EAQ 1
A patient has a lung infection. Which nursing standards of practice should the nurse adopt while caring for this patient? Select all that apply. A. Planning B. Diagnosis C. Assessment D. Collaboration E. Environmental health
ABC
Which type of interpretation errors may occur with a nursing diagnosis? Select all that apply. A. Inaccurate interpretation of cues B. Use of an insufficient number of cues C. Failure to consider conflicting cues D. Failure to validate the nursing diagnosis with the patient E. Insufficient cluster of cues
ABC
The nurse is learning about ethics in nursing practice. Which actions should the nurse perform to meet the American Nurses Association (ANA) code of ethics? Select all that apply. A. Consider the patient as the primary commitment. B. Strive to protect the health and rights of the patient. C. Consider personal and professional growth a priority. D. Contribute to nursing practice and knowledge development. E. Ignore other healthcare professionals and perform one's own duties.
ABCD
Which symptoms indicate the presence of a systemic infection? Select all that apply. A. Fatigue B. Redness C. Swelling D. Warmth E. Malaise
AE
What are the characteristics of well-written goals and expected outcomes? Select all that apply. A. Priority B. Observable C. Nonmeasurable D. Time-limited E. Patient-centered
BDE
What type of interview techniques is the nurse demonstrating when asking these questions, 'Do you have pain or cramping' or 'Does the pain get worse when you walk?' Select all that apply. A. Active listening B. Open-ended questioning C. Closed-ended questioning D. Problem-oriented questioning E. Back channeling
CD
Under which ethical principle is the patient's personal health information protected? A. Advocacy B. Nonmaleficence C. Beneficence D. Confidentiality
D
A patient on insulin comes for routine blood tests and the nurse finds that his blood sugar is very high. The patient informs the nurse that he measured his blood sugar at home before coming to the clinic, and it was normal. What is the most appropriate nursing action? A. Advise the patient to go to another endocrinologist. B. Advise the patient to change the type of insulin he is using. C. Advise the patient to decrease the dose of insulin. D. Ask the patient to show his technique for checking blood sugar levels.
D.
A nurse reviews the laboratory reports of a patient with infection. Which laboratory parameter would be normal during infection? A. Basophil count B. Monocyte count C. Neutrophil count D. Lymphocyte count
A
A patient is diagnosed with breast cancer. The healthcare provider educates the patient about the treatment options. The healthcare provider recommends and highly favors chemotherapy; however, the patient chooses to undergo surgery. Which is the mostappropriate intervention? A. Prepare the patient for surgery. B. Order the patient to undergo chemotherapy. C. Convince the patient of the disadvantages of surgery. D. Convince the patient of the advantages of chemotherapy.
A
A patient is diagnosed with influenza. Which type of isolation precaution is mostappropriate for this patient? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions
A
A patient with leukemia tells the nurse, 'I don't want my family to know about my condition; please keep it confidential.' The nurse promises to keep the information confidential while caring for the patient and keeps her word. Which ethical concept does this nursing action reflect? A. Fidelity B. Justice C. Autonomy D. Accountability
A
Following a procedure in an isolation room in which full personal protective equipment (PPE) is required, which is the first step the nurse follows when removing PPE? A. Remove gloves B. Remove mask C. Remove gown D. Perform hand hygiene
A
How can nurses negotiate differences of opinion and values with patients? A. Be clear about their values. B. Emphasize correctness of their values. C. Negate the patient's values. D. Ask the patients to accept the nurses' values.
A
The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the P in a three-part nursing diagnostic statement using the PES format? A. Severe pain B. Natural swelling C. Related to incisional trauma D. Wincing, guarding, restricted turning and positioning
A
The nurse is floated to work on a nursing unit where the assignment is beyond the nurse's 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 work.
