Nursing Exam 1

During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's blood pressure (BP) seems high. What is the next step? 1. Ask the client about past blood pressure ranges 2. Review the graphic record on the client's record 3. Examine the medication record for antihypertensive medications 4. Review the progress notes included in the client's record

2. Review the graphic record on the client's record *Rationale*: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not appropriate for validation assessment that is measurable. This is more appropriate for pain or dizziness. The medication record would not include documentation of blood pressure ranges (option 3). The progress notes (option 4) provide information about how the client is progressing. It may have information about the client's BP if it was a problem. The best answer is option 2.

Which of the following nursing diagnoses should the nurse identify as a priority after surgical repair of a cleft lip? 1. Acute pain 2. Risk for infection 3. Impaired physical mobility 4. Impaired parenting

2. Risk for infection

When evaluating a parent's understanding of poisoning prevention, which of the following statements indicates a need for further teaching? 1. "We'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk cartons." 2. "We'll display the phone number of hte poison control center near or on all telephones in our home so that it is available to babysitters, family, and friends." 3. "We'll teach our children never to eat any part of an unknown plant or mushroom and not to put leaves, stems, bark, seeds, nuts, or berries from any plant into their mouths." 4. "We'll not refer to medicine as candy or pretend false enjoyment when taking medications in front of our children."

1. "We'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk cartons."

A nurse is caring for a patient with long hair. The patient asks if something could be done about her hair to be more comfortable. How would the nurse respond? 1. "Yes, I can braid it for you if you want me to" 2. "Well I guess I could just cut it all off" 3. "You will have to ask your family to do that" 4. "No, deal with it"

1. "Yes, I can braid it for you if you want me to"

A major characteristic of the nursing process is which of the following? 1. A focus on client needs 2. A static nature 3. An emphasis on physiology and illness 4. Its exclusive use by and with nurses

1. A focus on client needs *Rationale*: The nursing process focuses on client needs. It is dynamic rather than static (option 2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4).

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104 degrees F, and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3. Which of the following should the nurse identify as the immediate priority nursing diagnosis? 1. Anxiety related to need for immediate and unplanned hospitalization 2. Risk for injury (airway obstruction) related to epiglottal edema 3. Impaired gas exchange related to excessive respiratory effort 4. Ineffective airway clearance related to aspiration

2. Risk for injury (airway obstruction) related to epiglottal edema

Organ donation prohibits the: (Select all that apply.) 1. Donation of organs in clients diagnosed with brain death 2. Sale of body organs 3. Marketing of body organs 4. Donation of cartilage and bones

2. Sale of body organs 3. Marketing of body organs *Rationale*: The National Organ Transplant Act prohibits the selling of organs and/or marketing of body parts. The other examples are acceptable.

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Having an annual mammogram ___________.

2. Secondary *Explanation*: It's a diagnostic test

A conceptual framework is considered to be: 1. A group of related ideas, statements, or concepts 2. A pattern of shared understandings and assumptions about reality and the world 3. The way to elucidate how social structures affect a wide variety of human experiences, from art to social practices 4. A belief system, often an early effort to determine nursing phenomena that serves as the basis for later theoretical formulations

1. A group of related ideas, statements, or concepts *Rationale*: A conceptual framework is a group of related ideas, statements, or concepts. A paradigm refers to a pattern of shared understandings and assumptions about reality and the world. A philosophy is a belief system, often an early effort to define nursing phenomena, and serves as the basis for later theoretical formulations. Critical theory is the way to elucidate how social structures affect a wide variety of human experiences, from art to social practices.

Major difference between baccalaureate degree in the nursing program and an associates degree in the nursing program is that the baccalaureate program includes studies in: 1. Basic sciences and theoretical courses 2. Social sciences and humanities 3. Theoretical and clinical courses 4. Basic sciences and clinical courses

2. Social sciences and humanities *Explanation*: (3) theoretical courses are fundamentals, which we are taking now. (2) social sciences includes history, we don't have to take that yet.

Which of the following elements is best categorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the last clinic visit 2. Spouse states the client has lost all appetite 3. The nurse palpates edema in lower extremities 4. Client states severe pain when walking up stairs

2. Spouse states the client has lost all appetite *Rationale*: Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion). whereas objective data can be measured or validated (weight - option 1, edema - option 3). If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective (measured) data.

Suicide and homicide are two leading causes of death among teenagers. When planning a workshop on adolescent suicide and homicide, the nurse knows that which of the following is NOT among the most common factors influencing the high suicide and homicide rates? 1. Economic deprivation 2. Strong emotions toward friendships 3. Availability of firearms 4. Family breakup

2. Strong emotions toward friendships

An antigen is a: 1. Host that produces antibodies in response to natural antigens (e.g., infectious microorganisms) or artificial antigens (e.g., vaccines) 2. Substance that induces a state of sensitivity or immune responsiveness (immunity) 3. Host that receives natural (e.g., from a nursing mother) or artificial (e.g., from an injection of immune serum) antibodies produced by another source 4. Part of the body's plasma proteins

2. Substance that induces a state of sensitivity or immune responsiveness (immunity)

A nurse planning a safety instruction class for parents of adolescents knows that the focus of the class should be on: 1. Teaching adolescents to sleep on a low bed 2. Teaching adolescents about driver safety 3. Teaching adolescents not to ingest lead paint chips 4. Teaching adolescents not to run or ride a tricycle into the street

2. Teaching adolescents about driver safety

Identify behaviors that would be classified as an invasion of privacy for a client. (Select all that apply.) 1. A nurse who removes articles from a bedside table in order to "clear out some of that junk" 2. A middle-aged, mentally alert client who requests a nursing assistant to "get rid of a bedpan, used ketchup container, and other unused items" 3. A nursing student who documents the client's name and address on paperwork to hand in to the clinical faculty member 4. A cousin who wants to review the chart for lab results and the health care provider's orders

1. A nurse who removes articles from a bedside table in order to "clear out some of that junk" 3. A nursing student who documents the client's name and address on paperwork to hand in to the clinical faculty member 4. A cousin who wants to review the chart for lab results and the health care provider's orders *Rationale*: Invasion of privacy is an intentional tort and nurses and nursing staff can be held liable if convicted, HIPAA, the American Health Insurance Portability and Accountability Act of 1996, requires that health information about clients be secured in such a way that only those with the right and need to acquire the information are able to do so. The clinical faculty would already know the client they had assigned to the student. The nurse should not randomly discard any items of a client's without express permission. If the cousin is not listed on a signed release from the client and hospital, then the cousin should not be allowed to review the client's record.

A quantitative research approach is most appropriate for which study? 1. A study measuring the effects of sleep deprivation on wound healing 2. A study examining the bereavement process in spouses of clients with terminal cancer 3. A study exploring factors influencing weight control behavior 4. A study examining a client's feelings before and after a bone marrow aspiration

1. A study measuring the effects of sleep deprivation on wound healing *Rationale*: Quantitative research collects numerical data. Sleep deprivation can be defined by numbers of hours without sleep and wound healing can be measured by the size of the wound in relation to a period of time. While some of the other options may be calculated using sophisticated numerical processes, they are not as easily measured and may be more appropriate for qualitative research methods.

Which example reflects a nurse manager with accountability but not authority? 1. To reduce costs, administrators instruct the manager to inform the stuff to reduce overtime 2. The manager evaluates the unit staff but cannot promote or terminate staff 3. The manager is to recommend a new staffing procedure to the institution's nurse manager group 4. The manager prepares a monthly budget variance report that includes plans to correct overspending

2. The manager evaluates the unit staff but cannot promote or terminate staff *Rationale*: The manager is responsible for evaluating the staff (accountable) but has no authority to terminate staff who do not meet the standards nor promote staff with outstanding performance. In option 1 the manager has authority to carry out the reduction, but is not accountable because the actions were delegated and not initiated independently. In option 3, the manager has only responsibility; in option 4, but authority and accountability.

Identify and select the advantages of using a taxonomy of nursing diagnoses. (Select all that apply.) 1. A taxonomy of nursing diagnoses would promote a classification system or set of categories for a single or set of principles for professional nurses 2. A taxonomy of nursing diagnoses can be used by physicians to define diagnostic nursing terminology 3. A taxonomy of nursing diagnoses enhances the professional practice of the nurse in generating and completing a nursing care plan 4. A taxonomy of nursing diagnoses consists of nursing diagnoses for a single principle or set of principles that were developed by other nursing professionals

1. A taxonomy of nursing diagnoses would promote a classification system or set of categories for a single or set of principles for professional nurses 3. A taxonomy of nursing diagnoses enhances the professional practice of the nurse in generating and completing a nursing care plan 4. A taxonomy of nursing diagnoses consists of nursing diagnoses for a single principle or set of principles that were developed by other nursing professionals *Rationale*: A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles. The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers. The group has currently approved more than 170 nursing diagnoses labels for clinical use and testing. Physicians do not use nursing diagnoses in their practice.

Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis 2. Always select independent interventions when possible 3. There is one best intervention for each goal/outcome 4. interventions should be "doing," not just "monitoring"

1. Actions should address the etiology of the nursing diagnosis *Rationale*: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions should be selected if appropriate (option 2) and several interventions may be needed for a single outcome (option 3). Both action and assessment-type interventions can be used (option 4).

What is the best example of documentation by the nurse in the client's record? 1. All facts and information regarding a person's condition, treatment, care, progress, any refusal of consent of treatment, and response to illness and treatment are noted 2. All facts and information regarding a person's condition, treatment, care, progress, and response to illness and treatment are noted 3. All facts and information regarding a person's condition, treatment, care, progress, any refusal or consent of treatment, physician's competence, and response to illness and treatment are noted 4. All facts and information regarding a patient that the nurse feels are appropriate are noted

1. All facts and information regarding a person's condition, treatment, care, progress, any refusal of consent of treatment, and response to illness and treatment are noted *Rationale*: All facts and information regarding a person's condition, treatment, care, progress, refused or consent of treatment, and response to illness and treatment should be documented in the chart.

A patient refuses to have a pain medication administration by injection. A nurse says, "if you don't let me give you the shot, I will get help to hold you down and give it." With what crime might the nurse be charged? 1. Assault 2. Battery 3. Slander 4. Defamation

1. Assault *Explanation*: Defamation is any sort of false communication that can result in injury to a reputation of a person. Libel is defamation by print. Slander is defamation by spoken word. Battery is touching of a person that may or may not cause harm. Assault (correct answer) is an attempt or threat to touch another person unjustifiably. The nurse didn't actually touch the patient yet, just threatened it.

Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds 2. Auscultation of bowel sounds 3. Presence of chest pain 4. Presence of peripheral edema 5. Color of nail beds

1. Auscultation of breath sounds 5. Color of nail beds *Explanation*: (1) should always listen to breath sounds of someone who has pneumonia. (2) won't be listening to bowel sounds in someone with pneumonia. (3) short of breath, so wouldn't usually have chest pain. (4) Swelling in legs or feet - not present with pneumonia. (5) if oxygen isn't getting to the limbs, the nail beds will be a different color which is important to know.

The nurse leader informs the staff of a local emergency and instructs them to stay at the hospital to prepare for major casualties. The staff displays high levels of anxiety and disorganization. Which is the most appropriate leadership style at this time? 1. Autocratic 2. Democratic 3. Laissez-faire 4. Bureaucratic

1. Autocratic *Rationale*: This is a situation in which urgent decisions are needed, and one person provides instructions without input from others (autocratic). This is especially appropriate if the rest of the group is not functioning at an appropriate level. Option 2 would be found in shared governance structures when the risks are low and there is time for collaboration. Option 3 is most effective in groups with high levels of professional and personal maturity and where cooperation and coordination are not significant. Option 4 involves the rigid use of rules. Because managing casualties is a highly unpredictable activity, enforcement of rules is not appropriate.

The nurse is caring for the patient who has had major abdominal surgery and also has a large sacral pressure sore. The nurse implements coughing and deep breathing exercises and consults the wound care specialist to evaluate and prescribe care for the pressure sore, even though no physician order has provided instructions to do so. In doing this, the nurse is implementing the element of: 1. Autonomy 2. Accountability 3. Advanced practice 4. Nurse practitioner

1. Autonomy *Explanation*: Part of autonomy is making our own decisions.

When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is which of the following? 1. Be able to defend the morality of one's own actions 2. Remain neutral and detached when making ethical decisions 3. Ensue that a team is responsible for deciding ethical questions 4. Follow the client and family's wishes exactly

1. Be able to defend the morality of one's own actions *Rationale*: A nurse's actions in an ethical dilemma must be defensible according to moral and ethical standards. The nurse may have strong personal beliefs but distancing oneself from the situation does not serve the client (option 2). A team is not always required to reach decisions (option 3), and the nurse is not obligated to follow the client's wishes automatically when they may have negative consequences for self or others (option 4)

A client is receiving digoxin (Lanoxin) 0.25 mg. daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D.. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? 1. Blood pressure 94/60 2. Heart rate 76 3. Urine output 50 mL/hour 4. Respiratory rate 16

1. Blood pressure 94/60 *Explanation*: Metoprolol decreases blood pressure, so need to know what normal blood pressure rates are.

After auscultating the abdomen, the nurse should report which finding to the primary care provider? 1. Bruit over the aorta 2. Absence of bowel sounds for 60 seconds 3. Continuous bowel sounds over the ileocecal valve 4. A completely irregular pattern of bowel sounds

1. Bruit over the aorta *Rationale*: A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. For absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes (option 2). Continuous bowel sounds are normally heard over the ileocecal valve following meals (option 3). Bowel sounds are more commonly irregular than they are regular (option 4).

Which of the following actions by the nurse indicates that the nurse needs further instruction non the nursing assessment prior to applying restraints on a client? 1. The nurse checks the status of skin to which a restraint is to be applied 2. The nurse checks the circulatory status proximal to restraints 3. The nurse takes consideration of other protective measures that may be implemented before applying a restraint 4. The nurse determines underlying cause for assessed behavior

2. The nurse checks the circulatory status proximal to restraints

A supposition or system of ideas that is proposed to explain a given phenomenon or something significant is called a: 1. Concept 2. Theory 3. Paradigm 4. Conceptual model

2. Theory *Rationale*: Theory is defined as a supposition or system of ideas that is proposed to explain a given phenomenon. Concepts are called the "building blocks" of theories and are difficult to explain or define. Paradigm refers to a pattern of shared understandings and assumptions about reality and the world. Conceptual models or frameworks ware defined as a broad range of the significant relationships among the concepts of a discipline.

Identify examples that health care professionals may use in order to communicate specific information regarding the client or the client's care. (Select all that apply.) 1. Change-of-shift report 3. Contacting the physician via telephone regarding new orders for medication to decrease an increased temperature 4. Care plan conferences

1. Change-of-shift report 2. Discussing the client's care in the cafeteria 3. Contacting the physician via telephone regarding new orders for medication to decrease an increased temperature 4. Care plan conferences *Rationale*: The client's status or care should never be discussed in situations where other persons may overhear the privileged information. Nurses have a legal and ethical duty to maintain confidentiality of the client's record, personal information, and any other information that relates to that individual's health care. Appropriate use of sharing client information includes during change-of-shift report, contacting the physician, and during care plan conferences.

If unable to locate the client's popliteal pulse during a routine examination, what should the nurse do next? 1. Check for a pedal pulse 2. Check for a femoral pulse 3. Take the client's blood pressure on that thigh 4. Ask another nurse to try to locate the pulse

1. Check for a pedal pulse *Rationale*: If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (option 2). Taking a thigh BP requires locating the popliteal pulse (option 3). Because the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (option 4).

What is a nursing function during the diagnosing phase of the nursing process? 1. Clarify all inconsistencies in the data before making inferences 2. Identify Gordon's functional health patterns and compare with the client 3. Review the literature and review professional journals and textbooks 4. Document the health assessment in a specific form

1. Clarify all inconsistencies in the data before making inferences *Rationale*: Clarifying the gaps and inconsistencies in the data is one of the three continuous and sequential activities involved in the diagnostic process.

During the client rounds, a client tells the nurse manager that he has not received his medications all shift. In using the skills and competencies of a manager, what will be the nurse's first action? 1. Communicate: Discuss the client's statement with the assigned nurse 2. Manage resources: Assign another nurse to administer the client's medications 3. Enhance employee performance: Provide the client's nurse with a mentor to review proper medication procedures 4. Manage conflict: Call the nurse into the client's room and mediate a discussion between them

1. Communicate: Discuss the client's statement with the assigned nurse *Rationale*: In this situation, the manager needs to verify and clarify the client's statement with the assigned nurse before taking any direction action. Assigning another nurse to administer the client's medications (option 2) could be dangerous because it assumes the client is accurate in his statement. It is premature to review proper medication procedures with the nurse before knowing for certain that the procedure has not been followed (option 3). If the manager determines that there is a disagreement about whether or not the medications have been given, it might be appropriate for the manager, nurse, and client to discuss the situation together (option 4) but certainly not before the manager has a private conversation about the situation with the nurse.

Choose the appropriate activities that the nurse may perform during the diagnosing component of the nursing process. (Select all that apply.) 1. Compare data against current nursing standards 2. Obtain a nursing health history 3. Cluster or group the data to generate a tentative hypothesis 4. Review the client records and nursing literature 5. Identify gaps and inconsistencies in the data

1. Compare data against current nursing standards 3. Cluster or group the data to generate a tentative hypothesis 5. Identify gaps and inconsistencies in the data *Rationale*: All of the listed activities are part of the diagnosing component of the nursing process except obtaining a nursing health history and reviewing the client records and nursing literature. These components are part of the patient assessment.

While attending a nursing educator's conference, a nursing instructor obtains information about the use of concept maps and clinical pathways. The nursing instructor returns to work at the university and discusses the new techniques with the other instructors. What is this an example of? 1. Creating an environment that supports critical thinking 2. Seeking information regarding new educational promotions 3. Intellectual humility 4. Judgment

1. Creating an environment that supports critical thinking *Rationale*: Discussing any problems in a collegial way creates an environment that supports critical thinking. A nurse cannot develop or maintain critical thinking attitudes in a vacuum. Nurses should encourage colleagues to examine evidence carefully before they come to conclusions and to avoid group thinking.

Which of the following activities are examples of how a professional nurse may participate in research? (Select all that apply.) 1. Critiquing research for application to practice 2. Identifying clinical problems suitable for nursing research 3. Encouraging patient participation in a study without informed consent 4. Using research findings in the development of policies, procedures, and practice guidelines for patient care

1. Critiquing research for application to practice 2. Identifying clinical problems suitable for nursing research 4. Using research findings in the development of policies, procedures, and practice guidelines for patient care *Rationale*: Answers 1, 2, and 4 are examples of the professional nurse's activities in nursing research. One of the nurse's responsibilities with research is in safeguarding the rights of the client, which includes informed consent.

A nurse documents in the client's chart that the health care provider is incompetent because the health care provider did not respond promptly to the nurse's call regarding the client. This is an example of __________ and __________. 1. Defamation 2. Slander 3. Libel 4. Battery 5. Unprofessional conduct

1. Defamation 3. Libel *Rationale*: The nurse defamed the health care provider's reputation by use of the word incompetent in the documentation. The nurse also committed libel because the defamation was by means of print, writing, or pictures. The nurse did not commit slander, defamation by spoken word. Unprofessional conduct includes incompetence or gross negligence, conviction for practicing without a license, falsification of client records, illegally obtaining, using, or possessing controlled substances.

While reviewing the transfer papers of a client, the nurse notes that the client has both a living will and a durable power of attorney. A living will dimers from a durable power of attorney in that a living will: 1. Describes how the client wants his wishes carried out in the event of a terminal illness 2. Designates who should make medical decisions of the client is incapable of making independent decisions 3. Determines which relative gets the house 4. Allows a health care provider to make decisions if the client is unable to make decisions

1. Describes how the client wants his wishes carried out in the event of a terminal illness *Rationale*: A living will provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions. A durable power of attorney for health care is a notarized or witnessed statements that appoints someone to make health care decisions when the client is unable to do so, designates who should make medical decisions if the client is incapable of making independent decisions. Neither a living will nor a durable power of attorney describes determining real estate or health care provider's actions when the client is unable to make his or her own health care decisions.

Data Analysis involves the application of which of the following procedures? (Select all that apply.) 1. Descriptive statistics 2. Inferential statistics 3. Measures of central tendency 4. Measures of variability

1. Descriptive statistics 2. Inferential statistics *Rationale*: New scientific knowledge acquired with new discoveries regarding health and cultural changes that are continuously changing as time progresses are two reasons for continually revising nursing education curricula. Disease and treatments evolve as time passes so nurses must keep up to date on all medical breakthroughs.

What statement is true regarding ethical committees and the role these committees play in dealing with health core conflicts? 1. Ethical committees ensure that relevant facts of a case are presented 2. Ethical committees are not designed to reduce the institution's legal risk 3. Ethical committees decide when laws have been violated 4. Nurses usually do not serve as team members on ethical committees

1. Ethical committees ensure that relevant facts of a case are presented *Rationale*: Ethics committees include nurses and can be asked to provide guidance to a competent client, an incompetent client's family, or health care providers. These committees ensure that relevant facts of a case are Brought out, provide a forum in which diverse views can be expressed, provide support for caregivers, and can reduce the institution's legal risks. These committees do not decide when a law has been violated; rather, these committees are formed to provide ethical guidance.

