NURS 101 Final Exam

A nurse calls a physician regarding a change in a client's condition. The physician gives orders over the telephone for arterial blood gases (ABGs) to be drawn stat. which is the most important safety consideration when obtaining the order? 1. Writing the order down & reading it back to the physician. 2. Calling the respiratory therapist stat to draw the ABGs 3. Giving the order stat to the health unit coordinator to place in the computer 4. Writing down the order for the ABGs immediately

Correct answer # 1 - The Joint Commission National Patient Safety Goals requires telephone orders to be written down & read back. This action will validate the accuracy of the order received. Although the order is state, calling the respiratory therapist or giving the order to the health unit coordinator is not the most important safety consideration. Writing down the order without reading it back does not met the Joint Commission safety goal requirements.

After a car/pedestrian accident, the pedestrian is brought to the ER. The client is alert & oriented but complains of dyspnea. O2 sat levels vary from 88-90%. O2 is applied at 2 L per nc with no improvement in SpO2. Radiograph films reveal no obvious injury or fractures. Suddenly the pt loses consciousness has a respiratory arrest & subsequently dies. During the respiratory arrest resuscitation it is determined that a nurse failed to open the valve to the O2 tank & the client had not been receiving O2. What is the key ethical principal involved in this situation? 1. Nonmaleficence 2. Fidelity 3. Beneficence 4. Justice

Correct answer # 1 - nonmaleficenceis the requirement that health care providers do no harm to their clients either intentionally or unintentionally. Think of remember nonmaleficenceis not harm 2 - incorrect - fidelity is the obligation of an individual to be faithful 3 - incorrect - beneficence is doing food for the clients 4 - incorrect - justice is the obligation to be fair to all people.

A client is admitted with vancomycinresistant enterococci (VRE) in a leg wound. The wound is draining although dressings are covering the wound. To prevent the spread of VRE which is a nurse's best plan of action? 1. Assign the client to a private room 2. Assign only one caregiver to the pt 3. Do not allow pregnant staff to enter the room 4. Place the client in a negative air flow room

Correct answer # 1 - single client rooms are preferred when there is a concern about transmission of an infectious agent. 2 - incorrect - It is not practical to assign only one caregiver as the client will likely require multiple caregivers throughout the hospitalization 3 - incorrect - VRE is not spread to pregnant staff at higher rates than non pregnant staff 4 - incorrect - a negative air flow room is required for airborne diseases. VRE is not an airborne disease.

A nurse assist a physician with the placement of a central venous catheter. The nurse notices the physician brush his sterile glove against the client's bedspread. Which action by the nurse demonstrates professional conduct? 1. Inform the Dr of the break in sterile procedure & provide new sterile gloves 2. Inform the Dr of the break in sterile procedure after the procedure is completed & observe the CVC for infection 3. Notify the supervisor of break in sterile procedure 4. Report the event to the Infection Control Nurse to educate the Dr on proper sterile procedure

Correct answer # 1 - the drshould be notified immediately of the break in sterile procedure to reduce risk of infection to the client 2, 3 & 4 - incorrect - to wait until after the procedure is completed to talk with the dror to report the event to someone else will not prevent this client from a hospital acquired infection

An experienced nurse is orienting a new nurse caring for multiple clients on an oncology nursing unit. The experienced nurse explains to the new nurse that to advocate for clients, a nurse must be able to identify ethical issues and communicate the clients' wishes to others. Which primary role of the nurse advocate should the experienced nurse also explain to the new nurse? 1. safeguard clients against abuse & violation of their rights 2. Make decisions for clients based on the nurse's knowledge & relationship 3. Assist clients in expressing their rights 4. Have knowledge of the clients' values so the nurse can assist in decision making

Correct answer # 1 - the primary role in advocacy is to keep the client safe - to safeguard clients against abuse & violation of their rights. Clients may not be able to advocate for themselves 2 - incorrect - The professional role of the nurse is to defend clients' autonomy in decision making 3 -incorrect - The nurse must never make a treatment decision for clients, however the nurse should keep clients informed about their treatment orders & their rights. 4 - incorrect - Although it is important to know the clients' values, it is not the primary role of the nurse advocate.

A nurse is caring for a hospitalized 10 y.o client who has chest contusions from a motor vehicle accident. The client is on room air and is being monitored by a pulse oximeter. When the nurse enters the room the pulse ox monitor is alarming and is showing an O2 saturation of 84%. The nurse should immediately: 1. Call the physician for an order for ABGs 2. Assess the client's level of consciousness & skin color 3. Replace the machine and probe 4. Administer O2 through a nasal cannula or mask

Correct answer # 2 - by immediately evaluating the client's mental status and skin color the nurse can quickly determine whether or not the signal tracing constitutes an emergency or if it is an artifact. An artifact in the pulse ox monitoring system can be caused by altered skin temperature, movement of the client's finger or probe disconnection. Equipment malfunction can also occur. You need to look at the entire picture. 1 - incorrect - call the physician is only necessary if the reading is accurate. 3 - incorrect - replacing the machine is only necessary if the machine is malfunctioning 4 - incorrect - applying O2 may be necessary if the nurse is unable to determine the client's pulse Ox reading wihina few seconds.

A client informs a nurse that a physician is recommending a kidney biopsy. The client fears the result will be cancer and would not want treatment. The client feels it would be better just "not to know." which action should be taken by the nurse to determine if the client understands his/her client rights? 1. Explain to the client that the physician is doing what is best for the client. 2. Inform the client of his/her right to make decisions based on personal values & beliefs 3. Encourage the client to talk with family & let the family decide 4. Talk with the physician about the client's fear of having the biopsy

Correct answer # 2 - clients have the right to make decisions based on personal values & beliefs. 1& 3 - incorrect - Physicians cannot make treatment decisions without the consent of the client, nor may the family. 4 - incorrect - It is important to notify the physician about the client's fear of the biopsy, however, it does not address the client's understanding of client's rights.

