Fundamentals of Nursing Practice Questions
A home health nurse makes weekly visits to an 87-year-old client who lives with her son. When home alone, the client is talkative and friendly, but when the son is home, the client is observed to be withdrawn and appears anxious. The client has bruises, which she states is from "bumping into things" and a weight-loss of 10 pounds in the past month. With these objective findings, the nurse is required to do which of the following? select all that apply. A. ask the client if she has any concerns about her living situation, maintaining an objective, non-accusatory role. B. Confront the son about the abuse, demanding that he turn himself in to seek help for the abusive pattern of behavior. C. Question the client's son privately about the suspicions of his mother's condition and about possible abuse or neglect. D. Report suspected abuse to adult protective services so investigation into the clients welfare can be performed.
C, D All states have statutes requiring mandatory reporting by nurses and other healthcare workers of any suspected abuse of children, disabled, and the elderly. The nurse should probably discuss with the client any concerns about the client safety The nurse is also required by law to report any suspected abuse or neglect because the nurses are mandated reporters.
Which nursing diagnosis reflects the highest priority for an 80-year-old client admitted to the hospital with new atrial fibrillation? A. Risk for activity intolerance related to increase cardiac output B. Risk for anxiety related to fear of recurrent palpitations C. Risk for injury related to syncope and confusion D. Risk for urgent urinary incontinence related to increased urine output
C. Clients with atrial fibrillation experience a decrease cardiac output and are at high risk for thrombi Risk for injury related to syncope and confusion is the highest priority nursing diagnosis because physiological and safety needs outweigh the patient's anxiety, according to Maslow's hierarchy of needs
The circulating nurse in the OR notices a small laceration on the patients hip while positioning pre-op, but this was missed and not reported during the pre-op assessment. Of the following, which is the appropriate action for the nurse to take? A. At the laceration to the pre-op nurses documentation so it won't be confused with a surgical injury B. Document the laceration along with the surgical sites in the peri-op note C. Document the presence of a preexisting skin laceration in the peri-op now. D. Report it to the receiving PACU nurse after the procedure so she can document it.
C. Document the presence of a preexisting skin laceration in the peri-op now. Pre-op assessment should always include any skin tears or lacerations, bruises, rashes, and pressure ulcers, so they can be documented and will not be misattributed to surgical injury or complication. A nurse may never alter documentation after-the-fact or alter the documentation of another nurse. So if something is Missed, a note should be made in the peri-op documentation to detail the pre-existing injury
The nurse manager is teaching a new grad nurse about recognizing unapproved abbreviations to avoid potential errors. The nurse recognizes which of the following as an incorrect drug order using an unacceptable abbreviation: A. 1000 mL of lacerated ringers to infuse over 10 hours, one time B. Acetaminophen, 1000 mg PO every 8 hours PRN for pain. Do not exceed 3000 mg in 24 hours C. Heparin sodium, 5000 u by subcutaneous injection BID For two weeks D. Timolol maleate, 1 gtt in the affected eye BID
C. Heparin sodium, 5000 u by subcutaneous injection BID For two weeks The use of "u" for a unit is on the joint commissions official list of "Do not use" abbreviations. "u" could be mistaken for 4, O, or cc. The requirement is to write "units"
A nurse witnesses another nurse slap a patient. The patient has been very difficult to manage and often very rude, observed screaming obscenities at other patients and staff. What action should the nurse take after witnessing this? A. ask the charge nurse reported to the bureau of adult protective services B. Call the patient's family to tell them about the incident. C. Reported to the bureau of adult protective services D. Tell the other nurse that it will be reported if it happens again.
C. Report it to the bureau of adult protective services Abuse is against the law, and the nurse is a mandated reporter. This means that the nurse is required to report such events directly to the appropriate authorities.
When preparing a patient for surgery, the nurse learns of the patient stopped taking her blood pressure medication because it was too expensive. The nurse should collaborate with which healthcare team member to provide the patient with information and resources for lowering medication costs? A. Chaplain B. Respiratory therapist C. Social worker D. Vascular surgeon
C. Social worker The social worker can find community resources to aid the patient and paying for her medication. Also, the social worker can contact pharmacies to find cheaper alternatives or help the patient apply for government assistance programs
The patient self-determination act of 1990 requires all of the hospitals to do which of the following? A. Collect data on contagious diseases B. Collect data on patient falls C. Inform patients about advanced directives D. Inform patients about medication side effects
C. The patient self-determination act of 1990 requires all hospitals to inform patients about advanced healthcare directives upon admission to a hospital
The patient refuses chemotherapy based on religious beliefs. The hospital staff must follow his decision based on which patient right? A. The right to counsel B. The right to informed consent C. The right to refuse treatment D. The right to suffer
C. The right to refuse treatment
The patient was recently admitted to hospice care for lung cancer. After filling out his advanced directive, the patient says that he worries his physician will be uninterested in his care. Which of the following statements made by the nurse best addresses the patient's concerns? A. "After you fill out an advance directive, the physician plays a limited role to allow you space and time to be with your family." B."Once you are admitted to hospice, the physician plays a passive role." C. "Your physician is required by law to help you, so don't worry." D. "Your physician will continue to take care of you. The advanced directive just states what type of care you want, so we can provide that care even when you cannot tell us too."
