Practice Test 1

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? A. "The virus changes too rapidly to develop a vaccine." B. "Vaccines are developed only for very serious illnesses." C. "Researchers are focusing their efforts on an HIV vaccine." D. "The virus for the common cold has not been identified."

A

A patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which type of infection does this best describe? A. Nosocomial infection B. Healthcare-associated infection (HAI) C. Multidrug-resistant organisms (MDROs) D. Unavoidable occurrence

A

A patient is brought to the emergency department after inhaling mercury. The nurse taking care of this patient should be alert for which acute adverse effects associated with mercury inhalation? A. Chest pain, pneumonitis, and inflammation of the mouth B. Intestinal obstruction and numbness of hands C. Hypotension, oliguria, and tingling of feet D. Tachycardia, hematuria, and diaphoresis

A

A patient who has been hospitalized for weeks becomes angry and tells the nurse who is providing care, "I hate this place; nobody knows how to take care of me or I'd be home by now." Which response by the nurse is best in this situation? A. "You seem angry. What's going on that makes you hate this place?" B. "I'm sorry that we aren't caring for you according to your expectations." C. "You were very sick. Don't be angry. You're lucky to be alive." D. "You shouldn't be angry with us. We're trying to help you."

A

A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time, she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? A. Immobility often causes constipation. B. A low-fiber diet will resolve the problem. C. A stool softener daily will relieve the problem. D. Use of a bedpan results in bloating and constipation.

A

After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model? A. To sort and cluster assessment data into specific categories B. To organize assessment data according to body systems C. To validate the use of the nursing process to collect data D. To follow the American Nurses Association Standards of Care

A

An older patient with newly diagnosed osteoporosis asks the nurse to explain their health problem. What is the correct description of osteoporosis? A. Loss of bone density that puts the patient at an increased risk of fracture B. Degenerative joint disease that produces pain and decreased function C. Chronic inflammatory joint disease that must be treated with steroids D. Acute infection in the bone that must be treated with antibiotics

A

At the end of a guided imagery session, which physical assessment finding would suggest to the nurse the relaxation technique was successful? A. Decreased blood pressure B. Decreased peripheral skin temperature C. Increased heart rate D. Increased respiratory rate

A

Before entering the room of a patient who is angry and yelling, the nurse removes the stethoscope from around their neck. Which is the best rationale for the nurse's action? A. The stethoscope could be used by the patient to hurt the nurse. B. The stethoscope may cause the patient to distrust the nurse. C. The stethoscope can distract the nurse from focusing on the patient. D. The stethoscope can function as another stressor for the patient.

A

For which patient is it most important to provide frequent perineal care? The patient: A. With active lower gastrointestinal bleeding. B. Who is continent of urine. C. Who has a circumcised penis. D. With a history of acute asthma.

A

Living in a healthy family is an important dimension of wellness. Which condition most accurately describes a characteristic of healthy families? A. A family in which individual members live a health-promoting lifestyle B. A family that responses to its members' needs only during serious illness C. A family that may avoid or withhold the truth to prevent hurting someone's feelings D. A family that understands a family member is powerless when experiencing severe illness

A

Nurses are aware of the trends that affect contemporary nursing practice. Which trend is a primary cause for changes in the nursing profession? A. The expected increase in the number of older adults in society B. The large amount of medical information that is technically accessible C. The increasing demands for more medical care from all aspects of society D. The multiple medical care expectations implemented by the government

A

Physiological changes, such as reduced muscle strength and joint mobility, which are associated with aging, place the older adult patient at an increased risk for which nursing diagnosis? A. Risk for falls B. Risk for ineffective airway clearance (choking) C. Risk for poisoning D. Risk for suffocation (drowning)

A

Professional nurses value the importance and application of nursing theory and research. Which commonly accepted practice came out of the Framingham study? A. Mammography is breast cancer screening. B. Colonoscopy in colon cancer screening. C. Papanicolaou (Pap) testing in cervical cancer screening. D. Digital rectal examination in prostate cancer screening.

A

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? A. Closing the patient's door to limit room traffic while preparing the sterile field B. Using clean procedure gloves to handle sterile equipment C. Placing the nonsterile syringes containing flush solution on the sterile field D. Remaining 6 inches away from the sterile field during the procedure

A

The nurse has just administered a subcutaneous insulin injection to a diabetic patient. What is the next immediate action by the nurse? A. Dispose of the needle/syringe uncapped into a disposable sharps container. B. Recap the syringe with a needle and dispose of it into a sharps container. C. Place the needle/syringe into a biohazard bag inside the patient's room. D. Separate the needle and syringe and place them into a sharps container.