A hospitalized client diagnosed with end stage cancer has suddenly decided to discontinue treatment. The client requests no additional treatment, such as antibiotics, tube feedings, & mechanical ventilation. When acting as the client's advocate, which action should a nurse take? 1. Respect the client's wishes & indicate those wishes on the plan of care 2. Encourage the client to share the decision with the family & the client's physician 3. Clarify other treatments that the client wishes to withhold. 4. Wait until additional treatment is required & then decide what to do based on the client's condition

Correct answer # 2 - in advocating for the client the nurse should encourage the client to share the decision with family & the physician. To advocate for someone means to speak for that person when the person is unable to speak for their self. The client is still able to make his or her own decisions, which will be better supported when the client shares with the family & physician. 1 - incorrect - although the wishes should be indicated on the plan of care this nurse action does not demonstrate advocating for the client 3 - incorrect - A physician order is required to limit treatment 4 - incorrect - Although additional treatments should be discussed, the priority at this time is the discussion with the family & physician.

A nurse is assigned to 6 clients along with an LPN and unlicensed assistive personnel (UAP) One client is scheduled for surgery in 15 min, another is having pain, one is complaining of a sudden onset of itching after receiving a new medication & another has a family who wants to talk to the physician immediately. Which action should the nurse take to best manage & delegate client care? 1. Ask the LPN to give the client in pain an analgesic & the UAP to get the client ready for surgery 2. Assess the client with itching & ask the UAP to get a cart for the client needing to go to surgery 3. Ask the LPN to talk to the family & the UAP to notify the client with pan that an analgesic will be given soon 4. Assess the client with pain & ask the LPN to let the family know the doctor is coming soon

Correct answer # 2 - the client with itching should be assessed immediately as this may be the 1stsign of an anaphylactic reaction to a new medication. Delegation of retrieving a cart is appropriate for an UAP. 1 - incorrect - It is appropriate for the LPN to give medication but not appropriate for the UAP to prepare the client for surgery. In preparation for surgery the client may require additional preoperative teaching, medication administration & validation of medical record documentation which are outside the UAPs scope of practice. 3 - incorrect - Communication with the family who is requesting an urgent consult with the physician should not be delegated. The UAP should not need to ask the client to wait for an analgesic as the LPN can administer analgesics and should be assigned that task. 4 - incorrect - The nurse should not prioritize the client withpain over the client with a new onset of itching as the itching may be a sign of an anaphylactic reaction

A nurse is evaluating teaching for a client who has diabetes & is beginning insulin therapy using an insulin pen. Which behavior should best indicate to the nurse that teaching about insulin therapy was effective? 1. The nurse showing the client a video that explains how to use the insulin pen 2. The client reading a handout that describes the different types of insulin & insulin pens 3. The nurse demonstrating the correct procedure for preparing the insulin pen for administration. 4. The client preparing the insulin pen & self-injecting correctly on the first attempt

Correct answer # 4 = the client correctly demonstrating preparing the insulin pen and administering the insulin suggests that the teaching about insulin therapy was effective. Options 1 & 3 are nursing interventions using various teaching strategies. 2 - incorrect - this is a client action but does not demonstrate that learning has occurred.

In the Laotian culture pain may be severe before relief is requested. Traditionally, the oldest male makes health care decisions and may answer questions for female clients. A nurse is caring for a female Laotian client who is in severe pain, rating an 8 / 10. her spouse will not allow the nurse to give any analgesics. What is the nurse's best course of action? 1. Administer the analgesic when the client's spouse leaves the room. 2. Educate the client's spouse on the reason for the pain and action of analgesics. 3. Respect the Laotian culture and d on administer the analgesic 4. Report the issue to the supervisor

Correct answer # 2 - the first stage of ethical decision making is to collect, analyze, and interpret the data. The spouse may not have enough information about the pain and pain management. Education may provide the information to assist him in making a decision without compromising his cultural beliefs. 1 - incorrect - administering the analgesic without the spouse present would be unethical. It would violate the Laotian culture. 3 - incorrect - not treating the pain would also be unethical. Promoting comfort is a nursing responsibility. 4 - incorrect - reporting to the supervisor may result in a action to relieve pain, although it would cause delay.

A nurse is caring for a client diagnosed with cystic fibrosis who is refusing to take a recommended nebulizer treatment. The client's refusal of treatment is classified as which of the following? 1. A moral obligation 2. A legal obligation 3. An ethical right 4. A basic human right

Correct answer # 3 - rights are generally defined as something owed to an individual. Ethical rights are based on an ethical principle and are often privileges allotted to individuals. 1 - incorrect - a moral obligation would be taking the treatment based on an ethical principle 2 - incorrect - a legal obligation would be one required by law. 4 - incorrect - basic human rights are based on the fundamental belief in the dignity and freedom of human rights.

A nurse admits a client who is experiencing nausea and vomiting to the ER. The client is alone. The nurse completes an assessment & prepares to leave the room. Which is the safest instructions for the client? 1. If you need to vomit, here is a basin for you. I don't want you to get up on your own. 2. I will be in the room next door. I'll check back in about 10 minutes 3. I will go update the doctor about you. Do you need anything before I go? 4. Here is the nurse call light. Press this button if you need me.

Correct answer # 4 - a newly admitted client should be oriented to the new environment. One of the most important features of safety is teaching the client how to use the call light; a mechanism to signal staff members at all times is essential to client safety. Making sure there is a basin available

A client is admitted to a surgical unit. The client has multiple rings, a watch, and $65 in cash. What is the safest action for a nurse to take regarding the valuables? 1. Allowing the client to keep the items so they will be safeguarded by the client 2. Collecting the items and placing them in the client's room closet 3. Giving the money to the client's spouse and allowing the client to keep the jewelry 4. Collecting the items according to hospital policy for safekeeping

Correct answer # 4 - hospital policy will determine if the items were handled appropriately in the case of loss 1, 2 & 3 - incorrect - Although the hospital policy may allow the items to stay with the client, to be in the room, or to be sent home with the spouse the safest action is to follow hospital policy

Two clients are in a semi-private room on a medical unit. A physician is about to inform client A of a cancer diagnosis. Which statement by the nurse is best when attempting to maintain client confidentiality? 1. To Client B: this would be a good time to go for a walk the Dr needs to tell your roommate something confidential 2. To the physician "for privacy, could you please wait to tell client A about his cancer? His roommate will be going home in a few hours." 3. To client B: "the Dr needs to talk to your roommate. Could you please turn on your TV & not listen to what they say?" 4. To client B: "I would like to take you in a wheelchair or have you walk down to the lobby for 10 -1 5 minutes. It's good for your lungs to do some deep breathing with activity. Do you feel like getting up for a little while?"

