Fundamentals of Nursing Midterm

80. A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using? A. Affirmation B. Open-ended question C. Reflection D. Restating

D. Restating

33. A nurse is providing an educational session on cognitive development at a community event. Which of the following statements by the nurse are consistent with Piaget's theory of cognitive development? (Select all that apply.) a. "Individuals acquire knowledge, intellect, and cognition over time." b. "Intelligence is a natural ability that develops as a child grows and adapts to their environment." c. "Children construct knowledge that evolves and changes over time." d. "Children construct knowledge in new ways at critical points during development." e. "Adolescents achieve formal operational thought by 16 years of age."

a. "Individuals acquire knowledge, intellect, and cognition over time." b. "Intelligence is a natural ability that develops as a child grows and adapts to their environment." c. "Children construct knowledge that evolves and changes over time." d. "Children construct knowledge in new ways at critical points during development."

120. A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care? a. A nurse did not read back a verbal medication prescription to a provider. b. A nurse did not return to a client's room with a promised blanket. c. A nurse documents client care as soon as it is completed. d. A nurse forgot to call a client's family after performing a procedure.

a. A nurse did not read back a verbal medication prescription to a provider.

32. A nurse is planning an educational session about human growth and development for a group of clients who are pregnant. Which of the following universal principles should the nurse include in the discussion? (Select all that apply.) a. Cephalocaudal principle b. Equifinality principle c. Simple to complex d. Continuous process e. Individualized rates

a. Cephalocaudal principle c. Simple to complex d. Continuous process e. Individualized rates

73. A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? a. Charting by exception b. Subjective, objective, assessment, plan format c. Problem, intervention, evaluation model d. Data, action, response charting

a. Charting by exception

131. A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? a. Critical thinking is the foundation for clinical decision making."

a. Critical thinking is the foundation for clinical decision making."

134. A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing? a. Evaluation b. Implementation c. Analysis d. Planning

a. Evaluation

8.During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness

a. Group decision making d. Group identity e. Group patterns of interaction f. Group cohesiveness

5. When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding? a. Jaundice b. Cyanosis c. Erythema d. Pallor

a. Jaundice

30. A home health nurse is planning care for an older adult client who has hypertension and is living alone. Which of the following health promotion topics should the nurse include in the client's plan of care? (Select all that apply.) a. Maintaining functional capacity b. Encouraging the use of free-weight exercises c. Participating in social functions d. Installing grab bars in the shower e. Preparing for age-related diminished cognition

a. Maintaining functional capacity b. Encouraging the use of free-weight exercises c. Participating in social functions d. Installing grab bars in the shower

*1.A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? a. Perform the focused assessment as this is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention. d. Request an order from the nutritionist since this is a collaborative intervention.

a. Perform the focused assessment as this is an independent nurse-initiated intervention.

70. A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? a. Synthroid 100 mg PO every morning ac b. Enoxaparin 75 mg SQ bid c. Digoxin 0.25 mg PO qd d. Metformin 500.0 mg PO with evening meal

a. Synthroid 100 mg PO every morning ac

29. A nurse is planning discharge teaching for a client who is newly diagnosed with type 2 diabetes mellitus. Which of the following topics should the nurse include in the teaching? (Select all that apply.) a. Weight management b. Low-protein diet c. Glucose testing d. Daily exercise e. Foot care

a. Weight management c. Glucose testing d. Daily exercise e. Foot care

97. A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make? a. "The nurse manager will need to email the discharge instructions to you." b. "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act." c. "You will need to ask your provider to email the discharge instructions to you." d. "Sending the discharge instructions to you via email would be a violation of the Affordable Care Act."

b. "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act."

5. Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? a. Assault b. Battery c. Invasion of privacy d.False imprisonment

b. Battery

9. A nurse is using the FOUR coma scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent? a. Localizing to pain b. Flexion response to pain c. Extension response to pain d. No response to pain

b. Flexion response to pain

77. A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? a. The "I" in PIE b. The "S" in SOAP c. The "R" in DAR d. The "E" in PIE

b. The "S" in SOAP

3. A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? a. Bathe the patient more frequently. b. Use an emollient on the dry skin. c. Massage the skin with alcohol. d. Discourage fluid intake.

b. Use an emollient on the dry skin.

59. A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make? a. "That is unusual. As clients age, they are typically more receptive to bathing." b. "It is fine if the client does not bathe regularly at home." c. "Give the client choices regarding their bathing preferences to encourage them to bathe." d. "Provide the client with the reasons why they need to bathe."

c. "Give the client choices regarding their bathing preferences to encourage them to bathe."

1.A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? a. Readminister the medication and notify the primary care provider. b. Readminister the pill in a liquid form if possible. c. Assess the vomit, looking for the pill. d. Notify the primary care provider.

c. Assess the vomit, looking for the pill.

13.During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next? a. Percussion b. Palpation c. Auscultation d. Whichever is more comfortable for the patient

c. Auscultation

4. A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? a. Accreditation b. Licensure c. Certification d. Board approval

c. Certification

9.A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first? a. Document the insulin administration. b. Assist with teaching the client about the insulin. c. Have a second nurse confirm the insulin dose. d. Monitor the client for adverse effects of the insulin

c. Have a second nurse confirm the insulin dose.

41. A nurse is interviewing a client to assess their self-concept and asks, "What are some of the accomplishments that make you feel good about yourself?" The nurse is assessing which of the following components of self-concept? a. Body image b. Role performance c. Self-esteem d. Identity

c. Self-esteem

5.A medication order reads: "K-Dur, 20 mEq po BID." When and how does the nurse correctly give this drug? a. Daily at bedtime by subcutaneous route b. Every other day by mouth c. Twice a day by the oral route d. Once a week by transdermal patch

c. Twice a day by the oral route

141. A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? a. "You can wear artificial fingernails if they are kept short." b. "Leave rings on your fingers when performing surgical hand asepsis." c. "Keep your fingernails less than half an inch in length." d. "Remove nail polish on your fingernails if it is chipped."

d. "Remove nail polish on your fingernails if it is chipped."

5. A nurse is preparing to administer an intradermal injection At which of the following degree angles should the nurse insert the needle? a. 60° angle b. 90° angle c. 45° angle d. 10° angle

d. 10° angle

6.19 A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every 3 hours b. Every 4 hours c. Daily d. As needed

d. As needed

9.A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? a. Use hydrogen peroxide on a clean washcloth to wipe the eyes. b. Wipe the eye from the outer canthus to the inner canthus. c. Position the patient on the opposite side of the eye to be cleansed. d. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

d. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

84. A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take? a. Leave the client's room to go check on other clients. b. Ask the client why they are ignoring the question. c. Repeat the question in a loud voice. d. Lower the volume on the television.

d. Lower the volume on the television.

8. When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What does this finding indicate? a. Secretions in the lungs b. Fluid in the airways c. Normal breath sounds d. Narrowed airways

d. Narrowed airways

1. The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. Comprehensive b. Initial c. Time-lapsed d. Quick priority

d. Quick priority

129. A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take? a. Counsel the coworker about substance use. b. report the coworker to the ethics committee at the facility. c. Ask the coworker how long they have been using substances d. Tell the charge nurse that the coworker might be impaired.

d. Tell the charge nurse that the coworker might be impaired.

10. A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client? a. The dosage is calculated by height. b. The preschooler is unable to take capsules. c. Preschoolers receive the same amount of medication as adults. d. The deltoid muscle can be used to administer intramuscular injections.

d. The deltoid muscle can be used to administer intramuscular injections.

2.A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions

d. The use of clarifying questions

13.A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? a. "Do you take two injections of insulin to decrease the complications?" b. "Most health care providers recommend diet and exercise to regulate blood sugar." c. Most complications of diabetes are related to neuropathy." d. What specific complications have you experienced?"

d. What specific complications have you experienced?"

28. A nurse is providing prenatal education to a client who is in the first trimester of pregnancy. Which of the following teratogens should the nurse instruct the client to avoid during pregnancy due to the risk to fetal development? (Select all that apply.) a. Chamomile tea b. Hyperthermia c. Uncontrolled glucose levels d. Rubella e. Smoking

b. Hyperthermia c. Uncontrolled glucose levels d. Rubella e. Smoking

2.19 A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Mark the entry "mistaken entry"; add correct information; date and initial. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly.

b. Mark the entry "mistaken entry"; add correct information; date and initial.

93. A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication? a. Auditory b. Nonverbal c. Emotional d. Energetic

b. Nonverbal

10. According to the National Advisory Council on Nurse Education and Practice, what is a current health care trend contributing to 21st century challenges to nursing practice? a. Decreased numbers of hospitalized patients b. Older and more acutely ill patients c. Decreasing health care costs owing to managed care d. Slowed advances in medical knowledge and technology

b. Older and more acutely ill patients

3. when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action? a. Intramuscular b. Oral c. Buccal d. Intravenous

b. Oral

64. A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a. Apply the amount of soap recommended by the manufacturer b. Wet hands with warm water c. Rub hands together vigorously for at least 15 seconds d. use a towel to turn off the faucet e. use a disposable towel to dry f. rinse hands with water.

b. Wet hands with warm water a. Apply the amount of soap recommended by the manufacturer c. Rub hands together vigorously for at least 15 seconds f. rinse hands with water. e. use a disposable towel to dry d. use a towel to turn off the faucet

8.A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. AD d. Loss of cardiac reserve

c. AD

17. A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors? (Select all that apply.) a. The use of automated dispensing systems b. Administering a generic medication c. Administering medication outside of prescribed time intervals d. Failing to administer a medication e. Incorrect dose of the prescribed medication administered to the client

c. Administering medication outside of prescribed time intervals d. Failing to administer a medication e. Incorrect dose of the prescribed medication administered to the client

114. A nurse is talking with a client who arrived at the clinic over an hour ago and states, "Doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the client and notifies the provider, relaying the needs of the client. In which of the following roles is the nurse performing? a. Educator b. Case manager c. Advocate d. Leader

c. Advocate

5. A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

c. Affective

11.A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? a. Shift the focus of the interaction to the "process of bathing." b. Wash the face and hair at the beginning of the bath. c. Consider using music to soothe anxiety and agitation. d. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. Consider using music to soothe anxiety and agitation.

14. During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninterrupted. c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation.

