Certified Medical-Surgical Registered Nurse 2025 Sample Questions
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV q6h. Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for the nurse to ask? 1) "Have you ever had this type of chest pain before?" 2) "How long have you had this pain?" 3) "What pain medication do you usually take?" 4) "What
1) "Have you ever had this type of chest pain before?" Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse should find out if the patient has had this time of pain previously.
Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment no longer relieved her symptoms. She underwent a total proctocolectomy and a permanent ileostomy 12 hours ago. The nurse should contact the physician immediately if Mrs. Warren has which of these findings? 1) The stoma appears pale and dry. 2) The stoma appears red and shiny. 3) There is 200 mL of dark green output from the stoma. 4) There is 50 mL of serosanguinous drainage from the stoma.
1) The stoma appears pale and dry. Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter per day.
Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes mellitus. Her blood glucose has been stabilized, and the nurse is preparing her for discharge. Her discharge orders will include metformin (Glucophage). Mrs. Clark is also being treated for hypertension. Because Mrs. Clark is to take Glucophage on a regular basis it is important to 1) monitor her glomerular filtration rate. 2) check her serum amylase routinely. 3) obtain her red blood cell count periodically. 4) examine her urine for casts.
1) monitor her glomerular filtration rate. Rationale: The estimated glomerular filtration rate (eGFR) is one way to measure the adequacy of kidney function. Glucophage is excreted by the kidney and the risk of lactic acidosis increases in patients with impaired kidney function. The drug may be used if the eGFR is between 45 and 60 mL/min/1.73 m2, i.e., in mild chronic kidney disease. Glucophage is absolutely contraindicated if the eGFR is below 30 mL/min/1.73 m2.
It is hospital policy to assess and record a patient's pulse before administering digoxin (Lanoxin). By auditing the nursing records to determine the frequency of compliance with this policy, the quality assessment and improvement committee is conducting: 1. A process analysis. 2. A quality analysis. 3. A system analysis. 4. An outcome analysis.
1. A process analysis.
The most common, preventable complication of abdominal surgery is: 1. Atelectasis. 2. Fluid and electrolyte imbalance. 3. Thrombophlebitis. 4. Urinary retention.
1. Atelectasis.
A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient's blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to: 1. Medicate the patient for pain. 2. Place the patient in a high Fowler position and administer oxygen. 3. Place the patient in a reverse Trendelenburg position and open the IV line. 4. Report the findings to the provider.
1. Medicate the patient for pain.
When a patient is having a chest tube removed, which of these instructions would be appropriate? 1) "Take short quick breaths with your mouth open." 2) "Take a deep breath and hold it." 3) "Breathe only through your mouth." 4) "Breathe as you normally do."
2) "Take a deep breath and hold it." Rationale: Taking a deep breath and holding it (or performing the Valsalva maneuver) will prevent air from being pulled back into the pleural space as the tube is removed.
An 80-year-old male who has mild dementia is readmitted for the third time with multiple pressure ulcers. During the nursing assessment, multiple bruises are also observed on his body. He lives with his son and daughter-in-law. The nurse suspects elder abuse/neglect. Which of these actions should the nurse take? 1) Have a staff member present during family visits. 2) Report the findings. 3) Discuss the situation with the family. 4) Ask the patient who is providing his care.
2) Report the findings. Rationale: Most states require that health care workers report suspected elder abuse to an official agency, such as Adult Protective Services.
Charles Haverford is diagnosed with prostate cancer and is to have a radical prostatectomy. Mr. Haverford has been researching his diagnosis and now asks the nurse to recommend a reliable web source for accurate prostate cancer information. The nurse should identify which of these websites as most reliable? 1) www.wikipedia.org. 2) www.cancer.gov. 3) www.caringbridge.org. 4) www.google.com.
2) www.cancer.gov. Rationale: When a patient asks about researching information on the internet, the patient should be instructed to look at reliable sites. Sites that are most reliable are those sponsored by the government (.gov).
The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of: 1. Agreeing to discontinue smoking. 2. Ambulating 50 feet without experiencing dyspnea. 3. Experiencing no dyspnea on exertion. 4. Tolerating activity well.
2. Ambulating 50 feet without experiencing dyspnea.
During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to: 1. Continue the hourly neurologic assessments. 2. Inform the neurosurgeon of the patient's status. 3. Prepare the patient for emergency surgery. 4. Recheck the patient's neurologic status in 15 minutes.
2. Inform the neurosurgeon of the patient's status.
After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, a medical-surgical nurse anticipates the next step in the immediate care of this patient to include: 1. Administering tissue plasminogen activator. 2. Obtaining a computed tomography scan of the head without contrast. 3. Obtaining a neurosurgical consultation. 4. Preparing for carotid Doppler ultrasonography.
2. Obtaining a computed tomography scan of the head without contrast.
A patient's family does not know the patient's end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects: 1. Justice. 2. Paternalism. 3. Pragmatism. 4. Veracity.
2. Paternalism.
Which is primarily a developmental task of middle age? 1. Learning and acquiring new skills and information 2. Rediscovering or developing satisfaction in one's relationship with a significant other 3. Relying strongly upon spiritual beliefs 4. Risk taking and its perceived consequences
2. Rediscovering or developing satisfaction in one's relationship with a significant other
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns about her body image? 1) "I will have to stop my aerobics classes." 2) "I'm so afraid I may not survive the surgery." 3) "I need to go shopping for some loose, baggy clothes." 4) "I'm concerned that this may be only the first of many surgeries."
3) "I need to go shopping for some loose, baggy clothes." Rationale:Body image refers to a person's perception of self and determines how the person interacts with others. One does not need to purchase special clothing after ileostomy surgery, although some minor adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
A patient's wife is visibly upset and says to the nurse, "I thought my husband only broke his hip, but the doctor thinks he might have had a stroke." Which of the following would be an appropriate response by the nurse? 1) "It's really too early to be concerned about that. Let's wait until the test results come back." 2) "If it is a stroke, your husband is in the right hospital for treatment." 3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out." 4) "I'm going to get you some information to read about strokes and their treatment."