Correct answer # 4 - offering client B to get out of bed for his benefit completely eliminates the need to share any information about client A 1 & 3 - incorrect - sharing with client B that client A will be receiving confidential information is not appropriate, nor is expecting client B to turn on his tvand not listen to the conversation 2 - incorrect - Asking the physician to return later may not be realistic for the physician's schedule & the client may have another roommate by that time

A client has an advance health care directive on file at a hospital that identifies a friend as the legal healthcare agent. A nurse is to obtain informed consent for the client to have an exploratory laparotomy. Because of sedation, the client is unable to sign the form or give verbal consent. Who should provide consent for this client? 1. The client's spouse 2. The client's oldest adult child 3. Since the client is unable to give consent, the surgery cannot be performed. 4. The clients'durable power of attorney for healthcare.

Correct answer # 4 - since the client has a durable power of attorney for health care that person is designated to make healthcare decisions when the client is unable to do so. 1 & 2 - incorrect - The client's spouse & oldest adult child would not be able to give consent. 3 - incorrect - Even though the client is unable to provide consent, the surgery may be performed by following the legal process for obtaining consent.

A nurse gives a medication without checking the medication administration record (MAR). When the nurse documents the med given, the nurse notices that the med was also given 15 minutes earlier by another nurse, resulting in the client receiving a double dose. The nurse notifies a supervisor & Dr of the event. Which action should the nurse who administered the 2nd med dose expect? 1. Assignment of few clients at one time 2. Disciplinary action to the 1st nurse for giving the 1st dose. 3. Disciplinary action possibly including suspension or termination 4. Completion of a variance report that would be reviewed by management.

Correct answer # 4 - the nurse who made the error should expect the completion of a variance report with review by management. A complete review of the situation needs to occur, including the type of med, dose outcome of the client & steps of medication administration including documentation. 1 - incorrect - the nurse should not expect a change in client assignments. 2 - incorrect - although disciplinary actions varies by organization, generally a pattern of incompetent actions must be demonstrated for suspension or termination.

A patient asks the nurse, "what is a Living Will?"the nurse should respond that it is a document that: 1. Instructs a physician to withhold/withdraw life sustaining procedures if death is near. 2. Enables a person to request medication to end life in a humane and dignified manner. 3. Gives consent to perform life sustaining medical interventions during an emergency 4. Wills ones organs to help others who needs a transplant to sustain life.

Correct answer - 1 - a living will provides specific instructions about the care the person does or does not want to receive, including withholding or withdrawing life sustaining procedures. 2 - incorrect - euthanasia is the act of painlessly putting to death a person who is suffering and is against the law in most states. 3 - incorrect - when an individual can not provide written or oral consent (express consent) during an emergency, care is provided under the concept of implied consent. 4 - incorrect - under the Uniform Anatomical Gift Act and the National Organ Transplant Act in the US, individuals 18 years or odlermay donate all or part of their bodies for education, research, advancement of science, therapy, or transplantation. Consent for organ donation usually is made via a signed organ donation card.

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen? 1. promptly send the specimen to the laboratory. 2. Send the specimen with the next pickup. 3. Send the specimen the next time a nursing assistant is available. 4. Store the specimen in the refrigerator until it can be sent to the laboratory.

Correct answer - 1 - a specimen for C & S should be sent to the lab promptly so that a smear can be taken before organisms start to grow in the specimen

The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique? 1. Stool for ova and parasites 2. Specimen for a throat culture 3. Urine for a retention catheter (foley) 4. Exudate from a wound for culture and sensitivity

Correct answer - 1 - stool for ova and parasites does not have to be sterile because test results for the presence of parasitic eggs and parasites are not altered if the specimen is contaminated with exogenous organisms. 2 - incorrect - sterile technique is used to collect a throat culture, to avoid contaminating the specimen with exogenous organisms that may alter the accuracy of test results. 3 - incorrect - the bladder is a sterile cavity and the nurse must use sterile technique to collect urine from the port of a foleycatheter so as not to introduce any pathogens. In addition, it is important not to introduce exogenous organisms that may contaminate the specimen and alter the accuracy of test results. 4 - incorrect - sterile technique is used to collect exudate from a wound to avoid contaminating the specimen with exogenous organisms that may alter the accuracy of test results.

The nurse walks into a room of a client who has a "do not resuscitate" order and finds the client without a pulse, respirations, or BP. What is the most appropriate action? 1. Stay in the room and notify the nursing team for assistance. 2. Push the emergency alarm to call a code. 3. Dial the hospital phone number for a code. 4. Pull the curtain and leave the room.

Correct answer - 1 - the nurse should call to the desk to ask for assistance. The nurse needs to notify the doctor of the client's death and the family must then be notified. 2 & 3 - incorrect - A code should not be called 4 - incorrect - Nursing personnel should begin postmortem care so thtathe family does not walk in unannounced to find their loved one deceased and looking disarrayed.

The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer? 1. Individualize the pain medication regimen for the client. 2. Select medications that are least likely to lead to addiction. 3. Administer pain medication as soon as the client requests it. 4. Change pain medications periodically to avoid drug tolerance.

Correct answer - 1 - the nurse should work with the client to individualize the plan of care for managing pain. Cancer pain is best managed with a combination of medications, and each client needs to be worked with individually to find the treatment regimen that works best. Cancer pain is commonly under treated because of fear of addiction. The cleintwho is in pain needs the appropriate level of analgesic and needs to be reassured that he will not become addicted. Cancer pain is best treated with regularly scheduled doses of medication. Administering the medication only when the client asks for it will not lead to adequate pain control as drug tolerance develops, the dosage of the medication can be increased.