A
The nurse provides care to four patients with different medical conditions in four units. In which medical unit should the nurse use an N95 respirator? UNIT 1: LARYNGEAL TB UNIT 2: SHINGELLA UNIT 3: SCABIES UNIT 4: DISSEMINATED VARICELLA ZOSTER A. Medical unit I B. Medical unit II C. Medical unit III D. Medical unit IV
A
What should a clinical interview ideally focus on? A. The patient B. The nurse's agenda C. Hospital policy D. Both the patient and nurse's agenda
A
Which disease requires contact precautions? A. Scabies B. Measles C. Diphtheria D. Pharyngitis
A
While reviewing the laboratory blood reports of a male patient, the nurse finds that his iron level is 60 mcg/mL. What does the nurse suspect from this finding? A. The patient has a chronic infection. B. The patient has a parasitic infection. C. The patient has a suppurative infection. D. The patient has a tuberculosis infection.
A
While teaching about Quality and Safety Education for Nurses (QSEN) competencies, the nurse states, 'This competency uses tools such as flowcharts and diagrams to make the process of care explicit.' Which QSEN competency is the nurse referring to? A. Quality Improvement B. Patient-Centered Care C. Evidence-Based Practice D. Teamwork and Collaboration
A
Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. What are the responsibilities of the nurse as a patient educator? Select all that apply. A. Explain concepts and facts about health to patients. B. Protect the patient's human and legal rights. C. Teach the patient to self-administer insulin injections. D. Provide adequate information to the patient to help make treatment decisions. E. Prescribe appropriate medications.
A and C
The nurse is teaching a group of nursing students about the normal defense mechanisms of the body against infections. Which statements are true about the skin as a primary defense against infections? Select all that apply. A. It provides a barrier to microorganisms. B. It helps in removing organisms when they adhere to outer layers of the skin. C. It contains fatty acids that have an antibacterial action. D. It helps in washing away particles containing microorganisms. E. It contains microbial inhibitors.
ABC
Inaccurate data collection is a source of error in diagnosis. What factors can cause errors in data collection? Select all that apply. A. Missing data B. Inaccurate data C. Disorganization D. Lack of knowledge or skill E. Premature or early closure of clustering
ABCD
Nursing is important in providing safe, patient-centered health care to the global community. Which statements are true about the nursing practice? Select all that apply. A. Nursing practice helps shape health policy and health systems management. B. Nursing practice involves collaborative care of sick individuals of all ages, families, groups, and communities. C. Nursing practice involves helping a dying patient find relief from pain. D. Nursing practice involves interpreting clinical situations and making complex decisions based on knowledge and experience. E. Nursing practice does not incorporate ethical and social values but only knowledge of behavioral sciences.
ABCD
The nurse is explaining the levels of prevention to a group of nursing students. Which information should the nurse include? Select all that apply. A. Primary prevention involves immunizations, health education programs, nutrition, and physical activities. B. Secondary prevention involves early diagnosis and prompt treatment. C. Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. D. Secondary prevention focuses on people who are experiencing health problems or illnesses. E. Tertiary prevention focuses on people who are at risk for developing complications or worsening conditions.
ABCD
The nurse works in a hospital. The nurse understands that health care-associated infections (HAIs) are difficult to treat. Which patient may be at increased risk of developing an HAI? Select all that apply. A. A patient who underwent bronchoscopy B. A patient who receives broad-spectrum antibiotics C. A patient who has an indwelling urinary catheter D. A patient who suffers from diabetes mellitus E. A patient who has a fever
ABCD
What points should the nurse keep in mind when formulating the nursing diagnosis? Select all that apply. A. Accurately selecting the diagnoses B. Identifying related factors pertinent to the diagnosis C. Selecting interventions suited for treating the diagnosed condition D. Identifying defining characteristics of the diagnosis E. Properly making medical diagnoses
ABCD
The nurse has collected data from a patient during the initial interview. The nurse clusters the collected data and prepares a care plan. What are acceptable components of a comprehensive nursing care plan? Select all that apply. A. Infection risk B. Respiratory rate of 24 breaths per minute C. Administering medications D. Preparing a patient for a diagnostic study E. Oxygen at 2 liters per nasal cannula
ABE
The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Select all that apply. A. Accurately interpreting cues B. Using reliable cues C. Failing to consider conflicting cues D. Using an insufficient number of cues E. Considering cultural influences or developmental stage
ABE
The nurse is caring for a patient who has been admitted to the hospital with terminal leukemia. The patient has expressed a preference for nonpharmacological pain control. The nurse refers to articles and systematic reviews to learn the best possible nonpharmacological methods to treat cancer pain. How would the nurse's actions be categorized, according to the QSEN competencies? Select all that apply. A. Patient-Centered Care B. Teamwork and Collaboration C. Evidence-Based Practice D. Safety
AC
Which statements best describe a consent form? Select all that apply. A. It may be signed by an emancipated minor. B. It protects the healthcare facility but not the healthcare provider. C. It signifies that the patient understands all aspects of the procedure. D. It signifies that the patient and family have been told about the procedure. E. It must be signed by the patient or responsible party at the healthcare facility, and consent may not be obtained by phone or fax.