3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out." Rationale: Symptoms of stroke vary greatly and the initial diagnosis is made after a non-contrast CT scan is done to determine if the event was ischemic or hemorrhagic. Then, further tests are done to confirm the diagnosis and decide on treatment.
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated. Which of these actions by the nurse would be appropriate before reapplying the appliance? 1) Wash the area with antiseptic soap and water. 2) Clean the site with Dakin's solution. 3) Use a solid skin barrier. 4) Obtain an order for a topical antibiotic.
3) Use a solid skin barrier. Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties, should be applied.
Mr. Haverford has the planned surgery and immediately postoperatively he has a urinary catheter inserted. After the urinary catheter is removed Mr. Haverford is urinating normally, however he is experiencing occasional incontinence with dribbling. Mr. Haverford is to be discharged. Mr. Haverford says to the nurse, "I'm so embarrassed. What will my wife think about this dribbling?" In addition to acknowledging his feelings, the nurse should encourage the patient to 1) limit oral intake of fluids before bedtime. 2) palpate his bladder to check for distention three times a day. 3) perform pelvic floor exercises several times daily. 4) avoid interrupting the urinary stream during voiding.
3) perform pelvic floor exercises several times daily. Rationale: It is not unusual for a patient who has had a prostatectomy, to complain of not having complete bladder control after catheter removal. To help the patient regain urinary control, pelvic floor strengthening exercises are recommended.
A medical-surgical nurse, who is caring for a patient with a new diagnosis of cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to: 1. Allow the patient and family members time to be alone. 2. Arrange time for the patient to speak with another patient with cancer. 3. Direct the discussion and validation of emotion, without false reassurance. 4. Request a consultation from a social worker on the oncology unit.
3. Direct the discussion and validation of emotion, without false reassurance.
For the evaluation feedback process to be effective, a manager: 1. Conducts weekly meetings with staff members. 2. Considers staff members' interests and abilities when delegating tasks. 3. Informs staff members regularly of how well they are performing their jobs. 4. Provides goals for staff members to meet.
3. Informs staff members regularly of how well they are performing their jobs.
For a patient with Crohn's disease, the medical-surgical nurse recommends a diet that is: 1. High in fiber, and low in protein and calories. 2. High in potassium. 3. Low in fiber, and high in protein and calories. 4. Low in potassium.
3. Low in fiber, and high in protein and calories.
The main goal of treatment for acute glomerulonephritis is to: 1. Encourage activity. 2. Encourage high protein intake. 3. Maintain fluid balance. 4. Teach intermittent urinary catheterization.
3. Maintain fluid balance.
To prepare a patient on the unit for a bronchoscopic procedure, a medical-surgical nurse administers the IV sedative. The medical-surgical nurse then instructs the licensed practical nurse to: 1. Educate the patient about the pending procedure. 2. Give the patient small sips of water only. 3. Measure the patient's blood pressure and pulse readings. 4. Take the patient to the bathroom one more time.
3. Measure the patient's blood pressure and pulse readings.
Nursing diagnoses mostly differ from medical diagnoses in that they are: 1. Dependent upon medical diagnoses for the direction of appropriate interventions. 2. Primarily concerned with caring, while medical diagnoses are primarily concerned with curing. 3. Primarily concerned with human response, while medical diagnoses are primarily concerned with pathology. 4. Primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
3. Primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
The first step in applying the quality improvement process to an activity in a clinical setting is to: 1. Assemble a team to review and revise the activity. 2. Collect data to measure the status of the activity. 3. Select an activity for improvement. 4. Set a measurable standard for the activity.
3. Select an activity for improvement.
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to: 1. A fluid and electrolyte imbalance. 2. A stimulating environment. 3. Sensory deprivation. 4. Sundowning.
3. Sensory deprivation.
A patient who has active pulmonary tuberculosis (TB) states, "I'm not going to take these TB pills!" Which of these responses by the nurse would be appropriate? 1) "You have a legal right to refuse to take this medication." 2) "You need to sign a Refusal of Treatment Form." 3) "You need to ask your doctor about the possibility of discontinuing the medication." 4) "You should know that the health department can require you to take the medication."
4) "You should know that the health department can require you to take the medication." Rationale: Tuberculosis (TB) is a public health problem that requires reporting of the disease to the health department. It is essential that the patient understand the need to take prescribed TB medications as directed. Patients who are unwilling or unable to adhere to treatment may be required to do so by law or may be quarantined or isolated until noninfectious. State governments have legal responsibility for TB control activities, including treatment protocols for nonadherent patients. Health care workers should be familiar with the law in their particular states for these procedures.
In the event of a fire in a hospital's dialysis unit, which of these actions should the nurse take first? 1) Extinguish the fire if possible. 2) Activate the fire response system. 3) Confine the fire by closing all fire doors. 4) Remove patients or staff in danger.
4) Remove patients or staff in danger. Rationale: When a fire occurs in a patient area within the hospital, the nurses' first actions are to protect patients and staff. This usually involves removing the patients and staff from exposure to the fire.
Mrs. Clark is prescribed metoprolol tartrate (Lopressor) for hypertension. Which symptom of hypoglycemia would be masked by Lopressor? 1) Diaphoresis. 2) Tingling. 3) Diplopia. 4) Tachycardia.
4) Tachycardia. Rationale: A side effect of Lopressor, a beta blocker, is bradycardia. The Lopressor-induced bradycardia can mask tachycardia, a symptom of hypoglycemia.
Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin. Because Mr. Palmer is receiving heparin, it is essential for the nurse to 1) monitor his prothrombin time. 2) observe him for signs of pulmonary embolism. 3) limit his intake of foods high in vitamin K. 4) check the femoral puncture site at frequent intervals.
4) check the femoral puncture site at frequent intervals. Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral puncture area, for signs of bleeding.
Which statement by a patient with diabetes mellitus indicates an understanding of the medication insulin glargine (Lantus)? 1. "Lantus causes weight loss." 2. "Lantus is used only at night." 3. "The duration of Lantus is six hours." 4. "There is no peak time for Lantus."
4. "There is no peak time for Lantus."