A

The nurse is aware that which function of antidiuretic hormone occurs when the hormone is released in the alarm stage of the general adaptation syndrome? A. Promotes fluid retention by increasing the reabsorption of water by kidney tubules B. Increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle C. Increases the use of fats and proteins for energy and conserves glucose for use by the brain D. Promotes fluid excretion by causing the kidneys to reabsorb more sodium

A

The nurse is caring for a patient who has hepatitis B, and the nurse accidentally sticks themself with a contaminated needle after administering an injection. Which action should the nurse take first? A. Thoroughly flush the area with water. B. Immediately notify the supervisor. C. Complete an incident report using objective data. D. Obtain baseline lab work as quickly as possible.

A

The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess? A. Depression B. Hypochondriasis C. Somatization D. Malingering

A

The nurse is helping the patient perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? A. Skeletal B. Smooth C. Cardiac D. Slow-twitch fibers

A

The nurse is providing care for a client with heart failure. The nurse obtains the client's medical and personal histories, measures vital signs, and then auscultates breath sounds. Which aspect of the nursing process is the nurse demonstrating? A. Assessment B. Planning interventions C. Planning outcomes D. Evaluation

A

The nurse is providing care for a patient who needs extensive acute care, which the patient is refusing because of financial and family stressors. Which healthcare worker does the nurse consult to counsel this patient? A. Social worker B. Occupational therapist C. Physician's assistant D. Technologist

A

The nurse is providing care for a patient who suddenly experiences a cardiac arrest. As the nurse responds to this emergency, which substance does the nurse's body secrete in large amounts to help prepare the nurse to react in this situation? A. Epinephrine B. Corticotropin-releasing hormone C. Aldosterone D. Antidiuretic hormone

A

The nurse is providing care to a patient who is nauseous, vomiting, experiencing abdominal pain, and has no bowel sounds. The nurse concludes the patient's symptoms may be associated with a paralytic ileus. Which type of thinking is the nurse using to arrive at this conclusion? A. Inductive reasoning B. Deductive reasoning C. Guesswork D. Diagnostics

A

The nurse researcher is conducting a research study. In preparation for the study, the nurse will develop a method for participants' identification while maintaining privacy and confidentiality. Which method is best for the researcher to use for participant identification? A. Use a code number for each participant. B. Use participant initials only. C. Use gender and age only. D. Use participant surnames only.

A

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? A. Encourage the child to continue coughing. B. Deliver upward abdominal thrusts with a fisted hand. C. Complete five rapid back blows between the shoulder blades. D. Perform a blind finger sweep of the child's mouth.

A

The nurse works in an extended care facility in the dementia unit. The nurse embraces the validation theory for communication with the clients on the unit. For which reason is the application of this theory most effective? A. Prevents the client from experiencing painful memories B. Helps the client to gradually accept the realities of their lives C. Gives the nurse an accepted method of orienting the client D. Aids the client to create whatever reality the client desires

A

The school nurse is teaching a group of middle-school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? A. "I can contract the infection by walking barefoot in the gymnasium's showers." B. "The best way to avoid contracting the infection is to use good handwashing." C. "Wearing unventilated shoes prevents the fungus from gaining contact with my feet." "D. There is really no way to prevent its spread; it's a highly contagious scalp infection."

A

What factor is most important in minimizing the effects of a bioterrorism event? A. Rapidly recognize unusual disease patterns, and detect the presence of unusual infectious diseases. B. Communicate any extraordinary events to the organization's safety officer. C. Report any suspicious findings to the Centers for Disease Control and Prevention. D. Institute a community-wide education program for standard precautions and handwashing.

A

What is clinical judgment defined as? A. Processes that promote safe client care decisions and outcomes B. Avoids clinical thinking and decision making C. Applying the same treatment regardless of a patient's needs or health problems D. Is based on not addressing a patient's response to a health problem

A

What type of exercise is performed by using specialized apparatuses that use resistance at a constant, preset speed? A. Isokinetic B. Isometric C. Isotonic D. Isomorphic

A

When transferring a patient from a hospital to a long-term care facility, which action by the nurse is most helpful in facilitating the patient's planning and emotional adjustment? A. Notify the patient and family as much in advance of the transfer as possible. B. Send a complete copy of the patient's medical records to the new facility. C. Carefully coordinate the transfer with the long-term facility to keep it smooth. D. Help arrange for transportation and accompany the patient to the transport vehicle.