13.A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? a. Aspirate before giving and gently massage after the injection. b. Do not aspirate; massage the site for 1 minute. c. Do not aspirate before or massage after the injection. d. Massage the site of the injection; aspiration is not necessary but will do no harm.

c. Do not aspirate before or massage after the injection

2. The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

c. Dynamic

6.A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? a. Determining the established goals of the institution b. Ensuring that verbal and nonverbal communication is congruent c. Engaging in self-talk to plan the day and decrease fear d. Speaking with fellow colleagues about how they feel

c. Engaging in self-talk to plan the day and decrease fear

95. A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take? a. Use medical terminology during teaching. b. Sit across from the client at a table in the cafeteria during teaching. c. Ensure the client is wearing their glasses during teaching. d. Use the communication technique of probing during teaching.

c. Ensure the client is wearing their glasses during teaching.

92. A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? a. Identification b. Orientation c. Exploitation d. Resolution

c. Exploitation

15. A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? a. Olfactory b. Optic c. Facial d. Vagus

c. Facial

82. A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of following components of the model? a. Sender b. Channel c. Feedback d. Receiver

c. Feedback

109. A nurse has completed administering a controlled substance to a client. There is 1 mL of the medication left in the syringe. Which of the following actions should the nurse take to dispose of the unused medication? a. Place the syringe with the unused medication in the sharps container in the client's room. b. Return the syringe with the unused medication to the client's medication drawer. c. Have a second nurse witness the disposal of the client's unused medication. d. Place the syringe with the unused medication in their pocket to use for the client's next dose

c. Have a second nurse witness the disposal of the client's unused medication.

43. A nurse is assessing the self-concept of a client who recently lost their job and, as a result, might lose their home to foreclosure. Which of the following questions should the nurse ask the client when gathering information regarding self-concept? a. What did your partner say when you lost your job b. Why do you think that you were fired c. How would you describe yourself and your situation d. What are you going to tell your friends about losing your job

c. How would you describe yourself and your situation

2.The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? a. Initial planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse? a. Appellates b. Defendants c. Plaintiffs d. Attorneys

c. Plaintiffs

3. A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be developmentally appropriate for this age group? a. Playing video games b. Playing peek-a-boo c. Playing in a sand box d. Playing board games

c. Playing in a sand box

12. A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

c. Self-Esteem Disturbance

1. A school nurse is preparing a talk on safety issues for parents of school-aged children to present at a parent-teacher meeting. Which topics should the nurse include based on the age of the children? Select all that apply. a. Child-proofing the home b. Choosing a car seat c. Teaching pedestrian traffic safety d. Providing swimming lessons and water safety rules e. Discussing alcohol and drug consumption related to motor vehicle safety f. Teaching child how to "stop, drop, and roll"

c. Teaching pedestrian traffic safety d. Providing swimming lessons and water safety rules f. Teaching child how to "stop, drop, and roll"

3.A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? a. Allow the UAPs to do the admission assessment and report the findings to the RN. b. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d. Contact his or her labor representative to report this practice to the state board of nursing.

c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until

6.A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? a. Protocols for treating the patient problem b. Standardized treatment guidelines c. The nurse's ideas about the patient problem and treatment d. Clinical pathways for the treatment of sickle cell anemia

c. The nurse's ideas about the patient problem and treatment

7.A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as: a. The patient can see twice as well as normal. b. The patient has double vision. c. The patient has less than normal vision. d. The patient has normal vision.

c. The patient has less than normal vision.

54. A nurse is performing foot care for a client. Which of the following actions should the nurse take? a. Soak the feet prior to washing the feet. b. Use hot water when performing foot care. c. Use a towel to completely dry between the toes. d. File the nail edges straight across with a file.

c. Use a towel to completely dry between the toes.

8. The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a. Inform the charge nurse. b. Inform the surgeon. c. Validate the finding. d. Document the finding.

c. Validate the finding.

10.A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

d. Altered Role Performance

18. A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method? a. Provide the client with an internet link to research the medications. b. Refer the client to the American Heart Association. c. Give the client written educational material about the medication. d. Ask the client to explain the information using their own words.

d. Ask the client to explain the information using their own words.

8. A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? a. The nurse is not responsible, because the nurse was following the doctor's orders. b. Only the nurse is responsible, because the nurse actually administered the medication. c. Only the health care provider is responsible, because the health care provider actually ordered the drug. d. Both the nurse and the health care provider are responsible for their respective actions

d. Both the nurse and the health care provider are responsible for their respective actions

4.A nurse providing health services for a 55 plus community setting formulates diagnoses for patients. Which of the following nursing diagnoses would be most appropriate for many middle adults? a. Risk for Imbalanced Nutrition: Less Than Body Requirements b. Delayed Growth and Development c. Self-Care Deficit d. Caregiver Role Strain

d. Caregiver Role Strain

1. A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take? a. Leave the medication at the client's bedside b. Prepare the medication to administer later. c. Document the medication was given prior to administration. d. Come back in a few minutes to administer the medication.

d. Come back in a few minutes to administer the medication.

1. A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? a. Public law b. Private law c. Civil law d. Criminal law

d. Criminal law

21. A nurse is caring for a 10-year-old child who is newly diagnosed with diabetes mellitus. Which of the following actions by the child should the nurse recognize as characteristic of Erikson's stage of industry versus inferiority? a. Becomes frustrated when their caregiver fills out the child's menu b. Apologizes to their caregiver for wanting to manage their insulin administration independently c. States frustration that diabetes mellitus will make them different from everyone else d. Expresses confidence in their ability to self-administer insulin

d. Expresses confidence in their ability to self-administer insulin

75. A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? a. American Nurse Association (ANA) standards prevent client records from being used for legal proceedings. b. HIPAA regulations vary from one state to another. c. Privacy regulations apply to electronic data transfer rather than verbal communication. d. Facilities can establish their own rules for documentation methods.

d. Facilities can establish their own rules for documentation methods.

8.19 A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Flow sheet d. Graphic record

d. Graphic record

4.A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? a. The nurse collects data to identify health problems. b. The nurse collects data to identify patient strengths. c. The nurse collects data to justify terminating the care plan. d. The nurse collects data to measure outcome achievement.

d. The nurse collects data to measure outcome achievement.

1. A student nurse asks an experienced nurse why it is necessary to change the patient's bed every day. The nurse answers: "I guess we have just always done it that way." This answer is an example of what type of knowledge? a. Instinctive knowledge b. Scientific knowledge c. Authoritative knowledge d. Traditional knowledge

d. Traditional knowledge

62. A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take? a. Trim the nails to a length that reaches beyond the edge of the finger b. Perform hand hygiene once nail hygiene is complete. c. Avoid the use of wooden orange sticks. d. Trim the nails straight across.

d. Trim the nails straight across.

127. A nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles? a. Justice b. Nonmaleficence c. Fidelity d. Veracity

d. Veracity

20. A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include? a. Place a new transdermal patch over the same site as an old patch. b. Apply no more than two transdermal patches at a time. c. Expect the transdermal medication to absorb rapidly. d. Wear clean gloves to apply the transdermal medication

d. Wear clean gloves to apply the transdermal medication

35. A nurse is meeting with a client who is recovering from a bilateral mastectomy. Since being discharged, the client has changed dressings as prescribed and completed arm exercises. The client tells the nurse, "I'm pleased with my postoperative progress." The nurse should identify that the client is displaying which of the following self-concept characteristics? A. Self-efficacy B. Emotional intelligence C. Self-awareness D. Generativity

A. Self-efficacy

53. A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include? a. "The skin contains Langerhans cells that kill pathogens." b. "The skin is the smallest organ of the body." c. "The skin is the second line of defense against micro-organisms." d. "The dermis is the outermost layer of the skin."

a. "The skin contains Langerhans cells that kill pathogens."

2.A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? a. "We're at the age when we should consider ceasing sexual activity." b. "We need more time for sexual stimulation than we used to." c. "If we are unable to have sex we can still have an intimate relationship." d. "If we change our position we can still have sex and be more comfortable."

a. "We're at the age when we should consider ceasing sexual activity."

89. A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing? a. "You said that you're sad. What is making you feel sad?" b. "If you want to lose weight, why do you keep eating fast food?" c. "Have you always struggled with depression?" d. "Do you have any health problems?"

a. "You said that you're sad. What is making you feel sad?"

3.A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. a. A 72-year-old man with a history of diabetes b. A 78-year-old man who has a new partner c. A 75-year-old man who has Parkinson's disease d. An 80-year-old man who is an alcoholic e. An 85-year-old man who takes antihypertensive medication f. tobacco

a. A 72-year-old man with a history of diabetes d. An 80-year-old man who is an alcoholic e. An 85-year-old man who takes antihypertensive medication

9.19 A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Narrative notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes

a. A patient problem list

3. A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. c. Following physical therapy, patient will begin to gradually participate in walking/running events. d. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body.

11.A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.) a. Age of the client b. First pass effect c. Lipid solubility of a medication d. Route of administration e. Metabolism of the medication

a. Age of the client c. Lipid solubility of a medication d. Route of administration

15. A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply) a. Ask the client what they know about the nitroglycerin patch. b. Find out whether the client is able to pay for the medication c. Determine the client's ability to apply the patch d. Check the client's reading comprehension level. e. Use medical terminology to instruct the client about the patch.

a. Ask the client what they know about the nitroglycerin patch. c. Determine the client's ability to apply the patch d. Check the client's reading comprehension level.

10.A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a. Bathe the feet thoroughly in a mild soap and tepid water solution. b. Soak the feet in warm water and bath oil. c. Dry feet thoroughly, including the area between the toes. d. Use an alcohol rub if the feet are dry. e. Use an antifungal foot powder if necessary to prevent fungal infections. f. Cut the toenails at the lateral corners when trimming the nail.

a. Bathe the feet thoroughly in a mild soap and tepid water solution. c. Dry feet thoroughly, including the area between the toes. e. Use an antifungal foot powder if necessary to prevent fungal infections.