In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following? 1. Family practice physician 2. Physical therapist 3. Case manager/discharge planner 4. Pharmacist

1. Family practice physician *Rationale*: Primary care providers are limited to generalist physicians and advanced practice nurses. In some cases a gynecologist may qualify as a primary care provider and in other cases not. Physical therapists (option 2) do not have a scope of practice broad enough to service as primary care providers. Pharmacists (option 3) and case managers/discharge planners (option 4) are not responsible for providing direct client care.

Identify the purposes of charting. (Select all that apply.) 1. To fill up the nurse's spare time 2. To communicate care and responses to care 3. To create a legal document 4. To demonstrate what the nurse did every moment of the shift 5. To provide a basis for evaluation

2. To communicate care and responses to care 3. To create a legal document 5. To provide a basis for evaluation *Rationale*: The main purposes of charting are to communicate care, help identify patterns of responses and changes in status, provide a basis for evaluation, provide a legal document, and supply validation for insurance purposes. The purpose of charting is not to fill up the nurse's spare time or to demonstrate what the nurse did every moment of the shift.

When distinguishing between morality and legal correctness, what indicators would the nurse recognize as reflecting the morality of a situation? (Select all that apply.) 1. Feelings such as shame, guilt, or hope 2. Tendency to respond to the situation with words such as should, right, ought to, or good 3. Legislative regulations requiring or preventing a specific action 4. Infringement on an individuals' human rights 5. Fear of imprisonment

1. Feelings such as shame, guilt, or hope 2. Tendency to respond to the situation with words such as should, right, ought to, or good *Rationale*: The feelings of shame and guilt, along with use of feeling words such as should, ought to, right, wrong, good, and bad, both indicate the morality involved in a specific situation. Legislative regulations, infringing on individual human rights such as the right to life or privacy, and fear or imprisonment indicate a legal situation.

A nurse measuring the client's intake and output: 1. Florence Nightingale 2. Hildegard Peplau 3. Martha Rogers 4. Imogene King

1. Florence Nightingale *Rationale*: Martha Roger's Science of Unitary Human Beings states the idea of non-contact therapeutic touch. This is the idea that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Florence Nightingale's Environmental Theory linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness. In addition tho those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect n the person. Peplau's Interpersonal Relations Model introduces the existence of a therapeutic relationship between the nurse and the client. Imogene King's Goal Attainment Theory describes the nature of and standard for nurse-client interactions that lead to goal attainment - that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment represents outcomes.

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1. Goggles 2. Gown 3. Surgical mask 4. Clean gloves

1. Goggles

Which of the following is the FIRST priority in preventing infections when providing care for a client? 1. Hand-washing 2. Wearing gloves 3. Wearing mask 4. Wearing a gown

1. Hand-washing

Which women made significant contributions to the nursing care of soldiers during the Civil War? Select all that apply. 1. Harriet Tubman 2. Florence Nightingale 3. Fabiola 4. Dorothea Dix 5. Sojourner Truth

1. Harriet Tubman 4. Dorothea Dix 5. Sojourner Truth *Rationale*: Option 2, Florence Nightingale, contributed to the nursing care of soldiers in the Crimean War. Option 3, Fabiola, used her wealth to provide houses of caring and healing during the Roman Empire.

Which of the following is a violating of a client's right to self-determination? 1. Hidden inducements 2. Sharing a client's information with a pharmaceutical company 3. Providing basic care to the client 4. Giving the client information about what participating in a study will involve

1. Hidden inducements *Rationale*: Hidden inducements, such as suggestions that by taking part in a study they might become famous or make an important contribution to science, must be strictly avoided. Sharing client information with the pharmaceutical company may be a violation of the client's right to privacy. Providing basic care to the client is a basic nursing function. Giving the client information about the study is part of full disclosure that is a basics client right.

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care

1. Hospital policies *Rationale*: Policy and procedure documents provide data about how certain situations are handled. Standardized care plans (option 2) and standards of care (option 4) are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmusical client needs. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually. Orthopedic protocols (option 3) would address elements specifically associated with the surgery, not whether the family slept in the room.

A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis. 1. If both medical and nursing interventions are required to treat the problem 2. When independent nursing actions can be utilized to treat the problem 3. In cases where nursing interventions are the primary actions required to treat the problem 4. When no medical diagnosis (disease) can be determined

1. If both medical and nursing interventions are required to treat the problem *Rationale*: A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated.

What is an example of illness prevention? 1. Immunizing children against chickenpox 2. Caring for a dying client 3. Assisting a stroke victim to the highest rehabilitation level possible 4. Secondary prevention

1. Immunizing children against chickenpox *Rationale*: Immunization is an illness prevention strategy that is primary prevention, not secondary. Caring for a dying client is palliative care and tertiary care. Assisting a stroke victim is rehabilitative care - also tertiary care. Secondary prevention is the diagnosis and treatment of disease, illness, or injury.

The nurse instructs the preoperative client to cough and deep breathe postoperatively to avoid respiratory complications. This is what type of nursing intervention? 1. Independent intervention 2. Dependent intervention 3. Collaborative intervention 4. Variable intervention

1. Independent intervention *Rationale*: This intervention is known as an independent intervention. These are activities that nurses are licensed to initiate on the basis of their knowledge and skills.

Which individuals are eligible for Supplemental Security Income (SSI)? (Select all that apply.) 1. Individuals who are blind 2. Individuals not eligible for Social Security 3. Children from low-income families that are covered under Medicaid 4. Anyone over age 65 5. Anyone with a diagnosed disability

1. Individuals who are blind 2. Individuals not eligible for Social Security 5. Anyone with a diagnosed disability *Rationale*: Supplemental Security Income (SSI) is for individuals with disabilities, individuals who are blind, or those who may not be eligible for Social Security. The benefits are not restricted to health care costs. Clients often use this money to purchase medicines or to cover the costs of extended health care.

The nurse is teaching a client about wound care during a follow-up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence-based practice when the client states, "I just don't know how I can afford these dressings"? 1. Integrity 2. Intellectual humility 3. Confidence 4. Independence

1. Integrity *Rationale*: By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attires characterized by an awareness of the limits of one's own knowledge, and being trustworthy. Option 4, indicates an attitude of not being easily swayed by the opinions of others.

While working in the critical care unit, a nurse is caring for client after cardiac bypass surgery. The nurse feels that "something is wrong" even though the client has no outward signs or symptoms. What is this an example of? 1. Intuition 2. Trial and error 3. Research process 4. Scientific method

1. Intuition *Rationale*: Intuition is the understanding or learning of things without the conscious use of reasoning, whereas the research process is a formalized, logical, systematic approach to problem solving. Intuition is also known as the "sixth sense."

What are the benefits of a nursing intervention classification system? (Select all that apply.) 1. It helps demonstrate the impact that nurses have on the health care delivery system 2. It assists educators to develop curricula that better articulates with clinical practice 3. It standardizes and defines the knowledge base for nursing curricula and practice 4. It facilitates the appropriate selection of a nursing intervention and communication of nursing treatments to other nurses and other providers

1. It helps demonstrate the impact that nurses have on the health care delivery system 2. It assists educators to develop curricula that better articulates with clinical practice 3. It standardizes and defines the knowledge base for nursing curricula and practice 4. It facilitates the appropriate selection of a nursing intervention and communication of nursing treatments to other nurses and other providers *Rationale*: All of the selections are correct. The benefits of specific nursing interventions enable nursing professionals to provide anticipated changes in the clients.

One of the goals of Betty Neuman's health care systems model is: 1. Maintenance of system equilibrium 2. Assisting the client to achieve the highest level of self-care 3. Promoting internal and external stimuli that influence the client's well-being 4. To heal the client and make the bed available for sicker clients

1. Maintenance of system equilibrium *Rationale*: Maintenance of system equilibrium is one of the goals of Betty Neuman's nursing theory. Orem's model is based on assisting the client to achieve the highest level of self-care. Internal and external stimuli are based on Roy's adaptation model. The last choice in this grouping of answers is not a factor in any of the nursing theories.

A client was discharged after having a 1-day surgery on her gallbladder. The nurse discharging the client failed to give the client oral or written discharge instructions. This failure to carry out the provision of discharge instructions could result in charges of: 1. Malpractice 2. Negligence 3. Assault 4. Battery

1. Malpractice *Rationale*: Failing to provide discharge instructions is a form of malpractice. The nurse should document in the client's chart that discharge instructions were given verbally, the client expressed understanding of the discharge instructions, and/or a copy of the discharge instructions were given to the client or caregiver. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Assault can be described as an attempt or threat to touch another person unjustifiably. Assault precedes battery; it is the act that causes the person to believe a battery is about to occur.

Which of the following actions is NOT appropriate for the nurse bathing a person with dementia? 1. Move quickly and let the person know when you are going to move him or her 2. Use a supportive, calm approach and praise the person often 3. Gather everything that you will need for the bath (e.g., towels, washcloths, clothes) before approaching the person 4. Help the person feel in control

1. Move quickly and let the person know when you are going to move him or her

The case management model using critical pathways would be appropriate for a client with which diagnosis? 1. Myocardial infarction (heart attack) 2. Diabetes, hypertension 3. Myocardial infarction, diabetes, hypertension 4. Diabetes, hypertension, an infected foot ulcer, senile dementia

1. Myocardial infarction (heart attack) *Rationale*: Critical pathways work best for clients with one diagnosis. Option 2 is a possibility; however, there may be many individualized needs. Because that information is not available, the best answer is 1. Options 3 and 4 have too many diagnoses to work well with a critical pathway.

A primary care provider prescribes one tablet, but the nurse accidentally administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for professional negligence? 1. No, the client was not harmed 2. No, the nurse notified the primary care provider 3. Yes, a breach of duty exists 4. Yes, foreseeability is present

1. No, the client was not harmed *Rationale*: All elements such as duty, foreseeability, causation, harm/injury, and damages must be present for professional negligence to be proven. The nurse is a licensed professional responsible for individual actions. Notifying the primary care provider does not exempt the nurse from liability. Because it is apparent the standard of practice was not performed, a breach of duty does exist. Violation/omission of the standard of practice resulted in an excessive dosage. Therefore, foreseeability is present; however, no harm occurred to the client.

Mrs. Treem is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? 1. Nosocomial 2. Viral 3. Iatrogenic 4. Antimicrobial

1. Nosocomial *Explanation*: (3) Iatrogenic infections are a result of diagnostic or therapeutic procedures. (1) Nosocomial infections are classified as infections that originate in the hospital. She acquired MRSA AFTER hospitalization, not just a procedure.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Repositioning a client in bed to prevent skin breakdown: ____________

1. Nurse caregiver

Which provides the best explanation for describing nursing as a practice discipline? 1. Nursing focuses on performing the professional role 2. It takes time and experience to become a competent nurse 3. Research and theory development is a central focus 4. Nurses function as members of a team who form a practice group

1. Nursing focuses on performing the professional role *Rationale*: Practice disciplines are fields of study in which the central focus is performance of a professional role. Time and experience are necessary for developing proficiency in any profession or career (option 2). Research and theory development do not have performance as their primary focus. The primary focus of nursing is providing quality service to humans (option 3). Team or group practice can be a part of a career in humanities, computer science, or rocket science (option 4).

The nurse reassesses a client's temperature 45 minutes after administering acetaminophen. This is an example of what type of an assessment? 1. Ongoing 2. Intermittent 3. Terminal 4. Routine

1. Ongoing *Rationale*: The ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, whereas terminal evaluation indicate the client's condition at the time of discharge.

An example of a middle-range nursing theory is: 1. Peplau's psychodynamic nursing model 2. Jean Watson's model of human caring 3. Roy's adaptation model 4. Imogene King's theory of goal attainment

1. Peplau's psychodynamic nursing model *Rationale*: Peplau's psychodynamic nursing model is an example of a middle-range theory. Watson's, Orem's, and King's theories are considered grand theories.

In the late 20th century, much of the theoretical work in nursing forced on articulating relationships among four major concepts. (Select the major concepts.) 1. Person 2. Environment 3. Nursing 4. Professionalism 5. Health

1. Person 2. Environment 3. Nursing 5. Health *Rationale*: The four major concepts are considered to be person or client, the recipient of nursing care (includes individuals, families, groups, and communities); the environment, the internal and external surroundings that affect the client - the environment includes people in the physical environment, such as families, friends, and significant others; health, the degree of wellness or well-being that the client experiences; and nursing, the attributes, characteristics, and actions of the nurse proving care on behalf of or in conjunction with the client.

What measures can the nurse take to maintain confidentiality of client records? (Select all that apply.) 1. Personal passwords are not shared with anyone else 2. Never leave the computer unattended after logging into the system 3. Do not leave paperwork with the client's information in an unsecured location 4. Discard all unneeded computer-generated worksheets in the trash can

1. Personal passwords are not shared with anyone else 2. Never leave the computer unattended after logging into the system 3. Do not leave paperwork with the client's information in an unsecured location *Rationale*: The nurse has a legal and ethical duty to maintain confidentiality of the client's record. Personal passwords should not be shared, the nurse should never leave the computer unattended, and paperwork should not be left unattended in an unsecured location. Client records should never be discarded into a trash can; they should be shredded or disposed of per the facility policies.

Which is an accurate statement about the role of nursing theory? 1. Practice theories assist nurses to reflect on the effectiveness of what they do 2. Midievel theories, describing the interrelationships among a broad range of concepts within nursing, have been well tested through nursing research 3. All schools of nursing in the US are organized around one of the conceptual models described in this chapter 4. Nursing theory guides the direction of research but not that of education or practice

1. Practice theories assist nurses to reflect on the effectiveness of what they do *Rationale*: Practice theories assist the nurse to reflect on nursing care. Theories describing the interrelationships among a broad range of concepts within nursing are grand theories, not midlevel, and both require more testing through nursing research (option 2). Schools of nursing in the Un item States may or may not be organized around any theory or conceptual model (option 3). Nursing theory guides the direction of research and education and practice (option 4).

While attending a continuing education seminar, several nurses from different states are discussing their individual state requirements for nursing licensure. Which of the following is the one common thread between all of the states' departments of nursing? 1. Protect the public 2. Further nursing education 3. Obtain continuing education contact hours 4. Gain specialization

1. Protect the public *Rationale*: Although nurse practice acts differ in various jurisdictions, they all have a common purpose: to protect the public.

What moral framework is the nurse operating under if she refuses to participate in a surgery for a 93-year-old client who has stated on numerous occasions that he does not want further surgery? His family and surgeon are insisting on the client having the surgery. The nurse's rationale is that the nurse-client relationship commits her to protecting him and meetings his needs. 1. Relationships-based theory 2. Consequences-based theory 3. Deontological-based theory 4. Principles-based theory

1. Relationships-based theory *Rationale*: The relationships-based (caring) theories stress courage, generosity, commitment, and the need to nurture and maintain relationships.

Following a motor vehicle crash, the parents of a child with no apparent brain function refuse to permit withdrawal of life support from the client. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse's actions? 1. Respect for autonomy 2. Nonmaleficence 3. Beneficence 4. Justice

1. Respect for autonomy *Rationale*: Autonomy is the client's (or surrogate's) right to make his or her own decision. The nurse is obliged to respect a client's or significant other's informed decision. These parents may modify their decision as time goes on and the child's condition, or their feelings, change. This situation is not clearly one of nonmaleficence (do no harm) in option 2 or beneficence (do good) in option 3 since there are many aspects of both. If the child appeared to be suffering or an effective treatment was being denied, these principles might apply. Justice (fairness) generally applies when the rights of one client are being balanced against those of another client (option 4).

Which of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness course 2. Risk for Falls related to tendency to collapse when having difficulty breathing 3. Impaired Communication related to stroke 4. Sleep Deprivation secondary to fatigue and a noisy environment

1. Risk for Caregiver Role Strain related to unpredictable illness course *Rationale*: States the relationship between the stem (caregiver role strain) and the cause of the problem. Option 2: The diagnostic statement says the same thing as the related factor (falls and collapse). Option 3: It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

Continuing education is the responsibility of the nurse to keep abreast of __________ and __________ changes and also changes within the nursing profession. 1. Scientific and technologic 2. Medical and technologic 3. Scientific and human responses 4. Cardiac and neurologic

1. Scientific and technologic *Rationale*: Scientific and technologic advances are key factors in keeping abreast of the changing health care environment.

Basic nursing interventions are based on: 1. Scientific knowledge, nursing research, and evidence-based practice 2. Creative thinking and intuition 3. Physician's orders 4. Client's wishes and nursing research

1. Scientific knowledge, nursing research, and evidence-based practice *Rationale*: Nursing interventions are based on scientific knowledge, nursing research, and evidenced-based practice. The nurse implements the interventions and evaluates the desired outcomes. Based on this evaluation, the plan of care is modified, continued, or modified.

A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation? 1. Six round skin lesions partially healed, on the inner thighs bilaterally 2. Several burned areas on both of the client's inner thighs 3. Multiple lesions on inner thighs possible related to elder abuse 4. Several lesions on inner thighs similar to cigarette burns

1. Six round skin lesions partially healed, on the inner thighs bilaterally *Rationale*: Option 1 is the most specific, non assuming, and nonjudgmental charting. Option 2 could be more specific by describing the lesions and not calling them "burns." Option 3 is making a judgment of elder abuse, and option 4 is also making an assumption that the lesions are from cigarette burns.

A quality-assurance (QA) program evaluates and promotes excellence in the health care provided to clients. Select the three components of care that are reviewed during this process: 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Internal processes and external agency evaluations

1. Structure evaluation 2. Process evaluation 3. Outcome evaluation *Rationale*: A quality assurance program is an evaluation that includes the consideration of the structures, processes, and outcomes of nursing care. Quality improvement is a philosophy and process internal to the institution, and does not rely on inspections by an external agency.

While implementing the plan of care for the client, the nurse should: (Select all that apply.) 1. Supervise unlicensed support personnel who provide care to the client 2. Completed every task for the client 3. Supervise and direct the physician providing care 4. Evaluate the client's reactions to the planned interventions

1. Supervise unlicensed support personnel who provide care to the client 4. Evaluate the client's reactions to the planned interventions *Rationale*: One of the steps during the implementation of the plan of care is to supervise delegated care of unlicensed personnel such as nursing assistants or patient care technicians. Evaluating the client's reaction to panner interventions is an important aspect of the nursing process. The nurse does not supervise and direct care of the physician. The nurse will not perform all patient care including all baths, vital signs, and activities of daily living. These activities may be performed by unlicensed personnel and the nurse should delegate these activities.

Which of the following would indicate a significant cue when comparing data to standards? Select all that apply. 1. The client has moved partway toward a set goal (e.g., weight loss) 2. The client's vision is within normal range only when wearing glasses 3. A child is able to control bladder and bowels at age 18 months 4. A recently widowed woman states she is "unable to cry." 5. A 16-year-old high school student reports spending 6 hours doing homework five nights per week

1. The client has moved partway toward a set goal (e.g., weight loss) 4. A recently widowed woman states she is "unable to cry." 5. A 16-year-old high school student reports spending 6 hours doing homework five nights per week *Rationale*: A client's movement toward a goal (option 1) or whose behavior is inconsistent with population norms (options 4 and 5) represents a cue that further analysis toward creating a nursing diagnosis is required. Corrected vision (option 2) are bladder and bowel control at age 18 months (option 3) are consistent with population norms.

Which example of documentation is most correct when charting a client's behavior? 1. The client was shouting, "I am so mad that I am going to hit you if you come any closer." 2. The client seems angry and moderately aggressive 3. The client is angry and shouting 4. The client stated that he was mad and wanted to hit someone

1. The client was shouting, "I am so mad that I am going to hit you if you come any closer." *Rationale*: The charting is specific, concise, descriptive, nonjudgmental, and objective. The other three examples are vague and subjective.

Which of the following is true regarding the relationship of implementing to the other phases of the nursing process? 1. The findings from the assessing phase are reconfirmed in the implementing phase 2. After implementing, the nurse moves to the diagnosing phase 3. The nurse's need for involvement of other health care team members in implementing occurs during the planning phase 4. Once all interventions have been completed, evaluating can begin

1. The findings from the assessing phase are reconfirmed in the implementing phase *Rationale*: During implementing, the nurse also assesses and compares with the initial assessment. Evaluating follows implementing (option 2), mobilization of other health care teams is a part of implementing (option 3), and evaluating occurs during or immediately after each intervention, not waiting for all interventions to be completed (option 4).

Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions is/are most appropriate? Select all that apply. 1. The nurse needs to know the Good Samaritan Act for the state 2. The nurse is not held liable unless there is gross negligence 3. After assessing the situation, the nurse can leave to obtain help 4. The nurse can expect compensation for helping 5. The nurse offers to help but cannot insist on helping

1. The nurse needs to know the Good Samaritan Act for the state 2. The nurse is not held liable unless there is gross negligence 5. The nurse offers to help but cannot insist on helping *Rationale*: The nurse is subject to the limitation of the state law and should be familiar with the Good Samaritan laws in the specific state. Gross negligence would be described by the individual state law. Unless there is another equally or more qualified person present, the nurse needs to stay until the injured person leaves. The nurse should ask someone else to call or go for additional help. Since there was no prior agreement, the nurse cannot accept compensation.Also, the nurse is not employed by the accident victim. The same client rights apply at the scene of an accident as well as those in the work.