A

Which action should the nurse take when scanning the patient's environment? A. Check to make sure the nurse call device is within reach. B. Place the bed in the high position. C. Keep a food tray in the patient's room for later snacking. D. Allow the linens to have a few wrinkles.

A

Which of the following is an example of what the nurse recognizes as a cluster of related cues? A. Complains of nausea and stomach pain after eating B> Has a productive cough and states stools are loose C. Has a daily bowel movement and eats a high-fiber diet D. Has a respiratory rate of 20 breaths/min, heart rate of 85 beats/min, and blood pressure of 136/84 mm Hg.

A

Which would be the most appropriate goal for a frail, elderly patient with a history of emphysema and a nursing diagnosis of risk for injury after hip surgery? A. Remain free from injury or falls throughout the hospital stay. B. Increase activity tolerance by discharge from the hospital. C. Demonstrate effective breathing when ambulating. D. Increase mobility by the time of discharge from hospital.

A

While assessing a patient, the nurse notes that their nails are excessively brittle. What does this finding suggest? A. Inadequate dietary intake B, Normal aging process C. Periodontal disease D. Pallor

A

While reading a journal article, the nurse mentally asks these questions: "What is this about overall? Is it true in whole or in part? Does it matter to my practice?" Which process is this nurse demonstrating? A. Reading the article analytically B. Performing a literature review C. Formulating a researchable question D. Determining the soundness of the article

A

Why is it important for nurses to be critical thinkers? A. All clients are unique and have individual needs and differences. B. All nursing actions are based on theoretical knowledge. C. Nurses choose their actions primarily from professional guidelines. D. Nurses provide care based on individual client preferences.

A

Which situation is most reflective of a life change for managing chronic illness? A. Beginning self-injection of insulin for diabetes mellitus B. Taking an antibiotic for a streptococcal throat infection C. Going to the gym and participating in an exercise program D. Taking prescribed pain medication after a tooth extraction

A Chronic illness last for a long period of time, usually 6 months of longer. Exercising may be part of chronic illness life style change, however may be a healthy lifestyle promotion activity.

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? A. Endogenous healthcare-related infection B. Exogenous healthcare-related infection C. Latent infection D. Primary infection

A Endogenous= within own body system Exogenous= due to environment

Which characteristics do the various definitions of critical thinking have in common? A. Requires reasonable thought B. Asks the questions "Why?" or "How?" C. Is a hierarchical process D. Demands specialized thinking skills

A See Box 2-1

The nurse is working in a doctor's office. Which annual assessment test would the nurse schedule for a 75-year-old patient? A. Timed Up and Go B. Get Up and Go C. Morse Fall Scale D. Safety Assessment Scale

A Timed up and go is for anyone 65 and older; get up and go is for anyone at fall risk.

For which patients should the nurse avoid using back massages? Select all that apply. A. One who underwent heart surgery 2 days ago B. One who sustained rib fractures from a fall C. One who has heartburn D. One who sustained a leg fracture in a sledding accident E. One who has a backache

A and B

For which reasons is it important for the nurse to understand stress and adaptation? Select all that apply. A. The nurse needs to self-identify stressors and develop healthy adaptation responses. B. Understanding stress helps the nurse identify client stressors and adaptive responses. C. Understanding stress will aid the nurse in balancing stress experienced by patients. D. The nurse needs to know the very specific adaptation strategies used for patients. E. The nurse is unable to address psychological issues without understanding stress.

A and B

The community-health nurse is making a presentation on carbon monoxide (CO) poisoning at the neighborhood health fair. Which information should the nurse include in the presentation? Select all that apply. A. Carbon monoxide is a colorless, odorless, and tasteless gas. B. Home-installed carbon dioxide detectors are shown to be ineffective. C. Carbon monoxide poisoning causes deaths among older adults in cold weather months. D. During rainy weather, a home fireplace with charcoal may be used for barbecuing. E. Occasionally using a kerosene heater to heat the house is recommended.