6. A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? a. Diaphragm b. Oral contraceptive pills c. Depo-Provera d. Evra patch

a. Diaphragm

94.A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? a. Ensure the room is well lit b. Have soft music playing in the background. c. Hand out samples of products during the teaching. d. Speak quickly during the teaching.

a. Ensure the room is well lit

115. A nurse is caring for a client who reports experiencing chills and not feeling well. The nurse informs the client that they will need to have their temperature taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research? a. Evidence-based practice b. Competencies c. Lifelong learning d. Change agent

a. Evidence-based practice

7. A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED, but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? a. Getting the patient into a safe environment and mobilizing support for her b. Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped c. Convincing the student to be assessed for pregnancy, STIs, or other complications d. Convincing the student to tell her parents so that she can receive their support

a. Getting the patient into a safe environment and mobilizing support for her

128 A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values? a. Human dignity b. Altruism c. Social justice d. Autonomy

a. Human dignity

68. A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? a. Immunization data b. Record of client health care payments c. Complete medical information for household members d. Facility policies

a. Immunization data

4.A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? a. Realistic and positively motivating his development b. Unrealistic and negatively motivating his development c. Unrealistic but positively motivating his development d. Realistic but negatively motivating his development

a. Realistic and positively motivating his development

45. A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.) a. The nurse's hands become visibly soiled b. The nurse removes the meal tray of a client who has infectious diarrhea c. The nurse moves the cell phone of a client who has pneumococcal pneumonia from the bedside table. d. The nurse empties the urinal of a client who has Clostridium difficile e. The nurse is preparing to insert an intravenous catheter.

a. The nurse's hands become visibly soiled b. The nurse removes the meal tray of a client who has infectious diarrhea d. The nurse empties the urinal of a client who has Clostridium difficile

83. A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.) a. "Interrupt the client occasionally during the conversation." b. "Respect the client during the conversation." c. "Use complex terms when explaining with the client." d. "Allow time for reflection during the conversation with the client." e. "Show empathy during the conversation with the client."

b. "Respect the client during the conversation." d. "Allow time for reflection during the conversation with the client." e. "Show empathy during the conversation with the client."

5.19A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." c. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?"

b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks."

67. A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? a. "The client is now asleep, and they ate most of their breakfast a few hours ago." b. "The client vomited 240 mL of clear emesis but denies pain or nausea." c. "The client reports not feeling good, but they look fine." d. "The client has 8 to 10 sores on their body."

b. "The client vomited 240 mL of clear emesis but denies pain or nausea."

105. A nurse is speaking with a client who is noncompliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make? a. "It is important that you monitor your blood glucose, or you can have more health problems." b. "What is preventing your consistency with your daily blood glucose checks? c. "Explain why you are not doing your daily checks as prescribed." d. "Do you understand the purpose of the daily checks?"

b. "What is preventing your consistency with your daily blood glucose checks?

4.A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a. A patient who is taking antibiotics for chronic bronchitis b. A patient diagnosed with type II diabetes c. A patient who is obese d. A patient who has a nervous habit of biting his nails e. A patient diagnosed with prostate cancer f. A patient whose job involves frequent handwashing

b. A patient diagnosed with type II diabetes c. A patient who is obese d. A patient who has a nervous habit of biting his nails f. A patient whose job involves frequent handwashing

*1.An RN working in a hospital setting is responsible for patient assessment. For which patient would the nurse perform a focused assessment? a. A patient newly admitted to the unit b. A patient with diabetes who develops secondary hypertension c. A patient who presents with signs of acute respiratory distress syndrome (ARDS) d. A patient who is recovering from abdominal surgery with no complications

b. A patient with diabetes who develops secondary hypertension

6. A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings related to the normal aging process would the nurse be likely to observe? Select all that apply. a. Patients with wrinkles on the face and arms due to increased skin elasticity b. A patient with skin pigmentation caused by exposure to sun over the years c. A patient with thinner toenails with a bluish tint to the nail beds d. A patient healing from a hip fracture that occurred due to porous and brittle bones e. Bruising on a patient's forearms due to fragile blood vessels in the dermis f. Decreased patient voiding due to increased bladder capacity

b. A patient with skin pigmentation caused by exposure to sun over the years d. A patient healing from a hip fracture that occurred due to porous and brittle bones e. Bruising on a patient's forearms due to fragile blood vessels in the dermis

124. A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice? A. "Health care should be a right for everyone." B. "All clients should have a private room in a health care facility." C. "I plan to volunteer at the local homeless shelter on my days off." D. "I will respect a client's right to refuse a procedure."

A. "Health care should be a right for everyone."

86. A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply.) A. Psychosocial factors B. Cognitive factors C. Situational factors D. Environmental factors E. Physiological factors

A. Psychosocial factors C. Situational factors

39. A nurse is caring for an adolescent client who plans to attend the same law school their parent attended and work at their parent's law firm upon graduation. The client has never questioned their academic and career pathway and states, "If it's good enough for my parent, it's good enough for me." The nurse should identify that which of the following identity statuses describes the client's position? A. Identity achievement B. Foreclosure C. Identity diffusion D. Moratorium

B. Foreclosure

79. A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating? A. Assertive B. Aggressive C. Passive-aggressive D. Passive

C. Passive-aggressive

10. A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

Order: D,A,E,B,F,C

25. A nurse is caring for a client during a prenatal visit. The client states, "Now that I'm pregnant, I drink wine with dinner. I've given up hard alcohol." Which of the following responses should the nurse make? a. "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby." b. "Since you've stopped drinking hard liquor, your baby will be fine." c. "You can drink two glasses of wine each day and not cause harm to your baby." d. "You should consume wine with food to minimize its effect on your baby."

a. "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby."

10. A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? a. "HPV causes genital warts and cervical and other genital cancers." b. "HPV causes a single painless genital lesion and can lead to sterility." c. "50% of women between the ages of 14 and 19 are infected with HPV." d. "The HPV vaccination is only recommended for the female population."

a. "HPV causes genital warts and cervical and other genital cancers."

102. A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching? a. "I should try to escape or put a barrier between myself and the client." b. "I should never hit an abusive client since they cannot control themselves." c. "The client must physically harm me for it to be abuse." d. "Nurses are rarely the subject of abusive clients."

a. "I should try to escape or put a barrier between myself and the client."

74. A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs? a. "I will be able to track my health information." b. "My personal information will be entered into a national database." c. "I will have one EHR that will encompass the health care I've received over my lifetime." d. "The goal of EHRs is to improve insurance coding."

a. "I will be able to track my health information."

107. A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching? a. "I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level." b. "I will cut all carbs out of my diet until I lose 25 pounds." c. "I will keep my calories at 1,000 a day so I can lose several pounds over time." d. "I need to lose 25 pounds and stop eating all the foods I love."

a. "I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level."

96. A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations? a. "I'm glad you decided to continue your fitness routine." b. "You could achieve better results if you applied yourself more." c. "You are adjusting very well for your age." d. "Reducing your caffeine intake is good, but you really need to stop completely."

a. "I'm glad you decided to continue your fitness routine."

7. An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? a. "I'm sorry, but I can't talk with you; you will have to contact my attorney." b. "I will answer your questions so you'll understand how the situation occurred. c. "I hope I won't be blamed for the death because it was so busy that day." d. "First tell me why you are doing this to me. This could ruin my career!"

a. "I'm sorry, but I can't talk with you; you will have to contact my attorney."

104. A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "Nurses will pair together to care for an assigned group of clients." b. "Nurses will be responsible for performing total care on clients." c. "I have never worked in ICU. I cannot take care of ventilated clients." d. "I will be caring for a group of clients with an assistive personnel."

a. "Nurses will pair together to care for an assigned group of clients."

9. A nurse is caring for an 80-year-old patient who is living in a long-term care facility. To help this patient adapt to the present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday? d. Why don't you want to talk about your feelings?"

a. "Tell me about how you celebrated Christmas when you were young."

2.The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e. "We need to check your health status and see what kind of nursing care you may need." f. "We need to see if you require a referral to a physician or other health care professional."

a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths. e. "We need to check your health status and see what kind of nursing care you may need." f. "We need to see if you require a referral to a physician or other health care professional.""

119. A nurse is discussing culturally competent care with another nurse. Which of the following statements should the nurse include? a. "Use a medical interpreter for a client who does not speak the same language." b. "Provide the client with information in print only so they can have it as a resource." c. "Provide standard educational materials to all clients for continuity." d. "Limit communication with the client if there is a language barrier."

a. "Use a medical interpreter for a client who does not speak the same language."

1.A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. a. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." b. "I should wean my infant by 4 months and encourage him to use a sippy cup." c. "I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." d. "I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." e. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." f. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

a. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." b. "I should wean my infant by 4 months and encourage him to use a sippy cup." e. "I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." f. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

8.A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) b. A young clergyperson whose vocal cords are paralyzed after a motorbike accident c. A 32-year-old accountant who survives a massive heart attack d. A 23-year-old model who just learned that she has breast cancer

a. A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus)

46. A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.) a. A fluoride mouthwash should be used to promote oral health. b. The teeth should be brushed twice daily for 2 min. c. Poor oral hygiene can lead to gingivitis. d. Teeth should be flossed every other day. e. Use a soft-bristled toothbrush for brushing the teeth.

a. A fluoride mouthwash should be used to promote oral health. b. The teeth should be brushed twice daily for 2 min. c. Poor oral hygiene can lead to gingivitis. e. Use a soft-bristled toothbrush for brushing the teeth.

4. A nurse working in a rehabilitation facility focuses on the goal of restoring health for patients. Which examples of nursing interventions reflect this goal? Select all that apply. • a. A nurse counsels adolescents in a drug rehabilitation program b. A nurse performs range-of-motion exercises for a patient on bedrest c. A nurse shows a diabetic patient how to inject insulin d. A nurse recommends a yoga class for a busy executive e. A nurse provides hospice care for a patient with end-stage cancer f. A nurse teaches a nutrition class at a local high school

a. A nurse counsels adolescents in a drug rehabilitation program b. A nurse performs range-of-motion exercises for a patient on bedrest c. A nurse shows a diabetic patient how to inject insulin

2. A nurse is using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model PET as a clinical decision-making tool when delivering care to patients. Which steps reflect the intended use of this tool? Select all that apply. a. A nurse recruits an interprofessional team to develop and refine an EBP question. b. A nurse draws from personal experiences of being a patient to establish a therapeutic relationship with a patient. c. A nurse searches the Internet to find the latest treatments for type 2 diabetes. d. A nurse uses spiritual training to draw strength when counseling a patient who is in hospice for an inoperable brain tumor. e. A nurse questions the protocol for assessing postoperative patients in the ICU. f. A nursing student studies anatomy and physiology of the body systems to understand the disease states of assigned patients.

a. A nurse recruits an interprofessional team to develop and refine an EBP question. c. A nurse searches the Internet to find the latest treatments for type 2 diabetes. e. A nurse questions the protocol for assessing postoperative patients in the ICU.