AC
A newly hired nurse is asked to perform a procedure that the nurse has not previously performed. What should the nurse do in such a situation? Select all that apply. A. Try to learn and obtain knowledge about the procedure. B. Ask the unit manager to assign the procedure to another nurse. C. Ask an experienced nurse to supervise and guide the new nurse during the procedure. D. Verbalize the steps of the procedure with an instructor before performing it. E. Refuse to perform the procedure.
ACD
Nurses are responsible for the quality of care provided to patients. Which will help nurses practice safe nursing? Select all that apply. A. Acquiring knowledge B. Minimizing documentation C. Improving competencies D. Acquiring technical skills E. Exhibiting complete dependence
ACD
The nurse is conducting an interview with a patient. Which closed-ended questions should the nurse use? Select all that apply. A. 'Do you have pain now?' B. 'Tell me more about your pain.' C. 'Are you experiencing cramping?' D. 'Do you think the medication is helping you?' E. 'How do you feel about using pain medications?'
ACD
The nurse understands that the use of the nursing process is necessary to provide effective patient care. What are some of the chief components of the nursing process? Select all that apply. A. Diagnosis B. Detection C. Assessment D. Identification E. Implementation
ACE
A group of nursing students is being taught independent nursing interventions. Which interventions should be included in the teaching? Select all that apply. A. Health promotion B. Starting an intravenous infusion C. Administration of analgesics D. Assisting with daily activities E. Repositioning a patient for pain relief
ADE
The nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. The nurse's colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. Before giving the medication, what is the nurse's best action? A. Consult with the colleague before giving the medication. B. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. D. Ask the colleague to administer the medication to her patient. E. Administer the medication as prescribed and on time.
B
The nurse notes that an advance directive is on a patient's medical record. Which statement best describes an advance directive guideline? A. A living will allows an appointed person to make healthcare 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
Which statement is true regarding the donning and removing of caps, masks, and eyewear? A. Surgical masks and eyewear should be worn only inside the sterile field. B. Eyewear should be worn only when the procedure has a risk of splashing. C. Surgical masks should be worn first and then a clean cap should be worn to cover the hair. D. Surgical masks should be removed after the completion of the procedure even if it takes several hours.
B
Which type of transmission-based precaution requires a gown and gloves? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Protective environment precautions
B
The nurse advised a patient to walk for 5 minutes at 6:00 AM every day. The next day, the patient did not follow the advice. The nurse explained to the patient the importance of walking and physical activity for health improvement. Thereafter, the patient started walking daily. What should be the next step in the care plan? A. Ask the patient to motivate other patients to walk daily. B. Discontinue the health education related to exercise in the care plan. C. Supervise the patient for adherence to the routine exercise regimen. D. Continue to advise the patient regarding exercise.
B.
The nurse has to start the interventions on a patient per the nursing plan of care. Which activity should the nurse perform before implementing interventions? A. Get authorization from the primary healthcare provider. B. Anticipate complications. C. Explain the interventions to the patient. D. Sedate the patient before starting interventions.
B.
Which factors must be considered when choosing a nursing intervention to address a patient problem? Select all that apply. A. Acceptability to the health care provider B. Outcomes that have been set for the patient C. Research evidence supporting the intervention D. Likelihood of successfully completing the intervention E. Nature of the nursing diagnosis
BCDE
The nurse is assessing a group of patients in a health screening program. A patient has an abscess under the right arm. The nurse suspects the possibility of a systemic infection. What signs and symptoms may indicate a systemic infection? Select all that apply. A. Increased appetite B. Fatigue and malaise C. Enlarged lymph nodes D. Increased blood pressure E. Elevated body temperature
BCE
The nurse is responsible for managing all the supplies and equipment required for a patient's minor procedure. Which actions performed by this nurse are correct? Select all that apply. A. Only keep the exact number of supplies as needed. B. Keep some extra supplies handy. C. Ensure that the equipment is safe and in working condition. D. Unseal all the equipment and place close to the patient. E. Place the equipment properly to ensure easy access during the procedure.
