fundamntal

. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

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

A nurse is teaching the staff about Benner's levels of proficiency. In which order should the nurse place the levels from beginning level to ending level?

. Novice, advanced beginner, competent, proeficient , expert

The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap test and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education?

22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners

A nurse is caring for a group of patients. Which patient will the nurse see first?

A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60

A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.)

A 47-year-old immigrant who speaks only Spanish A 40-year-old schizophrenic e. A 15-year-old rape victim

A nurse is caring for a 4-year-old patient. Which object will the nurse allow the child to play with safely to foster cognitive development?

A blood pressure cuff

A nurse is caring for a group of patients. Which patient will the nurse see first?

A calm adolescent with P-95 and R-26

A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain?

A graduate level education with a focus in public health science

health care delivery system

A mechanism for providing services that meet the health-related needs of individuals.

A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient's only son. What will the nurse suggest?

A nursing center because home care is no longer safe

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions?

A person's compliance is affected by economic status.

A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question?

A true PICOT question regardless of the number of elements

A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring?

Accessibility of health care services

While providing care to a patient, the nurse is responsible, both professionally and legally. Which concept does this describe?

Accountability

A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter "A"?

Act

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?

Administer pain medication.

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Administer the acetaminophen.

A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act?

Adult children up to age 26 are allowed coverage on the parent's plan.

Which action should the nurse take when teaching a 5-year-old patient about a scheduled surgery

Allow the child to touch and hold medical equipment such as thermometers.

A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research?

An article about emotional needs of dying patients and their families

A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use?

An article that uses randomized controlled trials (RCT)

A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer?

Asian american

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

The nurse is caring for a patient with known coronary artery disease who has recently been diagnosed with lung cancer. What should the nurse do?

Ask questions about cardiac symptoms and their relationship to the cancer

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications.

The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient's hand and lower arm to relieve a headache. What is the nurse's next action?

Ask the mother and/or spouse to explain the procedure.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment?

Ask the patient about the color of her stools.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

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

A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?

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

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked

A nurse is using the family as context approach to provide care to a patient. What should the nurse do next?

Assess how much the family provides the patient's basic needs

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action?

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

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?

Assesses the patient's readiness for the procedure

A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first?

Assessing own biases and attitude

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

Assessment

ANA Standards of Nursing Practice

Assessment Diagnosis Outcomes identification Planning Implementation Evaluation

A nurse assesses a patient's fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating?

Autonomy Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders

The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will have to cancel one or two of its nurses. The orthopedic unit has agreed to "float" two of its nurses to the oncology unit if oncology can "float" a nursing assistant to the orthopedic unit to help with obtaining vital signs. Which concepts does this situation entail? (Select all that apply.)

Autonomy, Accountability, teamwork and collaboration

A nurse follows the "ethics of care" when working with patients. Which action will the nurse take?

Becomes the patient's advocate based on the patient's wishes

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?

Begin with the highest priority diagnoses, then select appropriate interventions."

A nurse has compassion fatigue. What is the nurse experiencing?

Burnout and secondary traumatic stress

A nurse is working in community-based nursing. Which competency is priority for this nurse?

Caregiver

A nurse is providing pain medication to patients after surgery. Which component is key for the nurse's personal philosophy of nursing

Caring

A nurse determines that a middle-aged patient is a typical example of the "sandwich generation." What did the nurse discover the patient is caught between?

Caring for children and aging parents

A nurse wants to become an advanced practice registered nurse. Which options should the nurse consider? (Select all that apply.)

Certified nurse-midwife d. Clinical nurse specialist e. Certified nurse practitioner

In making rounds, the nurse meets a patient for the first time. The nurse asks the patient when morning medications are taken, such as before breakfast, after breakfast, or during breakfast. What does knowing the patient allow the nurse to do?

Choose the most appropriate time to give the medication.

Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient's lungs. Which critical health assessment step should the nurse have performed?

Cleaning stethoscope with alcohol

A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using?

Code of ethics

A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing?