Which statement by a patient demonstrates an accurate understanding about herbal supplements? 1. "Herbs may interact with prescribed medications but not other herbs." 2. "Most herbs have been tested and found to be safe and therapeutic." 3. "The Food and Drug Administration regulates herbs and allows advertising." 4. "There is no standardization among the manufacturers of herbs in this country."
4. "There is no standardization among the manufacturers of herbs in this country."
A 78-year-old patient is scheduled for transition to home after treatment for heart disease. The patient's spouse, who has chronic obstructive pulmonary disease, plans to care for the patient at home. The spouse says that their grown children, who live nearby, will help. The best approach to discharge planning is to: 1. Arrange nursing home placement for the couple. 2. Consult the spouse's healthcare provider about the spouse's ability to care for the patient. 3. Contact the children to ascertain their commitment to help. 4. Discuss community resources with the spouse and offer to make referrals.
4. Discuss community resources with the spouse and offer to make referrals.
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find: 1. Flaccidity of the upper extremities. 2. Hyperreflexia and spasticity of the upper extremities. 3. Impaired diaphragmatic function requiring ventilator support. 4. Independent use of upper extremities and efficient cough.
4. Independent use of upper extremities and efficient cough.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to: 1. Avoid crowds and obtain an annual influenza vaccination. 2. Drink at least 2 L of fluids daily, including 8 to 10 glasses of water. 3. Eat a potassium-rich, low sodium diet. 4. Practice good dental hygiene and report gum swelling or bleeding.
4. Practice good dental hygiene and report gum swelling or bleeding.
Which action occurs primarily during the evaluation phase of the nursing process? 1. Data collection 2. Decision-making and judgment 3. Priority-setting and expected outcomes 4. Reassessment and audit
4. Reassessment and audit
Which action best describes a sentinel event alert? 1. Documenting the breakdown in communication during a shift report 2. Indicating that a community or institution is unsafe 3. Recording the harm done when a medication error occurs 4. Signaling the need for immediate investigation and response
4. Signaling the need for immediate investigation and response
Which physiological response is often associated with surgery-related stress? 1. Bronchial constriction 2. Decreased cortisol levels 3. Peripheral vasodilation 4. Sodium and water retention
4. Sodium and water retention
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept? 1. Erikson 2. Maslow 3. Rogers 4. Watson
4. Watson
A patient becomes angry attending a treatment group and complains about it to the nurse. Which response could the nurse give that would best demonstrate clarifi cation? A. "Can you tell me what about the treatment group made you angry?" B. "Why are you upset? Attending the treatment group will help you get well." C. "It sounds like group today was pretty upsetting." D. "Treatment groups have been carefully planned by the staff to help patients."
A. "Can you tell me what about the treatment group made you angry?" Rationale: Option A uses clarifi cation to seek validation of what the patient said. Using "why," as in Option B, is accusatory and can hinder self-disclosure. Option C is an example of empathy, and Option D is a destructive sentence that negates the patient's importance.
The nurse is assessing pain in a patient with appendicitis. Which initial statement or question will be most effective in eliciting information? A. "Tell me how you feel." B. "Point to where you're feeling pain." C. "Does your pain medication relieve your pain?" D. "Coughing makes your pain worse, doesn't it?"
A. "Tell me how you feel." Rationale: Asking the patient to describe how he's feeling is an open-ended question, allowing for the widest range of responses. Asking the patient to point to his pain (Option B) may be an important follow-up question but is too limiting to be the nurse's first question. Asking if pain medication relieves his pain (Option C) is a closed question requiring only a yes-or-no response and should be avoided. Option D is leading as well as closed. It suggests to the patient that coughing should make his pain worse.
Using the average cost of a problem and the cost of intervention to demonstrate savings is: A. A cost-benefit analysis B. An efficacy study C. A product evaluation D. A cost-effective analysis
A. A cost-benefit analysis uses average cost of a problem (such as wound infections) and the average cost of intervention to demonstrate savings. For example, if a surgical unit averaged 10 surgical site infections annually at an additional average cost of $27,000 each, the total annual cost would be $270,000. If the total cost for interventions, (new staff person, benefits, education, and software) totals $92,000, and the goal is to reduce infections by 50% (0.5 X $270,000 for a total projected savings of $135,000), cost benefit is demonstrated by subtracting the proposed savings from the intervention costs ($135,000 - $92,000) for a savings of $43,000 annually.
Which of the following is considered identifi able health information? A. A photograph of a patient's leg showing a unique tattoo B. A patient's chart listing his history of a stroke last year C. A blank menu for a regular diet on the patient's over-bed table D. A laboratory report with the patient's name, address, Social Security number, date of birth, and room number deleted
A. A photograph of a patient's leg showing a unique tattoo Rationale: Any information that can identify the person or that relates to a past, present, or future physical or mental condition is considered identifiable health information. Options B, C, and D don't contain information that can identify the patient.
The nurse performs a nutritional assessment on a patient with lung cancer who is in the postoperative period after a lobectomy. Which of the following could be an early sign of malnutrition? A. A retinal-binding protein level of 2.0 mg/dL B. Dry, fl aky, discolored skin and brittle nails C. A body mass index (BMI) of 20 D. An albumin level of 3.0 g/dL
A. A retinal-binding protein level of 2.0 mg/dL Rationale: Retinal-binding protein has a half-life of 12 hours, so a decrease from the normal values of 2.6 to 7.6 mg/dL could be an early sign of malnutrition. Dry, fl aky, discolored skin and brittle nails (Option B) are later signs of malnutrition. A BMI of 20 (Option C) falls in the normal range. Albumin has a half-life of 20 days so, although a value of 3.0 g/dL (Option D) would be a decrease from the normal values of 3.5 to 5 g/dL, it would be a later sign of malnutrition
Which of the following acts committed by a nurse is an intentional tort? A. Battery B. Breach of confidentiality C. Negligence D. Abandonment
A. Battery Rationale: Battery, touching a patient without justifi cation or permission, is an intentional tort. Option B is incorrect because although a nurse who breaches a patient's confidentiality can be subject to a lawsuit or disciplinary action, the act isn't an intentional tort. Option C is incorrect because negligence, the failure to exercise the degree of care that a person of ordinary prudence would exercise under the same circumstances, is an unintentional tort. Option D is incorrect because although abandonment is a liability for nurses, the act isn't an intentional tort.