BCE
When performing the initial interview of a patient admitted to the hospital, which characteristics of the patient should the nurse document as objective data? Select all that apply. A. Severe throbbing headache B. Body temperature of 104° F C. A raised, red swelling on the back D. Nausea and feeling sick in the pit of the stomach E. Drainage from wounds on the right hand and the right foot
BCE
The nurse is preparing a nursing care plan. What implementation activities play a role in helping to achieve the patient's expected outcomes? Select all that apply. A. Reassessing the patient B. Focusing on preventative measures C. Organizing resources and care delivery D. Counseling and motivating the patient E. Reviewing and revising the existing nursing care plan
BD
A registered nurse teaches a nursing student about preparing a patient for a sterile procedure. Which statements made by the nursing student indicate effective learning? Select all that apply. A. 'I should avoid explaining the surgical procedure to the patient.' B. 'I should inform the patient to avoid touching the sterile supplies and gown.' C. 'I should place a surgical mask on the patient before performing any surgery.' D. 'I should administer ordered analgesics half an hour before surgery begins if a patient is in pain.' D. 'I should inform the patient to avoid sudden movements of any parts of the body covered by sterile drapes.'
BDE
The nurse is teaching a group of patients about the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Which statements regarding privacy and confidentiality are true? Select all that apply. A. All persons can view the medical records of a patient. B. Nurses should help organizations protect a patient's right to confidentiality. C. Nurses have the right to discuss a patient's health information in public places. D. Privacy is the right of patients to keep personal information from being disclosed. E. Patients have the right to consent to the disclosure of their protected health information.
BDE
Which outcome statements for the goal, 'Patient will achieve a gain of 10 lb (4.5 kg) in body weight in a month' are worded incorrectly? Select all that apply. A. Patient will eat at least three fourths of each meal by the end of week 1. B. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C. Patient will eat foods with high-calorie content by the end of week 1. D. Give patient liquid supplements 3 times a day. E. Provide patient high-calorie meals 3 times a day.
BDE
A 56-year-old patient has a severe, productive cough. The patient is diagnosed with tuberculosis (TB) and is placed in an isolation room. What are the possible reasons for this action? Select all that apply. A. To perform a chest x-ray B. To prevent the spread of infection C. To provide intravenous fluids D. To prevent the patient's exposure to other infections E. To restrict the patient's movements
BE
A registered nurse teaches a patient about measures to control the exit and entry of microorganisms. Which statement made by the patient needs correction? A. 'I will brush my teeth regularly.' B. 'I will apply lotion to my skin appropriately.' C. 'I will apply water-insoluble ointment to my lips.' D. 'I will clean my perineal area by wiping from the urinary meatus toward the rectum.'
C
A student nurse is gossiping with colleagues about a patient's many romantic relationships. The registered nurse warns the student nurse about talking about the patient's personal life in a public place. The nurse's warning is intended to prevent which error? A. Assault B. Libel C. Invasion of privacy D. Defamation of character
C
On examination, the nurse notes that a patient's surgical wound has become edematous, red, and tender. There is also new-onset fever, and laboratory results show leukocytosis. Which is the priority nursing intervention? A. Use clean technique to change the dressing. B. Reassure the patient and recheck the wound later. C. Notify the health care provider and support the patient's fluid and nutritional needs. D. Alert the patient and caregivers to the presence of an infection to ensure care after discharge.
C
The American Nurses Association (ANA) code of nursing ethics articulates that the nurse 'promotes, advocates for, and strives to protect the health, safety, and rights of the patient.' This includes protecting patient privacy. On the basis of this principle, if a nurse participates in a public online social network such as Facebook, could the nurse post images of a patient's x-ray film if all patient identifiers have been deleted? A. Yes; patient privacy would not be violated as long as the patient identifiers were removed. B. Yes; respect for autonomy implies that the nurse has the autonomy to decide what constitutes privacy. C. No; even though patient identifiers are removed, someone could identify the patient based on other comments about the patient's condition and the nurse's place of work. D. No; the principal of accountability requires the nurse to keep the identifiers on the image.
