B. Working phase C. Data validation D. Termination

B. Working phase

King Henderson Orem Neuman A. Based on the theory that focuses on wellness and prevention of disease. B. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes. C. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently. D. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently.

D C B A

Middle-range theory Shared theory Grand theory Practice theory A. Specific to a particular situation; brings theory to the bedside B. Very abstract; attempts to describe nursing in a global context C. Addresses a specific phenomenon and reflects practice D. Applies theory from other disciplines to nursing practice

D C B A

A nurse is using the Plan-Do-Study-Act (PDSA) strategy to do a quality improvement project to decrease patient falls on a nursing unit. What is the correct sequence for PDSA? 1. Bedside change of shift report is piloted on two medical-surgical units 2. Patient satisfaction levels after implementation of the bedside report are compared to patient satisfaction levels before the change 3. The nursing council develops a strategy for bedside change of shift report 4. After modifications are made in the shift report elements, bedside shift report is implemented on all nursing units

3 1 2 4

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: A. Patient's level of function. B. Patient's willingness to perform self-care. C. Patient's level of consciousness. D. Patient's health management values.

A. Patient's level of function.

Which of the following statements about evidence-based practice (EBP) made by a nursing student would require the nursing professor to correct the student's understanding? A. "In evidence-based practice the patients are the subjects." B. "It is important to talk with experts and patients when making an evidence-based decision." C. "A nurse wanting to investigate the evidence to solve a problem starts by forming a PICOT question." D. "It is important to ask a librarian for help when searching for literature to help you answer your PICOT question."

A. "In evidence-based practice the patients are the subjects."

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

A. 1, 3, 4, 2, 5

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

A. 5, 4, 2, 1, 3

A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter "A"? A. Act B. Alter C. Assess D. Approach

A. Act

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

A. Assessment

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

A. Completes a comprehensive database

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.

A. Develop a plan of care for the family.

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

A. Diagnosis

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.

A. Eliminate health disparities in America.

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient s activity tolerance a patient-centered effort? A. Engage the patient in setting mutual outcomes for distance he is able to walk B. Confirm with the patient s health care provider about ambulation goals C. Have physical therapy assist with ambulation D. Refer to medical record regarding nature of patient s physical problem

A. Engage the patient in setting mutual outcomes for distance he is able to walk

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

A. Health belief model

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.

A. Identify the patient's stage of change.

A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? A. Patient will be able to walk 200 feet without shortness of breath B. Wound will heal without signs of infection C. Patient will express concerns related to return to home D. Patient will identify strategies to improve sleep habits

A. Patient will be able to walk 200 feet without shortness of breath

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

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

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: A. Patient's level of function. B. Patient's willingness to perform self-care. C. Patient's level of consciousness. D. Patient's health management values.

A. Patient's level of function.

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

A. Peplau's theory

A nurse is using research findings to improve clinical practice. Which technique is the nurse using? A. Performance improvement B. Integrated delivery networks C. Nursing-sensitive outcomes D. Utilization review committees

A. Performance improvement

A nurse is using data collected from the unit to monitor the incidence of falls after the unit implemented a new fall protocol. The nurse is working in which area? A. Quality improvement B. Health care patient system C. Nursing informatics D. Computerized nursing network

A. Quality improvement

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

A. The patient's room with the door closed

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) An observation of how a patient turns and moves in bed The unit policy and procedure manual The care recommendations of a physical therapist The results of a diagnostic x-ray film Your experiences in caring for other patients with similar problems

An observation of how a patient turns and moves in bed The care recommendations of a physical therapist The results of a diagnostic x-ray film

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) Assess condition of skin before making the call Rely on the nurse specialist to know the type of surgery the patient likely had Explain the patient's response emotionally to the repeated leaking of stool Describe the type of bag being used and how long it lasts before leaking Order extra colostomy bags currently being used

Assess condition of skin before making the call Explain the patient's response emotionally to the repeated leaking of stool Describe the type of bag being used and how long it lasts before leaking

The public health nurse is working with the county health department on a task force to fully integrate the goals of Healthy People 2020. In the immigrant community, most of the population does not have a primary care provider, nor do they participate in health promotion activities; the unemployment rate in the community is 25%. How does the nurse determine which goals need to be included or updated? (Select all that apply.) Assess the health care resources within the community Assess the existing health care programs offered by the county health department Compare existing resources and programs with Healthy People 2020 goals Initiate new programs to meet Healthy People 2020 goals. Implement educational sessions in the schools to focus on nutritional needs of the children.