A patient is admitted to the hospital with cirrhosis of the liver caused by long term alcohol abuse. What is the best response by the nurse when the patient says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem?" 1. You find it hard to believe that beer can damage the liver? 2. How long have you been drinking a couple of beers a day? 3. Each beer is equivalent to one shot of liquor so its just as damaging to the liver as hard liquor 4. You may believe that beer is not harmful but research shows that it is just as bad for you as hard liquor.

Correct answer - 1 - this is an example of paraphrasing. It repeats the content in the patient' s message in similar words to provide feedback to let the patient know whether the message was understood and to prompt further communication. 2 - incorrect - this response does not address the comment or emotional theme of the patient's statement, in addition, this probing question may be a barrier to further communication. 3 - incorrect - this response is confrontational, which may put the patient on the defensive and inhibit further communication. 4 - incorrect - this assertive, confronting, judgmental response will put the patient on the defensive and cut off communication.

The nurse identifies that the patient statement that provides subjective data is: 1. I'm not sure that I am going to be able to manage at home by myself. 2 .I can call a home care agency if I feel I need help at home 3. What should I do if I have uncontrollable pain at home 4. Will a home health aide help me with my care at home?

Correct answer - 1 - this is subjective information because it is the patient perception and can be verified only by the patient. Subjective data are those adaptations feelings, beliefs, preferences, and information that only the patient can confirm. 2 - incorrect - this is neither subjective or objective. It is a statement indicating an understanding of how to seek home care services after discharge. 3 - incorrect - this is neither subjective or objective. It is a question indicating thathe patient wants more information on how to control pain when at home. 4- incorrect - this is neither subjective or objective. It is a statement exploring who will provide assistance with care once the patient goes home.

The nurse is planning a teaching plan for an older adult. Which common factor among older patients must be considered by the nurse? 1. Learning may require more energy 2. Intelligence decreases as people age 3. Older adults rely more on visual rather than auditory learning 4. Older adult patients are more resistant to change that accompanies new learning

Correct answer - 1- various physiological changes of aging impact on the rate of learning (declines in sensory perception and speed of mental processing, and more time needed for recall) requiring the use of multisensory teaching strategies and a slower approach. In addition, older adults may have less physical and emotional stamina because of more chronic illnesses, so they may require shorter and more frequent learning sessions. 2 - incorrect - although some older adults may experience a decline in short term memory, they are not less intelligent. When older adults experience a decline in sensory function (vision, hearing) they may feel ashamed or frustrated causing withdrawal. Behaviors reflective of withdrawal may be misperceived as a decline in intelligence. 3 - incorrect 0this is not necessarily true. Individuals usually have learning preferences that persist throughout life. 4 - incorrect - older adults generally are not resistant to change. Some older adults may be less motivated to learn if they believe that death is near. However, in this situation when older adults are shown how learning will improve quality of life and independence, they are motivated to learn.

The nurse understands that subjective data has been obtained when the patient states: 1. I just went in the urinal and it needs to be emptied. 2. My pain feels like a 5 on a scale of 1 to 10 3. The doctor said I can go home today 4. I only ate half my breakfast.

Correct answer - 2 - a patient's perception about a pain level is subjective information. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 1, 3, 4 - are objective data. 1 - this is checkable and measurable. 3 - this can be verified. 4 - this can also be checked and measured.

A patient is positive for clostridiumdifficile. The nurse should institute the isolation precaution known as: 1. Droplet 2. Contact 3. Reverse 4. Airborne

Correct answer - 2 - contact precautions are used for patients who have an illness transmitted by direct contact or with items contaminated by the patient; for example GI, respiratory, skin or wound infections or colonization of drug resistant bacteria including c diff, e coli, shigellaas well as other infections / infestations such as hepatitis A, herpes simplex virus, impetigo, pediculosos, scabies, syncytial virus, and parainfluenza. 1 - incorrect - droplet precautions are used for patients who have an illness transmitted by particle droplets larger than 5 microns. Ex: mumps, rubella, pharyngeal diptheria, mycoplasma pneumonia, pertussis, streptococcal pharyngitis and pneumonic plague. 3 - incorrect - reverse p4recautions, also known as neutropenicprecautions, are used for patients who are immunocompromised; isolation practices are employed and pe4rsonal protective equipment is worn by the caregiver to protect the patient from the caregiver. 4 - incorrect - airborne precautions are used for patients who have an illness transmitted by airborne droplet nuclei smaller than 5 microns, for example varicella, rubeola, and TB

When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that: 1. It is not necessary to wash your hands as long as you use gloves. 2. Hand washing is the best method for preventing cross contamination. 3. Waterless commercial products are not effective for killing organisms. 4. The hands do not serve as a source of infection

Correct answer - 2 - hand washing with the correct technique is the best method for preventing cross contamination. 3- incorrect - waterless commercial products contain at least 60% alcohol are as effective at killing organisms as handwashing. 1 & 4 - incorrect - the hands serve as a source of infection.

An obese patient has limited mobility after an open reduction and internal fixation of a fractured hip. The nurse should monitor this patient for the most serious complication of increased blood coagulability precipitated by immobility which is: 1. Muscle atrophy 2. Pain in the calf 3. Hypotension 4. Bradypnea

Correct answer - 2 - immobility promotes venous vasodilation, venous stasis and hypercoagulability of the blood, which can precipitate the formation of a clot in vein of the leg (venous thrombosis) and inflammation of the vein (phlebitis). 1 - incorrect - muscle atrophy can occur with immobility, it is unrelated to hypercoagulability. Muscle atrophy is the decrease in the size of a muscle resulting from disease. 3 - incorrect - hypotension, an abnormally low systolic blood pressure (less than 100 mmHg), is not related to hypercoagulability precipitated by immobility. 4 - incorrect - bradypnea, abnormally slow breathing (less than 10 breath/min) is unrelated to hypercoagulability caused by immobility

Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process? 1. Formulating a plan of care 2. Identifying the patient's potential risks 3. Designing ways to minimize a patient's stressors 4. Making decisions about the effectiveness of patient care.