7. In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diphtheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a. A patient diagnosed with rubella b. A patient diagnosed with diphtheria f. An infant diagnosed with adenovirus infection

*5.The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. a. A patient tells the nurse that she is feeling nauseous. b. A patient's ankles are swollen. c. A patient tells the nurse that she is nervous about her test results. d. A patient complains that the skin on her arms is tingling. e. A patient rates his pain as a 7 on a scale of 1 to 10. f. A patient vomits after eating supper.

a. A patient tells the nurse that she is feeling nauseous. c. A patient tells the nurse that she is nervous about her test results. d. A patient complains that the skin on her arms is tingling. e. A patient rates his pain as a 7 on a scale of 1 to 10.

13.Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. a. A patient who is breast-feeding b. A patient who is diagnosed with anorexia c. A patient who chooses to abstain from sexual intercourse d. A patient who has pelvic inflammatory disease e. A patient who is obsessed with exercising f. A patient who has a spinal cord injury

a. A patient who is breast-feeding b. A patient who is diagnosed with anorexia d. A patient who has pelvic inflammatory disease e. A patient who is obsessed with exercising

8.A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? a. Apply gentle pressure on the lower eyelid to center the lens prior to removing it. b. Move the eyelids toward one another to cause the lens to slide out between the eyelids. c. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. d. Have the patient look forward, retract the lower lid, and move the lens down on the sclera.

a. Apply gentle pressure on the lower eyelid to center the lens prior to removing it.

2. A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply. a. Are you able to dress yourself? b. Do you have a history of smoking? c. What is the problem for which you are seeking care? d. Do you prepare your own meals? e. Do you manage your own finances? f. Whom do you rely on for support?

a. Are you able to dress yourself? d. Do you prepare your own meals? f. Whom do you rely on for support?

8.A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identity by performing which action? a. Asking the patient his name and birthdate b. Reading the patient's name on the sign over the bed c. Asking the patient's roommate to verify his name d. Asking, "Are you Mr. Brown?"

a. Asking the patient his name and birthdate

60. A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take? a. Assist the client as needed to ensure proper hygiene is performed. b. Aggressively rub the skinfolds dry to manage moisture. c. Use a lye soap bar to cleanse the skinfolds and the rash area. d. Apply moisturizer to the skinfolds and rash area.

a. Assist the client as needed to ensure proper hygiene is performed.

8. A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a. Basing patient care on continuous healing relationships b. Customizing care to reflect the competencies of the staff c. Using evidence-based decision making d. Having a charge nurse as the source of control e. Using safety as a system priority f. Recognizing the need for secrecy to protect patient privacy

a. Basing patient care on continuous healing relationships c. Using evidence-based decision making e. Using safety as a system priority

42. A nurse is caring for a client who is 4 days postoperative following a below-the- knee amputation related to a work injury. The nurse should identify that which of the following are components of the client's self-concept that this injury can impact? (Select all that apply.) a. Body image b. Role performance c. Identity d. Health promotion e. Self-esteem

a. Body image b. Role performance c. Identity e. Self-esteem

31. A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept? (Select all that apply.) a. Both males and females experience a change of life referred to as climacteric." b. Climacteric in females is referred to as menopause." c. Climacteric in males means they are no longer able to fertilize a female egg." d. Climacteric changes in males occur gradually, over a number of years." e. Climacteric in females can manifest as heart palpitations."

a. Both males and females experience a change of life referred to as climacteric." b. Climacteric in females is referred to as menopause." d. Climacteric changes in males occur gradually, over a number of years." e. Climacteric in females can manifest as heart palpitations."

12. When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject

a. Cliché

7.A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies

a. Clinical judgment

6.A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

a. Cognitive

5.Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. Compare bilateral parts for symmetry. b. Proceed in a toe-to-head systematic manner. c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment. e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified.

a. Compare bilateral parts for symmetry. c. Use standard terminology to report and record findings. f. Perform the appropriate skin assessment when risk factors are identified.

5.The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? a. Compare this reading to standards. b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure. d. Consult with colleagues.

a. Compare this reading to standards.

111. A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role? a. Coordinating and overseeing the care the client is receiving b. Helping to develop nursing knowledge for clinical interventions c. Providing knowledgeable and compassionate care to promote health and address illness d. Instructing the client on specialized topics such as diabetes care

a. Coordinating and overseeing the care the client is receiving

87. A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request? a. Cultural factor b. Developmental factor c. Environmental factor d. Physiological factor

a. Cultural factor

135. A nurse is completing a medication reconciliation on a newly admitted client. Which of the following information should the nurse include? (Select all that apply.) a. Current prescribed medications b. Nutritional supplements the client takes c. Over-the-counter medications the client uses d. Medications the provider has discontinued e. List of vitamins the client has stopped taking

a. Current prescribed medications b. Nutritional supplements the client takes c. Over-the-counter medications the client uses

5. A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? a. Determining the progress made in achieving established goals b. Clarifying when the patient should take medications c. Reporting the progress made in teaching to the staff d. Including all family members in the teaching session

a. Determining the progress made in achieving established goals

2.A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation? a. Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration. b. Notify the primary care provider that medication cannot be given to the patient at this time via the gastric tube. c. Remove the tube in place and replace it with another tube prior to administering the medication. d. Flush the tube with 60 mL of water prior to administering the medication.

a. Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration.

3. A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. a. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. b. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. c. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. d. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. e. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. f. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

a. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. d. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. f. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

10. A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding? a. Document and report the finding of abnormal Rhonchi breath sounds b. Document the finding of normal bronchovesicular breath sounds c. Document and report the finding of abnormal stridor breath sounds d. Document the finding of normal bronchial sounds

a. Document and report the finding of abnormal Rhonchi breath sounds

138. A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? a. Droplet b. Indirect contact c. Airborne d. Direct contact

a. Droplet

38. A nurse is reviewing factors that can affect a client's self-concept. The nurse should identify that empathy, motivation, and self-awareness are domains of which of the following factors? a. Emotional intelligence b. Body image c. Self-efficacy d. Role performance

a. Emotional intelligence

61. A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion? a. Enamel protects the teeth from pathogens. b. Enamel is a substance that cannot be dissolved. c. Enamel is a soft material that protects the teeth. d. Enamel covers the pulp

a. Enamel protects the teeth from pathogens.

44. A nurse is reviewing the plan of care for a client who was recently divorced. Which of the following interventions should the nurse include to promote the client's positive self- concept? (Select all that apply.) a. Encourage the client to identify past and current accomplishments b. Contact delivery services to provide the client with in-home meals c. Encourage the client to verbalize perceptions that indicate a healthy self-esteem d. Assist the client to identify healthy coping strategies and support systems e. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

a. Encourage the client to identify past and current accomplishments c. Encourage the client to verbalize perceptions that indicate a healthy self-esteem d. Assist the client to identify healthy coping strategies and support systems e. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

27. A nurse is assessing an adolescent who reports feeling "very depressed." The nurse should recognize that which of the following are signs of increased risk for suicide? (Select all that apply.) a. Expressing feelings of gloom and helplessness b. Expressing loss of interest in activities once considered important c. Making threats of self-harm d. Having access to weapons e. Purchasing valued possessions

a. Expressing feelings of gloom and helplessness b. Expressing loss of interest in activities once considered important c. Making threats of self-harm d. Having access to weapons

2. A nurse caring for older adults in a skilled nursing home observes physical changes in patients that are part of the normal aging process. Which changes reflect this process? Select all that apply. a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. f. Visual and hearing acuity diminishes.

12.A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward f. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.

a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward

137. A nurse is assisting with teaching a class about HIPAA. Which of the following information should the nurse include? (Select all that apply.) a. HIPAA protects the unauthorized release of a client's protected health information. b. HIPAA prohibits clients from obtaining their medical record. c. HIPAA requires notification of a breach in privacy via an in-person report. d. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach. e. A breach in HIPAA should be reported within 60 days after the breach is discovered.

a. HIPAA protects the unauthorized release of a client's protected health information. d. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach. e. A breach in HIPAA should be reported within 60 days after the breach is discovered.

48. A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include? a. Health promotion programs emphasize behavior changes in relation to prevention of illness b. Health promotion programs encourage decreased use of health services. c. Health promotion programs restrict the client's control over their general health d. Health promotion programs discourage community involvement.

a. Health promotion programs emphasize behavior changes in relation to prevention of illness

24. A nurse is providing discharge teaching to parents of a preschooler who was admitted due to a severe asthma exacerbation. Which of the following instructions should the nurse include? (Select all that apply.) a. Instruct on the use of a metered-dose inhaler (MDI). b. Have family members smoke tobacco products outside of the house. c. Make changes in the home environment to reduce dust mites. d. Share the plan for managing an asthma attack with the child's preschool teachers e. Decrease fluid intake to prevent an exacerbation of asthma.

a. Instruct on the use of a metered-dose inhaler (MDI). b. Have family members smoke tobacco products outside of the house. c. Make changes in the home environment to reduce dust mites. d. Share the plan for managing an asthma attack with the child's preschool teachers

2.A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a. It promotes the patient's sense of well-being. b. It prevents deterioration of the oral cavity. c. It contributes to decreased incidence of aspiration pneumonia. d. It eliminates the need for flossing. e. It decreases oropharyngeal secretions. f. It helps to compensate for an inadequate diet.

a. It promotes the patient's sense of well-being. b. It prevents deterioration of the oral cavity. c. It contributes to decreased incidence of aspiration pneumonia.

7.A nurse is teaching new mothers about infant care and safety. What would the nurse include as a teaching point? a. Keep infants younger than 6 months out of direct sunlight. b. Use honey instead of sugar in homemade baby food. c. Place the baby on his or her stomach for sleeping. d. Keep crib rails down at all times.

a. Keep infants younger than 6 months out of direct sunlight.

36. A nurse is meeting with a client at a community health center to assess their self- concept. Which of the following factors should the nurse consider during the assessment? (Select all that apply.) a. Life experiences b. Societal and cultural attitudes c. Health status d. Academic achievement e. Meditation

a. Life experiences b. Societal and cultural attitudes c. Health status d. Academic achievement

72. A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply.) a. MSO4 b. IU c. PO d. Qhs e. NKA

a. MSO4 b. IU d. Qhs

14. A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.) a. Mark the area around the automated medication dispensing system. b. Encourage the use of cell phones while dispensing medications. c. Override the automated medication dispensing system during emergencies. d. Provide the nurse administering medications with a vest. e. Double check dosages of high-alert medications.

a. Mark the area around the automated medication dispensing system. d. Provide the nurse administering medications with a vest. e. Double check dosages of high-alert medications.