Community-based

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase

Completes a comprehensive database

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Completes a comprehensive database

The nurse uses a PICOT question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more evidence than is available at this time. What is the nurse's best option?

Conduct a pilot study to investigate findings.

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?

Conduction

Which action should the nurse take when using critical thinking to make clinical decisions?

Consider what is important in a given situation.

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal?

Constricting pupils when directly illuminated

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Which action will the nurse take next?

Contact social services and report suspected abuse.

A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying?

Contemplation

A nurse attends a workshop on current nursing issues provided by the American Nurses Association. Which type of education did the nurse receive?

Continuing education

A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching?

Controlling the amount of stress in my life may decrease the risk of illness."

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?

Convection

A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take?

Create social and physical environments that promote good health.

The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?

Culturally congruent care

Which action indicates the nurse is using the nursing process in patient care?

Delivers nursing care using a systematic approach.

Before a patient with beginning stage of Alzheimer's disease is discharged, the community-based nurse is making a visit to the patient's home. The patient's daughter and family live in the home with the patient. What is the major focus of this visit?

Demonstrate techniques for providing care.

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

Dependent

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

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

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Developing nursing diagnoses before completing the database

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

Diagnosis

The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient

Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost

A nurse is assessing a 17-year-old adolescent's cognitive development. Which behavior indicates the adolescent has reached formal operations?

Discusses the topic of justice in society

The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend

Doctor of Philosophy degree (PhD)

A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior?

EBP is a guide for nurses in making clinical decisions

In caring for patients, what must the nurse remember about evidence-based practice (EBP)?

EBP is dependent on patient values and expectations

A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely?

Ears

A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective?

Education

A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session

Eliminate health disparities in America.

A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.)

Empirical quality results b. Structural empowerment c. Transformational leadership d. Exemplary professional practice

A mother has delivered a healthy newborn. Which action is priority?

Encourage close physical contact as soon as possible after birth.

A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use?

Epidemiologist

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Etiology

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care

Evaluate whether patient goals and outcomes have been met.

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?

Evaluation

A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

Evaluation

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

Explain the procedure to the child

The patient has had a stroke that has affected the ability to speak. The patient becomes extremely frustrated when trying to speak. The patient responds correctly to questions and instructions but cannot form words coherently. Which type of aphasia is the patient experiencing?

Expressive

A nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring?

Family resiliency

A community-based nursing is working with a family. For which key areas will the nurse need a strong knowledge base? (Select all that apply.)

Family theory b. Communication c. Group dynamics d. Cultural diversity

A nurse is taking a history on a patient with cancer. Which assessment is priority?

Fatigue

A nurse is teaching the parents of a school-aged child about accidents most common in this age group. Which topic should the nurse address?

Fires

A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions?

Flea bites and lice infestation

Which nurse most likely kept records on sanitation techniques and the effects on health?

Florence Nightingale Nightingale was the first practicing nurse epidemiologist

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Focus on the patient's presenting situation.

A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence

Functions effectively in a multicultural context

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following?

Health belief model

The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize?

Healthcare Effectiveness Data and Information Set (HEDIS)

The nurse is caring for a young woman with breast cancer. The stress between the woman and spouse is obvious, as is anxiety among the children. What is the nurse's best action in this situation?

Help find or develop an educational program for the patient and spouse.

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using?

Holistic health model

A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.)

Homelessness b. Domestic violence c. Presence of illness d. Changing economic status

A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.)

Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries

A nurse is assessing a patient's ethnohistory. Which question should the nurse ask

How different is your life here from back home?

A nurse is preparing a teaching session about contemporary influences on nursing. Which examples should the nurse include? (Select all that apply.)

Human rights Affordable Care Act . Demographic changes Medically underserved

A nurse is caring for pediatric patients and using the developmental theory to plan nursing care. What is the focus of this nurse's care?

Humans have an orderly, predictive process of growth and development

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?

Hyperthermia occurs when the body cannot reduce heat production.

The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure and stops to listen. Which response by the nurse may bemost beneficial

I had a similar procedure and I can tell you what I went through."

. Which statement, if made by a parent, will require further instruction from the nurse?