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision making is the nurse engaging in? 1. The research method 2. The trial-and-error method 3. Intuition 4. The nursing process

1. The research method *Rationale*: The research method uses a research study-based approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the specific (research) process (option 4).

Which of the following is likely to occur if a goal statement is poorly written? 1. There is no standard against which to compare outcomes 2. The nursing diagnoses cannot be prioritized 3. Only dependent nursing interventions can be used 4. It is difficult to determine which nursing interventions can be delegated

1. There is no standard against which to compare outcomes *Rationale*: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option 2). Both independent and dependent interventions may be appropriate for any goal (option 3). Clarity of the goals does not influence delegation of the intervention (option 4).

Which is the most effective nursing action for preventing and controlling the spread of infection? 1. Thorough hand hygiene 2. Wearing globes and masks when providing direct client care 3. Implementing appropriante isolation precautions 4. Administering broad-spectrum prophylactic antibiotics

1. Thorough hand hygiene

How are nursing cognitive skills learned? 1. Through reading and applying health-related literature 2. Through the use of critical thought 3. Through the application of content the nurse has previously learned 4. Through the application of clinical scenarios the nurse has experienced

1. Through reading and applying health-related literature *Rationale*: Nursing cognitive skills are learned through reading and applying health-related literature. The other answer choices reflect how cognitive skills are enhanced, not learned.

According to HIPPA regulations, which of the following is a patient right regarding the patient's medical record? Select all that apply. 1. To see the health record 2. To copy the health record 3. To make additions to the health record 4. To cross out sections of the health record 5. To restrict certain disclosures of the health record 6. To destroy the health record

1. To see the health record 2. To copy the health record 5. To restrict certain disclosures of the health record *Explanation*: (2) It is okay to make a copy of the health record if the patient is moving and needs to get a copy of medical records for new doctor or something. (3) is not correct because you cannot make additions to a health record, you can just update one. (4) is incorrect because the patient is not allowed to take out any information; they can disagree, but you cannot say the patient said "this section is wrong" and then cross it out.

The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1. Turn the hearing aid off 2. Soak the hearing aid in soapy solution to clean it 3. Turn the volume all the way up 4. Remove the batteries

1. Turn the hearing aid off

According to the 2014 National Patient Safety Goals (NPSGs), what are the ways to improve accuracy of patient information? (Select all that apply.) 1. Use at least two patient identifiers when providing care, treatment, and services 2. Report critical results of test and diagnostic procedures on a timely basis 3. Eliminate transfusion errors related to patient misidentification 4. Maintain and communicate accurate patient medication information 5. Label all mediations, medication containers, and other solutions on and off the sterile field in preoperative and other procedural settings

1. Use at least two patient identifiers when providing care, treatment, and services 3. Eliminate transfusion errors related to patient misidentification

Which charting rule(s) will keep the nurse legally safe? Select all that apply. 1. Use military time 2. Document worries of concerns expressed by the client 3. Perform most of the. charting expressed by the client 4. Record any information that pertains to the client's health problems

1. Use military time 2. Document worries of concerns expressed by the client 4. Record any information that pertains to the client's health problems *Rationale*: Military time is commonly used; documenting worries or concerns provides clues to other nurses; gossip, unprofessional comments or thoughts, or personnel issues should not be recored in the client's chart. Option 3 is incorrect because charting should be done as events occur. Waiting until the end of the shift increases the change of forgetting something.

The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply. 1. Using a bottle during naps and bedtime can cause dental caries in a toddler 2. Schedule a visit to the dentist when your child is ready to go to school 3. It is important for parents to supervise a child's brushing of their teeth 4. Most older adults have dentures and don't need to worry about oral care 5. Older adults are at risk for periodontal disease

1. Using a bottle during naps and bedtime can cause dental caries in a toddler 3. It is important for parents to supervise a child's brushing of their teeth 5. Older adults are at risk for periodontal disease

Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part D is the: 1. Voluntary prescription drug plan that begin in January 2006 2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible 3. Plan section providing insurance toward hospitalization, home care, and hospice care 4. Plan section providing very limited financial coverage to low-income persons

1. Voluntary prescription drug plan that begin in January 2006 *Rationale*: The Medicare plan is divided into two parts, Part A and Part B. Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescription drug plan begun in January 2006. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes.

Readiness for Enhanced Parenting is an example of which type of diagnosis? 1. Wellness diagnosis 2. Health-seeking diagnosis 3. Two-part diagnosis 4. Three-part diagnosis

1. Wellness diagnosis *Rationale*: Soem diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only.

The CDC recommends antimicrobial hand cleansing agents in all of the following situations EXCEPT: 1. When there are unknown multiple nonresistant bacteria 2. Before invasive procedures 3. In special care units, such as nurseries and ICUs 4. Before caring for severely immunocompromised clients

1. When there are unknown multiple nonresistant bacteria

When providing foot care for a client, the nurse would perform which of the following? 1. When washing, inspect the skin of the feet for breaks or red or swollen areas 2. Do not cover the feet and between the toes with creams or lotions to moisten the skin 3. Do not check the water temperature before immersing the feet 4. Wash the feet every other day, and dry them well, especially between the toes

1. When washing, inspect the skin of the feet for breaks or red or swollen areas

A female is considering a career as a nurse because of the aspects of caring and nurturing. This individual is using which factor of nursing to base her decision? 1. Women's roles 2. Religion 3. War 4. Economics

1. Women's roles *Rationale*: The traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting. Religion has also played a significant role in the development of nursing. The Christian value of "love thy neighbor as thyself" and Christ's parable of the Good Samaritan both had a significant impact on the development of Western nursing. Wars accentuate the need for nurses. Greater financial support provided through public and private health insurance program has increased the demand for nursing care

A client with diarrhea also has a primary care provider's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "The primary care provider does not know the client has diarrhea." What type of statement is this? 1. A fact 2. An inference 3. A judgment 4. An opinion

2. An inference *Rationale*: The nurse has inferred and concluded something that is beyond the available information (and in this case may not be accurate). The prescription and the diarrhea are facts (option 1). It would be judgment and opinion if the nurse stated that the laxative would make the diarrhea worse and should not be given (options 3 and 4). (Note: Critical thinking will cause this nurse to examine the assumptions made and gather more data before acting.)

Which of the following means freedom from disease-causing microorganisms? 1. Medical asepsis 2. Asepsis 3. Surgical asepsis 4. Sepsis

2. Asepsis

Nightingale, Henderson, and Watson developed philosophies of nursing. Why are their works considered philosophies then discussed in nursing? 1. Because they were the first three nursing theorists 2. Because it was an early effort to define nursing phenomena that serves as the basis for later theoretical formulations 3. Because they had grand theories of nursing and not middle-level theories 4. Because it was a late effort to define nursing

2. Because it was an early effort to define nursing phenomena that serves as the basis for later theoretical formulations *Rationale*: It was an early effort to define nursing phenomena that serves as the basis for later theoretical formulations.

One of the major responsibilities the nurse has when conducting nursing research is: 1. Encouraging the participation of clients in nursing research 2. Being aware of and advocating on behalf of clients' rights 3. Exposing clients to the possibility of injury from the research 4. Pressuring clients into participating in the study

2. Being aware of and advocating on behalf of clients' rights *Rationale*: All nurses involved in research have a role in safeguarding the client's rights.

Person, environment, health, and nursing constitute the metaparadigm for nursing because they do which of the following? 1. Provide a framework for implementing the nursing process 2. Can be utilized in any setting when caring for a client 3. Can be utilized to determine applicability of a research study 4. Focus on the needs of a group of clients

2. Can be utilized in any setting when caring for a client *Rationale*: Person/client, environment, health, and nursing are relevant when providing care for any client whether in the hospital, at home, in the community, or in elementary school systems. These elements can be used to understand diseases, conduct and apply research, and develop nursing theories, as well as implement the nursing process.

Which clinical scenario is an example of nonmaleficence and unintentional harm? 1. Not locking a wheelchair and transferring a client into the wheelchair 2. Catching a client who is falling and bruising the client's arm 3. A client's allergic reaction to a prescribed medication 4. Administering oxygen at 6 L/min to a client when the order is for 2 L/min

2. Catching a client who is falling and bruising the client's arm *Rationale*: Unintentional harm occurs when the risk could not have been anticipated. The other examples are examples of intentional harm. Harm can be intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. A client may be at risk of harm as a known consequence of a nursing intervention that is intended to be helpful.

Some examples of concepts, which are defined as labels given to ideas, objects, or events, are: 1. Intelligence, motivation, and obesity 2. Comfort, fatigue, pain, depression, and/or environment 3. Self-care, adaptation, caring, behavioral system, and/or nurse-client transactions 4. Humanistic endeavors, unitary man, and/or learned helplessness

2. Comfort, fatigue, pain, depression, and/or environment *Rationale*: Concepts are labels given to ideas, objects, and/or events - a summary of thoughts or a way to categorize thoughts or ideas. Intelligence, motivation, learned helplessness, and/or obesity are examples of a construct, which is a group of concepts. A theory is the organization of concepts or constructs that shows the relationship of the ideas with the intent of describing, explaining, or predicting. An example of a theory includes self-care, adaptation, caring, behavioral system, unitary man, hierarchy of needs, interpersonal relationships, humanistic, and//or nurse-client transactions.

Which of the following identifies the "C" in PICO? 1. Comprehension 2. Comparison 3. Challenging 4. Confidentiality

2. Comparison *Rationale*: A strategy for identifying key terms when locating research literature is PICO. P stands for patient, population, or problem of interest. I stands for intervention or therapy to consider for the subject of interest. C stands for comparison of interventions, such as no treatment. O stands for outcome of the intervention.

A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner's stages of nursing expertise? 1. Advanced beginner 2. Competent 3. Proficient 4. Expert

2. Competent *Rationale*: Option 1, the advanced beginner, demonstrates marginally acceptable performance. Option 3, the proficient practitioner, has 3 to 5 years of experience and has developed a holistic understanding of the client. Option 4, the expert practitioner, demonstrates highly skilled intuitive and analytic ability in new situations.

Which is an example of continuing education for nurses? 1. Attending the hospital's orientation program 2. Completing a workshop on ethical aspects of nursing 3. Obtaining information about the facility's new computer charting system 4. Talking with a company representative about a new piece of equipment

2. Completing a workshop on ethical aspects of nursing Continuing education refers to formalized experiences designed to enhance the knowledge or skill of practitioners. The other answers are examples of in-service education, which is designed to upgrade the knowledge or skills of current employees with regard to the specific setting, and is usually less formal in presentation.

The nurse writes an evaluation statement after determining whether a nursing goal or client outcome has been met. What are the two parts in an evaluation statement? 1. Conclusion and implementation 2. Conclusion and supporting data 3. Implementation and summary 4. Implementation and data analysis

2. Conclusion and supporting data *Rationale*: The evaluation statement consists of two parts, conclusion, and supporting data. The conclusion is a statement that the goal or desired outcome was met, partially met, or not met. Supporting data are the list of client responses that support the conclusion. Reexamining the client care-plan is a process of making decisions about problem status and critiquing each phase of the nursing process.

Which of the following represents application of the components of evaluating? 1. Goal achievement must be written as either completely met or unmet 2. Data related to expected outcomes must be collected 3. If the outcome was achieved, conclude that the plan was effective 4. After determining that the outcome was not met, start over with a new nursing care plan

2. Data related to expected outcomes must be collected *Rationale*: Evaluating requires that client behavior be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved but not be a direct result of the plan or interventions (option 3). A care plan should be continued, modified, or terminated based on achievement of outcomes (option 4).

In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. Excess fluid volume 2. Decreased venous return 3. Edema 4. Unknown

2. Decreased venous return *Rationale*: Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem. Excess Fluid Volume is the nursing diagnosis, and edema of the lower extremity is the sign/symptom of critical attribute. The cause is known.

The nurse is conducting the diagnosing phase (nurse diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? 1. Assess the client's needs 2. Delineate the client's problems and strengths 3. Determine which interventions are most likely to succeed 4. Estimate the cost of several different approaches

2. Delineate the client's problems and strengths *Rationale*: In diagnosing, data from assessment (option 1) are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established. Interventions (option 3) are more commonly part of the planning and implementing phases of the nursing process. Cost (option 4) is an important consideration but would be estimated in the planning phase.

Most statutes include conscience clauses that are designed to protect hospitals and nurses in matters dealing with abortion services. These clauses allow the nurse to be protected from: 1. Prejudicial statements 2. Discrimination or retaliation 3. Defamation or unjust prejudice 4. Legal liability

2. Discrimination or retaliation *Rationale*: The conscience clauses give hospitals the right to deny admission to abortion clients and give health care personnel, including nurses, the right to refuse to participate in abortions. When these rights are exercised, the statutes also protect the agency and employee from discrimination or retaliation.

A nurse is providing oral care to a patient with dentures. What action would the nurse do first? 1. Assess the mouth and gums 2. Don gloves 3. Wash the patient's face 4. Apply lubricant

2. Don gloves *Explanation*: "Don" means to put on; "Doth" means to take off. You need to put on gloves before providing oral care to a patient with dentures... gross.

If the nurse makes an error while charting, what is the recommended method to correct the mistake? 1. Use "correction fluid" and obliterate the error 2. Draw one line through the error and write "mistaken entry" above it, then sign your name or initials beside it 3. Draw one line through the error and write "error" above it, then sign your initials beside it 4. Do nothing and hope no one notices the error

2. Draw one line through the error and write "mistaken entry" above it, then sign your name or initials beside it *Rationale*: Draw a line through it and write the words "mistaken entry" above or next to the original entry with your name or initials. Do not erase, blot out, or use correction fluid. Avoid writing the word "error" when recording that a mistake has been made.

Which types of precautions are used for clients known or suspected to have serious illnesses transmitted by particle droplets larger than 5 microns? 1. Airborne 2. Droplet 3. Contact 4. Connection

2. Droplet

Which of the following is a nursing responsibility when reading published nursing research? 1. Assume that the research was properly conducted since it has been published 2. Evaluate whether the findings are applicable to the nurse's specific clients 3. Implement the research findings if at least two studies have shown the same results 4. Request the raw data from the researchers so that the nurse can analyze the statistics again

2. Evaluate whether the findings are applicable to the nurse's specific clients *Rationale*: Since the primary purpose of research is to improve the quality of client care, the nurse should determine if published research results are applicable to the specific client population. Published studies may have flawed designs, data collection, or analysis (option 1). Although more than one well-conducted study with similar findings supports usefulness of the results, applicability must still be determined for the specific client population (option 3). It is not realistic for the nurse to rerun the raw data to check the results of the study.

A registered nurse is interested in functioning as a health care advocate for individuals whose lives are affected by violence. This nurse will be investigating which expanded career role? 1. Clinical nurse specialist 2. Forensic nurse 3. Nurse practitioner 4. Nurse educator

2. Forensic nurse *Rationale*: All of the expanded roles function as health care advocates and all could work with individuals affected by violence. However, the forensic nurse specifically integrates forensic skills into nursing practice.

Which nursing actions could result in professional negligence? Select all that apply. 1. Learns about a new place of equipment 2. Forgets to complete the assessment of a client 3. Does not follow up on client's complaints 4. Charts client's drug allergies 5. Questions primary care provider about an illegible order

2. Forgets to complete the assessment of a client 3. Does not follow up on client's complaints *Rationale*: Standards of practice require a complete assessment. A nurse needs to be sure the client's needs have been met. They both can impact client safety and do not follow standards of care. The other options meet the standards of practice.

The nurse needs to insert a hearing aid into a client's ear. Which of the following actions is NOT correct? 1. Determine from the client if the earned is for the left or the right ear 2. Gently press the earmold into the ear while rotating it forward 3. Inspect the earmold to identify the ear canal portion 4. Check that the earmold fits snugly by asking the client if it feels secure and comfortable

2. Gently press the earmold into the ear while rotating it forward

A client wants to read his chart, the nurse should: 1. Call the doctor to obtain permission 2. Give the client the chart and answer questions for him 3. Tell the client that he can read the chart when the doctor makes rounds 4. Ask the client what he wants to know and answer those questions without giving him the chart

2. Give the client the chart and answer questions for him

What framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior? 1. Orem's self-care model 2. Gordon's functional health patterns 3. Roy's adaptation model 4. The wellness model

2. Gordon's functional health patterns *Rationale*: Gordon's functional health pattern framework collects data about functional and dysfunctional behaviors. Orem delineates eight universal self-care requisites of humans. Roy uses the adaptation model and classifies observable behaviors into four categoriesL physiological, self-concept, role functions, and interdependence.

Which is more commonly a characteristic of a manager rather than a leader? 1. Is visionary 2. Has been given legitimate power by the organization 3. Primary effectiveness is through influencing others 4. Often tasks risks and explores new solutions to problems

2. Has been given legitimate power by the organization *Rationale*: Managers are employees and have been given authority by the institution for which they work. The other options are characteristic of leaders more than managers.

A nurse demonstrating therapeutic communication with a client who has been diagnosed with depression: 1. Florence Nightingale 2. Hildegard Peplau 3. Martha Rogers 4. Imogene King

2. Hildegard Peplau *Rationale*: Martha Roger's Science of Unitary Human Beings states the idea of non-contact therapeutic touch. This is the idea that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Florence Nightingale's Environmental Theory linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness. In addition tho those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect n the person. Peplau's Interpersonal Relations Model introduces the existence of a therapeutic relationship between the nurse and the client. Imogene King's Goal Attainment Theory describes the nature of and standard for nurse-client interactions that lead to goal attainment - that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment represents outcomes.

Which of the following nursing diagnostic statements is correct? 1. Fluid Replacement related to fever 2. Impaired Skin Integrity related to immobility 3. Impaired Skin Integrity related to ulceration of sacral area 4. Pain related to severe headache

2. Impaired Skin Integrity related to immobility *Rationale*: This statement is considered a two-part statement and lists the diagnosis with the related factors and characteristics.

Why is the nursing process method using in nursing? (Select all that apply.) 1. It allows the nurse to work independently without collaboration 2. It involves the interaction between the client and nurse as they work together 3. It is used to identify potential or actual health care needs, set goals, device a plan to meet the client's needs, and evaluate the plan's effectiveness 4. It is designed to work well in all environments

2. It involves the interaction between the client and nurse as they work together 3. It is used to identify potential or actual health care needs, set goals, device a plan to meet the client's needs, and evaluate the plan's effectiveness 4. It is designed to work well in all environments *Rationale*: The nursing process involves the interaction between client and nurse as they work together. It is used to identify potential or actual health care needs, set goals, devise a plan to meet the client's needs, and evaluate that plan's effectiveness. The nursing process is designed to work will in all environments.

The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. Delete the diagnosis since the problem has not occurred 2. Keep the diagnosis since the risk factors are still present 3. Modify the nursing diagnosis to Impaired Mobility 4. Demote the nursing diagnosis to a lower priority

2. Keep the diagnosis since the risk factors are still present *Rationale*: There is no reason to delete (option 1) or modify (option 3) the nursing diagnosis or demote its priority (option 4) because the risk factors that prompted it are still present.

Which charting entries are written correctly? Select all that apply. 1. MS 5 gr given IV for c/o abdominal pain 2. Lanoxin 0.25 mg given orally per Dr. smith's stat order 3. KCl 15 mL given orally for K+ level of 2.9 4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180 5. Ambien 5 mg given orally at bedtime per request

2. Lanoxin 0.25 mg given orally per Dr. smith's stat order 3. KCl 15 mL given orally for K+ level of 2.9 5. Ambien 5 mg given orally at bedtime per request *Rationale*: Option 1: "MS" is on the "Do Not Use" list - the nurse needs to write out morphine sulfate. Option 4 has three errors - should not have a trailing zero after the decimal point; "u" and "SQ" are on the "Do Not Use" list.

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current plan care? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection

2. Nausea *Rationale*: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client's pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option 3). Wound infection can occur, but there are no data to indicate that this requires a change in the current plan (option 4).

A nurse discovers that a primary care provider has prescribed an unusually large dosage of medication. Which is the most appropriate action? 1. Administer the medication 2. Notify the prescriber 3. Call the pharmacist 4. Refuse to administer the medication

2. Notify the prescriber *Rationale*: The nurse should call the person who wrote the order for clarification. Administering the medication is incorrect because knowing the dose is outside the normal range and not questioning the order could lead to client harm and liability for the nurse. Calling the the pharmacist is not the best answer because it will notes love the problem, and the nurse needs to seek clarification from the person who wrote the order. The nurse should suspend administration but not refuse to administer the medication until the issue is resolved.

The most significant method for reducing the ongoing increase in the cost of health care in the US includes controlling which of the following? 1. Number of children according to the family's income 2. Numbers of uninsured and underinsured persons 3. Number of physicians and nurses nationwide 4. Competition among drug and medical equipment manufacturers

2. Numbers of uninsured and underinsured persons *Rationale*: When people have inadequate insurance for health costs, they tend to avoid early and preventive care. This results in eventual use of much more costly resources such as emergency departments. Methods to provide minimum levels of insurance coverage have been successful in other countries. The number of children is increasing, but in the US and Canada, this is a non modifiable factor (option 1). Also, the majority of health care costs are incurred by adults and older adults who tend to have multiple and chronic health conditions. There is currently a significant shortage of nurses and maldistribution of physicians so reducing their numbers would only worsen the problem (option 3). Competition among manufacturers is more likely to cause costs to fall than to rise.