Assess the health care resources within the community Assess the existing health care programs offered by the county health department Compare existing resources and programs with Healthy People 2020 goals

A community center is presenting a nurse-led program on the Patient Protection and Affordable Care Act. Which statement made by a participant indicates a need for further teaching? A. "My small company will now have to offer the 75 employees health insurance or pay a penalty." B. "As long as my son is a full-time student in College, I will be able to keep him on my health insurance until he is 26 years old." C. "I signed up for the state health insurance exchange before the designated deadline to make sure I had health insurance." D. "Since I have now been diagnosed with diabetes, my health insurance plan cannot charge me higher premiums."

B. "As long as my son is a full-time student in College, I will be able to keep him on my health insurance until he is 26 years old."

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.

B. A person's compliance is affected by economic status.

Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. A. Self-actualization B. Air, water, and nutrition C. Safety D. Esteem and self-esteem need

B. Air, water, and nutrition

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

B. Contemplation

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

B. Holistic health model

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

B. Implements interventions based on scientific research

A researcher is studying the effectiveness of an individualized evidence-based teaching plan on young women's intention to wear sunscreen to prevent skin cancer. In this study, which of the following research terms best describes the individualized evidence-based teaching plan? A. Sample B. Intervention C. Survey D. Results

B. Intervention

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. Leininger's theory

A patient is worried about her 76 year old grandmother who is in very good health and wants to live at home. The patient s concerns are related to her grandmother s safety. The neighborhood does not have a lot of crime. Using this scenario, which of the following are the most relevant to assess for safety? A. Crime rate, locks, lighting, neighborhood traffic B. Lighting, locks, clutter, medications C. Crime rate, medications, support system, clutter D. Locks, lighting, neighborhood traffic, crime rate

B. Lighting, locks, clutter, medications

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

B. Making sure to involve the whole person

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

B. Not eating

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

B. Output

A nurse is presenting information to a management class of nursing students on the topic of financial reimbursement for achievement of established, measurable patient outcomes. The nurse is presenting information to the class on which topic? A. Prospective payment system B. Pay for Performance C. Capitation payment system D. Managed care systems

B. Pay for Performance

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

B. Physiological

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

B. Secondary prevention

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.

B. The chances of getting the disease are increased.

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

B. Withdrawal

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? A. Incorrect clustering B. Wrong diagnostic label C. Condition is a collaborative problem. D. Premature closure of clusters

B. Wrong diagnostic label

A nursing student is giving a presentation to a group of other nursing students about the needs of patients with mental illnesses in the community. The nursing professor needs to clarify the student's presentation when the student states: A. "Many patients with mental illness do not have a permanent home." B. "Unemployment is a common problem experienced by people with a mental illness." C. "The majority of patients with mental illnesses live in long-term care settings." D. "Patients with mental illnesses are often at a higher risk for abuse and assault."

C. "The majority of patients with mental illnesses live in long-term care settings."

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? A. "I can tell that your eating habits have led to your diabetes. Is that right?" B. "It's been difficult for people to find jobs. Is that why you work part time?" C. "You have four children; do you have any concerns about going home and caring for them?" D. "I wish patients understood how overeating affects their health."

C. "You have four children; do you have any concerns about going home and caring for them?"

Theory is essential to nursing practice because it: (Select all that apply.) Contributes to nursing knowledge. Predicts patient behaviors in situations. Provides a means of assessing patient vital signs. Guides nursing practice. Formulates health care legislation. Explains relationships between concepts.

Contributes to nursing knowledge. Predicts patient behaviors in situations. Guides nursing practice. Explains relationships between concepts.

While working in a rehabilitation facility, it is important to obtain nursing histories and develop a therapeutic nurse-patient relationship. Which of the following lists in correct order the phases of Peplau s theory as applied in this setting. The nurse: 1. Ensures that the patient has access to appropriate community resources for long-term care. 2. Collaborates with the patient to identify specific patient needs 3. Collects essential information from the patient s health record. 4. Works with the patient to develop a plan for resolving patient issues. A. 3, 4, 2, 1 B. 1, 3, 2, 4 C. 3, 2, 4, D. 2, 3, 4, 1

C. 3, 2, 4, 1

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

C. Acute pain

A nurse researcher is collecting data following approval from the institutional review board (IRB). In which part of the research process is this nurse? A. Analyzing the data B. Designing the study C. Conducting the study D. Identifying the problem

C. Conducting the study

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.