3.A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. a. Monitoring patient status every hour b. Using intuition to troubleshoot patient problems c. Turning a patient on bed rest every 2 hours d. Becoming a nurse mentor to a student nurse e. Administering pain medication ordered by the physician f. Becoming involved in community nursing events

a. Monitoring patient status every hour c. Turning a patient on bed rest every 2 hours e. Administering pain medication ordered by the physician

81. A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.) a. Move the client to a quiet area or private room. b. Speak at a slower pace. c. Delay the assessment until the client's family member brings the hearing aid. d. Have a sign language interpreter translate the communication with the client. e. Stand next to the client when talking. f. Avoid using medical terminology.

a. Move the client to a quiet area or private room. b. Speak at a slower pace. f. Avoid using medical terminology.

136. A nurse is teaching a class about using smart infusion pumps to administer intravenous medications. Which of the following information should the nurse include? a. Nurses enter client information into the smart infusion pump. b. Nurses should use workarounds when using smart infusion pumps. c. The use of smart infusion pumps is associated with increased medication errors. d. The smart infusion pump alerts the nurse when the setting is within the safety limits.

a. Nurses enter client information into the smart infusion pump.

140. A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? a. Open the first flap on the sterile package away from their body. b. Place objects on the sterile field at least 1.3 cm (0.5 in) from the edge. c. Unwrap both sides of the sterile package at the same time. d. Set up the sterile field next to a wall in the client's room.

a. Open the first flap on the sterile package away from their body.

9.A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? a. Pain b. Anxiety c. Depression d. Fluid volume deficit

a. Pain

6.A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. a. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b. Some people experience the same response with a placebo as with the active drug used in studies. c. People with liver disease metabolize drugs more quickly than people with normal liver functioning. d. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. e. Oral medications should not be given with food as the food may delay the absorption of the medications. f. Circadian rhythms and cycles may influence drug action.

a. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b. Some people experience the same response with a placebo as with the active drug used in studies. d. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. f. Circadian rhythms and cycles may influence drug action.

4.A student nurse interacting with patients on a cardiac unit recognizes the four concepts in nursing theory that determine nursing practice. Of these four, which is most important? a. Person b. Environment c. Health d. Nursing

a. Person

9.A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

a. Personal Identity Disturbance

7.A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.) a. Place the medication reconciliation form with the client's transfer documents. b. Reinforce teaching about the medications to the client upon discharge c. Add medications the client is no longer taking in the medication reconciliation. d. Include over-the-counter medications in the medication reconciliation. e. Compare the client's home medications with prescribed discharge medications.

a. Place the medication reconciliation form with the client's transfer documents. b. Reinforce teaching about the medications to the client upon discharge d. Include over-the-counter medications in the medication reconciliation. e. Compare the client's home medications with prescribed discharge medications.

22. A nurse is planning a health class at a local middle school about puberty during adolescence. Which of the following pieces of information should the nurse include in the discussion? (Select all that apply.) a. Primary sex organs mature during puberty. b. Puberty begins with a growth spurt in height and weight. c. Onset of puberty is influenced by genetics, environment factors, and gender. d. Secondary sex characteristics emerge during puberty. e. Maturation during puberty occurs at the same rate for everyone

a. Primary sex organs mature during puberty. b. Puberty begins with a growth spurt in height and weight. c. Onset of puberty is influenced by genetics, environment factors, and gender. d. Secondary sex characteristics emerge during puberty.

3. A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a. Providing a bed bath for a patient b. Visibly soiled hands after changing the bedding of a patient c. Removing gloves when patient care is completed d. Inserting a urinary catheter for a female patient e. Assisting with a surgical placement of a cardiac stent f. Removing old magazines from a patient's table

a. Providing a bed bath for a patient c. Removing gloves when patient care is completed d. Inserting a urinary catheter for a female patient f. Removing old magazines from a patient's table

71. A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply.) a. Reduces medical errors b. Improves listening skills among interdisciplinary team members c. Less convenient than paper-based charting d. Makes client medical history more easily available e. Increases accuracy of coding procedures

a. Reduces medical errors d. Makes client medical history more easily available e. Increases accuracy of coding procedures

15. A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply. a. Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer. b. Take shallow breaths when breathing through the spacer. c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply. d. After inhaling, exhale quickly through pursed lips. e. Wait 1 to 5 minutes as prescribed before administering the next puff. f. Gargle and rinse with salt water after using the MDI.

a. Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer. c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply. e. Wait 1 to 5 minutes as prescribed before administering the next puff.

12. A nurse is using the circular technique to palpate the breast of a woman during an assessment. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall. How would the nurse proceed with the palpation? a. Start at the tail of Spence and move in increasing smaller circles. b. Start at the outer edge of the breast and palpate up and down the breast. c. Work in a counterclockwise direction and palpate from the periphery toward the areola. d. Start at the inner edge of the breast and palpate up and down the breast.

a. Start at the tail of Spence and move in increasing smaller circles.

7.A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. a. Teach the parents to reinforce their child's positive qualities. b. Teach the parents to overlook occasional negative behavior. c. Teach parents to ignore neutral behavior that is a matter of personal preference. d. Teach parents to listen and "fix things" for their children. e. Teach parents to describe the child's behavior and judge it. f. Teach parents to let their children practice skills and make it safe to fail.

a. Teach the parents to reinforce their child's positive qualities. c. Teach parents to ignore neutral behavior that is a matter of personal preference. f. Teach parents to let their children practice skills and make it safe to fail.

6. A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? a. Tell the RN that he or she lacks the technical competencies to change the dressing independently. b. Assemble the equipment for the procedure and follow the steps in the procedure manual. c. Ask another student nurse to work collaboratively with him or her to change the dressing. d. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Tell the RN that he or she lacks the technical competencies to change the dressing independently.

116. A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include? a. The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficult decisions b. The National Academy of Medicine developed the Healthy People campaign to improve the health of all Americans c. The American Academy of Nursing requires members to have a doctorate degree in nursing to join. d. The National Student Nurses' Association is an organization created to encourage students to enter nursing.

a. The American Nurses Association's The Code of Ethics for Nurses with Interpretive

66. A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs? a. The Institute of Medicine b. Department of veteran affairs c. American hospital association d. The joint commission

a. The Institute of Medicine

145. A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? a. The door to the AIIR should remain closed. b. Clients who are on contact precautions require AIIR. c. An AIIR has at least 4 air exchanges each hr. d. A mask is not needed to care for clients who are in an AIIR.

a. The door to the AIIR should remain closed.

4. A high school nurse is counseling parents of teenagers who are beginning high school. Which issues would be priority topics of discussion for this age group? Select all that apply. a. The influence of peer groups b. Bullying c. Water safety d. Eating disorders e. Risk-taking behavior f. Immunizations

a. The influence of peer groups b. Bullying d. Eating disorders e. Risk-taking behavior

2. A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a. The nurse carefully removes the bandages from a burn victim's arm. b. The nurse assesses a patient to check nutritional status. c. The nurse formulates a nursing diagnosis for a patient with epilepsy. d. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. e. The nurse checks a patient's insurance coverage at the initial interview. f. The nurse checks for community resources for a patient with dementia.

a. The nurse carefully removes the bandages from a burn victim's arm. d. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. f. The nurse checks for community resources for a patient with dementia.

14.A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. a. The nurse makes a point to address the patient by name upon entering the room. b. The nurse avoids fatiguing the patient by performing all procedures in silence. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. e. The nurse ignores negative feelings from the patient since they are part of the grieving process. f. The nurse avoids conversing with the patient about her life, family, and occupation.

a. The nurse makes a point to address the patient by name upon entering the room. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way.

4.The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a. The nurse uses critical thinking skills to plan care for a patient. d. The nurse learns the correct dosages for patient pain medications.

76. A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation? a. The system alerts providers of possible actions that could cause client harm. b. An electronic system prevents breaches of confidentiality of client data. c. Providers can document client information in the electronic record during system downtime. d. System encryption eliminates the need for security firewalls.

a. The system alerts providers of possible actions that could cause client harm.

19. A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include? a. To convert g to mg, move the decimal point 3 places to the right. b. Liters is a unit of measurement for distance. c. The metric system uses fractions rather than decimals. d. Grains is used as a measurement of weight in the metric system.

a. To convert g to mg, move the decimal point 3 places to the right.

90. A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.) a. Verbal b. Written c. Electronic d. Nonverbal e. Assertive

a. Verbal b. Written d. Nonverbal

6.A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. a. Wash the skin twice a day with a mild cleanser and warm water. b. Use cosmetics liberally to cover blackheads. c. Use emollients on the area. d. Squeeze blackheads as they appear. e. Keep hair off the face and wash hair daily. f. Avoid sun-tanning booth exposure and use sunscreen.

a. Wash the skin twice a day with a mild cleanser and warm water. e. Keep hair off the face and wash hair daily. f. Avoid sun-tanning booth exposure and use sunscreen.

65. A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply.) a. the admitting provider b. the charge nurse on the unit c. the client's sibling d. the client e. the client's spiritual advisor

a. the admitting provider b. the charge nurse on the unit d. the client

26. During a wellness visit for a 4-year-old preschooler, a parent explains that their child enjoys playing games on a computer and asks the nurse about an acceptable amount of screen time for their child. Which of the following responses should the nurse make? a. "If the child is learning, there are no screen time limits." b. "An acceptable amount of screen time is 1 hour per day." c. If the child is content, there is no protocol for screen time." d. "Acceptable screen time is 4 hours per day."

b. "An acceptable amount of screen time is 1 hour per day."

51. A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include? a. "A standard toothbrush is more effective than a battery-operated toothbrush in decreasing plaque." b. "Clean the tongue with the toothbrush or tongue scraper during oral hygiene." c. Floss the teeth at least three times each day." d. Have the client use mouthwash after brushing their teeth."

b. "Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

63. A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting? a. "It is not important to wash your hands after removing gloves." b. "Effective handwashing can decrease hospital infection rates." c. Infections in health care staff are not considered health care-associated infections." d. Health care-associated infections are a rare event in health care delivery."

b. "Effective handwashing can decrease hospital infection rates."

3.A nurse caring for patients in a primary care setting refers to Erikson's theory that middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which patient statement is an example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. "I spend all of my time going to the doctor to be sure I am not sick."