Correct answer - 2 - potential risk factors are identified during the Diagnosis step of the Nursing Process. Risk diagnoses are designed to address situations where patients have a particular vulnerability to health problems. 1 - incorrect - this occurs during the Planning step of the Nursing process. 3 - incorrect - this occurs during planning step. 4 - incorrect - this occurs during the evaluation step.

The patient appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today."What interviewing approach did the nurse use? 1. Examining 2. Reflecting 3. Clarifying 4. Orienting

Correct answer - 2 - reflective technique refers to feelings implied in the content of verbal communication or in exhibited nonverbal behaviors. Patients who are crying, quiet, and withdrawn often are sad. 1 - incorrect - examining is not an interviewing technique 3 - incorrect this is not an example of clarifying which is the use of a statement to better understand a message when communication is unclear, rambling, or garbled. 4 - this is not an example of orienting. Reality orientation is a nursing technique used to assist patients in restoring an awareness of what is actual, authentic, or real.

When the nurse is administering a medication to a confused patient, the patient says, "This pill looks different from the one I had before." What should the nurse do? 1. Ask what the other pill looked like 2. Check the original medication order 3. Explain the purpose of the medication 4. Encourage the patient to take the medication.

Correct answer - 2 - this is the safest intervention because it goes to the original source of the order. 1 - incorrect- this action by itself is unsafe because the patient is confused and the information obtained may be inaccurate. 3 - incorrect - this intervention ignores the patient's concern. Although this ultimately may be done, it is not the priority action. 4 - incorrect - this action ignores the patient's statement and is unsafe without first obtaining additional information.

The nurse is planning a teaching session for an older adult about prescribed medication regimen. An issue of major concern for the nurse is that older adults: 1. Experience an increase in absorption of drugs from the GI tract 2. Often use alcohol to cope with the multiple stressors of aging 3. Are less motivated to follow a prescribed drug regimen 4. Have a decreased risk for adverse reactions to drugs

Correct answer - 3 - The literature documents that 75% of older adults are to some degree intentionally noncompliant with drug therapy because of inconvenience, side effects, and/or perceived ineffectiveness of the drugs. 1 - incorrect - older adults experience a decreased (not increased) absorption of drugs from the GI tract. 2 - incorrect - although approximately 10% of older adults have some problem with alcohol use late in life, the literature supports the fact t hat there is a decrease, not an increase in the incidence of alcoholism with the aged. 4 - incorrect - older adults have an increased, not decreased, risk for adverse reactions to the drugs. Adverse effects are any effects that are not therapeutic. Side effects are minor adverse effects that in most cases can be tolerated.

The nurse teaches the patient how to use an incentive spirometer. The nurse understands that the most appropriate expected outcome associated with the use of an incentive spirometer is: 1. Coughing will be stimulated 2. Sputum will be expectorated 3. Inspiratory volume will be increased 4. Supplemental oxygen use will be reduced

Correct answer - 3 - an incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume and reduces atelectasis. 1- incorrect - deep breathing is associated with the use of an incentive spirometer may stimulate coughing, this is not the primary reason for its use. 2 - increase sputum may be expectorated after the use of an incentive spirometer, this is not the primary reason for its use. 4 - incorrect - patients who use an incentive spirometer may or may not be receiving oxygen.

The physician writes an order for a medication that is larger than the standard dose. What should the nurse do? 1. Inform the supervisor 2. Give the drug as ordered 3. Discuss the order with the physician 4. Give the average dose of the medication

Correct answer - 3 - nurses have a professional responsibility to know or investigate the standard dose for medications being administered. In addition, nurses are responsible for their own actions regardless of whether there is a written order. The nurse has a responsibility to question and/or refuse to administer an order that appears unreasonable. 1 - incorrect - it is unnecessary to call the supervisor in this situation. 2 - incorrect - this is unsafe for the patent and may result in malpractice. 4 - incorrect - changing a medication prescription is not within the scope of nursing practice.

The nurse identifies that the person at greatest risk for problems with regulating body temperature is the: 1. Toddler 2. Teenager 3. Older adult 4. School-aged child

Correct answer - 3 - regulation of body temperature depends on the ability to dilate or constrict blood vessels and control the activity of sweat glands. In the older adult the production of sweat glands decreases, reducing a person's ability to perspire and resulting in risk for heat exhaustion; there are decreased amounts of muscle mass and subcutaneous fat, which lead to increase susceptibility to old; there is inefficient vasoconstriction in response to cold and ineficientvasodilation in response to heat; and there is a diminished ability to shiver, which increases body temperature. 1 - incorrect - toddlers generally are able to regulate body temperature as long as they are basically healthy. 2 - incorrect - adolescents generally are able to regulate body temperature as long as there are no coexisting health problems. 4 - incorrect - school aged children generally are able to regulate temperature as long as there are no other underlying medical conditions.

A client who is on nothing by mouth status is constantly asking for a drink. Which of the following is the most appropriate nursing intervention? 1. Re-explain to the client why she cannot drink. 2. Offer ice chips every hour to decrease thirst. 3. Offer the client frequent oral hygiene care. 4.Divert the client's attention by turning on the television.

Correct answer - 3 - the most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. 1 - incorrect - re-explaining why the client cannot drink may be helpful but will not relieve her thirst. 2 - incorrect - Ice chips cannot be given to a client who is on NPO status. 4 - incorrect - Diverting the client's attention does not treat her complaint.

The nurse identifies that the greatest risk for a wound infection exists for a patient with a: 1. Surgical creation of a colostomy 2. First degree burn on the back 3. Puncture of the foot by a nail 4.Paper cut on a finger

Correct answer - 3- of all the options, puncture of the foot by a nail has the greatest risk for a wound infection. A nail is a soiled object that has the potential of introducing pathogens into a deep wound that can trap them under the surface of the skin, a favorable environment for multiplication. 1 - incorrect - surgery is conducted using sterile technique. In addition, preoperative preparation of the bowel helps to reduce the presence of organisms that have the potential to cause infection. 2 - incorrect - there is no break in the skin in a first degree sunburn; therefore, there is less of a risk for a wound infection. 4 - incorrect - paper generally is not heavily soiled and the wound edges are approximated (close together - or closed). This is less of a risk than the example in another option.

