Funds week 4,5 &6 practice problems

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

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

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? a. "Was this diagnosis derived from a cluster of significant data or a single clue?" b. "This early diagnosis will help us manage the problem before it becomes more acute." c. "Have you determined if this is an actual or a possible diagnosis?" d. "This condition is a medical problem that should not have a nursing diagnosis."

a. "Was this diagnosis derived from a cluster of significant data or a single clue?"

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a. "You made an inference that she is fine because she has no complaints. How did you validate this?" b. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c. "Sometimes everyone gets lucky. Why don't you try to help another patient?" d. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

a. "You made an inference that she is fine because she has no complaints. How did you validate this?"

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

a. Cognitive

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

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

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

a. Compare this reading to standards.

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

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

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate

a. Dyspnea

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? a. Follow-up measurements of blood pressure b. Immediate treatment by a health care provider c. No action, because the nurse considers this reading is due to anxiety d. A change in dietary intake

a. Follow-up measurements of blood pressure

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

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

A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient? a. Encourage the patient to rise from a sitting position quickly to improve blood flow. b. Allow the patient to "dangle" for a few minutes prior to rising to a standing position. c. If the patient feels faint or dizzy, return the patient to bed and place in Fowler's position. d. Administer a beta-adrenergic blocker to increase blood pressure.

b. Allow the patient to "dangle" for a few minutes prior to rising to a standing position.

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

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

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

b. Flexion response to pain

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

b. Gordon's functional health patterns

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

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

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

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

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

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

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

b. Risk

A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient? a. Take the blood pressure in the right arm. b. Take the blood pressure in the left arm. c. Use the smallest possible cuff. d. Report inability to take the blood pressure.

b. Take the blood pressure in the left arm.

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

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

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

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

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

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

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

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

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

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

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

b. The patient's usual hygiene practices and preferences

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b. The size of the endotracheal tube

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

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

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

b. Use an emollient on the dry skin.

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

b. Wash the exposed area with warm water and soap

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

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

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

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

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

c. Ongoing planning

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

c. Quality improvement

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct the assistant to notify the primary care provider. b. Assess the patient's vital signs. c. Remove the tape, adjust the depth to ordered depth and reapply the tape. d. No action is required as depth will adjust automatically.

c. Remove the tape, adjust the depth to ordered depth and reapply the tape.

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

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

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

c. Validate the finding.

A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: a. the rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction. b. the lowest pressure present on arterial walls while the ventricles relax. c. the highest pressure present on arterial walls while the ventricles contract. d. the difference between the pressure on arterial walls with ventricular contraction and relaxation.

c. the highest pressure present on arterial walls while the ventricles contract.

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

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

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. c. Teach the patient to take short shallow breaths when performing hygiene measures. d. Group personal care activities into smaller steps, allowing rest periods between activities.

d. Group personal care activities into smaller steps, allowing rest periods between activities.

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

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

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

d. Infection

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

d. Narrowed airways

A nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding? a. Check the patient record for prescribed antipyretic medication. b. Report the finding to the primary care provider. c. Take the patient temperature using a different method. d. No action is necessary; this is a normal reading.

d. No action is necessary; this is a normal reading.

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

d. Nursing problem

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? a. Travelbee's b. Watson's c. Benner's d. Swanson's

d. Swanson's

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

d. The nurse collects data to measure outcome achievement.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs:(1) Disturbed Body Image(2) Ineffective Airway Clearance(3) Spiritual Distress(4) Impaired Social InteractionWhich answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model?

2, 4, 1, 3

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply. a. A 4-month-old infant whose temperature is 38.1°C (100.5°F) b. A 3-year-old whose blood pressure is 118/80 c. A 9-year-old whose temperature is 39°C (102.2°F) d. An adolescent whose pulse rate is 70 beats/min e. An adult whose respiratory rate is 20 breaths/min f. A 72-year-old whose pulse rate is 42 beats/min

a. A 4-month-old infant whose temperature is 38.1°C (100.5°F) d. An adolescent whose pulse rate is 70 beats/min e. An adult whose respiratory rate is 20 breaths/min f. A 72-year-old whose pulse rate is 42 beats/min

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. a. A newborn who has hypothermia b. A child who has pneumonia c. An older adult who is post MI (heart attack) d. A teenager who has leukemia e. A patient receiving erythropoietin to replace red blood cells f. An adult patient who is newly diagnosed with pancreatitis

a. A newborn who has hypothermia c. An older adult who is post MI (heart attack) d. A teenager who has leukemia e. A patient receiving erythropoietin to replace red blood cells

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

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

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

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

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

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

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. a. An increase in the pulse rate b. A decrease in body temperature c. A decrease in blood pressure d. An increase in respiratory depth e. An increase in respiratory rate f. An increase in body temperature

a. An increase in the pulse rate e. An increase in respiratory rate

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

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

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

a. Are you able to dress yourself? d. Do you prepare your own meals? e. Do you manage your own finances?