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning? 1. Notify the primary care provider 2. Obtain vital signs and oxygen saturation 3. Request a chest x-ray 4. Call the rapid response team

2. Obtain vital signs and oxygen saturation *Rationale*: The nurses intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully. Option 1 supports appropriate nursing actions, but the client's respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 2). The rapid response team (option 4) may be needed if the client's condition becomes more critical.

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed 2. Pad the bed with blankets 3. Inform the client about the importance of wearing a medical identification tag 4. Teach the client about epilepsy 5. Test oral suction equipment

2. Pad the bed with blankets 5. Test oral suction equipment

In the PICO format for phrasing research questions and identifying key terms for a literature search, what does the "P" stand for? 1. Patterns 2. Population 3. Probability 4. Purpose

2. Population *Rationale*: PICO stands for patient/client, population, or problem; intervention; comparison; and outcome. These are helpful components of a research question and help to identify key terms for a literature search. Options 1, 3, and 4 are incorrect.

The nurse, who is working in a well-baby clinic, administers routine immunizations and recognizes this as prating within what area of nursing practice? 1. Promoting health and wellness 2. Preventing illness 3. Restoring health 4. Providing care to the dying

2. Preventing illness *Rationale*: The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care, and prevention of sexually transmitted infections.

Curricula for nursing education are strongly influenced by which of the following? Select all that apply. 1. Physician groups 2. Professional nursing organizations 3. Individual state boards of nursing 4. Hospital administers 5. The National Council of State Boards of Nursing

2. Professional nursing organizations 3. Individual state boards of nursing 5. The National Council of State Boards of Nursing *Rationale*: State boards of nursing set minimum educational requirements for licensure. Professional organizations establish educational criteria for program accreditation. The National Council of State Boards of Nursing conducts practice studies and creates the NCLEX-RN". Neither physicians (option 1) nor hospital administrators (option 4) are involved in setting nursing curricula.

The student nurse is learning how to fit into the nursing profession by learning the rules defining relationships, the behavior expected of a nurse, and to see the world in a manner similar to other nurses. This is known as: 1. Case management 2. Professionalization 3. Socialization 4. Governance

2. Professionalization *Rationale*: Professionalization is the process of becoming professional, that is, of acquiring characteristics considered to be professional.

Which of the following statements is true regarding types of health care agencies? 1. Hospitals provide only acute, inpatient services 2. Public health agencies are funded by governments to investigate and provide health problems 3. Surgery can only be performed inside a hospital setting 4. Skilled nursing, extended care, and long-term care facilities provide care for older adults whose insurance no longer covers hospital stays

2. Public health agencies are funded by governments to investigate and provide health problems *Rationale*: City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community. Hospitals may provide a variety of wellness and clinical programs in addition to inpatient services (option 1). Surgery may be performed in outpatient surgery centers and physicians' offices in addition to within hospitals (option 3). Skilled nursing, extended care, and long-term care facilities provide care to persons of all ages who require rehabilitation or subacute care. This is not necessarily related to insurance coverage for hospitals stays (option 4).

Which is a normal finding on auscultation of the lungs? 1. Tympany over the right upper lobe 2. Resonance over the left upper lobe 3. Hyperresonance over the left lower lobe 4. Dullness above the left 10th intercostal space

2. Resonance over the left upper lobe *Rationale*: Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled) (option 1), hyper resonance is never a normal finding (option 3), and dullness would be heard below (not above) the 10th intercostal space (option 4).

Which of the following situations is most clearly a violation of the underlying principles associated with professional nursing ethics? 1. A hospital's policy permits use of internal fetal monitoring during labor. However, there is literature to both support and refute the value of this practice. 2. When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed." 3. The nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by fellow nurses at another facility 4. A client reports that he didn't quite tell the doctor the truth when asked if he was following his therapeutic diet at home

2. When asked about the purpose of a medication, a nurse colleague responds, "Oh, I never look them up. I just give what is prescribed." *Rationale*: The nurse has an ethical responsibility to act only when actions are safe or risks minimized. This nurse is putting the client at unnecessary risk for a medication error. Many medical practices are controversial but not necessarily unethical (option 1). The nurse should follow agency policy. Although some may view nurses' strikes as unethical, supporting others who are striking is a personal decision (option 3). Although a client statement in confidence to a nurse may have ethical overtones, it does not automatically constitute an ethical dilemma. Since the assigned health care provider is a member of the team, principles of confidentiality do not include him or her (option 4).

Which of the following statements would be most helpful when a nurse is assisting clients in clarifying their values? 1. "That was not a good decision. Why did you think it would work?" 2. "The most important thing is to follow the plan of care. Did yo follow all your doctor's orders?" 3. "Some people might have made a different decision. What led you to make your decision?" 4. "If you had asked me, I would have given you my opinion about what to do. Now, how do you feel about your choice?"

3. "Some people might have made a different decision. What led you to make your decision?" *Rationale*: In values clarification, clients are assisted to think about the factors that influence their beliefs and decisions. Any judgmental statement that reflects the rightness or wrongness of the client's thoughts or actions will impede this process (options 1, 2, and 4).

A primary care provider's orders indicate that a surgical consent form needs to be signed. Because the nurse was not present when the primary care provider discussed the surgical procedure, which statement best illustrates the nurse fulfilling the client advocate role? 1. "The doctor has asked that you sign this consent form." 2. "Do you have any questions about the procedure?" 3. "What were you told about the procedure you are going to have?" 4. "Remember that you can change your mind and cancel the procedure."

3. "What were you told about the procedure you are going to have?" *Rationale*: This is the best answer because the nurse is assessing the client's level of knowledge as a result of the discussion with the primary care provider. Based on this assessment, the nurse may initiate other actions (e.g., call the primary care provider if the client has many questions). In option 1, the nurse is not assessing if the client received enough information to give consent. Option 2 is one way to assess the client's level of knowledge regarding the procedure. However, it is not the best approach because it is a closed-ended question, asking for only a "yes" or "no" response. Option 3 provides more information from the client in his or her own words. The statement in option 4 is true; however, the nurse should first verify if the client received enough information to give consent. After the assessment, this statement may be appropriate but the assessment needs to be done first.

What client behavior might indicate unclear self-values? 1. A client with coronary heart disease who follows the recommended diet plan to reduce cholesterol and fat 2. A mother with a child diagnosed with asthma stops smoking tobacco 3. A client who has multiple admissions to the chemical dependency program 4. A client with diabetes who monitors finger-stick blood sugars and other health concerns relating to the diabetic condition

3. A client who has multiple admissions to the chemical dependency program *Rationale*: When clients hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as an intervention. The client who has multiple admissions to the chemical dependency program is demonstrating unclear self-values, while the other answer choices display individuals who are clear regarding self-values.

The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for educations of staff? 1. The nurse aide is not wearing gloves when feeding an elderly client 2. A client with active tuberculosis is asking to wear a mask when he leaves his room to go to another department for testing 3. A nurse with open and weeping lesions of the hands puts on gloves before giving client care 4. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation

3. A nurse with open and weeping lesions of the hands puts on gloves before giving client care *Explanation*: Discrepancy in this answer - weeping lesions on a nurse probably shouldn't be giving direct client care.

A qualitative research approach is most appropriate for which study? 1. A study measuring nutrition and weight loss or gain in clients with cancer 2. A study examining oxygen levels after endotracheal suctioning 3. A study examining client reactions to stress after open heart surgery 4. A study measuring differences in blood pressure before, during, and after a procedure

3. A study examining client reactions to stress after open heart surgery *Rationale*: This study investigates the subjective experience of stress, through the collection of narrative data. Options 1, 2, and 4 are examples of quantitative research using numbers and values.

"A supposition or system of ideas that is proposed to explain a given phenomenon" best defines which of the following? 1. A concept 2. A conceptual framework 3. A theory 4. A paradigm

3. A theory *Rationale*: A supposition or system of ideas proposed to explain a given phenomenon is a theory. Concepts are mental images that are included within a theory (option 1); a conceptual framework is a group of related ideas, statements, or concepts (option 2); and a paradigm is a pattern of sacred understandings and assumptions about reality and the world (option 4).

The nurse's partner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate? 1. Because the nurse is an employee, access to the chart is allowed 2. The relationship with the client provides the nurse special access to the chart 3. Access to the chart requires a signed release form 4. The nurse can ask the surgeon to discuss the outcome of the surgery

3. Access to the chart requires a signed release form *Rationale*: The only person entitled to information without written consent is the client and those providing direct care. The nurse has open access to information regarding assigned clients only.

A nurse has completed morning care for a patient. There is no visible soiling on her hands. What type of technique is recommended by the CDC for hand hygiene? 1. Do not wash hands, apply clean gloves 2. Wash hands with soap and water 3. Clean hands with an alcohol-based hand rub 4. Wash hands with soap and water, follow with hand rub

3. Clean hands with an alcohol-based hand rub *Explanation*: There is no need to use soap and water if there is no visible soiling. If there is visible soiling, then wash with soap and water.

Evaluation of the client's health care while the client is still receiving care from the agency is called a: 1. Retrospective audit 2. Audit 3. Concurrent audit 4. Peer review

3. Concurrent audit *Rationale*: An audit means the examination or review of records. A concurrent audit is the evaluation of a client's health care while the client is still receiving care from the agency. A retrospective audit is the evaluation of a client's record after discharge from an agency. Another type of evaluation is the peer review that involves other nurses reviewing the care based on reestablishing standards or criteria, which are normally conducted after the client's discharge.

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data 2. Applies a framework to the collected data 3. Confirms data are complete and accurate 4. Records data in the client record

3. Confirms data are complete and accurate *Rationale*: In validating, the nurse confirms the data is complete and accurate. Subjective data is collected in the collecting activity (option 1), a framework is applied to the data in the organizing activity (option 2), and data is recorded in the documenting activity (option 4).

Nurse practitioner is carrying for a couple who are the parents of an infant diagnosed with Down syndrome. The nurse makes referrals for a parent support group for the family. This is an example of which nursing role? 1. Teacher/educator 2. Leader 3. Counselor 4. Collaborator

3. Counselor *Explanation*: The nurse listened to what the parents had to say and then recommended a support group. A collaborator is someone who is more involved in wound care, physical therapy, or a cardiologist.

If a child cannot grasp the mechanics behind using an incentive spirometer, the nurse could give the client balloons and/or a jar of bubbles to blow. What does this best demonstrate? (Select all that apply.) 1. Modified scientific method 2. Scientific method 3. Creativity 4. Critical thinking

3. Creativity 4. Critical thinking *Rationale*: Implementation of client interventions requires critical thinking and creativity. The nurse is not using the scientific or modified scientific method.

Choose the correct example of a qualifier for a nursing diagnosis. 1. Syndrome 2. Potential 3. Deficient 4. Risk for

3. Deficient *Rationale*: Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

Which of the following statements about disinfectants is incorrect? 1. A disinfectant is a chemical preparation, such as a phenol or iodine compound, used on inanimate objects 2. Disinfectants are frequently caustic and toxic to tissues 3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution 4. A disinfectant is an agent that destroys pathogens other than spores

3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1. Hire only competent nurses 2. Improve the nurse's ability to multitask 3. Establish a reporting system for "near misses" 4. Communicate effectively 5. Create a culture of trust

3. Establish a reporting system for "near misses" 4. Communicate effectively 5. Create a culture of trust

What is the least effective decision-making process? 1. Analyzing the data 2. Formulating conclusions 3. Establishing assumptions 4. Synthesizing information

3. Establishing assumptions *Rationale*: Assumptions are not used in the nursing process and are not effective in decision making.

A nurse is making a bed occupied by a patient. Which of the following is a recommended step for this procedure? 1. Lower side rail on opposite side of you 2. Discard soiled linen onto the floor 3. Fan-fold soiled linens as close to patient as possible 4. Place the draw sheet under the patient's knees

3. Fan-fold soiled linens as close to patient as possible

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1. Wear a mask during dressing changes 2. Provide disposable meal trays and silverware 3. Follow standard precautions in all interactions with the client 4. Use surgical aseptic technique for all direct contact with the client

3. Follow standard precautions in all interactions with the client

The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1. Presence of pain 2. Condition of the skin 3. Gag reflex 4. Range of motion

3. Gag reflex

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1. Sports contribute to an adolescent's self-esteem 2. Sunbathing and tanning beds can be dangerous 3. Guns are the most frequently used weapon for adolescent suicide 4. A driver's education course is mandatory for safety

3. Guns are the most frequently used weapon for adolescent suicide

Prepaid group plans for insurance include: 1. Medicare and Medicaid 2. Blue Cross and Blue Shield 3. HMOs, PPOs, PPAs, IPAs, and PHOs 4. Social Security and Supplemental Security Income

3. HMOs, PPOs, PPAs, IPAs, and PHOs *Rationale*: Prepaid group plans include HMOs, PPOs, PPAs, IPAs, and PHOs. Medicare and Medicaid are government programs, and Blue Cross and Blue Shield are private-pay insurance plans. Social Security and Supplemental Security Income are government programs.

A nurse is planning a seminar on the chain of infection. Which of the following is NOT one of the six links? 1. Etiologic agent 2. Reservoir 3. Hand hygiene 4. Mode of transmission

3. Hand hygiene

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. which of the following represents a properly stated goal/outcome? The client will: 1. Turn in bed q2h 2. Report the importance of applying lotion to skin daily 3. Have intact skin during hospitalization 4. Use a pressure-reducing mattress

3. Have intact skin during hospitalization *Rationale*: The goal or outcome should state the opposite of the nursing diagnosis stem, and thus healthy intact skin is the reverse condition of impaired skin integrity. Turning in bed, applying lotion, and using a special mattress are all interventions that may result in achieving the goal (options 1, 2, and 4).

The purpose of theory in science is to: 1. Build a rationale for programs of research 2. Explain why scientists do what they do 3. Help scientists interpret phenomena 4. Distinguish science from art

3. Help scientists interpret phenomena *Rationale*: The purpose of any theory is to help interpret phenomena. Programs of research should have a theoretical framework but the theory is not he reason for the research (option 1). Theory is an applicable in science as it is in art (options 3 and 4).

The organization recently added a new wing to the hospital. What factor is likely to be influencing this organization related to the nursing shortage they are experiencing? 1. Aging workforce 2. Aging population 3. Increased demand for nurses 4. Workplace issues

3. Increased demand for nurses *Rationale*: Workplace issues include inadequate staffing, heavy workloads, increased use of overtime, and difficulty recruiting and retaining nurses.

What is the correct action by the nurse if a health care provider asks the nurse to perform a task in which the nurse does not have adequate knowledge or experience performing? 1. Inform the health care provider about the lack of education and experience, and then perform the task 2. Do not inform the health care provider and carry out the task 3. Inform the health care provider regarding the lack of education and/or experience necessary to safely perform the task. Refuse to do the task 4. Inform the health care provider, and then both parties can attempt to figure it out

3. Inform the health care provider regarding the lack of education and/or experience necessary to safely perform the task. Refuse to do the task *Rationale*: The nurse should inform the health care provider about the lack of education and/or experience and refuse to do the procedure or task. All of the other answers would make the nurse and health care provider negligent. However, if the nurse does not inform the health care provider, only the nurse would be liable.

A nurse is considering the delegation of administering medications to an unskilled assistant. What is the first question the nurse must ask herself before doing so? 1. Has the assistant been trained to perform the task? 2. Have I evaluated the patient's response to this task? 3. Is the delegated task permitted by law? 4. Is appropriate supervision available?

3. Is the delegated task permitted by law?

An unlicensed assistant (UAP) has previously performed client transfers safely (bed to chair) on many occasions. It would be inappropriate to delegate this unsupervised task to the UAP under which condition? 1. The unit had a new wheelchair 2. This was an older client 3. It was the client's first time out of bed after surgery 4. The UAP has just returned from an extended leave of absence

3. It was the client's first time out of bed after surgery *Rationale*: A fresh postoperative client is, by definition, in a somewhat unstable condition and the nurse must assess and supervise this initial transfer. A UAP should be able to perform the transfer safely with a new wheelchair; the scenario does not indicate that the wheelchair had special features (option 1) or that the client is an older adult. Age does not determine need for assistance and the UAP should be able to transfer the older adult client (option 2). The task is simple and can be easily recalled safely after an absence (option 4).

A nurse performing noncontact therapeutic touch: 1. Florence Nightingale 2. Hildegard Peplau 3. Martha Rogers 4. Imogene King

3. Martha Rogers *Rationale*: Martha Roger's Science of Unitary Human Beings states the idea of non-contact therapeutic touch. This is the idea that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Florence Nightingale's Environmental Theory linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness. In addition tho those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect n the person. Peplau's Interpersonal Relations Model introduces the existence of a therapeutic relationship between the nurse and the client. Imogene King's Goal Attainment Theory describes the nature of and standard for nurse-client interactions that lead to goal attainment - that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment represents outcomes.

Which of the following is an example of a primary prevention activity? 1. Antibiotic treatment of a suspected urinary tract infection 2. Occupational therapy to assist a client in adapting his or her home environment following a stroke 3. Nutrition counseling for young adults with a strong family history of high cholesterol 4. Removal of tonsils for a client with recurrent tonsillitis

3. Nutrition counseling for young adults with a strong family history of high cholesterol *Rationale*: Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary preventions. Treatment of a disease such as with antibiotic therapy (option 1) or surgery (option 4) is secondary prevention, while rehabilitation efforts following an illness (option 2) are considered tertiary prevention.

A nurse proposes that the hospital apply the findings from a recent research study that shows that clients appreciate classical orchestra music and playing it frequently lowers clients' blood pressure. Which aspect of research suggests that it may not be appropriate to implement this as evidence-based practice? 1. All research is flawed 2. The research would not have taken into consideration the cost of acquiring and playing the music in a hospital 3. One study would not be sufficient to show that all clients would find orchestral music pleasing 4. Research cannot demonstrate clients' appreciation of music since research is only appropriate for physiological problems

3. One study would not be sufficient to show that all clients would find orchestral music pleasing *Rationale*: There may have been unique aspects to this research that would not be applicable in a different setting or with different clients. Not all research is flawed (option 1) and it may or may not have taken cost into consideration (option 2). Research is not limited to the study of physiological problems (option 4).

During the process of data collection, the nurse must be aware of the different cultural aspects in health care. In the interview phase, what will the nurse consider may have a cultural implication? (Select all that apply.) 1. Time of the interview 2. Setting of the interview 3. Physical distance between the nurse and client 4. Seating arrangement

3. Physical distance between the nurse and client 4. Seating arrangement *Rationale*: *The seating arrangement and physical distance between the client and interviewer have cultural implications*. The distance between the interviewer and interviewee should be neither too small nor too great because people feel uncomfortable when talking to someone who is too close or too far away. The Japanese culture has an accepted difference of 36 inches, while clients from Arab countries maintain a distance of 8 to 12 inches.

Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part A is the: 1. Voluntary prescription drug plan that begin in January 2006 2. Voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible 3. Plan section providing insurance toward hospitalization, home care, and hospice care 4. Plan section providing very limited financial coverage to low-income persons

3. Plan section providing insurance toward hospitalization, home care, and hospice care *Rationale*: The Medicare plan is divided into two parts, Part A and Part B. Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescription drug plan begun in January 2006. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes.

Which statement is a nursing diagnosis? 1. Fever of unknown origin 2. Pancreatitis 3. Potential for sleep-pattern disturbances 4. Congestive heart failure

3. Potential for sleep-pattern disturbances *Rationale*: The potential for sleep-pattern disturbances is a nursing diagnosis; the other three answer choices are considered medical diagnoses.

Health promotion is best represented by which activity? 1. Administering immunizations 2. Giving a bath 3. Preventing accidents in the home 4. Performing diagnostic procedures

3. Preventing accidents in the home *Rationale*: Health promotion focuses on maintaining normal status without consideration of diseases. Option 1 is an example of illness prevention. Option 2 is aesthetic (i.e., not needed for health promotion or disease prevention). Option 4 focuses on disease detection.

The nurse instructs the client on turning, coughing, and deep breathing q2h. What is the relationship of nursing interventions to problem status? 1. Health promotion interventions 2. Treatment interventions 3. Prevention interventions 4. Observation interventions

3. Prevention interventions *Rationale*: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors.

When economic conditions are tight, a hospital may reduce the number of middle-level nurse managers. This can potentially disrupt nursing care because middle-level managers are responsible for which of the following? 1. Supervision of non managerial staff 2. Reporting institutional changes to direct-care staff 3. Productively and effectiveness of a group of managers 4. Creating institutional goals and strategic plans

3. Productively and effectiveness of a group of managers *Rationale*: Middle managers supervise first-level managers and service as liaison between first- and upper-level managers. First-level managers supervise non managerial staff (option 1) and report institutional changes to direct-care staff (option 2). Creating institutional goal and strategic plans is the responsibility of upper-level managers (option 4).