D. "Your physician will continue to take care of you. The advanced directive just states what type of care you want, so we can provide that care even when you cannot tell us too."
Which medication administration situations should be documented in a healthcare facility's incident reporting system? A. Medication errors and adverse drug reactions only B. Medication errors that cause patient harm C. Near misses and medication errors only D.near misses, medication errors, and adverse drug reactions
D. Near misses, medication errors, and adverse drug reactions must all be documented in the facility's incident reporting system.
A nurse notices at the start of the shift that the patient's IV anabiotic scheduled to be given six hours ago is still hanging on the patient's IV pole. The pump is turned off and the tubing is not connected to the patient. The antibiotic is documented as given on the MAR by the previous nurse. What is the first thing that the nurse should do? A. Document findings in the facilities incident reporting system B. Document physician notification in the medical record C. Notify the charge nurse of the missed dose D. notify the physician of the missed dose and seek orders for the next dose timing
D. Notify the physician of the missed dose and seek orders for the next dose timing The first action the nurse should take is to ensure the patient receives the order therapy by notifying the physician and seeking orders for the timing of the next dose of antibiotic. Antibiotics are most effective when there is a therapeutic level in the patient's system. The most important thing the nurse can do in this situation is to make sure the physician is aware of the missed dose so that the antibiotic schedule can be adjusted if needed. ** After notifying the physician and adjusting the dosing schedule, the nurse should document physician notification, notify the charge nurse, and complete an incident report.
A nurse is documenting after 76-year-old female with dementia was found on the floor after using the bathroom by herself. The nurse documents the following in the chart: patient fell on bathroom floor at 1715. Patient reported that she "lost her balance" while toileting. Vital signs were WNL and BP Was 115/87. Patient has a bruise on her right thigh and reports 4/10 pain at the thigh. No obvious deformity; CSM normal. POA and MD informed; pt put on fall precautions. Tylenol 650 mg by mouth given at 1740 hrs. Pain 1/10 at 1830 hrs. Of the following, which is an example of inappropriate documentation of this incident? A. POA and MD inform; pt put on fall precautions B. Patient has a bruise on her right thigh reports 4/10 pain at the thigh. Tylenol 650 mg PO Given at 1740 hrs. Paid 1/10 at 1830 hrs. C. Patient reported that she "lost her balance "while toileting D. Patient fell on the bathroom floor at 1715 hrs.
D. Patient fell on the bathroom floor at 1715 hrs. Documentation should include where the patient was found and who found them and any objective observations only. It should be noted if they were on precautions of any kind. Never document that the patient fell unless someone actually witnessed the fall
A nurse is assessing his patients in the morning and finds that a frail a 85 year-old female patient is soiled in bed. The patient reports that she has been asked to cleaned numerous times and has been ignored. Of the following, which demonstrates appropriate documentation in the patient's chart. A. The patient was found soiled in bed by this RN. she reports being left alone all night by the night shift RN, who did not clean her before the change of shift. She was given a bed bath and provided skin care. Her skin was reddened on her buttocks; emollient applied. B. The patient was found soiled in bed by this RN. She was incontinent of urine and feces and she said she was "ignored for hours" by the night shift RN. She was given a bed bath and provided skin care. Her skin was reddened on her buttocks; emollient applied. C.The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; Emollient applied. Incident report made. D. The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; emollient applied.
D. The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; emollient applied. **Documentation Must stick to objective descriptions of what happen in any assessments and interventions performed. Personal biases or information that applies misconduct should never be documented in the patient's chart
A patient was mistakenly given 40 mg of propranolol instead of her scheduled levothyroxine. After assessing the patient and reporting this to the physician, the nurse makes a written report that the medication was given in error to the patient due to a mixup in the med room. Where does this report go? A. The report goes in the patient's MAR ( medication administration record) only B. The report goes in the patient's chart C. The report goes to the charge nurse D. The report is sent to risk prevention
D. The report is sent to risk prevention Report is made to risk prevention, a part of the hospital management responsible for investigating the root causes a potential or actual errors on patient injuries This report should not be included in the patient's an MAR or medical record
The five-year-old is admitted to the hospital with pneumonia. The nurse observes bruises on the child's back and arms. The Mother is present in the patient's room. What should the nurse do next? A. Ask the mother if she is abusing her child B. Call the police C. Notify the physician of suspected child abuse D. When the mother leaves, ask the child if she feels scared or unsafe at home
D. When the mother leaves, ask the child if she feels scared or unsafe at home. If the nurse suspects abuse, he or she should ask the patient in private if he or she feels safe at home to gather more information. While The nurse is a mandated reporter, the nurse should first collect more information before calling the police or reporting her concerns to the physician
A nurse on the cardiovascular step down unit is caring for a patient who is post operative day two after arterial bypass surgery. The patient has a PCA with Hydromorphone infusion and has hydrocodone 10 mg PO Q4 hours ordered for breakthrough pain. During morning assessment, the patient complains of pain rated 10 on a scale of 0 to 10. The nurse offers the patient the hydrocodone for breakthrough pain. The patient states, "I asked for pain medication from the other nurse and was told no because I have a PCA." On further questioning the patient stated that the other nurse there and to disconnect the PCA if the patient continued to complain. The nurse knows that the next appropriate action is which of the following? A. Call the other nurse at home to confront them about the patients accusations. B. Discuss the accusations with the Charge nurse and complete an incident report C. Ignore patient claims since the patient should have adequate pain control with the PCA. D. investigate the patient's past medical history for possible substance abuse