Qualitative research emphasizes developing new insights, theories, and knowledge. Which term in qualitative research describes the researcher laying aside what is known about the experience being studied? A. Bracketing B. Saturation C. Intuiting D. Theoretical sampling
A. Bracketing Rationale: Bracketing requires the researcher to lay aside what's known about the experience being studied and be open to new insights. Saturation (Option B) describes the point at which data collection is ended because continuing would result in acquiring more of the same information or data. Intuiting (Option C) refers to the focused awareness on the phenomena being studied. Theoretical sampling (Option D) is the selecting of subjects on the basis of concepts that have theoretical relevance to an evolving theory.
When planning the postoperative care of a patient who underwent surgery for repair of a lacerated spleen after an alcohol-related motor vehicle accident, what intervention should take priority in the immediate postoperative period? A. Monitoring the patient for signs and symptoms of alcohol withdrawal B. Encouraging early ambulation C. Splinting the abdomen for coughing and deep-breathing exercise D. Monitoring the patient's renal function
A. Monitoring the patient for signs and symptoms of alcohol withdrawal Rationale: The nurse's priority should be monitoring the patient for signs and symptoms of alcohol withdrawal because alcohol withdrawal usually manifests several hours after the last intake of alcohol. Early recognition of withdrawal symptoms helps prevent progression into alcohol withdrawal delirium. Although encouraging early ambulation (Option B), splinting the abdomen (Option C), and monitoring the patient's renal function (Option D) are important nursing interventions, they don't take priority in the immediate postoperative period.
When implementing an evidence-based nursing program to decrease the incidence of pressure ulcers on a medical-surgical unit, which of the following is the most important to ensure its success? A. Obtaining support from management, administration, and physicians B. Determining and documenting patient outcomes C. Identifying a significant problem that needs to be addressed D. Evaluating research based on its validity and reliability
A. Obtaining support from management, administration, and physicians Rationale: To successfully implement an evidence-based nursing program, it's important to obtain the support of management, administration, and physicians. Option B is part of evaluating evidence-based nursing program implementation. Option C is part of the first step of the evidence-based nursing program process. Option D is part of the critical evaluation of resources.
When a nurse asks another nurse for advice on handling a particular patient problem, she's seeking what type of consultation? A. Patient-centered case consultation B. Consultee-centered case consultation C. Program-centered administrative consultation D. Consultee-centered administrative consultation
A. Patient-centered case consultation Rationale: Patient-centered case consultation (Option A) provides expert advice on handling a particular patient or group of patients. Consultee-centered case consultation (Option B) focuses on work difficulties with patients, which are used as a learning opportunity. Program-centered administrative consultation (Option C) provides expert advice on developing new programs or improving existing ones. Consultee-centered administrative consultation (Option D) considers work problems in the areas of program development and organization.
In the levels of basic human needs as defi ned by Abraham Maslow, which of the following levels is most basic? A. Physiologic B. Safety and security C. Love, affection, and belonging D. Esteem
A. Physiologic Rationale: Physiologic needs (Option A) are the most basic needs and essential for sustaining life. Once physiologic needs are met, needs for safety and security (Option B) can be met, followed by love, affection, and belonging (Option C), and esteem (Option D).
Where is a venous ulcer typically found on a patient? A. The medial lower leg and ankle B. The plantar aspect of foot C. On a bony prominence D. Under the heels
A. The medial lower leg and ankle Rationale: A venous ulcer is typically found on the medial lower leg and ankle. A diabetic ulcer is usually found on the plantar aspect of the foot (Option B) or under the heels (Option D). A pressure ulcer is usually found on a bony prominence (Option C).
A nurse failed to administer a medication to a patient according to accepted standards. Consequently, the patient suffered adverse effects. Failure to provide patient care and to follow appropriate standards is called: A. breach of duty. B. breach of contract. C. battery. D. tort
A. breach of duty. Rationale: Breach of duty means that the nurse provided care that didn't meet the accepted standard. When investigating breach of duty, the court asks: How would a reasonable, prudent nurse with comparable training and experience have acted in comparable circumstances? A breach of contract (Option B) results when one party fails to perform as required by a contract. Battery (Option C) is touching a patient without justification or permission. A tort (Option D) is a civil action for damages for injury to a person, property, or reputation
In the stages of death and dying as defi ned by Elisabeth Kübler-Ross, loss, grief, and intense sadness are symptoms of: A. depression. B. denial. C. anger. D. acceptance.
A. depression. Rationale: Loss, grief, and intense sadness indicate depression. Denial (Option B) is indicated by the refusal to admit the truth or reality. Anger (Option C) is manifested by rage and resentment. Acceptance (Option D) is evidenced by a gradual, peaceful withdrawal from life.
A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as: A. remission. B. convalescence. C. the acute phase. D. the subclinical acute phase.
A. remission. Rationale: A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as remission. Convalescence (Option B) is progression toward recovery. The acute phase (Option C) refers to the disease at its full intensity, possibly with complications. The subclinical acute phase (Option D) occurs when the patient is in the acute phase but still functions as if the disease weren't present.
Which diet would be most appropriate for a patient with ulcerative colitis? A. A low-fat diet B. A low-residue diet C. A high-calorie diet D. A high-fiber diet
B. A low-residue diet Rationale: A low-residue diet is used to avoid GI tract irritation and decrease fecal volume, appropriate measures for a patient with ulcerative colitis. Such a patient doesn't need to follow a lowfat diet (Option A) or to consume additional calories (Option C). A patient with ulcerative colitis should avoid a high-fiber diet (Option D), which contains such foods as whole grain cereals and fruit.