I should cover for my 10-year-old son when he makes mistakes until he learns the ropes."

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next

Identify the patient's stage of change.

A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?

Impaired physical mobility related to inability to bear weight on right leg.

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

Implementation

Which action demonstrates a nurse utilizing reflection to improve clinical decision making?

Improves a plan of care while thinking back on interventions effectiveness

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next

Include dressing change instructions and frequency in the care plan.

A nurse is using the Healthy People 2020 to establish goals for the community. Which goal is priority?

Increase life expectancy.

A nurse is teaching about the effects of globalization. Which information should the nurse include in the teaching session?

Increased spread of communicable diseases

After licensure, the nurse wants to stay current in knowledge and skills. Which programs are the most common ways nurses can do this? (Select all that apply.)

Inservice education, Continuing education

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?

Inspection and light palpation

A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination?

Inspection, auscultation,percussion palpation,

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform

Interdependent

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

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

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?

It has no risk of injury to patient or nurse

Which information indicates a nurse has a good understanding of a goal?

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

A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care?

Its priority is health promotion.

A nurse is using the proximodistal pattern to assess an infant's growth and development as normal. Which assessment finding will the nurse determine as normal?

Lifts head before grasps

The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, the patient says, "I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family." What should the nurse do first

Listen to the patient's concerns and fears.

The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?

Look at the patient when talking.

. A nurse is communicating with a newly admitted teenaged patient. Which action should the nurse take?

Look for meaning behind the patient's words and actions.

The nurse is caring for a 14-year-old patient in the hospital. Which goal will be priority?

Maintain identity

Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding?

Maintenance

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Making a clinical decision based on previous shift assessments

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care?

Making sure to involve the whole person

A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session?

Managed care causes providers to focus on prevention.

A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing?

Manager A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or facility

The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, "Why is it that not all poor people are considered members of vulnerable populations?" How should the nurse respond?

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

A nurse is reviewing literature for an evidence-based practice study. Which study should the nurse use for the mostreliable level of evidence that uses statistics to show effectiveness?

Meta-analysis

Which information from a co-worker on a gerontological unit will cause the nurse to intervene?

Most older people have dependent functioning.

Which information from the parent of an 8-month-old infant will cause the nurse to intervene?

My baby rides in the front-facing car seat when I go to the grocery store

The nurse is teaching a parent about developmental needs of a 9-month-old infant. Which statement from the parent indicates a correct understanding of the teaching?

My child will probably enjoy playing peek-a-boo."

A nurse is working as a public health nurse. What will be the nurse's primary focus?

Needs of a population

A nurse is developing a plan of care for an older adult. Which information will the nurse consider?

Needs to be individualized to the patient's unique needs

An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor?

Novice A beginning nursing student or any nurse entering a situation in which there is no previous level of experience (e.g., an experienced operating room nurse chooses to now practice in home health) is an example of a novice nurse

A nurse is assessing a cancer survivor for chemotherapy-induced peripheral neurotoxicity (CPIN). Which assessment finding is consistent with CPIN?

Numbness and tingling in hands and feet

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene?

Nursing assessment data are used only to provide information about the effectiveness of your medical care

A nurse is completing a minimum data set. Which area is the nurse working?

Nursing center

A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice?

Nursing theory can direct how a nurse uses the nursing process.

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

Observe wound appearance and edges.

The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse-midwife, the patient asks for a referral to a pediatrician for the newborn. Which action should the nurse-midwife take initially?

Offer to provide the newborn care

Which community-based nursing activities indicate the nurse is working in the role of educator? (Select all that apply.)

Offers prenatal classes b. Offers a child safety program

A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems?

One who has excessive risks

The nurse is caring for a patient diagnosed with essential hypertension. The health care provider prescribes blood pressure medication that the nurse administers. The nurse then monitors the patient's blood pressure for several days to help determine effectiveness. Which system component is the nurse evaluating?

Output

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

PLanning

A graduate of a baccalaureate degree program is ready to start working as an RN in the emergency department. Which action must the nurse take first?