D. discuss the accusations with the charge nurse and complete an incident report Pain is a subjective experience, and all patients will experience pain individually from others. When a patient complains of pain, it is the nurses duty to address the pain. If a patient has a PCA pump and orders for breakthrough pain medication, this is because pain medications provided through a PCA are shorter acting while breakthrough pain medication are longer acting to help achieve better pain control
Which of the following best illustrates evaluation step of the nursing process? after A. Ask the patient if there is anything else we need before you leave the room B. Assessment of lung sounds on the new admission C. Auscultating and palpating a patient's abdomen when he complains of new Abdominal pain D. Reassessment of pain after pain medication is administered
D. the evaluation phase of the nursing process involves measuring the effectiveness of the interventions implemented in the plan of care including reassessing pain after medication
The patient is scheduled for surgery later in the day. The surgeon is very busy with another surgery and asks the nurse to obtain informed consent. How should the nurse Proceed? A. Delegate the task to the charge nurse B. Explain the risk and benefits of the procedure and have the patient sign the consent. C. Get a physicians assistant to obtain consent D. Inform the physician that only he may legally obtain informed consent from the patient
D. the physician performing the surgery must explain the surgery to the patient and obtain written informed consent RNs can only obtain informed consent if they've been specifically trained to perform the procedure. Inserting a PICC is an example of a situation where trained nurses obtain informed consent
A patient with severe metabolic abnormalities is prescribed a peripherally inserted central catheter ( PICC). The nurse tells the patient informed consent is required. The patient asks why consent is needed. The best response for the patient would include the following: Select all that apply: A. "The joint commission requires it." B. "The consent ensures that you make an informed decision based on the indications for the procedure and the alternatives you have." C."To be fully informed, you need to be aware of the risk and the benefits of the procedure" D. We need consent unless it is an emergency." E. "You need to understand how dangerous this procedure is."
B, C The best answer explains that informed consent is about understanding the indications, alternatives, risks, benefits, and answers the patients questions accurately and appropriately
The nurse understands the following about informing and obtaining consent for an eight-year-old patient who is undergoing a heart transplant: Select all that apply. A. Since the child is a minor, he does not need to be informed about the surgery B. The child must be informed about the surgery. C. The child must sign the informed consent form along with their parent D. The child only needs to know the risks of the surgery. E. The parent/guardian must be informed of the risks and benefits of the procedure and sign the informed consent on behalf of the child
B, E The child must be informed about the surgery and the parent/guardian must be informed of the risks and benefits of the procedure and sign the informed consent on the half of the child
A physician involved in the patient's care asks to see the results of his HbA1c. How should the nurse respond? A. "Asked the clerk for that information." B. "I can't give you that information." C. "It is 8.5." D. "You can look it up on the computer"
B. "I can't give you that information." HIPPA regulations prohibit those not directly involved in patient care from accessing patient information
A nurse witnesses a mental health worker kissing a patient in the patient's room. The patient tells the nurse, "please don't tell anyone about this. It just happened. I care so much about him, but we have agreed not to date until I am discharged." Which of the following is an appropriate response? A. "I can't tell you what is appropriate outside the hospital, but while you are here you cannot engage in any physical contact with each other." B. "I have to report this situation to the authorities." C. "I will have to make a note about this and reassign him to work on another unit while you are here." D. "You should know better than to get involved with each other. It's inappropriate."
B. "I have to report this situation to the authorities." Patient safety must be the first priority. As a mandated reporter the nurse must document and report this situation to the hospital and to the required authorities in their jurisdiction. Professional sexual misconduct is a criminal offense
Patient requires mechanical ventilation through a tracheostomy after a motor vehicle accident one year ago. The patient's DPOA asks the nurse if the ventilator can be removed. Which of the following responses by the nurse best explains the legal rights of the power of attorney? A. "That decision is a difficult one to make." B. "This is something you need to discuss with the healthcare provider, but legally previous decisions can be changed." C. "We cannot do that. The decision to continue mechanical ventilation was already made." D. "You don't want to keep her alive anymore?"
B. "This is something you need to discuss with the healthcare provider, but legally previous decisions can be changed." Decisions about care made by the DPOA can be changed at any time. The healthcare provider should be notified so he or she can discuss this with the patients DPOA
A client on neutropenic precautions is being cared for by a healthcare team. What role in patient care would be appropriate for the LPN? A. Administer IV chemotherapy medication B. Administer oral antibiotics C. Determine what isolation precautions to initiate D. Screen visitors for communicable diseases
B. An LPN Can administer PO antibiotics
A nurse on the medical surgical floor is caring for an elderly patient with dementia. The patient's adult child is staying with the patient during the hospital stay. The patient's dementia and confusion is worse at night in a phenomenon known as "sundowners" the doctor has order for the patient to receive alpralozam 1mg PO q hs as needed for anxiety. The patients child called the nurses station at 7:30 PM requesting that the patient be given the medication early because the patient will not stay in bed. The nurse knows which of the following about this request? A. Alpralozam can be used as a chemical restraint since it is ordered by the doctor B. Giving the alpralozam early to keep the patient in bed is using it as a chemical restraint C. The alpralozam can be given at 7:30 PM since the patient will be in bed. D. The alprazolam order can only be given after 10 PM.