The two types of surgery primarily used to promote weight loss are restrictive and malabsorptive-restrictive. Which of the following is an example of restrictive weight-loss surgery? A. Gastric bypass B. Adjustable gastric banding C. Roux-en-Y D. Biliopancreatic diversion
B. Adjustable gastric banding Rationale: Adjustable gastric banding is a type of gastric restriction weight-loss surgery. Malabsorptive-restrictive procedures include gastric bypass (Option A) (also known as a Roux-en-Y bypass [Option C]) and biliopancreatic diversion (Option D).
Which of the following are external factors that subject the skin to injury? A. Emaciation and infections B. Allergens and radiation C. Radiation and emaciation D. Allergens and infections
B. Allergens and radiation Rationale: Allergens and radiation are external factors that subject the skin to injury. Emaciation (included in Options A and C) and infection (included in Options A and D) are internal factors.
Which of Piaget's cognitive developmental stages takes place from ages 7 to 11? A. Formal operations B. Concrete operations C. Preoperational D. Sensorimotor
B. Concrete operations Rationale: The concrete operations stage takes place between ages 7 and 11. The formal operations stage (Option A) occurs at age 11 and above. The preoperational stage (Option C) takes place between ages 2 to 7, and the sensorimotor stage (Option D) occurs from birth to age 2 years.
When planning the implementation of evidence-based practices to prevent falls, which of the following steps should the nurse take fi rst? A. Identify the common causes of falls. B. Gather and review currently existing literature and guidelines for the prevention of falls. C. Identify fall prevention practices that are applicable to the patient care setting. D. Gather data to identify the effectiveness of the new practice guidelines.
B. Gather and review currently existing literature and guidelines for the prevention of falls. Rationale: Options A, B, and C are correct steps in planning for the implementation of evidence-based practices; however, Option B would be the initial step, followed by Options A and C. Option D is part of the evaluation phase of evidence-based practice implementation
A patient, age 54, is admitted with a diagnosis of venous ulceration unresponsive to treatment. Which of the following is the nurse most likely to fi nd during an assessment of a patient with venous ulceration? A. Gangrene B. Heavy exudate C. Deep wound bed D. Pale wound bed
B. Heavy exudate Rationale: Moderate to heavy exudate is one characteristic of a venous ulcer. Other characteristics include irregular wound margins, superficial wound bed, and ruddy, granular tissue. Options A, C, and D are incorrect because they're characteristics of arterial ulcers.
When performing an assessment, the nurse identifi es the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis? A. Health-seeking behaviors B. Impaired physical mobility C. Disturbed sensory perception D. Deficient knowledge
B. Impaired physical mobility Rationale:Impaired physical mobility is a limitation of physical movement and is defined by the patient's signs and symptoms. Options A, C, and D are nursing diagnoses with different defining signs and symptoms.
When performing an abdominal assessment, the nurse should follow which examination sequence? A. Auscultation, inspection, percussion, palpation B. Inspection, auscultation, percussion, palpation C. Palpation, auscultation, percussion, inspection D. Percussion, palpation, auscultation, inspection
B. Inspection, auscultation, percussion, palpation Rationale: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.
What term describes the softening of tissue by wetting or soaking? A. Eschar B. Maceration C. Sloughing D. Angiogenesis
B. Maceration Rationale: Maceration is the softening of tissue by wetting or soaking. Eschar (Option A) is thick, leathery, necrotic, devitalized tissue. Sloughing (Option C) is the separation of necrotic tissue from viable tissue. Angiogenesis (Option D) is the formation of new granulation vessels.
The nurse is administering warfarin (Coumadin) to a patient with deep vein thrombophlebitis. Which laboratory value indicates warfarin is at therapeutic levels? A. PTT 1½ to 2 times the control B. PT 1½ to 2 times the control C. INR of 3 to 4 D. Hematocrit of 32%
B. PT 1½ to 2 times the control Rationale: Warfarin is at therapeutic levels when the patient's PT is 1½ to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, and lower values indicate increased risk of blood clot formation. Option A is incorrect because heparin, not warfarin, prolongs PTT. Option C is incorrect because although the INR may also be used to determine if warfarin is at a therapeutic level, an INR should be 2-3. Option D is incorrect because hematocrit doesn't provide information on the effectiveness of warfarin; however, a falling hematocrit in a patient taking warfarin may be a sign of hemorrhage.
Which measure most effectively reduces the risk of health care-associated infections? A. Keeping employee health records up-to-date B. Performing hand hygiene C. Providing annual influenza vaccinations D. Always wearing a mask when caring for patients
B. Performing hand hygiene Rationale: Performing hand hygiene in compliance with the World Health Organization or Centers for Disease Control and Prevention guidelines is the most effective in reducing the risk of health care-associated infections. Keeping employee health records up-to-date (Option A), providing annual influenza vaccinations (Option C), and always wearing a mask when caring for patients (Option D) aren't the most effective ways to reduce the risk of health care-associated infections.
In a negligence suit against a nurse, what must the plaintiff prove? A. The nurse intended to cause harm. B. The nurse's actions caused harm. C. The nurse knew she caused harm. D. The nurse was sorry for causing harm
B. The nurse's actions caused harm. Rationale: In a negligence suit, the plaintiff must prove that the nurse's actions caused harm to the patient. He doesn't need to prove that the nurse intended to cause harm (Option A), knew she caused harm (Option C), or was sorry she caused harm (Option D).
A 30-year old patient has been diagnosed with advanced ovarian cancer. The patient says, "This is all my fault." Which of Kubler-Ross's five stages of grief is the patient probably experiencing? A.Denial B.Anger C.Depression D.Acceptance
B. The patient is experiencing the stage of anger. People grieve individually and may not go through all stages, but most go through at least 2 stages. Kubler-Ross's 5 stages of grief include: Denial: Refusal to believe, confused, stunned, detached. Anger: Directed inward (self-blame) or outward. Bargaining: If - then thinking. ("If I go to church, then I will heal.") Depression: Sad, withdrawn. Acceptance: Resolution.