C. Create social and physical environments that promote good health.

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

C. Developing nursing diagnoses before completing the database

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

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

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 provided services primarily to the poor

C. Its priority is health promotion

A nurse is preparing to begin intravenous fluid therapy for a patient. Which category of theory would be most helpful to the nurse at this time? A. Grand theory B. Middle-range theory C. Practice theory D. Shared theory

C. Practice theory

The nurses on a medical unit have seen an increase in the number of medication errors on their unit. They decide to evaluate the medication administration process based on data gained from chart reviews and direct observation of nurses administering medications. Which process are the nurses using? A. Evidence-based practice. B. Research. C. Quality improvement. D. Problem identification.

C. Quality improvement

A group of staff nurses notice an increased incidence of medication errors on their unit. After further investigation it is determined that the nurses are not consistently identifying the patient correctly. A change is needed quickly. What type of quality improvement method would be most appropriate? A. PDSA B. Six Sigma C. Rapid-improvement event D. A randomized controlled trial

C. Rapid-improvement event

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? A. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? B. Have you taken anything for your headaches? C. Tell me what makes your headaches begin. D. Uh huh, tell me more.

C. Tell me what makes your headaches begin.

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

C. Tertiary prevention

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.

C. The patient is apprehensive about discharge.

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.

C. The patient will return to the contemplation or precontemplation phase.

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

C. Thinks about the patients and patients' environment

A patient tells a nurse that she is enrolled in a preferred provider organization (PPO) but does not understand what this is. What is the nurse's best explanation of a PPO? A. This health plan is for people who cannot afford their own health insurance B. This health plan is operated by the government to provide health care to older adults C. This health plan gives you with a list of physicians and hospitals from which you can choose D. This is a fee-for-service plan in which you can choose any physician or hospital

C. This health plan gives you with a list of physicians and hospitals from which you can choose

Using Healthy People 2020 as a guide, which of the following would improve delivery of care to a community? (Select all that apply.) Community assessment Implementation of public health policies Home safety assessment Increased access to care. Determining rates of specific illnesses

Community assessment Implementation of public health policies Increased access to care. Determining rates of specific illnesses

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."

D. "Members of vulnerable groups frequently have a combination of risk factors."

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? A. Review of systems approach B. Use of a structured database format C. Back channeling D. A problem-oriented approach

D. A problem-oriented approach

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

D. AHRQ

A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? A. Children B. Therapy dogs C. The pediatric unit D. Anxiety

D. Anxiety

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.

D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

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

D. Assess the patient

Which activity performed by a nurse is related to maintaining competency in nursing practice? A. Asking another nurse about how to change the settings on a medication pump B. Regularly attending unit staff meetings C. Participating as a member of the professional nursing council D. Attending a review course in preparation for a certification examination

D. Attending a review course in preparation for a certification examination

A nurse researcher studies the effectiveness of a new program designed to educate parents to promote the immunization of children. The nurse divides the parents randomly into two groups. One group receives the typical educational program and the other group receives the new program. This is an example of which type of study? A. Historical B. Qualitative C. Correlational D. Experimental

D. Experimental

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance pattern D. Health perception-health management pattern

D. Health perception-health management pattern

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D 5 ½ NS. Which intervention is a dependent intervention? A. Reporting hand-off at change of shift B. Ambulating patient down hallway C. Sleep hygiene D. IV fluid administration

D. IV fluid administration

A community nurse in a diverse community is working with health care professionals to provide for prenatal care for under employed and under insured South African women. Which overall goal of Healthy People 2020 does this represent? A. Assess the health care needs of individuals, families, or communities B. Develop and implement public health policies and improve access to care C. Gather information on incident rates of certain diseases and social problems D. Increase life expectancy and quality of life and eliminate health disparities

D. Increase life expectancy and quality of life and to eliminate health disparities

Which of the following statements is true regarding Magnet status recognition for a hospital? A. Nursing is run by a Magnet manager who makes decisions for the nursing units B. Nurses in Magnet hospitals make all of the decisions on the clinical units C. Magnet is a term that is used to describe hospitals that are able to hire the nurses they need D. Magnet is a special designation for hospitals that achieve excellence in nursing practice

D. Magnet is a special designation for hospitals that achieve excellence in nursing practice

A nurse ensures that each patient's room is clean, well ventilated, and free from clutter, excessive noise, and extremes in temperature. Which theorist's work is the nurse practicing in this example? A. Henderson B. Orem C. King D. Nightingale

D. Nightingale

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

D. Problem-oriented assessment

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? A. Health perception-health management pattern B. Value-belief pattern C. Cognitive-perceptual pattern D. Self-perception-self-concept pattern

D. Self-perception-self-concept pattern

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) Data collection. Data clustering. Data interpretation. Making a diagnostic statement. Goal setting.