C
The nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which option is an evaluative measure used by the nurse? A. Suctioning the airway B. Sitting the patient up in bed C. Auscultating the lung sounds D. Patient describing type of discomfort
C
The home health nurse notices significant bruising on a 2-year-old child's head, arms, abdomen, and legs. The patient's mother describes the child's frequent falls. Which is the best nursing action for the home health nurse to take? A. Document the findings and treat the child. B. Instruct the mother on safe handling of a 2-year-old child. C. Contact a child abuse hotline. D. Discuss this story with a colleague.
C.
The nurse is teaching a group of nursing students about priority setting. Which statement by the nursing students is true about intermediate priority? A. Intermediate-priority needs are not to be left untreated, because they may lead to the death of the patient. B. Intermediate-priority needs focus on the patient's long-term healthcare needs. C. Intermediate-priority needs include decreased physical mobility. D. Intermediate-priority needs include decreased cardiac output.
C.
A group of nursing students is being taught to avoid errors in writing nursing interventions. Which statements are correctly stated nursing interventions? Select all that apply. A. Turn the patient every 2 hours. B. Perform blood glucose measurements. C. Measure blood glucose before each meal: 7:00 AM, 11:00 AM, and 5:00 PM. D. Turn the patient every 2 hours from supine to prone to right side. E. Give sitz bath.
CD
A nursing student is learning about the role of the State Board of Nursing. Which are functions of the State Board of Nursing? Select all that apply. A. Provides for the rights of patients and protects employees B. Gives nursing home residents the right to be free of restraints C. Can suspend the license of the nurse who violates licensing provisions D. Licenses all registered nurses in the state in which they practice C. Has to follow due process before revoking or suspending a license
CDE
A patient is suspected of having chickenpox. What are the modes of transmission of the organism that causes this infection? Select all that apply. A. Vector B. Vehicle C. Droplet D. Airborne E. Direct contact
CDE
The nurse is assessing the patients on the unit. The nurse identifies some collaborative problems among the patients. What are some examples of collaborative problems? Select all that apply. A. Cold B. Nausea C. Paralysis D. Hemorrhage E. Wound infection
CDE
The nurse is learning about various modes of infection transmission. What are the sources for vehicle transmission of infection? Select all that apply. A. Mosquitoes B. Flies C. IV fluid D. Food E. Water
CDE
The nurse works in a hospital. What precautions are necessary to help prevent health care-associated infections? Select all that apply. A. Frequently irrigate urinary catheters. B. Insert drug additives to IV fluids. C. Ensure a closed, urinary catheter drainage system. D. Change the IV access site if inflamed. E. Use aseptic technique when suctioning the airway.
CDE
A registered nurse teaches a group of nursing students about home care considerations for patients with infections. Which statement made by the nursing student indicates the need for further learning? A. 'I should determine potential sources of contamination.' B. 'I should evaluate hand washing facilities in the patient's home.' C. 'I should anticipate the need for alternative hand washing products.' D. 'I should see if cold running water faucets are available.'
D
A woman who is a Jehovah's Witness has severe life-threatening injuries and is hemorrhaging following a car accident. The healthcare provider ordered two 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. 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. Abide by the husband's wishes and inform the healthcare provider.
D
In the hospital setting, what is the most likely means of transmitting infection between patients? A. Exposure to another patient's cough B. Sharing equipment among patients C. Disposing of soiled linen in a shared linen bag D. Contact with a healthcare worker's hands
D
The nurse is assessing a patient at home post splenectomy. The patient tells the nurse that he realizes that strain on the incision site could cause tearing of the stitches. Nevertheless, the nurse finds that some of the patient's stitches are pulled out. What should be the mostappropriate nursing action? A. Advise the patient to maintain complete bed rest for at least a month. B. Immediately arrange for admission of the patient to the hospital. C. Report to the caregiver that the patient is not following the instructions given. D. Ask if the patient understands which activities can cause strain at the incision site.