While auscultating the heart sounds of a patient with mitral insuffi ciency, the nurse hears an extra heart sound immediately after the second heart sound (S2 ). The nurse should document this extra heart sound as: A. a first heart sound (S1). B. a third heart sound (S3). C. a fourth heart sound (S4). D. a mitral murmur
B. a third heart sound (S3). Rationale: An S3 is heard following an S2 , indicating that the patient is experiencing heart failure and results from increased filling pressures. Option A (S1) is a normal heart sound made by the closing of the mitral and tricuspid valves. Option C (S4) is heard before S1 and is caused by resistance to ventricular filling. Option D (murmur of mitral insufficiency) occurs during systole and is heard when there's turbulent blood fl ow across the valve.
The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the nurse understands that the unlicensed assistant: A. interprets clinical data. B. collects clinical data. C. is trained in the nursing process. D. can function independently
B. collects clinical data. Rationale: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. Option A is incorrect because the registered nurse, who has learned critical thinking skills, interprets the data. Option C is incorrect because although unlicensed assistants are trained to perform skills, they don't learn the nursing process. Option D is incorrect because unlicensed assistants don't function independently; they're assigned tasks by a registered nurse who retains overall responsibility for the patient.
A patient is receiving captopril for heart failure. The nurse should notify the practitioner that the medication therapy is ineffective if an assessment reveals: A. a skin rash. B. peripheral edema. C. a dry cough. D. postural hypotension
B. peripheral edema. Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. The other options (a skin rash, dry cough, and postural hypotension) are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
To maintain a therapeutic environment with a patient and his family, the nurse can use communication techniques such as clarifi cation. An example of clarifi cation is: A. "How is it going?" B. "You say you aren't concerned, but you've asked me many questions on this same subject." C. "What do you mean when you say...?" D. "For now, I would like to concentrate on..."
C. "What do you mean when you say...?" Rationale: Option C is an example of clarification or seeking validation. Option A isn't an example of clarification but is instead an example of a broad-opening technique. Option B is an example of confrontation, which calls attention to discrepancies in what the patient is saying. Option D is an example of focusing or helping the patient direct his thoughts.
Which substance enables the transport of oxygen during wound healing? A. Zinc B. Vitamin B6 C. Folate D. Vitamin C
C. Folate Rationale: Folate enables the transport of oxygen during wound healing. Zinc (Option A) enables protein synthesis and tissue repair. Vitamin B6 (Option B) decreases collagen and protein synthesis, and vitamin C (Option D) is needed for collagen synthesis
A patient with an arterial ulcer over the left lateral malleolus complains of pain at the ulcer site. The nurse caring for this patient understands that the pain is caused most commonly by which of the following? A. Infection B. Exudate C. Ischemia D. Edema
C. Ischemia Rationale: Severe pain at an arterial ulcer site typically results from ischemia caused by reduced arterial blood flow. Option A is incorrect because infection is a complication of arterial ulceration that may not occur in all patients with arterial ulceration. Option B is incorrect because arterial ulcers have minimal exudate. Option D is incorrect because edema isn't present with arterial ulcers.
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do? A. Consider this to be a normal finding for his age and race. B. Recommend he have his blood pressure rechecked in 1 year. C. Recommend he have his blood pressure rechecked within 2 weeks. D. Recommend he go to the emergency department for further evaluation.
C. Recommend he have his blood pressure rechecked within 2 weeks. Rationale: A BP of 150/90 mm Hg should be rechecked within 2 weeks according to current recommendations. If confirmed, assessment and treatment should be initiated by the practitioner. Option A is incorrect because although hypertension is more prevalent among blacks, a BP of 150/90 mm Hg isn't considered normal. Option B is incorrect because a person with a BP of 150/90 mm Hg shouldn't wait as long as 1 year to have it rechecked. Option D is incorrect because he doesn't need to be treated on an emergency basis, but he should have his BP monitored.
The nurse is evaluating a postoperative patient for infection. Which sign or symptom would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Rectal temperature of 100° F (37.8° C) C. Redness, warmth, and tenderness at the incision site D. WBC count of 8,000/mL
C. Redness, warmth, and tenderness at the incision site Rationale: Redness, warmth, and tenderness at the incision site would lead the nurse to suspect a postoperative infection. Option A is incorrect because the presence of an invasive device predisposes a patient to infection but alone doesn't indicate infection. Option B is incorrect because a rectal temperature of 100° F is a normal finding in a postoperative patient because of the inflammatory response. Option D is incorrect because a normal WBC count ranges from 4,000 to 10,000/mL.
After assessing a patient's pressure ulcer, you note that subcutaneous fat is visible but that bone, tendon, and muscle are not exposed. You observe slough, but it does not obscure the depth of tissue loss. You also note some undermining and tunneling. What stage pressure ulcer is this? A. Stage II B. Suspected deep tissue injury C. Stage III D. Stage IV
C. Stage III Rationale: A Stage III pressure ulcer involves full-thickness tissue loss, possibly with visible subcutaneous fat but with no exposer of bone, tendon, or muscle; slough may be present but doesn't obscure the depth of tissue loss, and undermining and tunneling may also be present. A Stage II pressure ulcer (Option A) involves a partial-thickness tissue loss presenting as a shallow, open ulcer with a red-pink wound bed without slough. A suspected deep tissue injury (Option B) involves a purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage of underlying soft tissue from pressure, shear, or both. A stage IV pressure ulcer (Option D) involves full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed.
Which interaction style describes a nurse who cannot clearly separate her own emotional responses from the patient's needs and wants? A. Holistic B. Defensive C. Sympathetic D. Silence
C. Sympathetic Rationale: A sympathetic interaction style occurs when the nurse can't clearly separate her own emotional responses from the patient's needs and wants. Nurses who use a holistic interaction style (Option A) have healthy ego boundaries and provide an atmosphere that promotes patient growth. Nurses who tend to blame their patients and feel frustrated when they do not "measure up" have a defensive interaction style (Option B). Silence (Option D) is a type of therapeutic communication technique, not an interaction style
The nurse is providing care for a patient who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate when caring for a patient with a wet-to-dry dressing? A. The wound should remain moist from the dressing. B. The wet-to-dry dressing should be tightly packed into the wound. C. The dressing should be allowed to dry before it's removed. D. A plastic sheet-type dressing should cover the wet dressing
C. The dressing should be allowed to dry before it's removed. Rationale: A wet-to-dry dressing should be allowed to dry and adhere to the wound before being removed. The goal is to debride the wound as the dressing is removed. Option A is incorrect because the wet-to-dry dressing isn't applied to keep a wound moist; a moist saline dressing is applied to keep a wound moist. Option B is incorrect because tightly packing a wound damages the tissues. Option D is incorrect because a wet-to-dry dressing should be covered with a dry gauze dressing, not a plastic sheet-type dressing.