The nurse plans to foster a therapeutic relationship. It is most important that the nurse: 1. Work on establishing a friendship with the patient. 2. Use humor to defuse emotionally charged topics of discussion 3. Sympathize with the patient when the patient shares sad feelings 4. Demonstrate respect when discussing emotionally charged topics

Correct answer - 4 - Emotionally charged topics should be approached with respectful, sincere interactions that are accepting and nonjudmental, which will promote further verbalizations. 1 - incorrect - the nurse should maintain a professional relationship with the patient. Nurses may be "friendly" towards patients, but should not establish a friendship with a patient. 2 - incorrect - humor with emotionally charged issues may be viewed as minimizing concerns or frivolous and could be a barrier to communication. 3 - incorrect - sympathy denotes pity, which should be avoided. The nurse should empathize, not sympathize with the patient.

The practitioner's order reads, "6 L Oxygen via face mask."The patient who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. The nurse should: 1. Tighten the strap around the head 2. Reapply the mask every time the patient pulls it off 3. Provide an explanation of why the oxygen is necessary 4. Request that the order for oxygen be changed to a nasal cannula

Correct answer - 4 - agitated, confused patients generally tolerate a nasal cannula better than a face mask. A nasal cannula (nasal prongs) is less intrusive than a mask; masks are oppressive and may cause a patient to feel claustrophobic. 1 - incorrect - this is unsafe because it can compress the capillaries under the strap, which my interfere with tissue perfusion and result in pressure ulcers. 2 - incorrect -this may increase the patient's agitation and it is impractical 3 - incorrect - this will probably be useless because an agitated person often does not understand cause and effect.

The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion? 1. Implementation 2. Assessment 3. Evaluation 4. Diagnosis

Correct answer - 4 - during the diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in the order of priority. 1 - incorrect - this is not an example of Implementation - during this step planed nursing care is delivered. 2 - incorrect - this is not an example of assessment - during this step data may be gathered, but the manipulation of data is conducted in a different step of the Nursing Process. 3 - incorrect - evaluation occurs when actual outcomes are compared with expected outcomes, which reflect attainment or non-attainment of the goal.

To be culturally competent when implementing a teaching plan, the nurse first should assess the patient's: 1. Religious affiliation 2. Support system 3. National origin 4. Health beliefs

Correct answer - 4 - individuals have their own beliefs associated with cultural health practices faiths beliefs, diet, illness, death and dying, and lifestyle which all have a major impact on health beliefs. 12, 2, & 3 are incorrect - although religious affiliation, level of support and national origin may be important to know, it is only one part of a patient's sociocultural makeup. Another option has a higher priority.

What is being communicated when the nurse leans forward during a patient interview? 1. Aggression 2. Privacy 3. Anxiety 4. Interest

Correct answer - 4 - leaning forward is a nonverbal behavior that conveys involvement. It is a form of physical attending, which is being present to another. 2 - incorrect - privacy is not reflected by leaning forward during an interview. Privacy is facilitated by pulling a patient's curtain or finding a separate room or quiet space to talk. 3 - incorrect - a closed posture, avoidance of eye contact, increased muscle tension, and increased motor activity convey anxiety. 1 - incorrect - piercing eye contact, increased voice volume, challenging or confrontational conversation, invasion of personal space, and inappropriate touching convey aggression, which is a hostile, injurious, or destructive action or outlook.

The physician asks the nurse to witness an informed consent. The nurse understands that a patient who is unable to give informed consent for surgery is a: 1. 16 y.oboy who is married 2. 35 y.owoman who is depressed 3. 50 y.owoman who does not speak english 4. 65 y.oman who has received a narcotic for pain.

Correct answer - 4 - narcotics depress the central nervous system including decision making abilities. This person is considered functionally incompetent. 1 - incorrect - legally individuals younger than 18 y.ocan provide informed consent if they are married, pregnant, parents, members of the military or emancipated. 2 - incorrect - a depressed person is capable of making health care decisions until proven to be mentally incompetent 3 - incorrect - this person can provide informed consent after interventions ensure that the person understands the facts and risks concerning the treatment.

Which factor is unique to malpractice when comparing negligence and malpractice? 1. The action did not meet standards of care. 2. The inappropriate care is an act of commission. 3. There is harm to the patient as a result of the care 4. There is a contractual relationship between the nurse and patient.

Correct answer - 4 - only malpractice is misconduct performed in professional practice, where there is a contractual relationship between the patient and nurse, which results in harm to the patient. 1 - incorrect - there is a violation of standards of care with both negligence and malpractice 2 - incorrect - negligence and malpractice both involve acts of either commission (did do something) or omission (did not do something). 3 - incorrect - the patient must have sustained injury, damage, or harm with both negligence and malpractice.

A nurse must administer a medication. What should the nurse do first? 1. Determine the appropriateness of the medication. 2. Ensure the medication is in the medication cart. 3. Check the patient's identification armband. 4. Verify the physician's order for accuracy.

Correct answer - 4 - the administration of medications is a dependent function of the nurse. The physician's order should be verified for accuracy. The order must include the name of the patient, the name of the drug, the size of the dose, the route of administration, and the number of times per day to be administered. 1 - incorrect - a nurse is legally responsible for the safe administration of medications; therefore, the nurse should assess if a medication order is reasonable. However, this is not the first step when preparing to administer a medication to a patient. 2 - incorrect - although this may be done as a time management practice, it is not the first step when preparing to administer a medication to a patient. 3 - incorrect - this action may be essential for the safe administration of a medication, but again it is not the first step.

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient? 1. Reassess the patient 2. Examine the related to factors 3. Analyze the secondary to factors 4.Review the defining characteristics

Correct answer - 4 - the first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered. 1 - incorrect - if a thorough assessment is completed initially, a reassessment should not be necessary. 2 - incorrect - to establish which of two nursing diagnoses is most appropriate is not dependent upon identifying the factors that contributed to (also known as related to or etiology of the nursing diagnosis. These factors are identified after the problem statement is identified. 3 - incorrect - to establish which of two nursing diagnoses is more appropriate is not dependent upon analyzing the secondary to factors. Secondary to factors generally are medical conditions that precipitate the related to factors. The secondary to factors are identified after the related to factors of the problem are identifies.