D
The nurse is caring for a patient who is at risk for infection. The nurse isolates the patient in a room with positive airflow and the patient is instructed to use a mask when he or she is out of their room. What condition may the patient have? A. Laryngeal tuberculosis B. Streptococcal pharyngitis C. Disseminated varicella zoster D. Allogeneic hematopoietic stem cell transplants
D
The nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. Why is this an incorrectly stated diagnostic statement? A. It identifies the clinical sign instead of an etiology. B. It identifies a diagnosis based on prejudicial judgment. C. It identifies the diagnostic study rather than a problem caused by the diagnostic study. D. It identifies the medical diagnosis instead of the patient's response to the diagnosis.
D
The nurse pours a sterile liquid into a container. Which action made by the nurse is appropriate? A. Holding the bottle with its label pointed outside the palm of the hand B. Placing the cap with the inner surface facing down on the table C. Keeping the edge of the bottle close to the edge of the container D. Pouring a small amount in a disposable cap before pouring in the container
D
The nurse works in a medical-surgical unit. Which patient should the nurse evaluate as the highest risk for health care-associated infections (HAIs)? A. A 20-year-old patient admitted with gastroenteritis B. A 24-year-old patient admitted with a fracture of the leg C. A 34-year-old patient admitted for appendectomy D. A 53-year-old diabetic patient admitted for herniorraphy
D
The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. The nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Which career does the nurse consultant exemplify? A. Clinical nurse specialist B. Nurse administrator C. Nurse educator D. Nurse researcher
D
Which action is performed by the nurse in the given image? A. Opening of the last and innermost flap B. Opening of the first side flap and pulling aside C. Opening of the second side flap and pulling it aside D. Opening of the outermost flap of the sterile kit away from body
D
Which expected outcome is written in measurable terms? A. Patient will be pain free. B. Patient will have less pain. C. Patient will take pain medication every 4 hours. D. Patient will report pain acuity less than 4 on a scale of 0 to 10.
D
Which is the best example of practicing patient advocacy? A. Seeking out the nursing supervisor in conflicting procedural situations B. Documenting all clinical changes in the medical record in a timely manner C. Working to understand the law as it applies to an error in following standards of care D. Assessing the patient's point of view and preparing to describe it
D
A patient is admitted to the hospital with a respiratory infection. Following coughing and deep-breathing exercises, the nurse finds that the patient continues to have congested lungs. What should the nurse do? A. Increase the dose of antibiotics. B. Hand over the patient to another nurse. C. Refer the patient for a chest x-ray. D. Increase frequency of coughing and deep-breathing exercises.
D.
A patient is scheduled for a bone marrow biopsy. The nurse understands this procedure and knows it would be helpful for an accurate diagnosis of the patient's disease. However, the patient may experience pain and adverse effects from the procedure. Which ethical principle should guide the nurse's actions in this situation? A. Advocacy B. Beneficence C. Responsibility D. Nonmaleficence
D.
The critical care nurse is using a computerized decision support system to correctly position ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? A. Patient-centered care B. Safety C. Teamwork and collaboration D. Informatics
D. Informatics
What are the components of the evaluation phase of the nursing process? Select all that apply. A. Determining the goals B. Documenting the expected outcomes C. Assessing the patient for nursing needs D. Examining a condition or situation E. Judging if the desired change has occurred
DE
A patient is admitted in the hospital with a diagnosis of meningococcal pneumonia. Which is the priority nursing intervention in this condition? A. Isolating the patient B. Performing oral hygiene C. Providing antimicrobial therapy D. Keeping the patient well hydrated
A
The nurse is going through biographical information collected by the admitting office staff. What patient information is usually included in the biographical information? Select all that apply. A. Age B. Occupation C. Chief complaints D. Marital status E. Health care insurance status
A B D E
Expected patient outcomes are important components of a nursing care plan. What are the principles of care coordination that help to achieve the patient's desired outcomes? Select all that apply. A. Organizational skills B. Good time management C. Appropriate use of resources D. Providing the single best intervention E. Avoiding prioritization of patient needs
ABC
The nurse is planning to obtain a master's degree in nursing. Which role can the nurse with a master's degree in nursing fulfill? Select all that apply. A. Nurse educator B. Nurse administrator C. Advanced practice registered nurse D. Nurse researcher E. Physical therapist
ABCD
A nursing student is learning about the standards of care for nursing. Which should the student do to maintain high nursing standards? Select all that apply. A. Learn about the Nurse Practice Act in the state. B. Follow updates in laws and policies practiced. C. Read current nursing literature in specified practice areas. D. Avoid using procedures given by the employment agency. E. Understand current legal issues affecting nursing practice.