A 68-year old man with mild COPD refuses to exercise because he tires easily. He spends most of every day sitting in a chair watching television. What is the most appropriate nursing diagnosis? A.Ineffective health maintenance B.Impaired physical mobility C.Risk for disuse syndrome D.Activity intolerance
C. The most appropriate nursing diagnosis for a person who is able to exercise but remains sedentary is risk of disuse syndrome because the patient is putting himself at risk for the development of circulatory impairment and muscle atrophy. Failure to exercise may also exacerbate his condition. While his health maintenance may be ineffective, it is directly due to of his lack of activity. He does not have impaired physical mobility or activity intolerance that precludes exercise.
Which action should the nurse take when receiving a telephone order from a physician? A. Inform the physician that telephone orders are not permitted. B. Write the order in the patient's medical record immediately. C. Write down the order and then read back the complete order to the physician. D. Immediately carry out the order.
C. Write down the order and then read back the complete order to the physician. Rationale: When receiving a telephone or other verbal order, the nurse should write down the order and then read back the complete order to the physician to verify its accuracy. Options A, B, and D aren't appropriate actions for the nurse to take when receiving a telephone order from a physician.
When prioritizing a patient's care plan based on Maslow's hierarchy of needs, the nurse's fi rst priority would be: A. allowing the family to see a newly admitted patient. B. ambulating the patient in the hallway. C. administering pain medication. D. using two nurses to transfer the patient.
C. administering pain medication. Rationale: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (Option B) is on the second layer. Safety (Option D) is on the third layer. Love and belonging (Option A) are on the fourth layer
The belief that one's own cultural values and beliefs are superior or the only correct values and beliefs is: A. cultural competency. B. cultural diversity. C. ethnocentrism. D. cultural sensitivity.
C. ethnocentrism. Rationale: Ethnocentrism is the belief that one's own cultural values and beliefs are superior or the only correct values and beliefs. Cultural competency (Option A) is the ability to work and interact effectively with people of other cultures. Cultural diversity (Option B) describes the diverse groups in society, which have varying races and national origins, religious affiliations, languages, physical size, gender, sexual orientation, age, disabilities, socioeconomic status, occupational status, and geographic location. Cultural sensitivity (Option D) is the understanding of the diverse needs, characteristics, and values of individuals, families, and groups
The nurse is teaching a group of patient care attendants about infectioncontrol measures. The nurse tells the group that the fi rst line of intervention for preventing the spread of infection is: A. wearing gloves. B. administering antibiotics. C. hand hygiene. D. assigning private rooms for patients.
C. hand hygiene. Rationale: Hand hygiene is the fi rst line of intervention for preventing the spread of infection. Option B is incorrect because antibiotics should be initiated only when an organism is identifi ed. Although wearing gloves (Option A) and assigning private rooms (Option D) can also decrease the spread of infection, they should be implemented according to standard precautions when indicated.
OSHA is responsible for: A. compensating workers injured in the workplace. B. providing rehabilitation for workers injured in the workplace. C. inspecting high-hazard workplaces for compliance with protective standards. D. disciplining workers injured in the workplace.
C. inspecting high-hazard workplaces for compliance with protective standards. Rationale: OSHA is responsible for preventing work-related injuries, illnesses, and deaths. Options A and B are incorrect because it's the responsibility of workers' compensation to compensate workers for injuries occurring in the workplace and to provide rehabilitative services. Option D is incorrect because it's the employer's responsibility to improve the safety and health of employees. Employers who violate OSHA standards are subject to fines and penalties
The nurse is caring for a patient admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless the patient: A. is mentally ill. B. refuses to give informed consent. C. is in an emergency situation. D. asks the nurse to give substituted consent
C. is in an emergency situation. Rationale: The law doesn't require informed consent in an emergency situation when the patient can't give consent and no next of kin is available. Option A is incorrect because even though a patient who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the patient is incompetent to give such consent. Option B is incorrect because a mentally competent patient may refuse or revoke consent at any time. Option D is incorrect because although the nurse may act as a patient advocate, the nurse can never give substituted consent.
Measuring the effectiveness of an intervention rather than the monetary savings is: A.A cost-benefit analysis. B.An efficacy study. C.A product evaluation. D.A cost-effective analysis.
D. A cost-effective analysis measures the effectiveness of an intervention rather than the monetary savings. For example, annually 2 million nosocomial infections result in 90,000 deaths and an estimated $6.7 billion in additional health costs. From that perspective, decreasing infections should reduce costs, but there are human savings in suffering as well, and it can be difficult to place a dollar value on that. If each infection adds about 12 days to hospitalization, then a reduction of 5 infections (5 X 12 = 60) would result in a cost-effective savings of 60 fewer patient infection days.
In Erikson's psychosocial model of development, which stage is typical of those entering young adulthood? A.Identify vs role confusion B.Initiative vs guilt C.Ego integrity vs despair D.Intimacy vs isolation
D. Erickson's psychosocial development model focuses on conflicts at each stage of the lifespan and the virtue that results from finding balance in the conflict. The first 5 stages refer to infancy and childhood and the last 3 stages to adulthood: Intimacy vs isolation (Young adulthood): Love/intimacy or lack of close relationships. Generativity vs stagnation (Middle age): Caring and achievements or stagnation. Ego integrity vs despair (Older adulthood): Acceptance and wisdom or failure to accept changes of aging/despair.