B. Giving the Alpralozam early to keep the patient in bed is using it as a chemical restraint Medications ordered by the doctor to be used for anxiety as needed are only to be administered as directed for anxiety. Using these anxiolytics as a means to keep a patient in bed is considered a chemical restraint
The nurse coming on for the evening shift received report that one of the patients on the psychiatric unit is in four point restraints. Which of the following issue regarding the assessment of the patient? A. The nurse will assess the patient at change of shift and then at least every four hours when a new order is required to continue restraints. B. The nurse will assess the patient at change of shift and then at least every hour. C. The nurse will assess the patient at change of shift and then at least every two hours D. The nurse will assess the patient a change of shift and then assign a mental health care worker to check vital signs every hour
B. The nurse will assess the patient at change of shift and then at least every hour. Vital signs are taking hourly and range of motion is done every two hours for patients in restraints. At the hourly assessment, the nurse will evaluate the patient's response to seclusion or restraints, offer support or reassurance, and attempt to work with the patient to formulate a plan to expedite release. This may include utilizing PRN medications, considering coping skills to use, and contracting for safe behavior on the unit
The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the med-surg floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75 year old patient newly admitted with dehydration 2) 65 year old patient hospitalized for a stroke whose BP is 189/90 3) 92 year old patient with stable vital signs who was admitted with a UTI 4) 56 year old patient with chronic renal failure who has VS within his normal range.
1) 75 year old patient newly admitted with dehydration 3) 92 year old patient with stable vital signs who was admitted with a UTI 4) 56 year old patient with chronic renal failure who has VS within his normal range. A 65 year old who suffered a stroke and has high BP would not be appropriate for the CNA to bathe themselves.
The physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague to help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrian the client before inserting the urinary catheter. 4) Inform the physician that she cannot perform the procedure because the client is confused.
1) Ask a colleague to help, because the nurse cannot safely perform the procedure alone. Asking a colleague for help with a confused and combative patient because of safety issues in doing the procedure alone.
Which of the following are cues rather than inferences? Select all that apply. 1) Ate 50% of his meal 2) Patient is depressed today 3) States "I slept well today" 4) White blood cell count 15000/mm
1) Ate 50% of his meal 3) States "I slept well today" 4) White blood cell count 15000/mm Patient is depressed today is an inference.
In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include: 1) Cognitive and aesthetic 2) Love and belonging 3) Safety and Security 4) Physiological and Self-esteem
1) Cognitive and aesthetic needs
A family assessment should include the following areas: (choose all that apply) 1) Coping patterns 2) Health beliefs 3) Medical history 4) Physical exam
1) Coping patterns 2) Health beliefs Medical history and physical exams are only relevant to the family assessment if it affects other family members.
Which statement(s) about culture is/are true? Choose all that apply. 1) Culture exists on both material and nonmaterial levels 2) Culture mainly influences food choices and special holidays 3) Cultural customs change over time at different rates 4) Culture is learned through life experiences shared by other cultural members.
1) Culture exists on both material and nonmaterial levels 3) Cultural customs change over time at different rates 4) Culture is learned through life experiences shared by other cultural members.
The nurse should encourage a group of teenagers to eat plenty of _______________? 1) Dairy products 2) Fish 3) Nuts & Legumes 4) High fiber products
1) Dairy products Dairy products help build up calcium in growing bodies.
A nurse is caring for an 80 year old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Doing whatever it takes for the patient, no matter the cost 4) Involving the patient and family in formulating outcomes
1) Developing culturally appropriate outcomes 4) Involving the patient and family in formulating outcomes
Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A life-long journey involving accumulation of experience and understanding 4) Codes of ethics that integrate beliefs and values.
1) Discussions and theories related to God and His relation to the world Discussions and theories related to God and his relation to the world
The nurse should assess skin temperature by using the: 1) dorsum of the hand 2) pad of the fingertip 3) palm of the hand 4) dorsum of the wrist
1) Dorsum of the hand
The nursing instructor asks students how they would assess the 5th vital sign. Which student would be correct? 1) I would ask the patient what their pain was on a scale of 0-10 2) I would ask the patient when they last had a bowel movement 3) I would check the patient's respiratory rate 4) I would ask the patient about their tobacco use.
1) I would ask the patient what their pain was on a scale of 0-10
A patient with Parkinson's Disease is at risk for which complication? 1) Impaired kinesthesia 2) macular degeneration 3) seizures 4) Xerostomia
1) Impaired Kinesthesia
What is the body's first line of defense against bacteria? 1) intact skin 2) hair 3) immune system 4) lymph glands
1) Intact skin
The nurse notices that a patient has spoon-shaped brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less than body requirements related to deficiency to which nutrient? 1) Iron 2) Vitamin A 3) Protein 4) Vitamin C
1) Iron
Which of the following characteristics do the various definitions of critical thinking have in common? 1) Requires reasoned thought 2) Asks the questions "why" and "how" 3) Is a hierarchal process 4) Demands specialized thinking skills
1) Requires reasoned thought
Physiological changes associated with aging place the older adult at risk for which nursing diagnosis? 1) Risk for falls 2) Risk for ineffective airway clearance 3) Risk for poisoning 4) Risk for suffocation
1) Risk for falls Loss of muscle strength and joint mobility place the older adult at risk for falls
Which healthcare worker should the nurse counsel a patient about financial and family stressors impacting healthcare? 1) Social worker 2) Occupational therapy 3) Physician's assistant 4) Charge nurse
1) Social worker The social worker coordinates services and counsels patients about financial, housing, marital, and family issues.