The nurse is caring for her patients and is focused on managing their care as opposed to managing and performing skills. This nurse demonstrates which level of proficiency according to Benner? 1. Novice 2. Competent 3. Proficient 4. Expert

3. Proficient *Explanation*: Not just yet an expert, but almost... so proficient (3).

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire 2. Extinguish the fire 3. Protect the clients 4. Contain the fire

3. Protect the clients

Upon successful completion of the NCLEX-RN, the registered nurse is asked to participate in a research study on the coping and adjustment skills of a newly graduated registered nurse. The plan is to use an oral, recorded interview with a grounded theory. What type of research study is being conducted? 1. Pilot study 2. Quantitative study 3. Qualitative study 4. Ethnographic study

3. Qualitative study *Rationale* A qualitative study is not linear like quantitative research. The intent of qualitative research is to describe and then explain a phenomenon. The technique most often used to collect data for this type of research is interviews. Quantitative research progresses through systematic, logical steps according to a specific plan to collect numerical information, often under conditions of considerable control that is analyzed using statistical procedures. Ethnographic inquiry is related to selective topics specific to a group with the same beliefs or lifestyles. Pilot studies are often a tentative probe to see if further research study is needed on a topic.

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Proposes hypotheses 2. Generates desired outcomes 3. Reviews results of laboratory tests 4. Documents care

3. Reviews results of laboratory tests *Rationale*: During assessment, data are collected, organized, validated, and documented. Hypotheses are generated during diagnosing; outcomes are set during planning; and documentation occurs throughout the nursing process.

Who were America's first two trained nurses? 1. Barton and Wald 2. Dock and Sanger 3. Richards and Mahoney 4. Henderson and Breckinridge

3. Richards and Mahoney *Rationale*: All are noted nurses. Linda Richards was America's first trained nurse, and Mary Mahoney was America's first Black trained nurse.

The nurse asks an unlicensed assistant (UAP) to weigh a client. The UAP carefully assists the client out of bed to stand on the scale, weighs the client, and safely returns the client to bed. Later, when the UAP reports the weight to then nurse, it is discovered that the client has been placed on bed rest and should not have been allowed out of bed. This situation violates which of the following five rights of delegation? 1. Right task 2. Right person 3. Right direction and communication 4. Right supervision and evaluation

3. Right direction and communication *Rationale*: In this situation, the UAP was not given the right direction and communication - that the client was not permitted to be out of bed. UAPs commonly weigh clients so it was the right task and right person (options 1 and 2). Although supervision might have prevented the error, it was the nurse's responsibility to tell the UAP of the client's mobility status and, if necessary, the proper way to weigh such a client (option 4).

The nurse determines that a field remains sterile if which of the following conditions exist? 1. Tips of wet forceps are held upward when held in ungloved hands 2. The field was set up 1 hour before the procedure 3. Sterile items are 2 inches from the edge of the field 4. The nurse reaches over the field rather than around the edges

3. Sterile items are 2 inches from the edge of the field

When planning a safety in-service program for an independent living community for older adults, the nurse will include information on which of the following as the leading causes of injury among older adults? (Select all that apply.) 1. Firearms 2. Drownings 3. Suicide 4. Falls 5. Natural disasters

3. Suicide 4. Falls

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Going for physical therapy after knee surgery ___________.

3. Tertiary

Which statement indicates that the client understands informed consent of a surgical procedure? 1. The nurse discovers the signed informed consent form on the bedside table before the surgeon discusses the procedure with the client 2. The client's oldest son stated that the explained the procedure to the client and the client told him that he wanted the surgery 3. The client states that the surgeon explained the procedure to him, allowed him to ask questions, and explained the risks of not permitting the surgery 4. The client been declared legally incompetent; however, the client states understanding of the surgical procedure

3. The client states that the surgeon explained the procedure to him, allowed him to ask questions, and explained the risks of not permitting the surgery *Rationale*: In order for consent to be considered informed, the physician must describe the procedure, explain risk of the procedure, and alternative treatment options; the client must verbalize understanding of the explanation; and the informed consent form must be signed and witnessed. The client cannot sign the consent before the procedure is explained by the surgeon, cannot have the son give express consent for surgery if the client is competent to give consent for himself, and consent would need to be obtained if the client has been declared incompetent.

The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? 1. The client may no longer make decisions regarding his or her own health care 2. The client and family know that the client will most likely die within the next 48 hours 3. The nurses will continue to implement all treatments focused on comfort and symptom management 4. A DNR order from a previous admission is valid for the current admission

3. The nurses will continue to implement all treatments focused on comfort and symptom management *Rationale*: A DNR order only controls CPR and similar lifesaving treatments. All other care continues as previously ordered. Competent clients can still decided about their own care (including the DNR ordeR). Nothing about the DNR order is related to when the client may die Because clients' medical conditions and their view of their lives can change, a new DNR order is required for each admission to a health care agency. Once admitted, that order stands until changed or until it expires according to agency policy.

What is the purpose of a nursing diagnosis? 1. To define a taxonomy of nursing language 2. To promote a taxonomy of nursing language 3. To identify a client's problem and its etiology 4. To establish a set of principles

3. To identify a client's problem and its etiology *Rationale*: The client's problem statement consists of the diagnostic label plus etiology, which is the causal relationship between a problem and its related or risk factors.

What is the purpose of data collection and analysis? 1. To carry out the plan of care 2. To collect and then analyze data 3. To identify actual or potential health concerns 4. To identify a client's response to care

3. To identify actual or potential health concerns *Rationale*: The identification of the actual or potential health problems of a client is the result of data collection and analysis.

A nursing director who fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization's vision in which type of leader? 1. Charismatic 2. Transactional 3. Transformational 4. Shared

3. Transformational *Rationale*: A transformational leader fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization's vision. A charismatic leader is rare and is characterized by an emotional relationship with group members. The charming personality of the leader evokes strong feelings of commitment to both the leader and the leader's cause and beliefs. the transactional leader has a relationship with followers based on an exchange for some resource valued by the follower. These incentives are used to promote loyalty and performance. Shared leadership recognizes that professional workforce is made up of many leaders. No one individual is considered to have knowledge or ability beyond that of other members of the work group.

Conviction of practicing nursing without a license, incompetence or gross negligence, falsification of client records, and illegally obtaining, using, or possessing controlled substances is called: 1. Libel 2. Slander 3. Unprofessional conduct 4. Assault

3. Unprofessional conduct *Rationale*: Unprofessional conduct is defined by the Code of Ethics for Nurses. Unethical conduct may also be addressed in nurse practice acts. It includes violation of professional ethical codes, breach of confidentiality, fraud, or refusing to care for clients of specific socioeconomic or cultural origins.

After completing the health history and the physical assessment, the nurse identifies discrepancies in the information. What is this process called? 1. Assessing 2. Diagnosing 3. Validating 4. Evaluating

3. Validating *Rationale*: Validating is the act of "double-checking" or verifying data to confirm that it is accurate and factual. Validating data helps the nurse ensure that information is complete, that objective and subjective data agree, and that cues and inferences are differentiated.

Under which circumstance may a nurse communicate medical information without the client's consent? 1. When certifying the client's absence from work 2. When requested by the client's family 3. When treating the client with a sexually transmitted disease 4. When ordered by another physician

3. When treating the client with a sexually transmitted disease

When evaluating a parent's understanding of safety measures for an infant, which of the following statements indicates a need for further teaching? 1. "I will store all household chemicals in the garage." 2. "I will make sure my infant is in his car seat before starting the car." 3. "I will keep small crafting beads locked in the cabinet" 4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."

4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."

A nurse is evaluating a client's understanding of nail hygiene. Which of the following statements indicates a need for further teaching? 1. "I should have clean, short nails with smooth edges." 2. "I should have intact cuticles." 3. "I will avoid trimming or digging into nails at the lateral corners." 4. "I'll cut or file around the end of the fingernail or toenail."

4. "I'll cut or file around the end of the fingernail or toenail."

Which client will require more frequent documentation by the nurse? 1. A stable client who is 2 days postvaginal delivery of a term infant 2. A client presenting to the emergency department with signs/symptoms of a viral respiratory problem 3. An older adult client who is postoperative dat 4 of a hip replacement 4. A client admitted to the ICU after a major myocardial infarction

4. A client admitted to the ICU after a major myocardial infarction *Rationale*: The client with an MI would require more frequent charting due to the unstable changes occurring after a major MI.

A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with: 1. Medicare 2. An individual fee-for-service insurance 3. A preferred provider organization (PPO) 4. A health maintenance organization (HMO)

4. A health maintenance organization (HMO) *Rationale*: A health maintenance organization involves a set monthly membership fee and predictable visit or deductible costs. Medicare covers a minimal number of preventive and outpatient services so the cost cannot be anticipated (option 1). Individual fee-for-service insurance is perhaps the most costly to the client, with potentially large differences between the amount of coverage the insurance company pays and the provider's charges (option 2). PPOs are less costly than fee-for-service entities, but more expensive than HMOs (option 3).

Which nurse would be considered to be the "best expert witness" for the defense in a case regarding an obstetric patient who died after delivery complications? 1. A nurse who holds a bachelor's degree in nursing has been practicing for 2 years 2. A nurse who holds a master's degree in nursing and has a certification in emergency nursing 3. A nurse who holds a doctorate of nursing science in pediatric care 4. A nurse who holds a master's degree in nursing and a state certification in maternal-infant nursing

4. A nurse who holds a master's degree in nursing and a state certification in maternal-infant nursing *Rationale*: The nurse with a master's degree and a certificate in maternal-infant nursing is deemed an expert in that field because of the advanced preparation. The other choices do not address the needed expertise.

"A set of shared understandings and assumptions about reality and the world" is a definition for which of the following? 1. A concept 2. A conceptual framework 3. A practice discipline 4. A paradigm

4. A paradigm *Rationale*: A set of shared understandings and assumptions about reality and the world is a paradigm. A concept is a mental image (option 1); a conceptual framework is a group of related ideas, statements, or concepts (option 2); and a practice discipline is a field of study in which the central focus is performance of a professional role (option 3).

Medicaid is described as: 1. A voluntary prescription drug plan that begin in January 2006 2. A voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible 3. A plan section providing insurance toward hospitalization, home care, and hospice care 4. A plan providing very limited financial coverage to low-income persons

4. A plan providing very limited financial coverage to low-income persons *Rationale*: The Medicare plan is divided into two parts, Part A and Part B. Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescription drug plan begun in January 2006. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes.

What is the definition of the nursing process? 1. A skill essential to safe, competent, skillful nursing practice 2. A type of thinking that results in the development of new ideas and products 3. A critical thinking process for choosing the best actions to meet a desired goal 4. A systematic, rational method of planning and providing individualized nursing care

4. A systematic, rational method of planning and providing individualized nursing care *Rationale*: The nursing process is defined as a systematic, rational method of planning and providing individualized nursing care.

A staff nurse delegates a task to a nursing assistant, knowing that the assistant has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the nursing assistant should have known how to perform such a simple task. This nurse is demonstrating lack of: 1. Responsibility 2. Autonomy 3. Authority 4. Accountability

4. Accountability *Explanation*: (1) means you need to do everything, you are responsible. (4) he made the decision to delegate and something happened, so the nurse is still accountable for it

Which of the following actions performed by an organization would best improve the image of nursing? 1. Offering scholarships to high school students to attend nursing school 2. Television commercials showing nurses and doctors providing care together 3. A print advertisement with the statement "Nursing - The hardest job you'll ever love" 4. An ANA-sponsored radio commercial explaining the role of nurses in society today

4. An ANA-sponsored radio commercial explaining the role of nurses in society today *Rationale*: The ANA is actively working to improve the image of nursing. The radio commercial will most likely include information to help shape the listener's image of contemporary nursing.

A nurse threatens to give a loud, disruptive client an injection that will "knock the client out." The nurse follows through on the threat and gives the injection without the client's consent. What has the nurse committed? 1. Threat, assault 2. Battery, invasion of privacy 3. Assault, invasion of privacy 4. Assault, battery

4. Assault, battery *Rationale*: Assault is the attempt or threat to touch another person unjustifiably. It often precedes battery. Battery is the willful touching of a person that may or may not cause harm.

Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? 1. An unintentional tort 2. Assault 3. Invasion of privacy 4. Battery

4. Battery. *Rationale*: Battery is the willful touching of a person whit permission. Another name for an unintentional tort is professional negligence/malpractice, This situation is an intentional tort because the next executed the act on purpose. Assault is the attempt or threat to touch another person unjustifiably or without permission. Invasion of privacy injures the feelings of the person and does not take into consideration how revealing information or exposing the client will affect the client's feelings

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health care team 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care 4. Collection of all necessary information for a thorough appraisal

4. Collection of all necessary information for a thorough appraisal *Rationale*: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option 1). Cost-effective care (option 2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3).

A management function of bedside direct-care nurses includes determining whether the client has reached the intended outcomes designated in the care plan. This is an example of which of the four management functions? 1. Planning 2. Organizing 3. Directing 4. Coordinating

4. Coordinating *Rationale*: Evaluating outcomes and effectiveness is part of the coordinating function of management.

The nurse moves to a new area of the country and learns the new area has many people of South African descent, a higher incidence of hypertension, and people whose average age is 37. This information would be considered: 1. News 2. Health statistics 3. A targeted area of study 4. Demography

4. Demography *Rationale*: Demography is the study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease). From demographic data, population needs for nursing services can be assessed.

In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the following being implementing a plan? 1. Reexamines the purpose for making the decision 2. Consults the client and family members to determine their view of the criteria 3. Identifies and considers various means for reaching the outcomes 4. Determines the logical course of action should intervening problems arise

4. Determines the logical course of action should intervening problems arise *Rationale*: It is important to project what problems might interfere with the plan and have appropriate responses prepared to prevent the interferences. The purpose for the decision should have been clear enough at the outset as to not require reexamination at this point (option 1). Clients and families should be consulted early - in the purpose-setting and criteria-setting steps. Criteria should not be set until all significant participants have an opportunity to present their point of view (option 2). Considering various means for reaching the outcomes is the same as examining alternatives (option 3).

The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP? 1. Uses a clean portion of the washcloth for each stroke 2. Wipes from the pubis to the rectum 3. Uses clean gloves 4. Does not retract the foreskin

4. Does not retract the foreskin

After making a documentation error, which action should the nurse take? 1. Use correcting liquid to cover the mistake and make a new entry 2. Draw a line through it and write error above the entry 3. Draw a line through it and write mistaken entry above it 4. Draw a line through the mistake and write mistaken entry with initials above it

4. Draw a line through the mistake and write mistaken entry with initials above it *Rationale*: It is the most complete answer. The client's record is a legal record and should not be altered with correcting liquid. You may see "error" written about a mistake even though many authors suggest not writing it. It is important to also put your name or initials next to the words of the mistaken entry.

The nurse admits a client in active labor to the labor and delivery unit of the hospital. When does the planning for client care start? 1. After the physician has delivered the baby 2. After the admission process 3. When the client is discharged to the postpartum unit 4. During the initial meeting

4. During the initial meeting *Rationale*: *Planning begins with the first meeting, is revised throughout the hospital stay as the client's condition changes, and continues until the client is discharged*.

The nurse manager plans to implement a new method for scheduling staff vacations. Senior staff members oppose the change, whereas newer staff members are more accepting. Which is the most effective strategy for resolving this difference? 1. Provide an extensive and detailed rationale for the proposed change, then implement 2. Explain that the change will occur as designed, regardless of the staff's preference 3. Withdraw the proposal to prevent a decrease in staff morale 4. Encourage interaction between the opposing sides to attempt resolution

4. Encourage interaction between the opposing sides to attempt resolution *Rationale*: Interaction between the two groups may lead to a compromise. Option 1: although explain the reasons for the desired change is useful, overemphasis on the rationale may not be useful since resistance is often more emotional than rational. Option 2: this situation does not meet the criteria for an autocratic leadership style. There is no urgency and the task primarily involves the staff. Option 3: if the manager were not solidly committed to the new proposal, it should not be introduced, because it will result in unnecessary disturbance. Option 4: the manager should be open to modification of the proposal if justified.

Inflammation is a local and nonspecific defensive response of the tissues to an injurious or infectious agent. Which of the following is NOT a sign of inflammation? 1. Pain 2. Swelling 3. Redness 4. Fatigue

4. Fatigue

When the nurse places a check mark or a dash in an allocated space and uses an asterisk to reflect other pertinent information that has been recorded elsewhere on the chart, this is an example of what type of documentation? 1. Multidisciplinary charting 2. Charting by exception 3. Focus charting 4. Flow sheet charting

4. Flow sheet charting *Rationale*: Flow sheet charting allows nurses to record nursing data quickly and concisely. It provides an easy-to-read record of the client's condition over time.

A nurse is evaluating a client's understanding of dental care. Which of the following statement indicates a need for further teaching? 1. Brush the teeth thoroughly after meals and at bedtime 2. Floss the teeth daily 3. Avoid sweet foods and drinks between meals 4. Have a checkup by a dentist every year

4. Have a checkup by a dentist every year

The nurse positions the client sitting upright during palpating of which area? 1. Abdomen 2. Genitals 3. Breast 4. Head and neck

4. Head and neck *Rationale*: The client should sit for examination of the head and neck. For palpation of the abdomen (option 1), genitals (option 2), and breast (option 3), the client should be supine.

After recovering from her hip replacement, an older adult client wants to go home. The family wants the client to go to a nursing home. If the nurse were acting as a client advocate, the nurse would perform which of the following actions? 1. Inform the family that the client has a right to decide on her own 2. Ask the primary care provider to discharge the client to home 3. Suggest the client hire a lawyer to protect her rights 4. Help the client and family communicate their views to each other

4. Help the client and family communicate their views to each other *Rationale*: A major role of the client advocate is to mediate between conflicting parties. The nurse needs to assess the situation before offering an intervention. Informing the family is an intervention without assessment (option 1). If the primary care provider sends the client home, the nurse has not acted to assist in resolving or reducing the conflict (option 2). If the nurse assists in resolving or reducing the conflict, the added expense of an attorney may not be needed. However, legal action should be a last resort (option 3).

A nurse who plans care with the client to establish mutual goals and outcomes: 1. Florence Nightingale 2. Hildegard Peplau 3. Martha Rogers 4. Imogene King

4. Imogene King *Rationale*: Martha Roger's Science of Unitary Human Beings states the idea of non-contact therapeutic touch. This is the idea that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Florence Nightingale's Environmental Theory linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness. In addition tho those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect n the person. Peplau's Interpersonal Relations Model introduces the existence of a therapeutic relationship between the nurse and the client. Imogene King's Goal Attainment Theory describes the nature of and standard for nurse-client interactions that lead to goal attainment - that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment represents outcomes.

Identify the element that is NOT one of the functions of the law in the nursing environment. 1. Accountability helps to maintain a minimum standard of nursing practice 2. Law differentiates nurses' responsibilities from those of other health care professionals 3. Law specifies which nursing actions are legal in caring for clients 4. Law specifies which hospital policies are legal in caring for clients

4. Law specifies which hospital policies are legal in caring for clients *Rationale*: Hospital policies are not included in the laws of nursing. The other three items are functions of nursing laws.

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand 3. Ask a colleague to assist by unrolling the cuff 4. Leave the cuff rolled under

4. Leave the cuff rolled under

Which professional organization developed a code for nursing students? 1. ANA 2. NLN 3. AACN 4. NSNA

4. NSNA *Rationale*: The National Student Nurses Association developed the Code of Academic and Clinical Conduct for nursing students in 2001. Option 1, ANA, developed Standards of Nursing Practices. Option 2, NLN, focuses on nursing education. Option 3,the American Association of Colleges of Nursing (AACN), is the national organization that focuses on the advancement and maintenance of America's baccalaureate and higher degree nursing education programs.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Planning a budget to accommodate Medicare reimbursement cutbacks: ____________

4. Nurse administrator

Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense 2. Observing is done only when no other nursing interventions are being performed at the same time 3. Data should be gathered as it occurs, rather than in any particular order 4. Observed data should be interpreted in relation to other sources of collected data

4. Observed data should be interpreted in relation to other sources of collected data *Rationale*: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities (option 2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option 4).

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all of the side rails up 2. Review prescribed medications 3. Complete the "get up and go" test 4. Place the bed in the lowest position

4. Place the bed in the lowest position

The type of change that is an intended, purposeful attempt by an individual, group, organization, or larger social system to influence its own current status is referred to as: 1. Natural 2. Situational 3. Unplanned 4. Planned

4. Planned *Rationale*: Planned change is an intended, purposeful attempt by an individual, group, organization, or larger social system to influence its own current status. Unplanned change is an alteration imposed by external events or usually haphazard, and the results can be unpredictable. Drift is a type of unplanned change in which change occurs without effort on anyone's part. Natural, or situational, change also may be considered unplanned and occurs without any control by the person or group impacted.

An element of quality improvement, rather than quality assurance, is which of the following? 1. Focus is on individual outcomes 2. Evaluates organizational structures 3. Aims to confirm that quality exists 4. Plans corrective actions for problems

4. Plans corrective actions for problems *Rationale*: Quality improvement (QI) plans corrective actions for problems. QI Focuses on process rather than outcomes (option 1), client care rather than structure (option 2), and aims for improvement rather than confirmation of quality (option 3)

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition 2. Research process 3. Trial and error 4. Problem solving

4. Problem solving *Rationale*: A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound.

When written properly, NOC outcomes and indicators: 1. Do not require customization 2. Address several nursing diagnoses 3. Are broad statements of desired end points 4. Reflect both the nurse's and the client's values

4. Reflect both the nurse's and the client's values *Rationale*: NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved. The outcomes still must be customized (option 1), but address only one nursing diagnosis at a time (option 2). Outcomes are narrow/specific end points, not broad (option 3).