A and C

The nurse is preparing to write the nursing progress notes for a patient who has wrist restraints. Which chart entries will the nurse include in the progress notes? Select all that apply. A. Family teaching initiated regarding the need for patient restraint B. Restraint removed once per shift to assess skin color, sensation, and movement of an extremity C. Prescription for wrist restraint received from the primary care provider D. Wrist restraints were applied because of the patient's increasing confusion E. Double knot used to tie restraints to the bed frame

A and C

The nurse planning care for a patient after severe head trauma and long-term unresponsiveness considers which effect of immobility affecting the lungs? Select all that apply. A. Atelectasis B. Hyperventilation C. Pooled secretions D. Reactive airway E. Hypocarbia

A and C

Which information would the nurse include in a health promotion class about the association between smoking and pulmonary infections? Select all that apply. A. Smoking interferes with respiratory functions, including the ability to move the chest, cough, and sneeze. B. Smoking increases alveolar elasticity, leading to the overproduction of mucus that leads to pulmonary infections. C. Smoking decreases the movement of the cilia in the lower airways, creating a favorable environment for bacterial growth. D. Nonsmokers chronically exposed to secondhand smoke have minimal risk for pulmonary infections. E. Smoking increases the production of abnormal red blood cells, leading to ineffective protection against infections.

A and C

The nurse recognizes which examples of objective data? Select all that apply. A. Blood pressure of 120/80 mm Hg B. Patient reports feeling dizzy upon standing C. Moderate amount of yellow drainage from right ear D. Spouse stating the client is not sleeping well at night E. Patient reporting the presence of stomach pain

A and C Subjective is something said. Objective can be measured

The hospital nurse educator is preparing an orientation class for those newly hired on the surgical suite. Which information will the educator include in the orientation curriculum regarding hand and fingernail care? Select all that apply. A. Healthcare staff must routinely inspect their hands for breaks in the skin. B. Artificial nails are permitted if properly secured to the nail bed. C. Wristwatches may be worn as long as they are all metal. D. Healthcare staff are to avoid wearing nail polish. E. Fingernail length should be kept to half inch or less.

A and D

During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. How should the trained nurse intervene? Select all that apply. A. Use a flashlight to search for beads of mercury on hard surfaces. B. Notify the hazardous material management team immediately. C. Evacuate the area immediately. D. After putting on a gown, gloves, and a mask, clean up the mercury. E. Ventilate the area well.

A and E

A patient has started a fitness program. Which program features indicate that they have started a well-rounded program? Select all that apply. A. Flexibility training B. Balance exercises C. Resistance training D. Aerobic conditioning E. Isotonic exercises

A, B, C, D, and E

Which of the following are common etiologies that contribute to a patient's self-care deficit, meaning they are unable to perform one or more ADLs, such as bathing and toileting? A. Pain B. Fatigue and decreased strength and endurance C. Lack of knowledge D. Medication side effects E. Lack of motivation

A, B, C, D, and E

How does sleep nourish our bodies? Select all that apply. A. Tissue regeneration B. Formation of red blood cells C. Mental rejuvenation D. Synthesis of bone E. Mood disturbances

A, B, C, and D Lack of sleep can have an effect on mood and sensory deficits, but sleep does not nourish our bodies in that manner.

What is an example of a nutrient-deficient disease? Select all that apply. A. Scurvy B. Night blindness C. Anemia D. Goiter E. HIV

A, B, C, and D Scurvy is lack of vitamin C Night Blindness is lack of vitamin A Anemia lack of iron Goiter lack of iodine

The American Nurses Association (ANA) has set standards for registered nurses (RNs) in utilizing evidence-based interventions and treatments in practice. According to the ANA, which statements best describe the ANA standards? Select all that apply. A. The RN uses current evidence-based nursing knowledge to guide practice decisions. B. The RN critically analyzes evidence-based practice and research findings for application to practice. C. The RN shares the research activities and findings with healthcare peers and others. D. The RN uses specific competencies in conducting and integrating research. E. The RN incorporates evidence when initiating changes in nursing practice.

A, B, C, and E

The nurse is aware that patients may fail to comply with a proposed healthcare regimen and be perceived as being non-compliant. For which common reason(s) does a nurse identify as causing a patient to be noncompliant with a plan of care? Select all that apply. A. The patient lacks a support system. B. The patient does not understand the plan. C. The plan of care is inconvenient. D. The patient is stubborn by nature. E. The plan is financially inhibitive.