In what type of electrolyte imbalance would the nurse observe tall, tented T waves; a widened QRS complex; and a prolonged PR interval on the patient's ECG? A. Hypokalemia B. Hypocalcemia C. Hypercalcemia D. Hyperkalemia
D. Hyperkalemia Rationale: In hyperkalemia, the patient's ECG will show tall, tented T waves; a widened QRS complex; and a prolonged PR interval. In hypokalemia (Option A) the ECG will show a fl at ST segment and Q wave. Hypocalcemia (Option B) and hypercalcemia (Option C) won't show T wave, QRS, or PR interval changes on the ECG.
According to the stages of development, what confl ict does the older adult experience? A. Intimacy versus isolation B. Generativity versus stagnation C. Identity versus role confusion D. Integrity versus despair
D. Integrity versus despair Rationale: The key confl ict the older adult (age 66 and older) faces is integrity versus despair. Intimacy versus isolation (Option A) is the key conflict in young adulthood; generativity versus stagnation (Option B), the key conflict in middle adulthood; and identity versus role confusion (Option C), the key conflict of adolescence
The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the first for the nurse to take? A. Tell the patient that he must wait 4 hours for more pain medication. B. Give half of the ordered as-needed dose. C. Document the patient's pain. D. Notify the practitioner that the patient is still experiencing pain
D. Notify the practitioner that the patient is still experiencing pain Rationale: The practitioner should be notifi ed that the patient is still experiencing pain so that new medication orders can be established. Option A is incorrect because patients who have recently undergone surgery shouldn't have to wait 4 hours for pain relief. Option B is incorrect because a nurse can't alter a dose without first consulting the practitioner; doing so could result in a nurse being charged with practicing medicine without a license. Although the nurse should document the patient's pain, Option C, it isn't the first action the nurse should take
The nurse is caring for a patient who has just been diagnosed with a terminal illness. The patient says to her, "I can't believe this! I feel..." and pauses. The nurse allows the patient time to gather his thoughts. What type of therapeutic communication is this? A. Clarification B. Empathy C. Reflection D. Silence
D. Silence Rationale: The nurse allows the patient time to gather his thoughts by using silence. Clarifi cation (Option A) would be seeking validation for what the patient said. Empathy (Option B) would be the nurse placing herself temporarily in the patient's position. Reflection (Option C) would be paraphrasing what the patient said.
Which of the following is incorrect about informed consent? A. It can be revoked by the state, especially when the benefits outweigh the risks. B. A person has to be mentally competent to sign an informed consent. C. Physicians can waive informed consents in emergency situations. D. The name of the procedure, its risks and benefits, and other alternative procedures make up all the essential elements of informed consent
D. The name of the procedure, its risks and benefits, and other alternative procedures make up all the essential elements of informed consent Rationale: An informed consent should also contain the name of the health care professional who will be performing the procedure. The other options are correct statements about informed consent.
A patient became seriously ill after a nurse gave him the wrong medication. After his recovery, he fi led a lawsuit. Who is most likely to be held liable? A. No one because it was an accident B. The hospital C. The nurse D. The nurse and the hospital
D. The nurse and the hospital Rationale: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, the nurse and the hospital are liable. Therefore, Options B and C are incorrect. Option A is incorrect because although the mistake wasn't intentional, standard procedure wasn't followed.
During which stage of healing does granulation tissue form and epithelialization occur? A. The maturation phase B. The epithelial closure phase C. The infl ammatory phase D. The proliferative phase
D. The proliferative phase Rationale: During the proliferative stage of wound healing, granulation tissue forms and epithelialization occurs. In the final maturation phase (Option A), collagen reorganizes and strengthens. In the epithelial closure phase (Option B), the wound contracts and begins to close. The inflammatory phase (Option C) starts right after injury and doesn't involve granulation tissue formation or epithelialization.
The nurse is assessing the laboratory values of a patient with an abdominal wound healing by secondary intention. Which of the following laboratory values indicates that the patient is receiving adequate nutrition? A. Serum albumin level of 2.5 g/dL B. Prealbumin level of 12 mg/dL C. Transferrin level of 190 mg/dL D. Total lymphocyte count of 1,900 mL
D. Total lymphocyte count of 1,900 mL Rationale: A total lymphocyte count greater than 1,800 mL indicates adequate nutrition. Options A, B, and C are incorrect because these laboratory values indicate poor nutrition.
The nurse leaves a patient who is elderly and confused to fi nd someone to assist with transferring the patient to bed. While the nurse is gone, the patient falls and hurts herself. The nurse is at fault because she hasn't: A. properly educated the patient about safety measures. B. restrained the patient. C. documented that she left the patient. D. arranged for continual care of the patient.
D. arranged for continual care of the patient. Rationale: By leaving the patient, the nurse is at fault for abandonment. The better courses of action are to turn on the call bell or elicit help on the way to the patient's room. Options A and C are incorrect because neither excuses the nurse from her responsibility for ensuring the patient's safety. Option B is incorrect because restraints are only to be used as a last resort, when all other alternatives for ensuring patient safety have been tried and have failed; moreover, restraints won't ensure the patient's safety.
A patient is admitted to the health care facility with a possible electrolyte imbalance. The patient is disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. The patient most likely suffers from: A. hypernatremia. B. hyponatremia. C. hyperkalemia. D. hypokalemia.
D. hypokalemia. Rationale: Signs and symptoms of hypokalemia include GI, cardiac, renal, respiratory, and neurologic symptoms. Options A, B, and C are incorrect because the use of a potassium-wasting diuretic, such as hydrochlorothiazide, without potassium supplement therapy causes hypokalemia.
The nurse is assessing a patient who may be in the early stages of dehydration. Early signs and symptoms of dehydration include: A. coma and seizures. B. sunken eyeballs and poor skin turgor. C. increased heart rate with hypotension. D. thirst and confusion.
D. thirst and confusion. Rationale: Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Options A, B, and C are incorrect because coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs and symptoms of dehydration.
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse question? 1) Oxygen per nasal cannula at 4 L per minute. 2) Enoxaparin (Lovenox) 40 mg subcutaneously. 3) Troponin level. 4) Computed tomography (CT) angiogram.
Rationale: The nurse should questions the order for Lovenox because the patient is receiving a heparin drip.