ABCE
Which are examples of data validation? Select all that apply. A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. C. The nurse observes a patient reading a teaching booklet and asks the patient if she has questions about its content. D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. E. The nurse asks the patient to describe a symptom by saying, 'Go on.'
AD
A 50-year-old patient is admitted with acute exacerbation of asthma. The patient is treated with bronchodilators and oxygen therapy. The patient is clinically stable and is planned for discharge. Who is responsible for teaching the patient about managing asthma at home? A. The staff nurse B. The nurse educator C. The nurse administrator D. The clinical nurse specialist
B
The nurse is asked to perform a complex intervention for a patient. However, the nurse is unable to perform it successfully. What would be the appropriate action by the nurse? A. Continue until the intervention is successfully completed. B. Ask for assistance from a senior nurse. C. Tell the patient about the inability to perform it. D. Modify the intervention to make it easy to perform.
B
The night shift nurse is caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the first nursing action to take? A. Give the family the record. B. Give the patient the record. C. Allow the family to express concerns. D. Call the nursing supervisor.
C
Which nursing intervention should a nurse perform while dealing with a patient with a droplet infection? A. Wearing a gown while entering the room B. Wearing a respiratory device while entering the room C. Wearing a mask while working within 3 feet of the patient D. Placing the patient in a room with 12 air exchanges per hour
C
When does the nurse wear a gown? A. The patient's hygiene is poor. B. The nurse is assisting with medication administration. C. The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis. D. Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform.
D.
The nurse is planning routine care for a patient. What are the resources that will be reviewed while planning care? Select all that apply. A. Nursing literature B. Standard protocols C. Procedure manuals D. Consent form E. Nursing interventions classification
ABCE
The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the patient? Select all that apply. A. Explain the recovery process to the patient. B. Provide detailed instructions about the surgery. C. Consult with a psychologist regarding the patient's behavior. D. Teach postoperative care to the patient and his caregiver. E. Encourage health-promotion activities such as exercise and routine social activities.
ABD
The nurse is caring for a surgical patient in the preoperative area. The nurse witnesses the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent? Select all that apply A. It must be signed while the patient is free from mind-altering medications. B. It can be witnessed by the nurse or nursing student. C. It may be withdrawn at any time. D. It must be signed by patients age 16 and older. E. It is usually obtained by the healthcare provider and not the nurse.
ACE
A surgeon obtains patient consent for an appendectomy. While operating, the surgeon also removes the patient's gall bladder. This mistake could be classified as which type of tort? A. Assault B. Battery C. False imprisonment D. Defamation of character
B
A registered nurse is teaching a student nurse about resolving an ethical conflict. Which statement made by the student nurse indicates the need for further teaching? A. 'I should presume good will on the part of all participants.' B. 'I should strictly adhere to the confidentiality principle.' C. 'I should reduce the involvement of family in patient care.' D. 'I should ensure that all treatment provided is patient-centered.'
C
The nurse is caring for a patient with pneumonia. According to the patient's care plan, a reduction of the respiratory rate (RR) from 33 breaths per minute to 20 breaths per minute (bpm), reduced cough, and reduced sputum production in 2 days would indicate successful intervention. On the first day, the nurse finds that the cough has reduced following nebulization and the RR is 25 bpm. What should the nurse's evaluation be? A. The patient's condition is deteriorating. B. The patient can be discharged to home to continue treatments. C. The patient needs continued nebulization therapy. D. The patient needs to be transferred to the intensive care unit (ICU) immediately.
C
While preparing to do a sterile dressing change, the nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which principles of surgical asepsis, if any, has the nurse violated? A. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. B. Fluid flows in the direction of gravity. C. A sterile field becomes contaminated by prolonged exposure to air. D. None of the principles were violated.
C