The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurate stated goal? "The patient will: 1. be taught how to use a urinal when on bed rest. 2. Experience fewer incontinence episodes at night. 3. Be assisted to the toilet every 2 hrs and whenever necessary 4. Transfer independently and safely to a commode before discharge.

Correct answer - 4 - this is a correctly worded goal. Goals must be patient centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. The word independently indicates that no help is needed, and the word safely indicates that no injury will occur. The time frame is before discharge. 1 - incorrect - this is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal 2 - incorrect - this goal is inappropriate because the word fewer is not specific, measurable or objective. 3 - incorrect - this is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal.

The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent patient infections? 1. Provide small bedside bags to dispose of used tissues 2. Encourage staff to avoid coughing near patients. 3. Administer antibiotics as ordered 4. Identify patients at risk

Correct answer - 4 - this is the most important first step in the prevention of infection. A patient who is at high risk may need to receive special protective precautions as well as transmission based precautions to protect others. 1 - incorrect - this is something the nurse may provide to contain soiled tissues, it is not the first action the nurse should implement. 2 - incorrect - the nurse may do this as well as it will help limit airborne or droplet transmission of microorganisms, but again it is not the first step. 3 - incorrect - antibiotics generally are ordered by a practitioner for patients who have infections. Antibiotics rarely are ordered prophylactically to prevent the development of resistant strains of microorganisms.

A patient verbally communicates with the nurse while exhibiting nonverbal behavior. To confirm the meaning of the nonverbal behavior, the nurse should: 1. Look for similarity in meaning between the patient's verbal and nonverbal behavior. 2. Ask family members to help interpret the patient's behavior 3. Validate inferences by asking the patient direct questions 4. Recognize that what a patient says is most important

Correct answer 1 - the patient is the primary source of information. When nonverbal communication reinforces the verbal message, the message reflects the true feelings of the patient because nonverbal behavior is under less conscious control than verbal statements. 2 - incorrect 0 this abdicates the nurse's responsibility to others and obtains a response that is influenced by emotion and subjectivity. 3- incorrect - direct questions are too specific. Open ended questions or gently pointing out the incongruence between actions and words are more effective techniques than direct questions in this situation. 4 - incorrect - non verbal behaviors, rather than verbal statements, better reflect true feelings. Actions speak louder than words.

The nurse is administering medication to an older adult. For which response to medication that occurs most frequently in older adults should the nurse assess the patient? 1. Toxicity 2. Side effects 3. Hypersensitivity 4. Idiosyncratic effects

Correct answer 1 - this is a serious concern because of a decrease in the efficiency of the hepatic metabolism and renal excretion of drugs in older adults. 2 - incorrect - although side effects are a concern in the older adult, option # 1 is a greater concern. 3 - incorrect - hypersensitivity is also a concern in the older adult, but option # 1 is a greater concern. 4 - incorrect - idiosyncratic effects are a concern as well, but again the toxic effects are of greater concern.

A patient asks the nurse, "what does 96 indicate when my BP is 140 over 96?" What is the best response by the nurse? 1. The 96 is the pressure within an artery when the heart is resting between beats. 2. The 96 reflects the lowest pressure within a vein when blood moves through it. 3. Everyone is different so it's really relative to each individual what it means. 4. Let's talk about concerns you may have about your blood pressure.

Correct answer 1 - this response is simple, direct, and uses language that is easily understood. 2 - incorrect - 96 is the pressure in the artery not the vein. 3 - incorrect - this does not answer the question, which can be frustrating to the patient. When a question receives a meaningless response, the patient may perceive that the nurse is not interested in taking the time to explain the concept. 4 - incorrect - the patient is requesting simple information. The question has to be answered first, and then any concerns can be answered.

When attempting to apply a pulse oximetryprobe, the nurse identifies that a patient's hands are edematous. The priority action should be to: 1. Attach the probe to one of the patient's toes 2. Connect the probe to one of the patient's earlobes 3. Wash the patient's hand before attaching the probe to the finger 4. Encourage the patient to perform active range of motion exercises of the hand

Correct answer 2 - an earlobe is an excellent site to monitor pulse oximetry. It is least affected by decreased blood flow, has greater accuracy at lower saturations, and rarely is edematous. This site is used for intermittent, not continuous monitoring. 1 - incorrect - the use of a toe for pule oximetrycan result in inaccurate results because of concurrent problems such as vasoconstriction, hypothermia, impaired peripheral circulation and movement of the foot. 3 - incorrect - soap and water will not resolve the edema. In addition attaching a pulse oximeterclip sensor to an edematous finger is contraindicated because interstitial fluid interferes with obtaining accurate oxygen saturation level. 4 - incorrect - the cause of the edema must be identified first because range of motion exercises may be contraindicated.

The nurse is planning to engage a patient in a program to learn about a newly diagnosed illness. Which psychosocial adaptation to illness has the greatest impact on the patient's future success with learning? 1. Fear 2. Denial 3. Fatigue 4. Anxiety

Correct answer 2 - of all the options presented the patient in denial is the person least ready and motivated to learn. The patient in denial is unable to recognize the need for the learning. 1 - incorrect - although fear will affect the success of a teaching program and will need to be assessed and modification employed, it is not the factor that will have the greatest impact on the future success of a teaching program. Fear initially causes change; however, as fear subsides a person usually returns to the previous behavior. 3 - incorrect - fatigue is a physiologic, not psychosocial adaptation to an illness. When teaching, the nurse needs to assess the patient's stamina and modify the teaching program so as not to unduly strain the patient, and yet meet the objectives. 4 - incorrect - anxiety is important, but it is not the factor that has the greatest impact on the future success of a teaching program. Mild anxiety is motivating. Moderate anxiety will motivate a patient to learn but may require the nurse to keep concepts and approaches simple. The person with moderate anxiety may need to be focused and distractions minimized to facilitate learning. If severe anxiety or panic are present, the teaching program will have to be postponed until the patient is less anxious

An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, "If you keep ringing, there will come a time I won't answer your bell."this is an example of: 1. Slander 2. Assault 3. Battery 4. Libel

Correct answer 2 - this is an example of assault. Assault is a verbal attack or unlawful threat causing a fear of harm. No actual contact is necessary for a threat to be an assault. 1 - incorrect - slander is a false spoken statement resulting in damage to a person's character or reputation. 3 - incorrect - battery is the unlawful touching of a person's body without consent. 4 - incorrect - libel is a false printed statement resulting in damage to a person's character or reputation.