Pass the National Council Licensure Examination

A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, "I have no idea what is going to happen. I couldn't ask any questions." The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying?

Patient advocate

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

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

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

Perception of functioning

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

Perform a thorough nursing health history.

. The nurse is caring for a patient who reports feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

Perform an apical/radial pulse assessment.

A nurse is using research findings to improve clinical practice. Which technique is the nurse using?

Performance improvement

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute. According to Maslow's hierarchy of needs, which patient need should the nurse address first?

Physiological

The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation

Place a nonadhesive sensor on the patient's earlobe.

A nurse is conducting Weber's test. Which action will the nurse take?

Place a vibrating tuning fork in the middle of patient's forehead

The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following?

Planning In planning, the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes

A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause themost improvement in core measures?

Poor people

A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP?

Pregnant females

. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?

Preventive care

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing?

Primary prevention

Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.)

Professional standards review organizations b. Prospective payment systems c. Diagnosis-related groups

A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts?

Protect the public

The patient is terminal and very near death. When the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating?

Protective touch

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

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

A nurse is working as a community health nurse. Which action is a priority for this nurse?

Provide direct care to sub populations.

The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next?

Provide referral to an abortion service.

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care?

Provides care that fits the patient's valued life patterns and set of meanings

Which action indicates the nurse is meeting a primary goal of cultural competent care for patients?

Provides care to transgender patients

The patient is afraid to have a thoracentesis at the bedside. The nurse sits with the patient and asks about the fears. During the procedure, the nurse stays with the patient, explaining each step and providing encouragement. What is the nurse displaying?

Providing a presence

A nurse is providing presence to a patient and the family. Which nursing action does this involve?

Providing closeness and a sense of caring

The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process?

Public health nursing

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting

Qualitative research

A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating?

Quality improvement Quality improvement identifies gaps between local and best practices. Safety minimizes risk of harm to patients and providers through both system effectiveness and individual performance

A nurse is implementing an evidence-based practice project regarding infection rates. After reviewing research literature, which other evidence should the nurse review?

Quality improvement data

Which action should the nurse take first during the initial phase of implementation?

Reassess the patient

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?

Reassess the patient's pain level in 30 minutes.

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

Reassess the patient.

A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using

Reduce disparities

A nurse is caring for a patient in pain. Which nursing approach is priority?

Relationship-centered

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Respiration 16

The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work?

Restorative

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?

Review the effectiveness of nursing actions.

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Review the patient's activity orders.

Which action indicates a nurse is using caring touch with a patient?

Rubs a patient's back

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving?

Secondary prevention

A breast cancer survivor has chemotherapy-related cognitive impairment. Which area should the nurse assess?

Short term memory

The nurse is observing a 2-year-old hospitalized patient in the playroom. Which activity will the nurse most likely observe?

Sitting beside another child while playing with blocks

An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient?

Skilled nursing

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)?

Smoking result in vasoconstriction, falsely elevating BP.

When planning for cancer survivor care needs, which information should the nurse consider

Some survivors are discharged with no survivor plan

A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions?

Specific knowledge base

Which finding indicates the best quality improvement process?

Staff identifies the wait time in the emergency department is too long.

While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment?

Structure

A nurse is teaching a parenting class for families with adolescents. Which health concerns will the nurse include in the teaching session? (Select all that apply.)

Suicide b. Eating disorders c. Violence/Homicide d. Sexually transmitted infections

Which action indicates a registered nurse is being responsible for making clinical decisions?

Takes immediate action when a patient's condition worsens

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Teaches proper handwashing technique

A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse's best response?

Technology use has to be combined with nursing judgment."

. After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?

Temperatures vary depending on the route used.

A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing?

Tertiary care Hospital emergency departments, urgent care centers, critical care units, and inpatient medicalsurgical units provide secondary and tertiary levels of care

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving?

Tertiary prevention

A nurse is assessing the cognitive changes in a preschooler. Which standard will the nurse use to determine normal?

The ability to classify objects by size or color

A nurse is assessing an 18-month-old toddler. The nurse distinguishes normal from abnormal findings by remembering Gesell's theory of development. Which information will the nurse consider?