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

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

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

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

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a. Checking the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

a. Checking the amount of oxygen in the cylinder before using it

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

a. Clinical judgment

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80 to 150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80 to 150 mm Hg).

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

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

A nurse notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurse's response to the student? a. If you use the wrong cuff you will get an incorrect reading. b. If you use the wrong cuff you will cause injury to the patient. c. If you use the wrong cuff you will cause dangerous pressure on the arm. d. If you use the wrong cuff you will cause the loss of Korotkoff sounds.

a. If you use the wrong cuff you will get an incorrect reading.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! d. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving.

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

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

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

a. Jaundice

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

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

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

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

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference? a. Pulse deficit b. Pulse amplitude c. Ventricular rhythm d. Heart arrhythmia

a. Pulse deficit

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: a. Quality by inspection b. Quality by punishment c. Quality by surveillance d. Quality by opportunity

a. Quality by inspection

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? a. Remove the catheter. b. Notify the primary care provider. c. Check that the airway is the appropriate size for the patient. d. Place the patient on his or her back.

a. Remove the catheter.

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

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

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

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

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b. The nurse uses a binary decision tree for stepwise assessment and intervention. c. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. d. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. e. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. f. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. c. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes.

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

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

Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response? a. Turn off the overhead fan in the patient's room. b. Remove the patient's ice pack. c. Reduce the temperature in the room. d. Increase the temperature in the room.

a. Turn off the overhead fan in the patient's room.

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

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

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a. A nurse sits down with a patient and prioritizes existing diagnoses. b. A nurse assesses a woman for postpartum depression during routine care. c. A nurse plans interventions for a patient who is diagnosed with epilepsy. d. A busy nurse takes time to speak to a patient who received bad news. e. A nurse reassesses a patient whose PRN pain medication is not working. f. A nurse coordinates the home care of a patient being discharged.

b. A nurse assesses a woman for postpartum depression during routine care. d. A busy nurse takes time to speak to a patient who received bad news. e. A nurse reassesses a patient whose PRN pain medication is not working.

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

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

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

b. A patient with diabetes who develops secondary hypertension

A patient is experiencing dyspnea. What is the nurse's priority action? a. Remove pillows from under the head. b. Elevate the head of the bed. c. Elevate the foot of the bed. d. Take the blood pressure.

b. Elevate the head of the bed.

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. a. Blood pressure decreases with age. b. Blood pressure is usually lowest on arising in the morning. c. Women usually have lower blood pressure than men until menopause. d. Blood pressure decreases after eating food. e. Blood pressure tends to be lower in the prone or supine position. f. Increased blood pressure is more prevalent in African Americans.

b. Blood pressure is usually lowest on arising in the morning. c. Women usually have lower blood pressure than men until menopause. e. Blood pressure tends to be lower in the prone or supine position. f. Increased blood pressure is more prevalent in African Americans.

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

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

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

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

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient.

b. Hold the mask tightly over the patient's nose and mouth.

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

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

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

b. Interpersonal

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. It is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. e. It is constantly re-evaluating, self-correcting, and striving for improvement.

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

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

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

b. Lethargic

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d. A complete list of reimbursable charges for each nursing intervention

b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

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

b. Possible

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

b. Prodromal stage

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? a. Thoracentesis b. Pulse oximetry c. Diffusion capacity d. Maximal respiratory pressure

b. Pulse oximetry

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: a. Quality assurance b. Quality improvement c. Process evaluation d. Outcome evaluation

b. Quality improvement

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

b. Reassess the patient.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b. Reduce anxiety d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible.

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

b. Related to prescribed bed rest

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

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

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative adult b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia

c. A teenager with cystic fibrosis

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

c. Affective

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

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

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

c. Auscultation

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

c. Consider using music to soothe anxiety and agitation.

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

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

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

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

c. Facial

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

c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a. The nurse assures that the oxygen is flowing into the prongs. b. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c. The nurse encourages the patient to breathe through the nose with the mouth closed. d. The nurse adjusts the flow rate to 6 L/min or more.

c. The nurse encourages the patient to breathe through the nose with the mouth closed.

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

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

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

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

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

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

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

c. The patient has less than normal vision.

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

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

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. A nosebleed is noted with continued suctioning.

d. A nosebleed is noted with continued suctioning.

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

d. All patients receiving care in hospitals

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

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

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

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

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? a. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). d. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V. a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery c. The last sound heard before a period of continuous silence, known as the second diastolic pressure d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure c. The last sound heard before a period of continuous silence, known as the second diastolic pressure

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

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

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

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

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

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

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

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

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the health care provider. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline.

d. Put on gloves and insert the chest tube in a bottle of sterile saline.

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

d. Quick priority

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? a. Check the pulse again in 2 hours. b. Check the blood pressure. c. Record the information. d. Report the rate to the primary care provider.

d. Report the rate to the primary care provider.