A nursing student documents the client's full name and date of birth on the required paperwork for a clinical course and turns it in to the instructor. Which of the following client rights is being violated? 1. Right not to be harmed 2. Right to full disclosure 3. Right to self-determination 4. Right of privacy and confidentiality

4. Right of privacy and confidentiality *Rationale*: The nursing student should not document any identifiers on paperwork that would be made public or could cause potential embarrassment to the client. The use of identifiers would violate the right of privacy and confidentiality for the client.

An 85-year-old client in a nursing home tells a nurse, "Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me." Which client right is being violated? 1. Right not to be harmed 2. Right to full disclosure 3. Right to privacy and confidentiality 4. Right to self-determination

4. Right to self-determination *Rationale*: The right to self-determination means that subjects feel free of constraints, coercion, or any undue influence to participate in a study. There is not enough information given to indicate if any of the other rights in options 1, 2, and 3 have been violated.

An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client? 1. Nutritional status 2. Urinary incontinence 3. Episodes of confusion 4. Right-sided paralysis

4. Right-sided paralysis

If a client can accurately read only the top three lines, what would be an appropriate nursing diagnosis? 1. Deficient Knowledge 2. Impaired Memory 3. Ineffective Tissue Perfusion 4. Risk for Injury

4. Risk for Injury *Rationale*: If the client can only read the first three lines, vision is impaired and could lead to falls or other injuries. This impaired vision is not related to deficient knowledge (option 1) or memory (option 2) and may or may not be related to circulation (option 3).

What is required of a patient who leaves the hospital against medical advice? (AMA) 1. Nothing 2. Discharge instructions 3. Providing contact phone numbers 4. Signing a form releasing legal responsibility

4. Signing a form releasing legal responsibility

The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? 1. Open bed in low position 2. Occupied bed in low position 3. Closed bed in high position 4. Surgical bed in high position

4. Surgical bed in high position

Values, moral frameworks, and codes of ethics influence the professional nurse's moral decisions in which of the following ways? 1. The nurse will provide direct client care that is consistent with the nurse's personal values 2. The nurse will seek to ensure that the client's values and the nurse's are the same 3. The choice of moral framework determines what the client outcome will be 4. The nurse is bound to act according to the nurses' code of ethics even if the nurse's values are different

4. The nurse is bound to act according to the nurses' code of ethics even if the nurse's values are different *Rationale*: The nurse is obliged to design care and to act according to the professional code of ethics even if the nurse holds different values. The client's need for value-based care takes precedence over the nurse's values; however, nurse can choose not to participate in care with which they have conflicting values (options 1 and 2). The client outcome can be the same even when different moral framework are used (option 3).

A patient gets out of bed following hip surgery and falls and re-injures her hip. The nurse caring for her knows that it is her duty to make sure an incident report is filed. Which of the following statements accurately describes the correct procedure for filing an incident report? 1. The physician in charge should fill out the report 2. The names of the staff involved should not be included 3. The reports are used for disciplinary action against the staff 4. The report should contain all the variables related to the incident

4. The report should contain all the variables related to the incident

A male client is having his facial hair shaved with a razor. Which action by the student nurse is NOT correct? 1. The student nurse holds the skin taut, particularly around creases, to prevent cutting the skin 2. The student nurse wears gloves in case facial nicks occur and she comes in contact with blood 3. The student nurse applies shaving cream or soap and water to soften the bristles and make the skin more pliable 4. The student nurse holds the razor so that the blade is at a 90 degree angle to the skin, and shaves in short, firm strokes in the direction of hair growth

4. The student nurse holds the razor so that the blade is at a 90 degree angle to the skin, and shaves in short, firm strokes in the direction of hair growth

The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: 1. Check that the feeding solution matches the dietary order 2. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach 3. Ensure that feeding solution is at room temperature 4. Verify correct placement of the tube

4. Verify correct placement of the tube *Explanation*: All important and true, but if it isn't in the right place, then nothing else matters.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Educating a community about MRSA: ____________

5. Nurse educator

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Orientating a staff to new equipment and technology: ____________

5. Nurse educator

The parent of a toddler is cleaning the child's teeth. Which of the following statements indicates a need for further teaching? 1. "I'll brush my child's teeth with a hard toothbrush." 2. "I'll give a fluoride supplement daily or as recommended by the physician or dentist, unless the drinking water is fluoridated." 3. "I'll schedule an initial dental visit for my child at about 2 or 3 years of age or as soon as all 20 primary teeth have erupted." 4. "I'll seek professional dental attention for any problems such as discoloring of the teeth, chipping, or signs of infection such as redness and swelling."

1. "I'll brush my child's teeth with a hard toothbrush."

A patient with an upper respiratory infection (common cold) tells the nurse, "I am so angry with the nurse practitioner because he would not give me any antibiotics." What would be the most accurate response by the nurse? 1. "Antibiotics have no effect on viruses" 2. "Let me talk to him and see what you can do" 3. Why do you think you need an antibiotic" 4. I know what you mean; you need an antibiotic

1. "Antibiotics have no effect on viruses" *Explanation*: It's not what you say, it's how you say it. (1) is okay because you're just teaching them the truth. (2) talking to the doctor is pointless, you know antibiotics have no effect on viruses. (3) NEVER ask a patient "why".

During discharge planning, the nurse is teaching a client how to prevent dry skin. Which of the following statements by the client indicates the need for further teaching? 1. "Bathe using soap or detergent only." 2. "Use bath oils, but take precautions to prevent falls caused by slippery tub surfaces." 3. "Humidify the air with a humidifier or by keeping a tub or sink full of water." 4. "Use moisturizing or emollient creams that contain lanolin, petroleum jelly, or cocoa butter to retain skin moisture."

1. "Bathe using soap or detergent only."

The PES format for writing a nursing diagnosis is used for which of the following? 1. Actual nursing diagnoses 2. Potential nursing diagnoses 3. Risk for nursing diagnoses 4. Wellness diagnoses

1. Actual nursing diagnoses *Rationale*: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. The signs and symptoms have been identified, and the PES system is ideal for beginning nursing students.

Robert is the pastor of your church. He comes to you as you are leaving the Sunday service and tells you about a parishioner who is now an inpatient at your hospital. You are very good friends with the pastor and he asks you to find out what her diagnosis and prognosis is. Because of your position you have access to this information. What is the best response by the nurse? 1. "I'm sorry, out of respect to that patient, that information is confidential" 2. "I am sure she would be so appreciative to have you visit. She is in stable condition and was admitted with a heart problem" 3. "Thank you for your concern. Let me check with my nursing supervisor first" 4. "Because of the HIPAA laws, I cannot give you that information"

1. "I'm sorry, out of respect to that patient, that information is confidential" *Explanation*: (4) is also a true statement, but the pastor might not know what HIPAA is...

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What components of the infection cycle does the woman illustrate? 1. A reservoir 2. An infectious agent 3. A portal of exit 4. A portal of entry

1. A reservoir *Explanation*: A reservoir can be any source of microorganism. Common places include humans, client's own microorganisms, plants, animals, or the general environment

In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? 1. A risk nursing diagnosis 2. A syndrome nursing diagnosis 3. A health promotion nursing diagnosis 4. An actual nursing diagnosis

1. A risk nursing diagnosis *Rationale*: A risk nursing diagnosis is appropriate when the evidence for the problem indicates that a condition exists that makes the client vulnerable to a problem. A syndromes diagnosis is assigned by a nurse's clinical judgment to describe a cluster of nursing diagnoses that have similar interventions (option 2). Health promotion diagnoses are used when the client seeks to increase well-being but need not currently be well (option 3). An actual diagnosis is used when the client already exhibits the problem (option 4).

The nursing director who has the ability and willingness to assume responsibility for one's actions and to accept consequences of one's behavior is demonstrating what management principle? 1. Accountability 2. Authority 3. Responsibility 4. Coordinating

1. Accountability *Rationale*: The management principle being demonstrated is accountability. Accountability is the ability and willingness to assume responsibility for one's actions and to accept the consequences of one's behavior. Authority is defined as the legitimate right to direct the work of others. It is an integral component of managing. Responsibility is an obligation to complete a task. Coordinating is the process of ensuring that plans are carried out and evaluating outcomes.

Which social force is most likely to significantly impact the future supply and demand for nurses? 1. Aging 2. Economics 3. Science/technology 4. Telecommunications

1. Aging *Rationale*: All will impact nursing but not necessarily the supply and demand issue. The aging population contributes to more older adults needing specialized care (increasing the demand). Fewer nursing faculty to educate students and fewer nurses practicing because of retirement contribute to the decreasing supply.

Which of the following organizations has established standards for clinical nursing practice? 1. American Nurse Association 2. National League for Nursing 3. International Council of Nurses 4. State Board of Nursing

1. American Nurse Association *Explanation*: Looks like the nursing process - assessment, diagnosing, planning, etc.

A research critique can best be defined as a/an: 1. Appraisal of a study's strengths and weaknesses 2. Conclusion about the utilization potential of a study's findings 3. Criticism of a study's flaws 4. Summary of a study's key points

1. Appraisal of a study's strengths and weaknesses *Rationale*: A research critique is the thoughtful consideration of a study's strengths and weaknesses, and how these affect the quality and usefulness of study results. Options 2 and 3 describe elements of a research critique. The summary of a study and its key findings (option 4) comprise an abstract.

A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided 2. Continue to leave the food at the bedside until the client is hungry enough to eat 3. Notify the primary care provider that tube feeding may be indicated soon 4. Believe the client is not really hungry

1. Assess why the client is not ingesting the food provided *Rationale*: The nurse recognizes that many assumptions (beliefs) could interfere with the client eating - such as that the food presented is not culturally appropriate. These assumptions must be clarified with the process of clinical reasoning. Options 2 and 3 reach conclusions not supported by the facts. In option 4, the nurse has made a judgment or has an opinion that may not be accurate. Also, the nurse is acting without assessment. Implementation should be preceded by assessment.

A client presents to the emergency department with complaints of chest pain. The nurse takes the client's vital signs. The nurse is performing which phase of the nursing process? 1. Assessing 2. Diagnosing 3. Planning 4. Implementing

1. Assessing *Rationale*: The first step in the nursing process is assessment, the process of collecting data. The other processes rely on accurate and complete data.

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that hitch topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1. Automobile crashes

List five aspects of the skin that the nurse assesses during a routine examination. 1. 2. 3. 4. 5.

1. Color 2. Turgor 3. Temperature 4. Moisture 5. Lesions 6. Odor 7. Edema

Student nurse is working in the library on her plan of care for clinical assignment. She has the patient's name written at the top of her paper. What is the student violating? 1. Confidentiality 2. Autonomy 3. The parents wishes 4. Nothing

1. Confidentiality

After licensure, the practicing nurse is required to update his or her knowledge about the latest research and practice developments. The most common way nurses do this is through _____ programs. Select all that apply. 1. Continuing education 2. Master's degree 3. In-service education 4. DNP

1. Continuing education 3. In-service education

The nurse is discussing strategies with the unlinked assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply. 1. Cover the client as much as possible 2. Sing or talk to the client 3. Complete the bath as quickly as possible 4. Be organized 5. Expect the client to protest - finish quickly

1. Cover the client as much as possible 2. Sing or talk to the client 4. Be organized

The primary purpose of the evaluation phase of the care planning process is to determine whether: 1. Desired outcomes have been met 2. Nursing activities were carried out 3. Nursing activities were effective 4. Client's condition has changed

1. Desired outcomes have been met *Rationale*: The desired outcomes and indicator statements reflect the parameters by which success will be measured. The goal can be met even if the nursing activities were not carried out or were ineffective (options 2 and 3). Although the desired outcome, by definition, indicates a change in the client's condition (behavior, knowledge, or attitude), only specific changes (desired outcomes) reflect the success of the care plan (option 4).

A nurse explains the informed consent form to a patient who is scheduled for heart bypass surgery. Which of the following are elements of this consent form? Select all that apply. 1. Disclosure 2. Organ donation 3. DNR orders 4. Comprehension 5. Competence 6. Voluntariness

1. Disclosure 4. Comprehension 5. Competence 6. Voluntariness *Explanation*: (1) patient needs to know everything - benefits, risks, who is going to do it, etc. (4) needs to understand what was said. (5) client needs to be competent in order to consent. (6) needs to know what they're getting into and agree to the surgery.

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints 2. Ensure that the restraints are tied to the side rails 3. Provide range-of-motion exercises when the restraints are removed 4. Orient the client 5. Assess the tightness of the restraints

1. Document the behavior(s) that require continued use of the restraints 3. Provide range-of-motion exercises when the restraints are removed 4. Orient the client 5. Assess the tightness of the restraints

Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status 2. Identify client strengths and problems 3. Develop an individualized plan of care 4. Implement care, prevent illness, and promote wellness

1. Establish a database of client responses to his or her health status *Rationale*: Assessing provides a database of the client's physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3).

What is the fifth and last phase of the nursing process? 1. Evaluating 2. Assessment 3. Planning 4. Implementing

1. Evaluating *Rationale*: Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client's progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. The steps of the nursing process in order are assessment, diagnosis, planning, implementation, and evaluation.

Which of the following outcomes is most appropriate for a nursing diagnosis of ineffective tissue perfusion related to interruption of arterial flow? Select all that apply. 1. Extremities warm to touch 2. Improved respiratory status 3. Decreased muscle pain with activity 4. Participation in self-care measures 5. Lungs clear to auscultation

1. Extremities warm to touch 3. Decreased muscle pain with activity

Which outcomes is MOST appropriate for a nursing diagnosis of ineffective tissue perfusion related to interruption of arterial flow. Select all that apply. 1. Extremities warm to touch 2. Improved respiratory status 3. Decreased muscle pain with activity 4. Participation in self-care measures 5. Lungs clear to auscultation

1. Extremities warm to touch 3. Decreased muscle pain with activity

Which actions are true of a situational leader? (Select all that apply.) 1. Flexes task and relationship behaviors 2. Considers the staff members' abilities 3. Knows the nature of the task to be done 4. Is sensitive to the context or environment in which the task takes place 5. Has a relationship with followers based on an exchange for some resource valued by the follower

1. Flexes task and relationship behaviors 2. Considers the staff members' abilities 3. Knows the nature of the task to be done 4. Is sensitive to the context or environment in which the task takes place *Rationale*: The situational leader flexes task and relationship behaviors, considers the staff members' abilities, knows the nature of the task to be done, and is sensitive to the context or environment in which the task takes place. The transactional leader has a relationship with followers based on an exchange for some resource valued by the follower

The client is complaining of shortness of breath. his respiration's are 28 and labored. The bed is currently in the flat position. The nurse puts the bd in which position? 1. Fowler's 2. Semi-Fowler's 3. Trendelenburg 4. Reverse Trendelenburg

1. Fowler's

A nurse is providing perineal care (PERI care) to a female patient. In which direction would the nurse move the washcloth? 1. From the pubic area toward the anal area 2. From the anal area to the public area 3. From side to side within the labia 4. The direction does not many any difference

1. From the pubic area toward the anal area

Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development? 1. Identify at-risk clients on admission to the health care facility 2. Place at-risk clients on an every-2-hour turning schedule 3. Automatically place clients in speciality beds 4. Provide at-risk clients with a high-protein, high-carbohydrate diet

1. Identify at-risk clients on admission to the health care facility

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs 2. Organizing data in the client's family history 3. Establishing short-term and long-term goals 4. Administering an antibiotic

1. Identifying major problems or needs *Rationale*: Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea) as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is part of the planning phase. Administering an antibiotic is part of the implementation phase.

The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses? 1. Imbalanced nutrition: less than body requirements 2. Acute pain related to abdominal muscle spasms 3. Adult failure to thrive 4. Ineffective health maintenance

1. Imbalanced nutrition: less than body requirements

A nurse is planning a seminar on the comparison of leader and manager roles. Which of the following characteristics describes a leader role? 1. Influences others toward goal setting, either formally or informally 2. Maintains an orderly, controlled, rational, and equitable structure 3. Relates to people according to their roles 4. Feels rewarded when fulfilling the organizational mission or goals

1. Influences others toward goal setting, either formally or informally *Rationale*: The leader role influences others toward goal setting, either formally or informally. The manager role carries out predetermined policies, rules, and regulations; maintains an orderly, controlled, rational, and equitable structure; relates to people according to their roles; and feels rewarded when fulfilling the organizational mission or goals.

"Client will ambulate 20 yards without assistance in 8 weeks" is an example of a: 1. Long-term goal 2. Short-term goal 3. Nursing intervention 4. Rationale

1. Long-term goal *Rationale*: Long-term goals are often used for clients who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers.

Which two frameworks for care are used for the delivery of nursing care that supports continuity of care and cost-effectiveness? (Select all that apply.) 1. Managed care 2. Nonfunctional method 3. Secondary nursing 4. Team nursing

1. Managed care 4. Team nursing *Rationale*: Managed care and team nursing are used as frameworks for care in today's health care system, which supports continuity of care and cost effectiveness.

The research process of problem solving is: 1. Most effective when used by experienced nurses 2. Least effective when used by experienced nurses 3. Illogical at times 4. Lacking in formality

1. Most effective when used by experienced nurses *Rationale*: *The research process is most effective when use by experienced nurses*. The research process is a formalized, logical, systematic approach to problem solving.

A nurse teaching a safety class for parents identifies the main causes of death for school-age children. Which of the following is NOT one of the leading causes? 1. Natural disasters 2. Fires 3. Drownings 4. Firearms

1. Natural disasters

Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. No interventions should be carried out without the nurse having clear rationales 2. Always follow the primary care provider's orders exactly, without variation 3. Encourage all clients to be as dependent as desired and allow the nurse to perform care for them 4. When possible, give the client options in how interventions will be implemented 5. Each intervention should be accompanied by client teaching

1. No interventions should be carried out without the nurse having clear rationales 4. When possible, give the client options in how interventions will be implemented 5. Each intervention should be accompanied by client teaching *Rationale*: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet individual client needs (option 2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option 3).

The client's VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT. Interpret the commonly used abbreviations. 1. NKA: 2. BRP: 3. PRN: 4. DAT:

1. No known allergies *Rationale*: 1. No known allergies 2. Bathroom privileges 3. When necessary 4. Diet as tolerated.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Monitoring the urine output of postoperative client: ____________

1. Nurse caregiver

What phases of the nursing process are identified by the most current Scope and Standards of Nursing Practice that are not recognized by the national licensure examination for registered nurses (NCLEX-RN)? 1. Outcomes identifications and diagnosis 2. Analysis and diagnosis 3. Outcomes identifications and analysis 4. Assessment and evaluation

1. Outcomes identifications and diagnosis *Rationale*: The national licensure exam does not recognize outcomes identification and diagnosis as phases of the nursing process. Analysis is recognized by the national licensure exam but its not recognized by the Scope and Standards of Nursing Practice and both recognize assessment and evaluation as phases of the nursing process.

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Getting a flu shot every fall ___________.

1. Primary

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Running 3 miles per day to stay fit ___________.

1. Primary

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Wearing a seat belt ___________.

1. Primary

Third-party reimbursement refers to the insurance company that pays the client's (first party) bill to the provider (second party). This component is part of the: 1. Private health insurance plan 2. Diagnosis-related group (DRG) 3. Group health insurance plan 4. Preferred provider organization

1. Private health insurance plan *Rationale*: Private health insurance pays either the entire bill or a percentage of the costs of health care services.

A nurse who is planning care for a client requiring seizure precautions should plan to include which of the following? 1. Provide education to the client and family regarding the need to wear a medical identification tag 2. Assist the client in alerting all persons in the community about their seizure disorder 3. Provide education regarding safety precautions for inside of the home only 4. Discuss with the client, family, and persons in the community factors that may precipitate a seizure

1. Provide education to the client and family regarding the need to wear a medical identification tag

A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply. 1. Provides the medical diagnosis or reason for admission 2. States the time the client last received pain medication 3. Speaks loudly when giving report 4. States priorities of care that are due shortly after the report 5. Reports on number of visitors for each client

1. Provides the medical diagnosis or reason for admission 2. States the time the client last received pain medication 4. States priorities of care that are due shortly after the report *Rationale*: Option 3 is incorrect because it could be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a concern and it would not be done for every client.

Identify the components of a nursing diagnosis. (Select all that apply.) 1. Related factors 2. Risk factors 3. Problem 4. Definition 5. Defining characteristics 6. Medical conditions

1. Related factors 2. Risk factors 3. Problem 4. Definition 5. Defining characteristics *Rationale*: A nursing diagnoses has three components and consists of all answer choices except the medical conditions. A medical diagnosis is made by a physician and refers to a condition that only a physician can treat.

The nurse recognizes which of the following as therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the patient "why" 4 Maintaining a neutral response 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1. Restating 2. Listening 4 Maintaining a neutral response 5. Providing acknowledgment and feedback *Explanation*: They don't want your opinion, and you should never ask a patient why.