In performing a hand-off report, the nurse should communicate information on: (select all that apply) 1) Teaching performed 2) Any change in client status 3) Treatments administered 4) Hygiene measures performed
1) Teaching performed 2) Any change in client status 3) Treatments administered
A community health nurse wants to provide health promotion classes through the local hospital, which of the following topics might be included in this endeavor? Select all that apply. 1) Time Management 2) Healthy eating habits 3) Exercise after a stroke 4) Bicycle safety for children
1) Time Management 2) Healthy eating habits 4) Bicycle safety for children Teaching exercise after a stroke focuses more on rehabilitation.
A patient takes anticoagulants. Which is the most important for the nurse to include on the patient's care plan? Teach the patient to: 1) Use an electric razor for shaving 2) Apply skin moisture 3) Use less soap 4) Floss teeth daily
1) Use an electric razor Use an electric razor instead of a double edged razor for shaving to reduce the risk of excess bleeding.
Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial Spores 3) Yeast 4) Mold
1) Virus 3) Yeast 4) Mold Alcohol-based solutions are ineffective against bacterial spores.
Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Wearing a gown 4) Wearing a face mask
1) Washing hands Hand washing is the most important part of medical asepsis
A patient suddenly develops right lower quadrant pain, nausea, vomiting. How should the nurse classify this patient? 1) Acute 2) Chronic 3) Intralatable 4) neuropathic
1) acute
Which of the following reflects understanding of the characteristics of older adults? 1) Fewer than 5% of older adults live in nursing homes. 2) Average life expectancy has declined in the past 10 years. 3) In general, men live longer than women. 4) Black men have the lowest life expectancy.
1) fewer than 5% of older adults live in nursing homes. Only 3.3% of people 65 years and older live in nursing homes.
Reviewing the following: 38 year old, growth in height 5'2", female gender, weight gain 15 lbs. This list can be reffered to as which of the following? 1) information 2) knowledge 3) data 4) patient record
1) information
Which body fluid lies in the spaces between the body cells? 1) interstitial 2) intracellular 3) intravascular 4) transcellular
1) interstitial
Which of the following terms refers to the ethics questions that arise out of nursing practice? 1) nursing ethics 2) bioethics 3) ethical dillema 4) moral distress
1) nursing ethics
Which of the following contributions of Florence Nightingale had an immediate impact on improving patient's health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) establishing nursing as a distinct profession
1) providing a clean environment Improved sanitation greatly and immediately reduced the rate of infection and mortality in hospitals.
Which of the following health information is protected in electronic health records? choose all that apply. 1) social security number 2) insurance information 3) physicians name 4) lab results
1) social security number 2) insurance information 4) lab results
Which food provides the body with no usable glucose? 1) wheat germ 2) apples 3) white bread 4) white rice
1) wheat germ
Which of the following informatics concept concerns the appropriate use of knowledge in managing or solving human problems? 1) wisdom 2) knowledge 3) data 4) information
1) wisdom
A nurse if preparing to assess a toddler. To make it go smoothly the nurse should _____________? 1) Ask the parents to step out 2) Ask the child about his favorite toy 3) Show the child your name tag 4) Yell at the child if he doesn't follow instructions
2) Ask the child about his favorite toy This will show the child that you are interested in his things.
The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking. 2) Availability of community resources. 3) Adherence to a low-fat diet 4) Importance of physical exercise.
2) Availability of community resources.
Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) K 4) E
2) D
In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called _______: 1) information 2) data 3) knowledge 4) wisdom
2) Data
When changing a diaper, the nurse observes that a 2 day old infant has a green, black, tarry stool. What should the nurse do? 1) notify the physician 2) Do nothing, this is normal 3) Give the baby sterile water 4) Apply a skin barrier
2) Do nothing this is normal
Which medication will the physician most likely prescribe to increase urine output for patient with CHF? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin
2) Furosemide
Which question helps the nurse assess family structure? 1) Where does your family live? 2) How are family decisions made? 3) With which religious affiliation is your family associate? 4) What is your ethnic background?
2) How are family decisions made? Asking how family decisions are made helps the nurse assess family structure.
Bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Edema 2) Jaundice 3) Cyanosis 4) Pallor
2) Jaundice
Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back 2) Keep the telephone number of poison control center nearby 3) Use a front-facing car seat placed in the back seat 4) Keep syrup of ipecac on hand in case of poisoning
2) Keep the telephone number of poison control center nearby 3) Use a front-facing car seat placed in the back seat Infants, not toddlers should sleep on their backs, and syrup of ipacac is no longer a recommendation to induce vomiting after poisoning.
______________ is a health program, administered by the state and funded by federal and state governments to provide care for low-income people. 1) Medicare 2) Medicaid 3) Obama care 4) Welfare
2) Medicaid Medicaid is intended to provide healthcare individuals without ability to pay for services. Medicare is designed to protect people age 65 and older from the rising cost of healthcare.