23. A nurse is caring for adolescents in a school-based health clinic. Which of the following client statements should the nurse recognize as an indication that the client is experiencing Erikson's stage of identity versus role confusion? a. "I'm coaching a little league team." b. "I think I might be gay. c. "I can't seem to do anything right for my parents." d. "Why would someone want to help me? What's in it for them?"

b. "I think I might be gay.

7. A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? a. "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." b. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" c. I will need to call in on the 8th of August because I have a doctor's appointment." d. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?"

5.The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? a. "Children should be taught not to masturbate because most people believe self- stimulation is wrong." b. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." c. "There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." d. "Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

b. "Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty."

10.A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"

b. "May I help you with a bed bath now or later this morning?"

8. A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1. Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a. (1) and (3) b. (2) and (4) c. (1), (2), and (3) d. (1), (2), (3), (4), and (5)

b. (2) and (4)

9. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. a. An incident report is used as disciplinary action against staff members. b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. d. The facility manager completes the incident report. e. An incident report makes facts available in case litigation occurs. f. Filing of an incident report should be documented in the patient record.

b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. e. An incident report makes facts available in case litigation occurs.

9. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. a. An incident report is used as disciplinary action against staff members. b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. d.The facility manager completes the incident report. e. An incident report makes facts available in case litigation occurs. f. Filing of an incident report should be documented in the patient record

b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. e. An incident report makes facts available in case litigation occurs.

130. A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take? a. Explain the procedure in detail to the client. b. Ask the provider to discuss the procedure with the client. c. Encourage the client to reread the consent form before signing d. Tell the client that the surgeon will explain it to them in the operating room

b. Ask the provider to discuss the procedure with the client.

11.A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? a. Personal Identity Disturbance b. Body Image Disturbance c. Self-Esteem Disturbance d. Altered Role Performance

b. Body Image Disturbance

12.Ms. Hall has an order for hydromorphone, 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to hydromorphone. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? a. Administer the medication; the doctor is responsible for medication administration. b. Call Dr. Long and ask that the medication be changed. c. Ask the supervisor to administer the medication. d. Ask the pharmacist to provide a medication to take the place of hydromorphone.

b. Call Dr. Long and ask that the medication be changed.

144. A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement? a. Protective b. Contact c. Standard d. Airborne

b. Contact

148. A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? a. Protective b. Contact c. Droplet d. Airborne

b. Contact

4.19When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. a. News media are preparing a report on the condition of a patient who is a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's disease wants to help provide care.

b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation.

2.A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? a. Lack of self-esteem b. Deficient self-knowledge c. Unrealistic self-expectation d. Inability to evaluate himself

b. Deficient self-knowledge

7. A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? a. A single dose during the postoperative period b. Doses administered as needed for pain relief c. One dose administered immediately d. Doses routinely administered as a standing order

b. Doses administered as needed for pain relief

143. A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? a. Direct contact b. Droplet c. Airborne d. Indirect contact

b. Droplet

4. A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. Offer the patient 60-mL fluid every 2 hours while awake. b. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. d. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

b. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL.

34.A nurse is preparing an educational session about school-age children to a group of caregivers. Which of the following characteristics should the nurse include in the teaching? (Select all that apply.) a. Attributes feelings and motives to objects b. Egocentrism decreases c. Begins to understand reversibility d. Understands events can be interpreted in different ways e. Deductive reasoning develops

b. Egocentrism decreases c. Begins to understand reversibility d. Understands events can be interpreted in different ways

122. A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action? a. HIPAA violation b. Falsification of records c. Assault d. Defamation

b. Falsification of records

7. A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? a. Maslow's human needs b. Gordon's functional health patterns c. Human response patterns d. Body system model

b. Gordon's functional health patterns

11.A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take? a. Repeat the least important information to the client. b. Have the client perform a return demonstration of the procedure. c. Provide the client with educational materials written at an 8th-grade reading level. d. Dim the lights in the client's room before beginning the teaching.

b. Have the client perform a return demonstration of the procedure.

11. A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply. a. Bring a penlight from the side of the patient's face and briefly shine the light on the pupil. b. Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. c. Hold a finger about 6 to 8 in from the bridge of the patient's nose. d. Darken the room. e. Ask the patient to look straight ahead. f. Ask the patient to first look at a close object, then at a distant object, then back to the close object.

b. Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose. f. Ask the patient to first look at a close object, then at a distant object, then back to the close object.

2.A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complication: sepsis e. Infection related to pneumonia f. Risk for septic shock

b. Impaired gas exchange c. Ineffective airway clearance f. Risk for septic shock

11.A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior

b. Information clarification

11. A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. b. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. c. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. d. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

b. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin.

3. A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? a. Ask the patient to sit about 3 ft away facing the nurse. b. Keep a penlight about 1 ft from the patient's face and move it slowly through the cardinal positions. c. Move a penlight in a circular motion in front of the patient's eyes. d. Ask the patient to cover one eye with a hand or index card.

b. Keep a penlight about 1 ft from the patient's face and move it slowly through the cardinal positions.

15.A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply. a. LGBT youth are four times more likely to attempt suicide. b. LGBT youth are more likely to be homeless. c. Lesbians are less likely to get preventive services for cancer. d. Lesbians and bisexual females are more likely to be underweight. e. Transgender people have a high prevalence of HIV and sexually transmitted infections. f. LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

b. LGBT youth are more likely to be homeless. c. Lesbians are less likely to get preventive services for cancer. e. Transgender people have a high prevalence of HIV and sexually transmitted infections.

14. A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document? a. Awake and alert b. Lethargic c. Stuporous d. Comatose

b. Lethargic

100. A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use? a. Instruct the assistive personnel on a task outside their range of function. b. Make a list and prioritize a plan. c. Dispense all of the day's scheduled medications together. d. Document client care at the end of the day.

b. Make a list and prioritize a plan.

8. An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. a. Performing the initial patient assessments b. Making patient beds c. Giving patients bed baths d. Administering patient medications e. Ambulating patients f. Assisting patients with meals

b. Making patient beds c. Giving patients bed baths e. Ambulating patients f. Assisting patients with meals

146. A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? a. Wear an N95 respirator when caring for the client. b. Place the client in a private room. c. Place a mask on the client when they leave their room. d. Place the client in a negative airflow room.

b. Place the client in a private room.

5.A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? a. Actual b. Possible c. Risk d. Collaborative

b. Possible

2. A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

b. Prodromal stage

10. Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S—Senility b. P—Problems with feeding c. I—Irritability d. C—Confusion e. E—Edema of the legs f. S—Skin breakdown

b. P—Problems with feeding d. C—Confusion f. S—Skin breakdown

5. A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? a. Administer pain medication. b. Reassess the patient. c. Prepare the equipment. d. Explain the procedure to the patient.

b. Reassess the patient.

3. A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for Impaired Skin Integrity b. Related to prescribed bed rest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

b. Related to prescribed bed rest

110. A newly licensed nurse is assigned to care for a client who has a newly inserted chest tube. The nurse has not previously cared for a client who has a chest tube. Which of the following actions should the nurse take? a. Decline the assignment. b. Review the facility's policy and procedure (P&P) manual. c. Review a nursing textbook. d. Search the internet for information about how to care for a chest tube.

b. Review the facility's policy and procedure (P&P) manual

15.A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? a. Do not remove or wash the piercings without permission from the patient. b. Rinse the sites with warm water and remove crusts with a cotton swab. c. Wash the sites with alcohol and apply an antibiotic ointment. d. Remove the jewelry and allow the sites to heal over.

b. Rinse the sites with warm water and remove crusts with a cotton swab.

6. A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness

b. Risk

99. A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? a. Send an email to staff via the facility's email system. b. Schedule a face-to-face unit staff meeting. c. Place a copy of the policy on a bulletin board in the hallway. d. Leave a voicemail on each staff member's phone

b. Schedule a face-to-face unit staff meeting.

85. A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? a. Receiver b. Sender c. Channel d. Decoder

b. Sender

2.The nurse encourages parents of hospitalized infants and toddlers to stay with their child to help decrease what potential problem? a. Problems with attachment b. Separation anxiety c. Risk for injury d. Failure to thrive

b. Separation anxiety

5.A nurse working with adolescents in a group home discusses the developmental tasks appropriate for adolescents with the staff. What is an example of a primary developmental task of the adolescent? a. Working hard to succeed in school b. Spending time developing relationships with peers c. Developing athletic activities and skills d. Accepting the decisions of parents

b. Spending time developing relationships with peers

13. A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first? a. Notify the client's provider. b. Stop the infusion of the vancomycin. c. Administer diphenhydramine to the client. d. Document the incident in the client's chart.

b. Stop the infusion of the vancomycin.

10. A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? a. Students are not responsible for their acts of negligence resulting in patient injury. b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. c. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. d. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.

139. A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? a. Reservoir b. Susceptible host c. Portal of entry d. Portal of exit

b. Susceptible host

6. The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing actions could the nurse perform with the patient in this position? Select all that apply. a. Assessing the abdomen b. Taking peripheral pulses c. Performing a breast examination d. Auscultating the heart e. Assessing vital signs f. Assessing balance and gait

b. Taking peripheral pulses c. Performing a breast examination d. Auscultating the heart

108. A nurse is caring for a client whose neighbor works on another unit. The neighbor calls the unit and asks the client's nurse, "What happened to the client?" Which of the following actions should the nurse take? a. Give the neighbor the client's admitting diagnosis. b. Tell the neighbor they cannot give them that information. c. Tell the neighbor to access the client's electronic medical record. d. Give the neighbor the client's home phone number.

b. Tell the neighbor they cannot give them that information.

1. A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. The nurse uses the nursing interview to collect patient data. b. The nurse analyzes data collected in the nursing assessment. c. The nurse develops a care plan for the patient. d. The nurse points out the patient's strengths. e. The nurse assesses the patient's mental status. f. The nurse identifies community resources to help his family cope.

b. The nurse analyzes data collected in the nursing assessment d. The nurse points out the patient's strengths. f. The nurse identifies community resources to help his family cope.

1.A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a. The nurse formulates nursing diagnoses. b. The nurse identifies expected patient outcomes. c. The nurse selects evidence-based nursing interventions d. The nurse explains the nursing care plan to the patient. e. The nurse assesses the patient's mental status. f. The nurse evaluates the patient's outcome achievement.

b. The nurse identifies expected patient outcomes. c. The nurse selects evidence-based nursing interventions d. The nurse explains the nursing care plan to the patient.

4. Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply. a. The nurse compares the patient's bilateral body parts for symmetry. b. The nurse takes a patient's pulse. c. The nurse touches a patient's skin to test for turgor. d. The nurse checks a patient's lymph nodes for swelling. e. The nurse taps a patient's body to check the organs. f. The nurse uses a stethoscope to listen to a patient's heart sounds.

b. The nurse takes a patient's pulse. c. The nurse touches a patient's skin to test for turgor. d. The nurse checks a patient's lymph nodes for swelling.

15.A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a. The nurse puts on PPE after entering the patient room b. The nurse works from "clean" areas to "dirty" areas during bath c. The nurse personalizes the care by substituting glasses for goggles d. The nurse removes PPE after the bath to talk with the patient in the room

b. The nurse works from "clean" areas to "dirty" areas during bath

15.A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? a. The patient will make above-B grades in all tests at school. b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne. c. The patient reports that she feels more self-confident in her music and art, which she enjoys. d. The patient expresses that she is very smart in school

b. The patient will demonstrate, by diet control and skin care, increased interest in control of acne.

1.A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? a. When the patient had his or her most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the patient care assistant

b. The patient's usual hygiene practices and preferences

14.A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? a. It is the personal preference of the nurse whether or not to use clean technique b. The use of clean technique is safe for the home setting c. Surgical asepsis is the only safe method to use in a home setting d. It is grossly negligent to recommend clean technique for changing a wound dressing

b. The use of clean technique is safe for the home setting

3. A nurse is using general systems theory to describe the role of nursing to provide health promotion and patient teaching. Which statements reflect key points of this theory? Select all that apply. a. A system is a set of individual elements that rarely interact with each other. b. The whole system is always greater than the sum of its parts. c. Boundaries separate systems from each other and their environments. d. A change in one subsystem will not affect other subsystems. e. To survive, open systems maintain balance through feedback. f. environment.

b. The whole system is always greater than the sum of its parts. c. Boundaries separate systems from each other and their environments. e. To survive, open systems maintain balance through feedback.

56. A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client? a. Changes in skin integrity decrease the risk of infection. b. Urinary incontinence can cause a yeast infection. c. Mild soap is contraindicated for cleansing the skin. d. A pH-balanced cleanser increases skin irritation.

b. Urinary incontinence can cause a yeast infection.

98. A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take? a. Administer an antagonist to reverse the effects of the anesthesia. b. Use an alternative method for determining the client's pain level. c. Administer a pain medication as prescribed for severe pain. d. Wait until the client is awake, alert, and able to vocalize their pain level.

b. Use an alternative method for determining the client's pain level.

11. A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure? a. Report the incident to the appropriate person and file an incident report b. Wash the exposed area with warm water and soap c. Consent to PEP at appropriate time d. Set up counseling sessions regarding safe practice to protect self

b. Wash the exposed area with warm water and soap

4. A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. Removes all jewelry including a platinum wedding band b. Washes hands to 1 in above the wrists c. Uses approximately one teaspoon of liquid soap d. Keeps hands higher than elbows when placing under faucet e. Uses friction motion when washing for at least 20 seconds f. Rinses thoroughly with water flowing toward fingertips

b. Washes hands to 1 in above the wrists c. Uses approximately one teaspoon of liquid soap e. Uses friction motion when washing for at least 20 seconds f. Rinses thoroughly with water flowing toward fingertips

49. A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client? a. Bathing the client completely in bed preserves the client's dignity. b. Washing the client in bed is less effective than taking a shower. c. A complete bed bath should be performed using a basin, soap, and water. d. Perform this type of bath early in the morning.

b. Washing the client in bed is less effective than taking a shower.

12.An 18-year-old presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? a. "Vaginal intercourse is most commonly performed in the missionary position." b. "The side-by-side position achieves better clitoral stimulation than the missionary position." c. "Achieving simultaneous orgasms is the goal of vaginal intercourse." d. "The period after coitus is just as significant as the events leading up to it."

c. "Achieving simultaneous orgasms is the goal of vaginal intercourse."

7.A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? a. "You know your personal situation better than I do, so I will respect your wishes." b. "If you don't accept these services, your baby's health will suffer." c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." d. "I'm going to assign your case to a social worker who can explain the services better."

c. "Let's take a look at the plan again and see if we can adjust it to fit your needs."

5.A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? a. I love my child so much I 'hug him to death' every day." b. "I think children need challenges, don't you?" c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." d. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want."

69. A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? a. "Accessing the medical record of clients on units other than where you are assigned is allowed." b. "There are large financial penalties for charting vital signs you obtain for another nurse's client." c. "Personnel can be terminated for breaching a client's confidentiality." d. "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits.

c. "Personnel can be terminated for breaching a client's confidentiality."

2.A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate— i.e., expected patient outcomes) Which item below places them in their correct sequence? a. 1, 2, 3, 4, 5 b. 3, 2, 1, 4, 5 c. 5, 2, 1, 3, 4 d. 2, 3, 1, 4, 5

c. 5, 2, 1, 3, 4

1.19 A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. a. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

12. The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm³ c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c. A 65-year-old patient who has an indwelling urinary catheter in place

2. identify is at the greatest risk of developing medication toxicity? a. A client who has a respiratory infection b. A client who has rheumatoid arthritis c. A client who has impaired kidney function d. A client who has hyperthyroidism

c. A client who has impaired kidney function

4. A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b. A nurse consults with a psychiatrist for a patient who abuses pain killers. c. A nurse checks the skin of bedridden patients for skin breakdown. d. A nurse orders a kosher meal for an orthodox Jewish patient. e. A nurse records the I&O of a patient as prescribed by his health care provider. f. A nurse prepares a patient for minor surgery according to facility protocol.

c. A nurse checks the skin of bedridden patients for skin breakdown. d. A nurse orders a kosher meal for an orthodox Jewish patient. f. A nurse prepares a patient for minor surgery according to facility protocol.

6. A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take? a. Mix the medication with the client's feeding infusion. b. Flush the feeding tube with 10 mL of water prior to administration of the medication. c. Administer the medication to the client in a liquid form. d. Place the client in a supine position prior to administering the medication.

c. Administer the medication to the client in a liquid form.

125. A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values? a. Integrity b. Human dignity c. Altruism d. Social justice

c. Altruism

142. A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? a. Use a brush to scrub the surface of the hands. b. Rinse antiseptic solution from the hands before it dries. c. Apply chlorhexidine and ethanol to the hands. d. Leave jewelry on the hands when cleansing them.

c. Apply chlorhexidine and ethanol to the hands.

6.A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? a. Recommend that she discipline her daughter more strictly and consistently. b. Make a list of things her husband can do to give her more time and help her improve her parenting skills. c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. d. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve.

13.A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? a. Add bath oil to the water to prevent dry skin. b. Allow the patient to lock the door to guarantee privacy. c. Assist the patient in and out of the tub to prevent falling. d. Keep the water temperature very warm because older adults chill easily.

c. Assist the patient in and out of the tub to prevent falling.

14.A nurse discovers that a medication error occurred. What should be the nurse's first response? a. Record the error on the medication sheet. b. Notify the physician regarding course of action. c. Check the patient's condition to note any possible effect of the error. d. Complete an incident report, explaining how the mistake was made.

c. Check the patient's condition to note any possible effect of the error.

117. A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience? a. Advanced beginner b. Proficient c. Competent d. Novice

c. Competent

103. A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk? a. Quality assessment skills b. Interprofessional collaboration c. Continuity of care d. Consistent client monitoring

c. Continuity of care

1. A nurse caring for adults in a provider's office researches aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. a. Chemical reactions in the body produce damage to the DNA. b. Free radicals have adverse effects on adjacent molecules. c. Decrease in size and function of the thymus results in more infections. d. There is much interest in the role of vitamin supplementation. e. Lifespan depends on a great extent to genetic factors. f. Organisms wear out from increased metabolic functioning.

c. Decrease in size and function of the thymus results in more infections. d. There is much interest in the role of vitamin supplementation.

8. A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? a. Ask another nurse to hold the hand of the patient and continue setting up the field b. Remove the instrument that was touched by the patient and continue setting up the sterile field c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand d. No action is necessary since the patient has touched his or her own sterile field

c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand

7.A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. Old age means mental deterioration.

1.A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? a. Negative self-concept and low self-esteem b. Negative self-concept and high self-esteem c. Positive self-concept and fairly high self-esteem d. Positive self-concept and low self-esteem

c. Positive self-concept and fairly high self-esteem

6. A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

c. Quality improvement

78. A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? a. The client states, "I've had abdominal pain for the past 3 days." b. The client reports consuming about 1,500 mL of water per day. c. Rebound tenderness noted in RLQ of the abdomen. d. Recommend client referral to a registered dietitian

c. Rebound tenderness noted in RLQ of the abdomen.

113. A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media? a. Posting a comment on social media about facility staffing shortages b. Accepting a social media friend request from a client c. Reviewing the use of a fitness application with a client d. Sharing client information with a coworker in a private social media message

c. Reviewing the use of a fitness application with a client

7.19 A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? a. State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." b. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. c. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift.

c. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them

106. A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR? a. The client in room 1 is postoperative exploratory laparotomy surgery yesterday. No complications besides some post-operative pain. b. The client in room 1 states "pain is a 4 out of 10" despite pain medication. Vital signs are stable. No outward manifestations of distress. Plan to call the provider if it continues. c. The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues. d. he client in room 1 had surgery and is experiencing pain post-operative. By the end of this shift, the client will have pain controlled, with a pain rating of no more than a 2 out of 10 without breakthrough pain, or need additional medications for breakthrough pain.

c. The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues.

55. A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include? a. Nails, made of pterygium, protect the fingers and toes. b. The cuticle is a form of keratin that connects the skin and nail plate together. c. The cuticle of the nail forms a barrier to prevent infections. d. The nail consists of layers of pterygium that protect against pathogens.

c. The cuticle of the nail forms a barrier to prevent infections.

58. A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis? a. The epidermis acts as a cushion against physical trauma. b. The epidermis separates the dermis from the underlying organs. c. The epidermis consists of squamous epithelial cells. d. The epidermis contains blood vessels and blood.

c. The epidermis consists of squamous epithelial cells.

1. A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal

1.A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The nurse reassesses the patient and decides how best to intervene in her care.