A, B, C, and E

The field of nursing has struggled to prove that nursing is a profession. Which strategies to improve the status of nursing will promote professionalism? Select all that apply. A. Standardizing the educational requirements for entry into practice B. Mandating uniform continuing education requirements for licensure C. Guaranteeing that all nurses will obtain employment upon graduation D. Encouraging participation of nurses in professional organizations E. Educating the public about the true nature of nursing practice

A, B, D, and E

The nurse works in an acute care facility with a culturally diverse client population. Using critical thinking, which aspects of healthcare does the nurse recognize as being affected by a client's culture? Select all that apply. A. How the client views healthcare B. How the client views illness C. The type of insurance the client has D. The types of treatments the client will accept E. When the client will seek healthcare services

A, B, D, and E

The Centers for Disease Control and Prevention (CDC) is a federal agency devoted to infection control and prevention in healthcare settings. What are the goals of the CDC? Select all that apply. A. Reduce catheter-associated urinary tract infections B. Reduce targeted antimicrobial-resistant bacterial infections C. Decrease ventilator-associated pneumonia D. Establish competencies to improve the quality and safety of nursing education E. Develop the National Patient Safety Goals

A, B, and C

To reflect the changes in healthcare and nurses' expanded roles, the International Council of Nurses revised the definition of nursing. Which statements are consistent with the revised definition of nursing? Select all that apply. A. Nursing encompasses the autonomous and collaborative care of others. B. Nursing includes the care of ill, disabled, and dying people. C. Nursing is involved in shaping health policy and system management. D. Nursing involves the use of the nursing process to plan care. E. Nursing requires knowledge regarding the process of nursing education.

A, B, and C

While working with an unlicensed assistive personnel (UAP) in a local nursing home, which of the following fall risk and prevention measures may be delegated to the UAP by the nurse? Select all that apply. A. Remove clutter and spills in patient rooms. B. Place nonskid slippers on patients. C. Lock beds and wheelchairs. D. Assess each patient for fall risk. E. Monitor for injuries if the patient falls.

A, B, and C

An older adult patient is tearful, shaky, and withdrawn. The patient shares with the nurse, "I am worried to death" about losing an aging spouse and being "all alone." For which reasons does the nurse diagnose this reaction as anxiety rather than fear? Select all that apply. A. It concerns future or anticipated events. B. It concerns anticipation of danger rather than a present danger. C. The response is expected in older adult patients. D. There is a psychological threat rather than a physical threat. E. The patient flinches when touched by the nurse.

A, B, and D

The nurse in a retirement complex is intrigued by the time and energy residents spend on their favorite activities, which they refer to as their "work." Which statements best describe what can be identified as "meaningful work"? Select all that apply. A. Volunteering in the children's ward at the local hospital B. Starting a garden club in the living community C. Reaching a desired salary after 10 years of employment D. Playing an instrument in a rock and roll band E. Deciding to return to work because of boredom

A, B, and D

The nurse is instructing a patient about the need to replace fluid before, during, and after exercise to avoid dehydration. On what basis should they teach the patient to determine the amount of fluid to consume? Select all that apply. A. Duration of exercise B. Environmental temperature C. Level of fitness D. Degree of thirst E. Intensity of exercise

A, B, and E

The nurse is obtaining a patient's health history related to infections. Which are the appropriate questions the nurse will ask the patient? Select all that apply. A. "Have you recently traveled out of the country?" B. "How would you describe your current stress level?" C. "Do you like fruits and vegetables?" D. "What is your normal heart rate?" E. "What types of herbal products do you use?"

A, B, and E

Which statements best describe the phases of nursing research? Select all that apply. A. Selection and definition of the problem B. Formulation of a research question C. Selection of individual participants D. Molding data to the research question E. Reporting the research findings

A, B, and E

The nurse is teaching a group of newly hired unlicensed assistive personnel (UAP) about proper handwashing with soap and water. The nurse will know that the teaching was effective if a UAP demonstrates which behaviors? Select all that apply. A. Uses a dry paper towel to turn off the faucet B. Holds fingertips above the wrists while rinsing off the soap C. Removes all rings and watch before washing hands D. Cleans underneath each fingernail E. Vigorously rubs hands together for at least 15 seconds

A, C, D, and E

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. A. Viruses B. Bacterial spores C. Yeasts D. Molds E. Organic material

A, C, and D

The home-health nurse is performing an initial assessment in the home of an 80-year-old client. Which instructions will the nurse provide to minimize and prevent bathroom accidents? Select all that apply. A. Install grab bars in the bathtub or shower. B. Avoid handheld shower attachments. C. Use a nonskid mat in the bathtub. D. Install a raised toilet seat. E. Avoid shower chairs.