Which of the following includes objective and subjective data? 1) Patient's BP is 132/68 and HR is 88 2) Patient's cholesterol is elevated, and stated that he likes fried food 3) Patient states she is having trouble sleeping and drinks coffee at night 4) Patient states he gets frequent headaches and takes aspirin for it.
2) Patient's cholesterol is elevated, and stated that he likes fried food Elevated cholesterol is objective and states "likes fried food" is subjective
After suffering a heart attack, a patient needs cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of needs, cardiac rehab addresses what need? 1) Safety and Security 2) Physiological 3) Self-actualization 4) Self-esteem
2) Physiological Cardiac rehabilitation most directly addresses the patient's physiological need for physical activity as well as health and healing.
A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed child-bearing, developmental stages can vary among families, which typical stage of family development is this couple most likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frail elderly 4) Family with teenagers and young adults.
2) Postparental family
Nursing research is based on the _________________ method. 1) Qualitative 2) Scientific 3) Self-transcendence 4) Mechanical
2) Scientific
When providing postmortem care, why would the nurse place dentures in the mouth and close the eyes and mouth of the patient within 2 to 4 hours after death? 1) To prevent blood from settling in the head, neck, and shoulders 2) To preform these actions more easily before rigor mortis develops 3) To set mouth in natural position fro viewing by the family 4) To prevent discoloration caused by blood settling in the facial area.
2) To preform these actions more easily before rigor mortis develops
The nurse is preparing a patient for a CT scan of the abdomen, which statement by the nurse is the best? 1) You will need to remain NPO for 4 hours prior to CT scan 2) You cannot have anything to eat or drink before your test 3) You will need to be NPO and drink this contrast 4) You may need to void before your CT scan
2) You cannot have anything to eat or drink before your test
Skin integrity and wound healing are compromised in a patient who takes blood pressure medications because antihypertensives: 1) cause cellular toxicity 2) increase the risk of ischemia 3) delay wound healing 4) predispose to hematoma formation
2) increase the risk of ischemia
Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) small group 2) interpersonal 3) group 4) intrapersonal
2) interpersonal
You are admitting a 54 year old with COPD. The physician describes the O2 at 24% F io2. What is the appropriate oxygen delivery method for this patient? 1) Nasal canula 2) nonrebreather mask 3) trach collar 4) venturi mask
2) nonrebreather mask
A patient who underwent a left above the knee amputation complains of pain in his left foot. What type of pain is he experiencing? 1) psychogenic 2) phantom 3) reffered 4) radiating
2) phantom
The nurse checks a patient's pupils using a pen light, which receptor is the nurse stimulating? 1) chemoreceptors 2) photoreceptors 3) proprioceptors 4) mechanoceptors
2) photoreceptors
Which of the following is an example of an illness prevention activity? 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering the immunization for HPV 4) Teaching a diabetic client about his diet
3) Administering the immunization for HPV This is a prevention activity.
A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4mg IV q 1 hr PRN for pain. When should the nurse administer the medication? 1) Every hour around the clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last dose administered.
3) As needed, but not more than once per hour
Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care
3) Consulting
A child is brought to the ER after swallowing liquid cleanser. He is awake, alert, and able to swallow. Which action should the nurse take first? 1) Administer a does of ipacac. 2) Administer activated charcoal 3) Give water to the child immediately 4) Call the nearest poison control center
3) Give water to the child immediately If the child is awake and able to swallow, and child has swallowed a household chemical, give a glass of water immediately and then call the poison control center.
Which of the following most accurately describes nursing diagnoses? A nursing diagnosis: 1) Supports the nurse's diagnostic reading 2) Supports the patient's medical diagnosis 3) Identifies a patients response to a health issue 4) Identifies a patients health problem
3) Identifies a patients response to a health issue
Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning in, facing the patient 4) Sitting with legs crossed
3) Leaning in, facing the patient
What is the most influential factor that has shaped the nursing profession? 1) Physician's need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation
3) Military demand for nurses in the field
From what stage of sleep are people typically most difficult to arouse? 1) NREM alpha waves 2) NREM sleep spindles 3) NREM delta waves 4) REM
3) NREM delta waves
Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures 2) Nurses work with other healthcare professionals 3) Nurses care for patients with multiple health issues 4) Nurses have to be flexible and work different schedules
3) Nurses care for patients with multiple health issues Nurses use critical thinking to care for them.
Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palm of hands
3) Oral Mucosa
Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Patient 4) Nurse
3) Patient The patient is the primary decision maker.
The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most appropriate for the nurse to include? 1) Be sure to put mittens on the baby 2) Layer the infant's clothing 3) Place a cap on the baby's head 4) Put warm booties on the baby
3) Place a cap on the baby's head Most heat is lost through the head.
Chest percussion and postural drainage would be appropriate intervention for which of the following conditions? 1) COPD 2) CHF 3) Pneumonia 4) Pulmonary embolism
3) Pneumonia
According to Maslow's hierarchy of needs, which patient need should the nurse address first? 1) Protecting against falls. 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change
3) Promoting rest in the critically ill patient Basic physiological needs should be met first, which include the need for rest, food, air, temperature regulation, elimination, sex, and physical activity.
A nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient 2) Use cool water to bathe 3) Provide care in small intervals 4) Rub briskly when drying
3) Provide care in small intervals
A person who is deprived of REM sleep for several nights in succession will usually experience: 1) extended NREM sleep 2) paradoxical sleep 3) REM rebound 4) insomnia
3) REM rebound
Which of the following indicates a 4 year old has successfully gone through Erikson's stage 3 (Initiative vs. Guilt)? 1) Talks about his parents negatively 2) Asks questions about medical instruments 3) Refrains from hitting his friend 4) Stared blankly while you ask questions
3) Refrains from hitting his friend
A patient who moved to the US from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet still retains some customs from her homeland. This patient is experiencing: 1) assimilation 2) socialization 3) acculturation 4) immigration
3) acculturation
Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden urge of activity may occur: 1) 1 to 3 months before death 2) 1 to 2 weeks before death 3) days to hours before death 4) moments before death
3) days to hours before death
Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology: 1) is the cause of the problem 2) can not always be observed 3) directs nursing care 4) is an inference
3) directs nursing care
A patient has an area of non-blancheable erythemia on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) transparent film dressing 2) sheet hydrogel 3) frequent turn schedule 4) debridement
3) frequent turn schedule
Computers are important for evidence-based practice because: 1) they are available in all healthcare settings 2) extra training is not required 3) information can be processed and managed more efficiently 4) all the best evidence is located on a computer
3) information can be processed and managed more efficiently
Which of the following would be a priority for most adolescents? Being ________________ 1) a good student 2) sexually active 3) picked to be on the soccer team 4) able to function independently
3) picked to be on the soccer team The developmental task during adolescence is to establish personal identity. Teens are driven to belong to a group.
What is the function of the stratum corneum? 1) provides insulation 2) provides strength and elasticity 3) protects the body against entry of pathogens 4) produces new skin cells
3) protects the body against entry of pathogens
Which electrolyte is the primary regulator of fluid volume? 1) potassium 2) calcium 3) sodium 4) megnesium
3) sodium
__________________ is the use of telecommunications to send healthcare information between patients and professionals at different locations. 1) informatics 2) NANDA 3) telehealth 4) MAR
3) telehealth
Which of the following behaviors indicates the highest potential for spreading infectious among patients. The nurse ___________________ 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds 3) washes hands only after leaving patients room 4) uses cold water for medical asepsis.
3) washes hands only after leaving patients room Healthcare workers need to have clean hands before and after going into a patients room.
The nurse notes that an electrical cord on an IV pump is cracked. Which action by the nurse is the best? 1) Continue to monitor the IV pump to see if the crack worsens. 2) Place the pump back in the utility room. 3) Continue using the pump. 4) Clearly label the pump and send it for repair
4) Clearly label the pump and send it for repair Whenever an electrical safety hazard is suspected or visible, label it and send it for repair.
A patient tells the nurse, "I can't see well enough to read anymore. I have new glasses but it is still hard." What should the nurse advise the patient to do first? 1) Go back to the eye doctor and have the glasses checked. 2) Buy some audio books and listen to those. 3) Adapt to reading less. 4) Install a bright, but glare-free light near where you read.
4) Install a bright, but glare-free light near where you read. With aging, there is also sensitivity to glare, so the light should be glare-free. Patient should try this first, since the glasses are new.
To which age group do most hospitalized patients belong? 1) Infants 2) Young adults 3) Middle adults 3) Older adults
4) Older adults. Half of all hospitalized patients are older adults.
A patient with end-stage cancer is prescribed morphine to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative
4) Palliative
Which action should the nurse take to relax the vastus lateralis muscle before administering an IM injection into this site? 1) Apply a warm compress 2) Massage the site in a circular motion 3) Apply a soothing lotion 4) Put the patient in a sitting position
4) Put the patient in a sitting position
In caring for a client who has a fever, it would be most important for the nurse to monitor for increased: 1) urine output 2) sensitivity to pain 3) blood pressure 4) respiratory rate
4) Respiratory rate
Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or gods. 3) Rules prohibiting alcohol consumption. 4) Sacred writings that reveal the nature of the Supreme Being
4) Sacred writings that reveal the nature of the Supreme Being Sacred writings that reveal the nature of a Supreme Being are common in world religions.
A patient is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow, which level is the patient struggling with? 1) Physiological 2) Safety & Security 3) Love & Belonging 4) Self-esteem
4) Self-esteem Self-hatred & disgust is opposite of what one would expect in the self-esteem level of Maslow's model.
Which of the following is an example of data that should be validated? 1) The patient's weight is 185 lbs at the clinic 2) The patient's liver function test is elevated 3) The patients blood pressure if 160/90: he says that is normal for him 4) The patient says she eats a low sodium diet: later describes eating fast foods
4) The patient says she eats a low sodium diet: later describes eating fast foods Validate the patient says she eats a low sodium diet but describes eating fast food that is not low in sodium.
The nurse is talking to a class of children ages 9-12. For this group, it would be most important for the nurse to discuss______. 1) Safe sex practices 2) Healthy food choices 3) Importance of getting enough sleep 4) Use of seat belts and safety equipment
4) Use of seat belts and safety equipment Children of this age group are very active and injuries are common. Motor vehicle accidents are the most common cause of injury.
A patient infected with a virus but who does not have any outward signs of the disease is considered a: 1) pathogen 2) fomite 3) vector 4) carrier
4) carrier Carriers have no outward signs of active disease, yet they can pass the infection to others.