The cephalocaudal pattern describes the sequence in which growth is fastest at the top.

Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding

The chances of getting the disease are increased.

A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, "None of her jobs are getting done, and I don't do those jobs, so the house and the kids are falling apart." How will the nurse interpret this finding?

The family structure is rigid.

A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.)

The five realms of family life that should be assessed include: developmental, interactive, integrity, coping, and health

A nurse is working with a patient who wants needs to be met and is impatient and demanding when these needs are not met immediately. How should the nurse interpret this finding according to Freud?

The id is functioning.

A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. What should the nurse realize?

The individual nurse can influence legislative decisions.

Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which expected inspiratory-to-expiratory breath sounds will the nurse hear?

The inspiratory phase is 3 times longer than the expiratory phase.

A cancer survivor is in the intensive care unit (ICU). Some of the patient's family is from out of town and would like to see the patient even though it is not "official" visiting hours. The patient is anxious to see family members. The nurse allows the family to visit. What is the rationale for the nurse's actions?

The nurse believes that the visit will help relieve psychological stress.

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?

The patient has calcium channel blockers or digitalis medication prescriptions.

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

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

A patient follows all the instructions a nurse provides because the patient wants to be perceived as a "good" patient. How should the nurse interpret this information according to moral development?

The patient is in conventional reasoning.

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?

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

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate?

The patient will return to the contemplation or precontemplation phase.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

The nursing instructor is teaching a class on nursing theory. One of the students asks, "Why do we need to know this stuff? It doesn't really affect patients." What is the instructor's best response?

Theories help explain why nurses do what they do.

The nurse is caring for a patient who has successfully undergone cancer therapy and will be discharged home soon. The patient is concerned about going home and not knowing what to do. Which information is the most valuable for the nurse to share with the patient?

There is a team that will provide support and care that may be needed.

A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient?

There is an increased incidence of disease.

Which behavior from a nurse indicates the nurse is using Nightingale's theory to plan nursing care

Thinks about the patients and patients' environments

A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow's hierarchy of needs is the nurse promoting when the family is encouraged to visit?

Third level

Which types of nurses make the best communicators with patients?

Those who develop critical thinking skills

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings?

Thyroid-stimulating hormone test

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

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

The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse's action?

To prevent community outbreak of illness

A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning?

Upon admission to the hospital

A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change?

Use a PICOT format for the search.

A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.)

Use informatics. Apply quality improvement. e. Use evidence-based practice

A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use?

Use partnered rather than married.

The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique?

Uses an inverted otoscope grip while pulling the auricle downward and back.

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions?

Uses critical thinking for the highest level of quality nursing care

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment?

Uses the diaphragm to listen for bowel sounds

Which assessment finding of a school-aged patient should alert the nurse to a possible developmental delay?

Verbalization of "I have no friends"

A nurse is assessing the social system of a community. Which area should the nurse assess?

Volunteer programs

The nurse is teaching a young-adult couple about promoting the health and psychosocial development of their 8-year-old child. Which information from the parent indicates a correct understanding of the teaching?

We will provide proper support for learning new skills."

A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the "C"?

Who receive standard nursing care

The nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). Which activity is appropriate for a CRNA?

Works under the guidance of an anesthesiologist

The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family?

You're hesitant about changing the dressing like I was before I was shown an easier way; would you li

A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care?

Young adults are quite active but are at risk for illness in later years.

A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely

Young bisexual

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?

assess the patient

Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and decreased range of joint motion. Which area is priority

fall precaution

A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using?

family as systems

A nurse is using Jean Piaget's developmental theory to focus on cognitive development. Which area will the nurse assess in this patient?

formal operations

A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?

lives with a spouse

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?

not eating

A nurse is working in the delivery room. Which action is priority immediately after birth?

open the airway

A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use?

supine

The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" What is the rationale for the nurse's action?

to assess the family structure

A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include?

unplanned pregnancy

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions?

using nursing process

The parent brings a child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. Which finding will cause the nurse to intervene?

weigh of 16 pounds