50. A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client? a. The nurse should perform personal hygiene tasks for the client. b. The client has a minor loss of strength on the right side of the body. c. The nurse should have the client remove clothing from the unaffected side first. d. Oral care is much easier for the client to perform than bathing.

c. The nurse should have the client remove clothing from the unaffected side first.

*4.A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended? a. The nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected. b. The nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site. c. The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track. d. The nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended site.

c. The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track.

14.A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? a. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b. Cut the gown with scissors to allow arm movement. c. Thread the bag and tubing through the gown sleeve, keeping the line intact. d. Temporarily disconnect the tubing from the IV container, threading it through the gown.

c. Thread the bag and tubing through the gown sleeve, keeping the line intact.

9. A nurse is assessing a patient who is visiting her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? a. Human papillomavirus (HPV) b. Syphilis c. Trichomoniasis d. Herpes simplex virus

c. Trichomoniasis

10. A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. Remove gown, goggles, mask, gloves, and exit the room b. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles c. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene d. Remove goggles, mask, gloves, and gown, and perform hand hygiene

c. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene

9.The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? Select all that apply. a. Crush the enteric-coated pill for mixing in a liquid. b. Flush open the tube with 60 mL of very warm water. c. Use the recommended procedure for checking tube placement in the stomach or intestine. d. Give each medication separately and flush with water between each drug. e. Lower the head of the bed to prevent reflux. f. Adjust the amount of water used if patient's fluid intake is restricted.

c. Use the recommended procedure for checking tube placement in the stomach or intestine. d. Give each medication separately and flush with water between each drug. f. Adjust the amount of water used if patient's fluid intake is restricted.

11.A patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. How would the nurse document this data? a. Masochism b. Pedophilia c. Voyeurism d. Sadism

c. Voyeurism

7. A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? a. "Outcome not met." b. "1/21/20—Patient reports no change in diet." c. "Outcome not met. Patient reports no change in diet or activity level." d. "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

d. "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

14.Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? a. "Do you currently have a new partner?" b. "Have you been diagnosed with a neurologic disorder?" c. "Do you take antihypertensive medication?" d. "Do you use antihistamines?"

d. "Do you use antihistamines?"

12. A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make? a. "You can expect to experience a rash while taking this medication." b. "Natural supplements do not interact with antibiotics." c. "This medication is used to treat a viral infection." d. "Finish the entire course of the prescription."

d. "Finish the entire course of the prescription."

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medical records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

d. "I will need to check with our records department to get you a copy."

4. A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? a. "Each person is born with a certain amount of sexual drive, which can be depleted in later years." b. "If you want to be a great athlete, sexual abstinence is necessary when you are training." c. "If you have a nocturnal emission (wet dream), it is an indicator of a sexual disorder." d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

d. "It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

3.A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

57. A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include? a. The mucous membranes secrete a thin, salty liquid that traps pathogens and particles." b. "The mucous membranes provide a chemical barrier against pathogens." c. "The mucous membranes of the auditory tube contain cilia that move particles toward the front of the nose." d. "The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

d. "The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

1.During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? a. "You need to speak to the patient quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."

d. "When your patient is safe and comfortable, meet me at the desk."

8. A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? a. "Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." b. "The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." c. "Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs." d. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

d. "Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

7. A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1. Ineffective Coping related to inability to maintain marriage 2. Defensive Coping related to loss of job and economic security 3. Altered Thought Processes related to panic state 4. Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. (1), (2), (3), and (4)

d. (1), (2), (3), and (4)

126. A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity? a. A nurse involves a client in making decisions about their care. b. A nurse implements fall precautions for a client who is at risk for falling. c. A nurse tells the truth about forgetting to perform a procedure for a client. d. A nurse keeps a promise to a client not to tell their family about their diagnosis.

d. A nurse keeps a promise to a client not to tell their family about their diagnosis.

121. A nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy? a. A nurse provides the same quality care for every client. b. A nurse maintains client confidentiality. c. A nurse admits they forgot to change a client's dressing. d. A nurse respects a client's wish to discontinue a treatment.

d. A nurse respects a client's wish to discontinue a treatment.

4.A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take a. Administer the medication whenever the client reports specific manifestations, such as pain. b. Administer the medication at specific times until directed by health care provider. c. Administer the medication at regular intervals of 4 hr. d. Administer the medication within 30 min of the health care provider prescribing the medication.

d. Administer the medication within 30 min of the health care provider prescribing the medication.

147. A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? a. Protective isolation b. Contact c. Droplet d. Airborne

d. Airborne

6. The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? a. Only patients with diagnosed infections b. Only patients with visible blood, body fluids, or sweat c. Only patients with nonintact skin d. All patients receiving care in hospitals

d. All patients receiving care in hospitals

9.A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. b. Schedule the testing and meal planning first and complete hygiene as time permits. c. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

6. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? a. Thank the wife for being present. b. Ask the wife if she wants to remain. c. Ask the wife to leave. d. Ask the patient if he would like the wife to stay.

d. Ask the patient if he would like the wife to stay.

132. A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? a. Evaluation b. Implementation c. Analysis d. Assessment

d. Assessment

5. The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? a. Keep splashes on the sterile field to a minimum b. Cover the nose and mouth with gloved hands if a sneeze is imminent c. Use forceps soaked in a disinfectant d. Consider the outer 1 in of the sterile field as contaminated

d. Consider the outer 1 in of the sterile field as contaminated

52. A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take? a. Ensure the nurse caring for the client is of the same sex. b. Leave the water running while the client takes a bath. c. Allow the client time for prayer immediately following bath time. d. Discuss with the client their individual perspective on health and illness.

d. Discuss with the client their individual perspective on health and illness.

10.A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. What should the nurse do? a. Give all the medication in the cartridge because it expanded when it was mixed and this is what the pharmacy sent. b. Call the pharmacy and request the proper dose. c. Refuse to give the medication and document refusal in the EHR. d. Dispose of 0.2 mL before administering the drug; verify the waste with another nurse.

d. Dispose of 0.2 mL before administering the drug; verify the waste with another nurse.

6.Following assessment of an obese adolescent, a nurse considers nursing diagnoses for the patient. Which diagnosis would be most appropriate? a. Risk for injury b. Risk for delayed development c. Social isolation d. Disturbed body image

d. Disturbed body image

16. A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include? a. Use closed-ended questions b. Provide written material at a 9th-grade reading level. c. Use passive listening skills. d. Encourage the client to ask questions.

d. Encourage the client to ask questions.

5.A nurse is formulating a clinical question in PICOT format. What does the letter P represent? a. Comparison to another similar protocol b. Clearly defined, focused literature review of procedures c. Specific identification of the purpose of the study d. Explicit descriptions of the population of interest

d. Explicit descriptions of the population of interest

8. A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications? a. Verify the client's identity using their diagnosis. b. Use one identifier to confirm the client's identity. c. Use the client's room number to identify the client d. Have the client confirm their name and date of birth.

d. Have the client confirm their name and date of birth.

118. A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smoking cessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply.) a. Advocate b. Collaborator c. Change manager d. Health promotor e. Nurse educator

d. Health promotor e. Nurse educator

37. A nurse is meeting with a client who was recently diagnosed with rheumatoid arthritis. The client tells the nurse, "I'm never going to be able to do anything fun." Which of the following questions should the nurse ask to assess the client's identity? a. Can you describe one of your primary roles? b. How do you respond when you feel you have failed? c. What aspects of your body would you like to change? d. How do others' opinions impact the way you see yourself.

d. How do others' opinions impact the way you see yourself.

7.A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? a. Make a recommendation for the patient to see an oral surgeon. b. Report the condition to the primary care provider. c. Gently scrape the oral cavity with a tongue depressor. d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

13. A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? a. Imbalanced nutrition b. Impaired physical mobility c. Chronic pain d. Infection

d. Infection

40. A nurse is caring for a client who reports enjoying retirement because they are reading more, visiting with children and grandchildren, and playing bridge with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development? a. Trust b. Autonomy vs. shame and doubt c. Identity vs. role confusion d. Integrity vs, despair.

d. Integrity vs, despair.

13.A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? a. There is no disturbance in self-concept. b. This patient has ego strength and high self-esteem but may have a disturbance of body image. c. The area of self-esteem has very low priority at this time and should be ignored until much later. d. It is probable that there are disturbances in self-esteem and body image.

d. It is probable that there are disturbances in self-esteem and body image.

3.A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? a. Negative self-concept b. Modesty (lack of conceit) c. Body image disturbance d. Low self-esteem

d. Low self-esteem

1. A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? a. Congratulate the student and continue the care plan. b. Terminate the care plan since it is not working. c. Try giving the student more time to reach the targeted outcome. d. Modify the care plan after discussing possible reasons for the student's partial success.

d. Modify the care plan after discussing possible reasons for the student's partial success.

4.A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing problem

*3.A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment of skin integrity.

d. Perform and document a focused assessment of skin integrity.

133. A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? a. Evaluation b. Implementation c. Analysis d. Planning

d. Planning

9. A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down b. Hold the bottle inside the edge of the sterile field c. Hold the bottle with the label side opposite the palm of the hand d. Pour the solution from a height of 4 to 6 in (10 to 15 cm)

d. Pour the solution from a height of 4 to 6 in (10 to 15 cm)

112. A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements? a. Take the client's vital signs now and document them as being completed 8 hr earlier. b. Document vital signs that are the same as those obtained earlier. c. Make a reminder note to be more diligent when returning the next day. d. Report this omission to the charge nurse and the nurse on the next shift.

d. Report this omission to the charge nurse and the nurse on the next shift.

88. A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? a. Ask a staff member who speaks the same language as the client to interpret. b. Ask a family member of the client to interpret the information. c. Search the internet for an electronic application to use for translating. d. Request assistance from the facility's interpreter.

d. Request assistance from the facility's interpreter.

101. A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety? a. Right scope b. Right directions c. Right supervision d. Right task

d. Right task

91. A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? a. Explain the daily schedule to the client in detail. b. Turn the overhead lights on in the client's room when speaking with them. c. Speak in a loud voice to the client. d. Speak to the client clearly and at a slow pace.

d. Speak to the client clearly and at a slow pace.

6. A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? a. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. b. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. c. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. d. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

d. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

4.A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

47. A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include? a. The most common oral hygiene problem is gingivitis. b. The client's ability to obtain dental care is unaffected by their visual impairment. c. The visually impaired client has better oral hygiene than those clients without visual impairment d. The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health

d. The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health