The client has refused to have a Foley catheter inserted after surgery. What would need to be charted in the client's chart? 1. The client refused the Foley catheter. The client was educated about the need for the Foley and the consequences of refusing the treatment; client verbalized understanding of the education 2. The client stubbornly refused the Foley catheter insertion 3. The client was medicated and the Foley was inserted without difficulty 4. The client refused the Foley catheter

1. The client refused the Foley catheter. The client was educated about the need for the Foley and the consequences of refusing the treatment; client verbalized understanding of the education *Rationale*: The documentation is complete and states that education was given informing the client of the consequences of refusal.

Consider the following nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inability to feed self. What is an example of a short-term goal for this client? 1. The client will eat 75% of his meals by Friday (September 20) with the use of modified eating utensils to feed self with minimal assistance 2. The client will learn about nutritious meal planning as exhibited by choosing one correct menu 3. The client will acquire competence in managing cookware signed for clients with handicaps 4. The client will learn preparation techniques that are quick and easy to manage

1. The client will eat 75% of his meals by Friday (September 20) with the use of modified eating utensils to feed self with minimal assistance *Rationale*: This is a short-term nursing goal. It is useful for clients who require health care for a short period of time and clients who are frustrated by long-term goals that seem difficult for them to attain and who need the satisfaction of completing a short-term goal. The other answer choices are either not short term or are not specific goals.

The nurse is assessing the sputum characteristics of a client with pneumonia. What are the senses that the nurse may use in the assessment of the sputum? (Select all that apply.) 1. Vision 2. Smell 3. Hearing 4. Touch

1. Vision 2. Smell *Rationale*: Vision and smell would be used. The color of the sputum and any smell associated with it may be important cues to the disease process. Touch is usually not useful in regards to sputum because consistency can be seen.

Which skills best describe nursing interpersonal skills? 1. Problem solving, decision making, critical thinking, and creativity 2. All of the activities, verbal and nonverbal, used when interacting directly with others 3. Manipulating equipment, giving injections, and bandaging 4. Leadership management and delegation

2. All of the activities, verbal and nonverbal, used when interacting directly with others *Rationale*: Interpersonal skills are the combination of verbal and nonverbal activities individuals use when interacting with one another.

During the change-of-shift report, the nurse reports that the client is having "respiratory difficulty." What should the nurse add to this report?" 1. "But she seems okay." 2. "Her respiratory rate is up to 28 breaths/min; oral temperature is 100 degrees; heart rate is 96 beats/minute; 02 saturation of 90%." 3. "I put her on 3 liters of oxygen." 4. "I called the doctor but he didn't do anything."

2. "Her respiratory rate is up to 28 breaths/min; oral temperature is 100 degrees; heart rate is 96 beats/minute; 02 saturation of 90%." *Rationale*: When giving the change-of-shift report, the nurse should use a guide, begin by giving background information of the client, be specific, describe abnormal findings and provide supporting evidence.

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching? 1. "I am going to use a mirror to check my feet." 2. "I enjoy walking barefoot around the house." 3. "I will file my nails." 4. "I will increase the time that I wear new shoes each day."

2. "I enjoy walking barefoot around the house."

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2. "We must wash or peel all raw fruits and vegetables before eating." 3. "A wound or sore is not infected unless we see it draining pus." 4. "We should not share toothbrushes but it is OK to share towels and washcloths."

2. "We must wash or peel all raw fruits and vegetables before eating."

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. "I will get a dietary consult to talk to you before next week." 2. "What do you think is so difficult about following a low-sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "You may not need to follow a low-sodium diet for as long as you think."

2. "What do you think is so difficult about following a low-sodium diet?" *Rationale*: The nurse recognizes the need to obtain further information from the client in order to respond directly to the client's statement. Option 1 passes off the client's educational needs to another practitioner. Options 3 and 4 are non-therapeutic.

"A group of related ideas or statements" best defines which of the following? 1. A philosophy 2. A conceptual framework 3. A theory 4. A paradigm

2. A conceptual framework *Rationale*: A group of related ideas or statements is a conceptual framework. A philosophy is a belief system (option 1); a supposition or system of ideas proposed to explain a given phenomenon is a theory (option 3); and a paradigm is a pattern of sacred understandings and assumptions about reality and the world (option 4).

Formulating a research problem is often facilitated by the researcher performing: 1. A feasibility study 2. A literature review 3. A methodology evaluation 4. A pilot study

2. A literature review *Rationale*: Formulating a research problem is facilitated by performing a literature review.

A nurse is making the client's bed. Which of the following actions should the nurse perform? (Select all that apply.) 1. Hold the soiled linen close to his or her uniform to conserve energy 2. Avoid shaking soiled linen in the air because shaking can disseminate secretions and excretions and the microorganisms they contain 3. When stripping and making a bed, conserve time and energy by stripping and making up one side as much as possible before working on the other side 4. Place the clean linens on another client's bed if needed, in order to strip the client's dirty linens 5. Raise the bed to a comfortable working height when stripping and making the bed

2. Avoid shaking soiled linen in the air because shaking can disseminate secretions and excretions and the microorganisms they contain 3. When stripping and making a bed, conserve time and energy by stripping and making up one side as much as possible before working on the other side 5. Raise the bed to a comfortable working height when stripping and making the bed

The client is chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 1. Eliminate the reservoir 2. Block the portal of exit from the reservoir 3. Block the portal of entry into the host 4. Decrease the susceptibility of the host

2. Block the portal of exit from the reservoir

Which role is the nurse assuming when initiating, motivating, and implementing change? 1. Advocate 2. Change agent 3. Teacher 4. Change role model

2. Change agent *Rationale*: The nurse who is initiating, motivating, and implementing change is acting in the role of change agent. The other answer choices do not apply to this nursing role.

Which component is part of the permanent client record? 1. Nursing protocols 2. Client care plan 3. Procedures for client care 4. The nurse's notebook of daily notes to herself

2. Client care plan *Rationale*: The client care plan is a permanent part of the record. The protocols and procedures are not part of the permanent record. The nurse's notes are sometimes called the nurse's "brain." The nurse may write down short notes about any events that happen during the shift to help the nurse to correctly document events in the client's chart.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Reviewing wound care products from vendors to determine which would be the best for the hospital to purchase: ____________

2. Clinical nurse specialist *Explanation*: Clinical nurse specialist is advanced practice and in a specialty - can be researcher, administrator, etc. A practitioner just diagnosis, treats, etc.

A client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifestations. What do these actions represent? 1. Clinical judgment 2. Clinical reasoning 3. Reflection 4. Intuition

2. Clinical reasoning *Rationale*: Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of clinical reasoning. Past experiences in care enhance the nurse's ability to recognize and respond in the delivery of client-centered care. Clinical judgment in nursing is a decision-making process to ascertain the right action to implement at the appropriate time during client care (option 1). Reflection is the nurse's review of the care provided to determine strategies to improve future care (option 3). Institution is a problem-solving approach that relies on a nurse's inner sense (option 4).

Which of the following is an expected finding during assessment of the older adult? 1. Facial hair that becomes finer and softer 2. Decreased peripheral, color, and night vision 3. Increased sensitivity to odors 4. An irregular respiratory rate and rhythm at rest

2. Decreased peripheral, color, and night vision *Rationale*: Visual actuity often lessens with age. Facial hair is likely to become coarser, not finer (option 1). The sense of smell becomes less, rather than more acute (option 3). The respiratory rate and rhythm is regular at rest (option 4). However, both may change quickly with activity and be slow to return to the resting level.

Primary purpose of standards of nursing practice? 1. Provide method by which nurses perform skills safely 2. Ensure knowledgeable, safe, comprehensive nursing care 3. Establish nursing as a profession and a discipline 4. Enable nurses to have a voice

2. Ensure knowledgeable, safe, comprehensive nursing care

Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes 2. Ensure that no one can overhear the interview conversation 3. Stand near the client's head while he or she is in the bed or chair 4. Keep approximately 3 feet from the client during the interview 5. Use a standard form to be sure all relevant data are covered in the interview

2. Ensure that no one can overhear the interview conversation 4. Keep approximately 3 feet from the client during the interview 5. Use a standard form to be sure all relevant data are covered in the interview *Rationale*: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information. Lighting should be at a normal level - neither bright nor dim (option 1). The nurse should be at the same height as the client, usually sitting, at approximately a 45 degree angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3).

A key function of a study's methodology is to: 1. Determine the hypotheses that will be tested in the study 2. Exercise control over contaminating factors in the study environment 3. Identify grants and other funding sources for conducting the study. 4. Protect the rights of the study's participants

2. Exercise control over contaminating factors in the study environment *Rationale*: The key purpose of a study's methodology is to generate data that are reliable and valid, thus controlling extraneous variables is a major function. The hypotheses that are tested are formed during the problem identification phase of a study (option 1). Grants and funding sources are not related to methodology (option 3). Protecting subjects' rights (option 4) is an important consideration, but not the key purpose of a methodology.

A nurse is planning a seminar on guidelines for dealing with resistance to change. Which of the following would NOT be an appropriate guidelines for dealign with resistance to change? 1. Clarify information and provide accurate information 2. Explain the positive and negative consequences of the change and how the individual or group will get the change done 3. Maintain a climate of trust, support, and confidence 4. Communicate with those who oppose the change. Get to the root of their reasons for opposition

2. Explain the positive and negative consequences of the change and how the individual or group will get the change done *Rationale*: Guidelines for dealing with resistance to change include the following: Emphasize the positive consequences of the change and how the individual or group will benefit. Clarify information and provide accurate information. Maintain a climate of trust, support, and confidence. Communicate with those who oppose the change. Get to the root of their reasons for opposition.

Who is considered to be the founder of professional nursing? 1. Dorothea Dix 2. Florence Nightingale 3. Harriet Tubman 4. Sojourner Truth

2. Florence Nightingale

A leader is most likely to be effective when acting which way? Select all that apply. 1. Adopts the leadership style of the leader who had the position before him or her 2. Gives equal consideration to group members who are in favor of and opposed to a desired change 3. Plans and organizes group activities 4. Modifies his or her own behaviors based on the needs of individual members of the group 5. Asks members for opinion of the leader's effectiveness

2. Gives equal consideration to group members who are in favor of and opposed to a desired change 3. Plans and organizes group activities 5. Asks members for opinion of the leader's effectiveness *Rationale*: an effective leader is open to members' views on both sides of issues, orchestrates group activities, and is open to and solicits feedback on their style. They use the style most natural to them rather than adopt another (option 1) and use a style appropriate to the situation and the groups as a whole, not varying for each member (option 4).

A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is? 1. Start a peripheral IV 2. Initiate closed-chest massage 3. Establish an airway 4. Obtain the crash cart

2. Initiate closed-chest massage *Explanation*: Always need to begin CPR immediately, and "closed-chest massage" is another way of saying perform CPR.

A taxonomy of nursing outcome statements is developed to describe measurable states, behaviors, or perceptions to respond to which part of the nursing process? 1. Nursing assessments 2. Nursing interventions 3. Nursing goals 4. Nursing outcomes

2. Nursing interventions *Rationale*: A taxonomy of nursing outcome statements, the Nursing Outcomes Classification (NOC), has been developed to describe measurable states, behaviors, or perceptions that respond to nursing interventions. Each has a definition, a measuring scale, and indicators.

When caring for several acutely ill clients, the nurse exhibits professional autonomy when? 1. Delivering medications and prescribed treatments in a timely manner 2. Prioritizing client according to client needs 3. Communicating with peers when help is needed 4. Informing the supervisor about high acute level and staff-to-client ratio

2. Prioritizing client according to client needs

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Audit

2. Process evaluation *Rationale*: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation (option 1) would focus on the setting (e.g., how well equipment functions), and outcome evaluations (option 3) focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit (option 4) would be a chart or document review.

Nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? 1. Administer the medication based on the order 2. Question the order for the medication 3. Refuse to administer the medication 4. Document concerns about the order

2. Question the order for the medication

The nurse evaluates the chart of a 65-year-old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply. 1. Last tetanus booster was at age 50 2. Receives a flu shot every year 3. Has not received the hepatitis B vaccine 4. Has not received the hepatitis A vaccine 5. Has not received the herpes zoster vaccine

2. Receives a flu shot every year 3. Has not received the hepatitis B vaccine 4. Has not received the hepatitis A vaccine

A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is: 1. Malpractice 2. Respondeat superior 3. Negligent 4. Tort

2. Respondeat superior

Identify the level of prevention in the following action: 1. Primary 2. Secondary 3. Tertiary Taking antibiotics for a sinus infection ___________.

2. Secondary

"Client will walk to end of hallway without assistance by Friday" is an example of a: 1. Long-term goal 2. Short-term goal 3. Nursing intervention 4. Rationale

2. Short-term goal *Rationale*: Short-term goals are useful for clients who require health care for a short time and for those who are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal.

In long-term care facilities, what two types of care are provided? (Select all that apply.) 1. Easy 2. Skilled 3. Intermediate 4. Unskilled

2. Skilled 3. Intermediate *Rationale*: Skilled care clients require more extensive nursing with specialized nursing skills. The intermediate care focus is on clients with chronic illnesses.

A nurse is able to provide care to several complex clients and focuses on those items that are the most important. Within which stage of Benner's stages of nursing expertise is this nurse functioning? 1. Stage II 2. Stage III 3. Stave IV 4. Stage V

2. Stage III *Rationale*: Stage III, Competent, is able to coordinate multiple complex care demands and focuses on the important aspects of care.

The nurse is measuring the drainage from a Jackson-Pratt drain. What is considered objective data? 1. The client is complaining of abdominal pain 2. The drainage measurement is 25 mL 3. The client stated, "I did not empty the drain." 4. The client stated that he has a pain level of 5

2. The drainage measurement is 25 mL *Rationale*: Data that is measurable is objective data. The client's statements and complaints of symptoms are documented as subjective data.

The home health registered nurse needs to assign a person to inset a Foley catheter on a client. To whom can she delegate this task? 1. The unlicensed personnel with extensive training 2. The licensed practical/vocational nurse 3. The physician 4. The client's daughter

2. The licensed practical/vocational nurse *Rationale*: A licensed practical/vocational nurse has the necessary skills and training to insert Foley catheters. Unlicensed personnel, regardless of his or her experience, cannot insert a Foley catheter. It is inappropriate to delegate this intervention to the physician. The client's family member cannot perform this intervention.

The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed 2. The nurse chooses from a list of interventions 3. They are much shorter than nurse-authored care plans 4. They have been approved by accrediting agencies

2. The nurse chooses from a list of interventions *Rationale*: Standardized care plans provide a list of interventions from which the nurse can choose. The plan must still be individualized (option 1). Standardized plans could no longer or shorter than nurse-authored ones (option 3), but have not been approved by any outside accreditor (option 4).

Which clients could make decisions regarding health care? (Select all that apply.) 1. A woman who arrives in the emergency department with an altered mental state and the aroma of ethyl alcohol 2. The parents of a 14-year-old girl involved in a car collision 3. A middle-aged man who has the mental capacity of an 8-year-old 4. A 10-year-old boy who has arrived with friends and has a shallow laceration needing three sutures 5. A competent older adult who requires surgery on a prolapsed bladder

2. The parents of a 14-year-old girl involved in a car collision 5. A competent older adult who requires surgery on a prolapsed bladder *Rationale*: Of these options, the parents of the 14-year-old child and the competent older client would be the best persons to make health care decisions. The other responses are incorrect due to the altered mental state and age of consent limitations. If the child with the laceration was hemorrhaging, implied consent would be adequate enough in order to save the child's life.

A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1. Soak her feet frequently 2. Use a non perfumed lotion 3. Apply foot powder 4. Avoid knee-high elastic stockings

2. Use a non perfumed lotion

Medicare is divided into two divisions, Part A and Part B, and one supplemental plan. Part B is the: 1. Voluntary prescription drug plan that begin in January 2006 2. Voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible 3. Plan section providing insurance toward hospitalization, home care, and hospice care 4. Plan section providing very limited financial coverage to low-income persons

2. Voluntary plan that provides partial coverage of outpatient and health care provider services to those who are eligible *Rationale*: The Medicare plan is divided into two parts, Part A and Part B. Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescription drug plan begun in January 2006. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes.

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to the diagnosis." 4. "How is your family responding to the diagnosis?"

3. "Tell me about your reactions to the diagnosis." *Rationale*: Eliciting feelings requires an open-ended question that does more than seek factual information (option 1) and cannot be answered with a single word (option 2). The family can provide indirect information about the client, but is not most likely to provide the most accurate information (option 4).

A patient, unsure of the need for surgery, asks the nurse, "What should I do?" What answer by the nurse is based on advocacy? 1. "If I were you, I sure would not have this surgical procedure" 2. "Gosh, I don't know what I would do if I were you" 3. "Tell me more about what makes you think you don't want the surgery" 4. "Let me talk to your doctor and I will get back to you as soon as I can"

3. "Tell me more about what makes you think you don't want the surgery" *Explanation*: You are the nurse listening and restating his concerns. Advocate for the patient by asking why without actually asking "why". If you go to the doctor, the first question they're going to ask is why don't they want the surgery - so you need to ask all the questions first and bring as much information back to the doctor as you can.

A patient diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one whose dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about the anger with your family" 3. "You are feeling angry that your family continues to hope for you to be cured" 4. "You are probably very depressed, which is understandable with such a diagnosis"

3. "You are feeling angry that your family continues to hope for you to be cured" *Explanation*: (1) You're dismissing what they're feeling by moving it to the family. (2) They don't want your opinion, it's not about you. (3) You listened to what they said, restated what they said, and acknowledged their feelings.

What is the correct bath water temperature for an adult client? 1. 110 degrees F - 125 degrees F 2. 90 degrees F - 100 degrees F 3. 100 degrees F - 115 degrees F 4. 125 degrees F - 135 degrees F

3. 100 degrees F - 115 degrees F

A nurse is evaluating a nursing student's understanding of the various types of infections. Which of the following statements demonstrates a need for further teaching? 1. A local infection is limited to the specific part of the body where the microorganisms remain 2. If the microorganisms spread and damage different parts of the body, it is a systemic infection 3. Acute infections may occur slowly, over a very long period, and may last months or years 4. Nosocomial infections are classified as infections that are associated with the delivery of health care services in a health care facility

3. Acute infections may occur slowly, over a very long period, and may last months or years

If the client reports loss of short-term memory, the nurse would assess this using which one of the following? 1. Have the client repeat a series of three numbers, increasing to eight if possible 2. Have the client describe his or her childhood illnesses 3. Ask the client to describe how he or she arrived at this location 4. Ask the client to count backward from 100 subtracting seven each time

3. Ask the client to describe how he or she arrived at this location *Rationale*: Recent memory includes events of the current day. Recalling a series of numbers tests immediate recall (option 1). Recalling childhood events tests remote (long-term) memory (option 2), and subtracting backwards from 100 tests attention span and calculation skills (option 4).

A new nursing student is disappointed because classes so far are focused on topics such as communication and planning, and she wanted to be a nurse to "provide care." This nursing student is describing which role of the nurse? 1. Teacher 2. Client advocate 3. Caregiver 4. Counselor

3. Caregiver *Rationale*: The caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client's dignity.

What is the name of the head-to-toe approach that usually begins the nurse physical examination? 1. Review of systems 2. Screening examination 3. Cephalocaudal 4. Caudal approach

3. Cephalocaudal *Rationale*: The cephalocaudal or head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes.

When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to: 1. Deliver care to a client in an organized way 2. Implement a plan that is close to the medical model 3. Identify client needs and deliver care to meet those needs 4. Make sure that standardized care is available to clients

3. Identify client needs and deliver care to meet those needs

When caring for a client with stage 4 pressure ulcers on the coccyx, the nurse turns the client every 2 hours while in bed. What part of the nursing process is being carried out? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

3. Implementation *Rationale*: Implementation of the nursing care plan is part of the nursing process to achieve the goals and/or outcomes. Reassessment continues at this time to see if the interventions are working effectively. The plan of care may be altered at any time during the client's stay at the facility as needed.

In the emergency department, the nurse observes that a client is actively bleeding from an abdominal gunshot wound. The nurse assumes that the client is at an increased risk for hypovolemic chock after observing frank red blood spurting from the wound. What is this an example of? 1. Creativity 2. Deductive reasoning 3. Inductive reasoning 4. Critical analysis

3. Inductive reasoning *Rationale*: Inductive reasoning generalizations are formed from a set of facts or observations.

The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with the finding. Which nursing skill of implementing would be needed most? 1. Cognitive 2. Intellectual 3. Interpersonal 4. Psychomotor

3. Interpersonal *Rationale*: This client goals psychosocial support rather than skills related to knowledge (options 1 and 2) or hands-on activity (option 4).

Which of the following would NOT be a preventive measure for an older client with poor vision? 1. Ensure eyeglasses are functional 2. Ensure appropriate lighting 3. Mark doorways only 4. Keep the environment tidy

3. Mark doorways only

Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1. The original taxonomy has proven to be adequate in scope 2. The organizing framework of the taxonomy is based on the work of Florence Nightingale 3. More research is needed to validate and refine the diagnostic labels 4. New diagnostic labels are approved by means of a vote of registered nurses

3. More research is needed to validate and refine the diagnostic labels *Rationale*: Diagnostic labels are continuously reviewed and revised as indicated by research - much more of which is needed. The original taxonomy has been replaced by Taxonomy II and is no longer based on a nurse theorist (options 1 and 2). New diagnoses are approved by NANDA International's Diagnostic Review Committee, not by a vote of nurses (option 4).