Data collection. Data interpretation.

A nursing student in the last semester of the baccalaureate nursing program is beginning the community health practicum and will be working in a community based clinic with a focus on asthma and allergies. What is the focus of the community health nurse in this clinic setting? (Select all that apply.) Decrease the incidence of asthma attacks in the community. Increase patients ability to self-manage their asthma. Treat acute asthma attack in the home care setting Provide asthma education programs for the teachers in the local schools Provide scheduled immunizations to people who come to the clinic

Decrease the incidence of asthma attacks in the community. Increase patients ability to self-manage their asthma. Provide asthma education programs for the teachers in the local schools

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Allows physicians and allied health staff to communicate with nurses how they provide care among themselves Helps nurses focus on the scope of nursing practice Creates practice guidelines for collaborative health care activities Builds and expands nursing knowledge

Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Helps nurses focus on the scope of nursing practice Builds and expands nursing knowledge

The nurse in a community health clinic noticed an increase in the number of positive tuberculosis (TB) skin tests from students in a local high school during the most recent academic year. After comparing these numbers to the previous years, 10% increase in positive tests was found. The nurse contacts the school nurse and the director of the health department. Together they begin to expand their assessment to all students and employees of the school district. The community health nurse was acting in which nursing role(s)? (Select all that apply.) Epidemiologist Counselor Collaborator Case manager Caregiver

Epidemiologist Collaborator

A nursing student is preparing to read the methods section of a research article. What type of information will the student expect to find in this section? (Select all that apply.) How the researcher conducted the study A description about how to use the findings of the study The number and type of subjects who participated in the study Summaries of other research articles that support the need for this study Implications for future research studies

How the researcher conducted the study The number and type of subjects who participated in the study

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) Listen attentively to the patient s story. Use gestures that reinforce your questions or comments. Stand back away from the bedside. Maintain direct eye contact. Ask questions quickly to reduce the patient s fatigue.

Listen attentively to the patient s story. Use gestures that reinforce your questions or comments. Maintain direct eye contact. Ask questions quickly to reduce the patient s fatigue.

Which of the following statements related to theory-based nursing practice are correct? (Select all that apply.) Nursing theory differentiates nursing from other disciplines. Nursing theories are standardized and do not change over time. Integrating theory into practice promotes coordinated care delivery. Nursing knowledge is generated by theory. The theory of nursing process is used in planning patient care. Evidence-based practice results from theory-testing research.

Nursing theory differentiates nursing from other disciplines. Integrating theory into practice promotes coordinated care delivery. Nursing knowledge is generated by theory. Evidence-based practice results from theory-testing research.

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague RN's years of experience Competency of patient care technician

Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague

Which of the following are characteristics of managed care systems? (Select all that apply.) Provider receives a predetermined payment for each patient in the program. Payment is based on a set fee for each service provided. System includes a voluntary prescription drug program for an additional cost. System tries to reduce costs while keeping patients healthy. Focus of care is on prevention and early intervention.

Provider receives a predetermined payment for each patient in the program. System tries to reduce costs while keeping patients healthy. Focus of care is on prevention and early intervention.

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? (Select all that apply.) The nurse asks the patient to rate his pain on a scale of 0 to 10. The nurse asks the patient what caused his fall. The nurse asks the patient if he has had pain in his back in the past. The nurse assesses the patient's lower-limb strength. The nurse asks the patient what pain medication is most effective in managing his pain.

The nurse asks the patient to rate his pain on a scale of 0 to 10. The nurse assesses the patient's lower-limb strength.

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) The skin around the wound is tender to touch. Fluid intake for 8 hours is 800 mL. Patient has a heart rate of 78 beats/min and regular. Patient has drainage from surgical wound. Body temperature is 38.3° C (101° F). Patient states, I m worried that I won t be able to return to work when I planned.

The skin around the wound is tender to touch. Patient has drainage from surgical wound. Body temperature is 38.3° C (101° F). Patient states, I m worried that I won t be able to return to work when I planned.

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D 5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) IV site not tender Uses cane to walk Walked to end of hall No shortness of breath Slept better during night

Walked to end of hall No shortness of breath