The primary care provider prescribes furosemide 40 mg IV for the patient with CHF. Which drug name is used in this order? 1) chemical 2) Brand 3) trade 4) generic
4) generic
Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) apply to every patient on a particular unit 2) included medical and nursing diagnoses 3) specify each patient outcomes for each day 4) help to ensure that important interventions are not overlooked.
4) help to ensure that important interventions are not overlooked.
While assisting an older adult patient, the nurse notes clubbing of the fingers. This is a sign of: 1) Fungal infection 2) Iron deficiency 3) Poor Hygiene 4) Long term hypoxia
4) long term hypoxia
Before administering medication, the nurse must verify the rights of medication administration which include: 1) right patient, right room, right drug, right route, right time 2) right drug, right dose, right route, right physician, right time 3) right patient, right drug, right route, right equipment, right time 4) right patient, right drug, right dose, right route, right time, right documentation
4) right patient, right drug, right dose, right route, right time, right documentation
The nurse approaches the nurse manager to advocate for the hiring of more nurses to reduce the nurse to patient ratio. What Rational should the nurse emphasize? Select all that apply. A. Patient outcomes B. Quality of care C. Staff morale D. Staff recruitment E. Stress reduction
A, B Quality of care and improve patient outcomes should be the center of any institutional change or policy change. Although reducing the nurse to patient ratio would increase recruitment, reduce stress, and boost morale, quality patient care should come first.
Which of the following tasks can be delegated to a nursing assistant? Select all that apply. A. Ambulating a stable patient B. Emptying and measuring a foley catheter reservoir C. Intake and output documentation D. Irrigating a nasogastric tube E. nasotracheal suctioning of a stable patient F. Setting up patient controlled analgesia
A, B, C The are in a can safely delegate the ambulation of the patient, I&O documentation, and emptying and measuring urine from the Foley to the nursing assistant All other options cannot be safely delegated to the nursing assistant
The Charge nurse on the pediatric unit has just been informed of the potential admission from the emergency department. Which of the following nurses should not be assigned to admit the patient? Select all that apply. A. The nurse caring for a child with multiple gastrointestinal bleeds B. A Nurse caring for a child with no family or visitors C. A Nurse caring for a patient who began receiving a blood transfusion one hour ago D. A Nurse preparing for a complex dressing change E. A nurse who recently discharged two patients
A, B, D A patient with no visitors can still require frequent monitoring and assessment. This nurse should not be assigned the new admit A complex dressing change requires time from the nurse, leaving her unable to admit a new patient Patient with multiple G.I. bleed requires frequent assessment. This nurse should not be assigned a new patient. A Patient does not need to be monitored as frequently one hour into a blood transfusion, this Nurses free to take the new admission After discharging two patients this nurse is free to take on additional patients
A living will includes which of the following? Select all that apply: A. Documentation requirements B. How and when the Living will takes effect C. How the patient's valuables are distributed among the family D. Immunity from liability for following the living will E. Which family member will inherit the patient's home
A, B, D The living will includes what circumstances are needed in order for the Living will to be executed, documentation requirements, healthcare worker immunity from liability, and witness requirements
Which of the following should the nurse delegate to the LPN. Select all that apply: A. Administering a piggyback IV medication B. IM medication administration C. Initiating a primary IV medication D. Oral medication administration E. Urinary catheterization
A, B, D, E Initiating a primary IV medication must be done by an RN All other options are within the LPN scope of practice
A nurse on the medical surgical floor is caring for patient who is confused and combative after abdominal surgery. The patient has pulled out the nasogastric tube required for gastric rest. The nurse called the doctor to discuss these issues. The doctor has ordered two point restraints , so the nurse creates a telephone order read back. The nurse knows that the restraint order will require which of the following? Select all that apply. A.The doctor must perform an in person assessment of the patient's need for restraints within one hour B. The doctor must sign a telephone order and assess the need for continued restraints every four hours C. The doctor must sign a telephone order and assess the need for continued restraints within 24 hours D. The nurse my three assess the patient's need for restraints and obtain another telephone order each hour
A, C Restraints for non-violent behavior: typically, these types of physical restraints are interventions to keep the patient from pulling at tubes, drains, and lines. The doctor must perform an in person assessment of the patient's need for restraints within one hour and must assess the need for continued restraints every 24 hours
The nurse fills out an incident report after a patient received the wrong blood transfusion. What should the nurse do? Select all that apply: A. Document the description of the incident itself in the patient's chart B. Document in the patient's record that incident report was completed. C. Make a copy of the incident report for the patient's chart D. Stabilize the patient E. Submit the incident report to the risk management department per policy F. Withhold incident report from the patient's medical records
A, E, F The incident report is an internal document for the hospital and should not be mentioned in the medical record, nor should a copy be made for the patient's record. Only an actual description of the incident and any actions taken are documented in the patient's chart. **The patient should already be stable before the nurse fills out an incident report
A nurse is preparing a patient for surgery and the LPN is asked to help. For which of the following tasks must the RN confirm that the LPN has received special training? A. Administering IV fluid therapy B. Ambulating the patient C. Assisting the patient with a bath D. Collecting a urine specimen
A. Administering IV fluid is usually beyond the scope of an LPN. The LPN must have special training in order to administer IV fluids