A registered nurse is considered additional education so that she can provide nonemergent acute care in an ambulatory clinic. This nurse is considering which expanded career role? 1. Nurse anesthetist 2. Clinical nurse specialist 3. Nurse practitioner 4. Nurse administrator

3. Nurse practitioner *Rationale*: A nurse who has an advanced education and is a graduate of a nurse practitioner program is considered a nurse practitioner. Nurse practitioners usually deal with nonemergency acute or chronic illness and provide primary ambulatory care.

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Conducting study on relationship between postpartum... (didn't get the rest of the question): ____________

3. Nurse researcher

Match the role with the task: 1. Nurse caregiver 2. Clinical nurse specialist 3. Nurse researcher 4. Nurse administrator 5. Nurse educator Gathering data to prevent ventilator-acquired pneumonia: ____________

3. Nurse researcher

Which of the following is considered a driving force? 1. Low tolerance for change related to intellectual or emotional insecurity 2. Misunderstanding of the change and its implications 3. Perception that the change will improve the situation 4. Lack of time or energy

3. Perception that the change will improve the situation *Rationale*: Perception that the change will improve the situation is considered a driving force. Restraining forces include low tolerance for change related to intellectual or emotional insecurity; misunderstanding of the change and its implications; and lack of time or energy

How does the nurse begin a diagnostic label for a collaborative problem? 1. Readiness for Enhanced Spiritual Well-Being 2. Alteration of Respiratory Status 3. Potential Complication for Pneumonia: Atelectasis 4. Impaired Respiratory System

3. Potential Complication for Pneumonia: Atelectasis *Rationale*: A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions.

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1. Leave the bathroom light on 2. Withhold the client's diuretic medication 3. Provide a bedside commode 4. Keep the side rails up

3. Provide a bedside commode

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? 1. Carrying out nursing interventions 2. Determining the need for assistance 3. Reassessing the client 4. Documenting interventions

3. Reassessing the client *Rationale*: The first step of implementing is reassessing the client to determine that the activity is still indicated and safe. The next action would be to determine if assistance is required (option e2), then implement the intervention (delegating if appropriate) (option 1), and last document the intervention (option 4).

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1. Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

3. Risk for Poisoning

Planning consists of which component? 1. Reassessing the client 2. Analyzing data 3. Selecting nursing interventions 4. Determining the nurse's need for assistance

3. Selecting nursing interventions *Rationale*: Selecting nursing interventions based on the assessment findings and nursing diagnosis is the next step in the nursing process.

A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0)

3. Semidependent (+2)

Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes 2. Write the care plan 3. Set priorities 4. Choose interventions

3. Set priorities 1. Establish goals/outcomes 4. Choose interventions 2. Write the care plan *Rationale*: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan.

Disciplines without a strong theory and research base were historically referred to as: 1. Hard 2. Concrete 3. Soft 4. Medium

3. Soft *Rationale*: Disciplines without a strong theory and research base historically were feared to as "soft," a negative comparison wit hate "hard" natural sciences. Many of the soft disciplines attempted to emulate the sciences, so theory and scientific research became a more important part of academic life, both in the practice disciplines and in the humanities.

The nurse uses Montgomery straps primarily to achieve which of the following client outcomes? 1. The client is free from falls 2. The client is free from bruises 3. The client is free from skin breakdown 4. The client is free from wandering

3. The client is free from skin breakdown *Explanation*: Montgomery straps adhere to skin, pack wound, and put big ABD over it which ties and keeps it there.

Which action by a nurse ensures confidentiality of a client's computer record? 1. The nurse logs on to the client's file and leaves the computer to answer the client's call light 2. The nurse shares her computer password 3. The nurse closes a client's computer file and logs off 4. The nurse leaves client computer worksheets at the computer workstation

3. The nurse closes a client's computer file and logs off *Rationale*: All of the other answers endanger the client's confidentiality.

A nurse is planning a seminar on leadership styles. Which of the following statements describes a democratic leadership style? 1. The leader assumes a "hands-off" approach 2. Under this leadership style, the group may feel secure because procedures are well defined and activities are predictable 3. This leadership style demands that the leader have faith in the group members to accomplish the goals 4. This leadership style does not trust self or others to make decisions and instead relies on the organization's rules, policies, and procedures to direct the group's work efforts

3. This leadership style demands that the leader have faith in the group members to accomplish the goals *Rationale*: The democratic leadership style demands that the leader have faith in the group members to accomplish the goals. In the laissez-faire leadership style, the leader assumes a "hands-off" approach. Under the autocratic leadership style, the group may feel secure because procedures are well defined and activities are predictable. The bureaucratic leader does not trust self or others to make decisions and instead relies on the organization's rules, policies, and procedures to direct the group's work efforts.

The care plan includes a nursing intervention "4/2/15 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None

3. Time *Rationale*: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals (e.g., q4h). The nurse is also aware, however, the critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings.

The organizational executives who are primarily responsible for establishing goals and developing strategic plans are considered to be: 1. First-level managers 2. Middle-level managers 3. Upper-level managers 4. Supervising managers

3. Upper-level managers *Rationale*: Upper-level (top-level) managers are organizational executives who are primarily responsible for establishing goals and developing strategic plans. First-level managers are responsible for managing the work of non managerial personnel and the day-to-day activities of a specific work group or groups. Middle-leve managers supervise a number of first-level managers and are responsible for the activities in the departments they supervise. Middle-level managers serve as liaisons between first-level managers and upper-level managers. They may be called supervisors, nurse managers, or head nurses. Supervising managers are not a category of organizational executives.

Which of the following consists primarily of nucleic acid and therefore must enter living cells in order to reproduce? 1. Fungi 2. Bacteria 3. Viruses 4. Parasites

3. Viruses

Four commonly used methods of sterilization are moist heat, gas, boiling water, and radiation. Which of the following is the most practical and inexpensive method for sterilizing in the home? 1. Gas 2. Moist heat 3. Radiation 4. Boiling water

4. Boiling water

What is an example of an open-ended question that the nurse may use in the interview process? 1. "Did you take your medication today" 2. "Have you ever had to undergo surgery?" 3. "Are you a student at the local college?" 4. "How have you been feeling lately?"

4. "How have you been feeling lately?" *Rationale*: Open-ended questions are those questions that allow the interviewee to do the talking. These questions are easy to answer, are nonthreatening, and require more than a simple "yes" or "no" answer.

A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in the nursing program. When the UAP says "Yes," the nurse asks him to help her out by doing a urinary catheterization on a post surgical client. What is the best response by the UAP? 1. "Let me get permission from the client first." 2. "Sure. Which client is it?" 3. "I can't do it unless you supervise me." 4. "I can't do it. Is there something else I can help you with?"

4. "I can't do it. Is there something else I can help you with?" *Rationale*: A sterile, invasive procedure that places the client at significant risk for infection is generally outside the scope of practice of a UAP. Even though the UAP is a nursing student, the agency job description should be followed. The job description is the standard of care in this situation.

Which of the following nursing actions would be considered a violation of HIPPA regulations? Select all that apply. 1. A nurse ambulates a patient through a hospital hallways in a hospital gown that is open in the back 2. A nurse shoves a confused, bedridden patient into bed after he made several attempts to get up 3. A nurse inadvertently administers the wrong dose of morphine to a patient in the ICU 4. A nurse uses a patient's chart as a sample teaching case without changing the patient's name 5. A nurse reports the condition of a patient to the patient's employer 6. A nurse misrepresents herself to obtain a license to practice nursing

4. A nurse uses a patient's chart as a sample teaching case without changing the patient's name 5. A nurse reports the condition of a patient to the patient's employer *Explanation*: (4) when teaching, you wouldn't actually use the patients real name or full name. (1 & 3) are very bad, but not against HIPPA

What is the best example of altruism exhibited by a nurse? 1. Turning the bed-bound client every 4 hours 2. Withholding scheduled pain medication to a client who has a level 6 pain scale rating 3. Insisting that a client use the bedpan instead of assisting the client to the restroom because it is easier for the nurse 4. Allowing a Catholic client to keep his rosary beads within each as a comfort measure

4. Allowing a Catholic client to keep his rosary beads within each as a comfort measure *Rationale*: Altruism is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse's concern for the welfare of patients, other nurses, and other health care providers. Turning the patient every 4 hours is an example of standards of practice more than altruism because failure to do so would result in malpractice and negligence.

The nurse recognizes that which client would be most at risk for a nosocomial infection? 1. A client in the ER with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy

4. An 86-year-old female client on steroid therapy *Explanation*: She's old and on steroids

The nurse documents that the goal or desired outcome was met, partially met, or not met. What part of the evaluation statement is the nurse documenting? 1. Supporting data 2. Collecting data 3. Finale 4. Conclusion

4. Conclusion *Rationale*: Conclusions are drawn when the nurse uses judgments about the goal achievement status. The nurses determine whether the care plan needs to be modified.

What is the name of the classification system that prospective payment systems utilize? 1. Medicare 2. Medicaid 3. State Children's Health Insurance Program (SCHIP) 4. Diagnosis-related groups (DRGs)

4. Diagnosis-related groups (DRGs) *Rationale*: Diagnosis-related groups (DRGs) are a prospective payment system limiting the amount paid to hospitals that are reimbursed by Medicare. The system has categories that establish pretreatment diagnosis billing categories.

What are two nursing phases that overlap each other in the nursing process? 1. Assessing; diagnosing 2. Planning; implementing 3. Implementing; evaluation 4. Evaluating; assessing

4. Evaluating; assessing *Rationale*: *The nursing process is a dynamic, ever-changing process*. Evaluating and assessing are two phases of the nursing process that often overlap because the nurse is continually evaluating the plan of care and assessing the client's responses to it.

What does the trial-and-error method of problem solving lack? 1. Effectiveness 2. Organization 3. Thoughtfulness 4. Exactness

4. Exactness *Rationale*: Trial-and-error methods lack exactness or precision because there is no guarantee any of the attempts tried will result in an optimal outcome and some attempts may cause more problems than solutions. While not an optimal method in nursing, trial-and-error can sometimes be effective, may require organization, and often requires thought to determine approaches to be tried.

What information does HIPAA mandate be given to patients upon admission to a healthcare facility? 1. What type of insurance is necessary for care 2. Who will be providing different types of care 3. What different levels of care are provided 4. How different health information will be used

4. How different health information will be used

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. When the activity is routine (e.g., raising the bed rails) 2. When the activity occurs at regular intervals (e.g., turning the client in bed) 3. When the activity is to be carried out immediately (e.g., a stat medication) 4. It is never acceptable

4. It is never acceptable *Rationale*: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity.

Which theorist addresses hospice nursing issues during end-of-life care? 1. Imogene King 2. Callista Roy 3. Dorothea Orem 4. Jean Watson

4. Jean Watson *Rationale*: Jean Watson's theory is based on a humanistic and caring concept of nursing. The holistic outlook addresses the impact and importance of altruism, sensitivity, trust, and interpersonal skills. Imogene King's theory is based on systems theory and the behavioral sciences. A transactional model of interaction between the nurse and client was developed. Creation, spirituality, the client, and the environment are the basis of Roy's model of nursing. Orem's theory of nursing is based on self-care and restoring the client to the highest level of functioning.

What is used to organize client data, allowing quick access for health care professionals to review information regarding the client? 1. End-of-shift report 2. SOAPIER notes 3. Variance reports 4. Kardex

4. Kardex *Rationale*: The Kardex is used to provide quick access to client information. It should be kept updated at all times.

Which charting entry would be the most defensible in court? 1. Client fell out of bed 2. Client drunk on admission 3. Large bruise on left thigh 4. Notified Dr. Johns of BP of 90/40

4. Notified Dr. Johns of BP of 90/40 *Rationale*: Option 4 is the "best" answer although it could be more complete by adding the response of the primary care provider. Option 1 is too vague because it is not clear if the nurse found the client or was present when the client fell. Also, there is no need to write the word client because it is the client's chart. Option 2 is judgmental, revealing a negative attitude toward the person. It would be better to describe specific signs and symptoms such as staggering, slurred speech, and smell of alcohol on breath. Option 3 is too general and can be more specific by charting "2 cm x 3 cm purplish bruise on mid-inner thigh along with color."

The student nurse is learning to chart effectively in the clinical setting. Which action by the student nurse increases the student's knowledge about effective charting? 1. Chart and hope it is correct 2. Practice charting and hope it will improve with time 3. Do nothing now and learn charting after graduation 4. Read charts to learn from actual situations

4. Read charts to learn from actual situations *Rationale*: The student nurse needs to read the charts and ask questions such as "What are the diagnoses?" "What are they doing to treat the client? "How is the client responding?"

What does critical thinking allow nurses to do during emergency situations? 1. Establish teamwork with other disciplines 2. Maintain a calm demeanor 3. Meet the physician's needs 4. Recognize important cues

4. Recognize important cues *Rationale*: Critical thinking enables the nurse to respond quickly even when unexpected situations arise. It enables the nurse to adapt interventions to meet specific client needs, not physician needs. While critical thinking allows the nurse to respond quickly in emergent situations, this does not necessarily allow the nurse to maintain a calm demeanor during these situations or establish teamwork with others during emergency situations.

One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following? 1. Decreases the cost of health care 2. Improves communication between nurse and client 3. Helps the nurse focus on health and wellness elements 4. Standardizes organization of client data

4. Standardizes organization of client data *Rationale*: The PES format assists with comprehensive and accurate organization of client data. More efficient planning may or may not reduce health care costs. Nursing diagnostic statements should be confirmed with the client but using PES does not ensure this. PES statements can be wellness or illness focused.

After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the post anesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1. Initial 2. Ongoing 3. Discharge 4. Strategic

4. Strategic *Rationale*: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1). Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option 2). Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option 3).

Which situation will the nurse need assistance with implementing the nursing interventions? 1. Applying Buck's traction for the fifth time 2. Documenting care delivered over the past hour 3. Turning the client in bed without the client experiencing discomfort 4. Transferring a bilateral amputee form bed to chair

4. Transferring a bilateral amputee form bed to chair *Rationale*: The nurse will need assistance during transfer of a bilateral amputee in order to provide safe care. The nurse needs to be holistic, implement safe care, adapt activities to the individual clients, and clearly understand the needed nursing interventions.

Which of the following is the lowest level of "best evidence" for evidence-based practice? 1. Clinical experiences 2. Opinions of experts 3. Client values and preferences 4. Trial and error

4. Trial and error *Rationale*: Trial and error is not considered valid evidence, and may even be harmful to clients. Clinical experience )motion 1) and opinions of experts (option 2), and client values and preferences (option 3) are all considered valid evidence in evidence-based practice.

A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1. Restrain the client in bed 2. Ask a family member to stay with the client 3. Check the client every 15 minutes 4. Use a bed exit safety monitoring device

4. Use a bed exit safety monitoring device

When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? A. Creating environments that support critical thinking B. Tolerating dissonance and ambiguity C. Self-assessment D. Seeking situations where good thinking is practiced

A. Creating environments that support critical thinking *Rationale*: Nurses must embrace exploration of the perspectives of individuals from different ages, cultures, religions, socioeconomic levels, and family structures to create environments that support critical thinking. Option 2 relates to nurses who should increase their tolerance for ideas that contradict previously held beliefs. Option 3 is conducted when a nurse benefits from a rigorous personal assessment to determine which attitudes he or she already possesses and which need to be cultivated. Option 4 occurs when nurses find it valuable to attend conferences in clinical or educational settings that support open examination of all sides of issues and respect for opposing viewpoints.

What does this abbreviation stand for? ACO

Accountable care organizations - characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be __________.

Because a malnourished client with a wound is less able to resist an infection. Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.

What does this abbreviation stand for? CBE

Charting by Exception - documentation system where only abnormal or significant findings or exceptions to norms are recorded

What does this abbreviation stand for? CE

Continuing Education - refers to formalized experiences designed to enhance knowledge or skills of practicing professionals.

What does this abbreviation stand for? DRG

Diagnosis-related groups - system that determines reimbursements; establishes pretreatment diagnosis billing categories.

What does this abbreviation stand for? DNR

Do not resuscitate - "no code" for clients who are in stage of terminal, irreversible illness, or expected death.

What does this abbreviation stand for? EHR

Electronic Health Record - used to manage huge volume of information required in contemporary health care

What does this abbreviation stand for? EBP

Evidence-based practice - occurs when nurse can "integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care"

What does this abbreviation stand for? HMO

Health maintenance organization - group health care agency that provides health maintenance and treatment services to voluntary enrollees.

What does this abbreviation stand for? IPA

Independent practice association - somewhat like HMOs and PPOs, but it provides care in offices, just as providers belonging to a PPO do.

What does this abbreviation stand for? IDS

Integrated delivery system - incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services.

What does this abbreviation stand for? LPN/LVN

Licensed practical nurse/Licensed vocational nurse - nurse who practices under supervision of registered nurse, providing basic direct technical care to clients

What does this abbreviation stand for? NIC

Nursing Interventions Classification - taxonomy of nursing interventions and consists of three levels (domains, classes, and interventions)

What does this abbreviation stand for? NOC

Nursing Outcomes Classification - taxonomy that helps describe client outcomes that respond to nursing interventions

What does this abbreviation stand for? PSDA

Patient Self-Determination Act - requires that every competent adult be informed in wring on admission to a health care institution about his or her rights to accept or refuse medical care and use advance directives

What does this abbreviation stand for? PPA

Preferred provider arrangements - similar to PPOs, but PPAs can be contracted with individual health care providers, whereas PPOs involved organization of health care providers.

What does this abbreviation stand for? PPO

Preferred provider organization - consists of group of providers and perhaps a health care agency (often a hospital) that provide an insurance company or employer with health services at a discounted rate.

What does this abbreviation stand for? PE format

Problem & Etiology - basic two-part statement

What does this abbreviation stand for? PES format

Problem, Etiology, and Signs & Symptoms - basic three-part statement

What does this abbreviation stand for? POMR/POR

Problem-Oriented Medical Record/Problem-Oriented Record - data are arranged according to problems the client has rather than the source of the information

Fill in the blank: Instead of debating academic requirements for RN preparation, nursing is now focusing on academic __________ for nursing students and graduates.

Progression. *Rationale*: The focus has changed to academic progression for all nurses.

What does this abbreviation stand for? QA

Quality Assurance (QA) Program - ongoing, systematic process designed to evaluate and promote excellence in health care provided to clients

What does this abbreviation stand for? QI

Quality Improvement - follows client care rather than organizational structure, focuses on process rather than individuals, and uses a systematic approach with the intention of improving quality of care rather than ensuring the quality of care

What does this abbreviation stand for? SSI

Supplmental Security Income (SSI) Benefits - benefits available to people not eligible for social security, with disabilities, or blind, and payments are not restricted to health care costs

What is the term used to describe a behavior, characteristic, or outcome that the researcher wishes to explain or predict? 1. Dependent variable 2. Independent variable 3. Hypothesis 4. Sample

1. Dependent variable *Rationale*: The dependent variable is a behavior, characteristic, or outcome that the researcher wishes to explain or predict.

As a nurse researcher, what is involved in a research project? (Select all that apply.) 1. Identifying a research question or problem 2. Writing a thesis paper 3. Collecting data using various means such as computer searches and/or questionnaires 4. Analyzing the data and writing up the results 5. Publishing or presenting the research findings to expand the body of nursing knowledge

1. Identifying a research question or problem 3. Collecting data using various means such as computer searches and/or questionnaires 4. Analyzing the data and writing up the results 5. Publishing or presenting the research findings to expand the body of nursing knowledge *Rationale*: The research process involves identifying the problem or question, collecting data using various means such as computer searches and/or questionnaires, analyzing the data and writing up the results, and publishing or presenting the research findings to expand the body of nursing knowledge.

The nurse notices that a colleague's behaviors have changed during the past month. Which behaviors could indicate signs of impairment? Select all that apply. 1. Is increasingly absent from the nursing unit during the shift 2. Interacts well with others 3. "Forgets" to sign out for administration of control substances 4. Offers to administer pro opioids for other nurses' clients 5. Is able to say "no" to requests to work more shifts

1. Is increasingly absent from the nursing unit during the shift 3. "Forgets" to sign out for administration of control substances 4. Offers to administer pro opioids for other nurses' clients *Rationale*: Interacting with others (versus isolating self from others) and setting limits on the number of hours working are positive behaviors and not indicative of possible impairment. The other options are warning signs for impairment.

This theorist based her theory of nursing on the principle that nursing assists clients with 14 essential functions that move them toward independence. 1. Myra Estrin Levine 2. Dorothea Orem 3. Madeline Leininger 4. Virginia Henderson

4. Virginia Henderson *Rationale*: Virginia Henderson's theory explains the 14 essential functions toward independence that a client must meet to achieve the highest level of health. myra Estrin Levine's theory was based on four conservation principles of inpatient client resources. Dorothea Orem uses nursing interventions to meet clients' self-care needs. Madeline Leininger's theory uses transcultural nursing and caring nursing, in which the concepts are aimed toward caring and the components of a culture care theory.