The nurse working in a nursing home is providing care to a group of older adults. The decline in which system in the older adult most often influences the ability to maintain safety? 1. Integumentary 2. Respiratory 3. Sensory 4. Cardiovascular

Correct answer 3 - a decline in vision, hearing, tactile sensation to pan and pressure, and a slower response time have the greatest impact on older adult's ability to maintain safety over all of the systems offered in the other options. Integumentary / Respiratory / Cardiovascular - incorrect - alterations in these systems generally do not pose a threat to safety when compared to a decline in another system of the body

The nurse is to provide nutritional counseling for an older adult. What should the nurse do first? 1. Plan educational sessions in the late afternoon 2. Speak louder when talking 3. Provide large print books 4. Assess for readiness

Correct answer 4 - if the patient does not recognize the need to learn or value the information to be learned, the patient will not be ready to learn. 1 - incorrect - late in the afternoon is not the best time to schedule teaching sessions for older adults. They may tire from the energy and effort to perform daily activities and therefore, may be too tired to concentrate. 2 - incorrect speaking in a lower pitch tone rather than speaking louder is more effective. Older adults often experience a decline in the ability to hear high pitch tones. 3 - incorrect - not all older adults have vision problems this should be done only for the patient who has visual problems.

Licensure of Registered Professional Nurses is required primarily to protect: 1. Nurses 2. Patients 3. Common law 4. Healthcare agencies

Correct answer is # 2 - licensure indicates that a person has met minimal standards of competency, thus protecting the public's safety. 1 - incorrect - licensure does not protect the nurse. Licensure grants an individual the legal rights to practice as a RN. 3 - incorrect - licensure does not protect common law. Common law comprises standards and rules based on the principles established in prior judicial decisions 4 - incorrect - it is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that determines if agencies meet minimal standards of healthcare delivery, thus protecting the public.

A patient with a colostomy wants to learn how to irrigate a newly created colostomy. The nurse provides this teaching by developing a therapeutic nurse patient relationship and implementing teaching strategies. Identify the statements that are included in the working phase of this therapeutic relationship. Select all that apply. 1. How do you feel about doing this procedure? 2. Would you like to try to insert the cone yourself today? 3. You did a great job managing the instillation of fluid today. 4. I am here to help you lean how to irrigate your colostomy. 5. I'll arrange for a home care nurse to visit you in your home when you are discharged.

Correct answers - 2 & 3 2 - this statement reflects the working phase of a therapeutic relationship. It involves completing interventions that address expected outcomes, such as learning how to perform a colostomy irrigation. 3 - this statement reflects the working phase as it includes providing feedback and encouragement. 1 - incorrect - this statement reflects the orientation phase of a therapeutic relationship. Although exploration of feelings is done throughout the phases, the primary goal of the orientation phase is the establishment of trust. Trust is promoted when the nurse focuses on the patient's emotional needs, is respectful, and individualizes care.4 - incorrect - this reflects the orientation phase of a therapeutic relationship. The nurse and patient make a verbal agreement to work together to assist the patient to achieve a goal. 5 - incorrect - this reflects the termination phase of a therapeutic relationship. It focuses on summarizing what has taken place and has been accomplished and looks to the future.

Which are the most important nursing actions when speaking with an older adult who is hearing impaired? Select all that apply. 1. Limit background noise 2. Exaggerate lip movements 3. Raise the pitch of your voice 4. Stand directly in front of the patient when speaking 5. Raise the volume of your voice while speaking directly toward the patient's good ear.

Correct answers 1 & 4 - 1 - limiting competing stimuli promotes reception of verbal messages. 4 - focuses the patient's attention on the nurse. A hearing impaired receiver must be aware that a message is being sent before the message can be received and decoded. 2 - incorrect - this may be demeaning and ineffective because the patient may not be able to read lips. 3 = incorrect - this is not helpful. Hearing loss in the older adult typically involves a decreased perception of high pitched sounds. 5 - incorrect - this is demeaning and may be viewed by the patient as aggressive behavior.

A patient falls while getting out of bed unassisted. When completing an Incident Report, the nurse understands that its main purpose is to: 1. Ensure that all parties have an opportunity to document what happened. 2. Help establish who is responsible for the incident 3. Make data available for quality control analysis 4. Document the incident on the patient's chart

Corrrectanswer - 3 - incident reports help identify patterns of risk so that corrective action plans can take place. 1 - incorrect - the nurse who identifies or creates the potential or actual harm completes the Incident Report. The report identifies the people involved in the incident, describes the incident, and records the date, time, location, actions taken, and other relevant information. 2 - incorrect - documentation should be as factual as possible and avoid accusations. Questions of liability are the responsibility of the courts. 4 - incorrect - the report is not part of the patient's medical record, and reference to the report should not be made in the patient's medical record.

A nurse is calculating the amount of urine output at the end of an 8 hrshift for a client with a TransUrethralResection of the Prostate. The nurse emptied the foley bag twice during the shift. The 1st time there was 900 mL & the 2nd time there was 1000 mL. The amount of the irrigation hung at the beginning of the shift was 3000 mL & there is 1600 mL left at the end of the shift. The nurse should record the client had _____ mL of urine output over the 8 hrperiod.

Determine the amount of irrigation solution used: 3000 - 1600 = 1400 Next subtract the 1400 mL of irrigation used from the combined amounts in the urinary drainage bag: 900 + 1000 = 1900 1900 - 1400 = 5oo mL The client had 500 mL of urine output during the past 8 hrs

Medication Administration- You Should Know:

•the different sized needle lengths and gauges •Angles of injection for SC, ID, IM •Sites of injections for subcutaneous e.g. insulin, intramuscular