A, C, and D

The nurse believes a patient is experiencing high levels of stress at home. The patient is angry and states, "It is too much for me to handle. You don't know what I am going through." Which are the most appropriate responses by the nurse? Select all that apply. A. "I don't know what you are going through. Can you tell me more?" B. "Please don't be angry with me. We all do the best we can here." C. "How long have you been dealing with this stress?" D. "How do you usually manage your stress?" E. "Can we set up some family counseling?"

A, C, and D

Which actions by the nurse are considered "skilled nursing care"? Select all that apply. A. Changing a wound dressing B. Assisting with bathing and grooming C. Monitoring intravenous (IV) antibiotic administration D. Teaching a patient how to use a blood glucose monitor E. Helping a patient to get dressed

A, C, and D

Which areas should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. A. Buccal mucosa B. Around the lips C. Palms D. Tongue E. Sclera

A, C, and D

Which factors protect the body against infection? Select all that apply. A. Eating a healthy well-balanced diet B. Being an older adult or an infant C. Engaging in stress-reduction activities D. Exercising regularly E. Taking chemotherapeutic agents

A, C, and D

Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Select all that apply. A. Stand with the body in alignment and erect posture. B. Bend at the waist to lift heavy objects from the floor. C. Use a wide base of support with your feet at shoulder width. D. Keep objects close to your body when carrying them. E. Use a soft mattress to allow for the muscles to rest adequately.

A, C, and D

The community-health nurse is preparing a teaching plan on motor vehicle accidents. Which information should the nurse include in the plan? Select all that apply. A. The risk of being injured or killed in a car crash increases for older adult drivers. B. Young children should be placed in the front seat of a motor vehicle so that the driver can watch them. C. Airbags have no effect on injury or death related to motor vehicle accidents. D. Cell phone use while driving is directly correlated with an increase in motor vehicle accidents. E. Failure to use seat belts is a major contributing factor to injury and death with regard to motor vehicle accidents.

A, D, and E

Using Maslow's hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4) 1. Anxiety 2. Risk for infection 3. Disturbed body image 4. Sleep deprivation

4, 2, 1, and 3

A healthcare facility hires new nursing graduates to work on patient care units. The hired nurses come from a variety of accredited nursing programs. Additionally, applicants need to be aware of facility hiring practices based on which criteria? A. Graduate of a nursing education program and passed the National Council Licensure Exam (NCLEX) B. Obtained certification permitting the administration of medications in certain healthcare settings C. Specifically licensed to practice in either an acute care setting or in a home environment D. Received advanced education and is licensed to practice under the direct supervision of a physician

A

A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via a nasal cannula. Which positioning technique will best assist him with his breathing? A. Fowler's position B. Sims' position C. Prone position D. Lateral position

A

A nurse is teaching a group of parents about first aid. If mercury comes in contact with their child's clothing and/or skin, which action should the nurse instruct the parents to take first? A. Remove the contaminated clothing immediately. B. Flood the contaminated area with lukewarm water. C. Wash the contaminated area with soap and water and rinse. D. Call the nearest poison control center immediately.

A

A parent of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days and calls the children's grandmother for assistance with caring for the children. Which illness behavior is the parent experiencing? A. Sick role behavior B. Dependence on others C. Seeking professional care D. Experiencing symptoms

A

.A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply? A. "You don't need tests; I can tell by the way your ankle looks and feels whether you have a strain or a fracture." B. "Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain." C. "We will need to get a venous Doppler study to make sure that there is not a fracture." D. "First, we need to get an MRI to determine if you have a fracture, a strain, or a sprain."

B

A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate? A. Risk for infection B. Risk for impaired skin integrity C. Risk for deficient fluid volume D. Impaired skin integrity

B

A nurse is caring for a 25-year-old quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? A. Active range of motion (ROM) B. Passive ROM C. Turning the patient every 2 hours D. Administering glucosamine supplements

B

A nurse recognizes which type of loss is most common among patients hospitalized for complex health conditions? A. Privacy B. Dignity C. Functional D. Identity

B

A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process does the researcher complete next? A. Select and define the problem B. Select a research design C. Collect data D. Analyze data

B

A nurse who has been practicing for 3 years in an acute care facility is caring for a postsurgical patient. The nurse observes an abnormal change in vital signs and associates these changes with a postoperative bleeding problem. Which level of proficiency is the nurse demonstrating? A. Advanced beginner B. Competent C. Proficient D. Expert

B

A patient with dementia becomes belligerent when the nurse attempts to give them a tub bath. How should the nurse proceed? A. Call for assistance to help the patient into the bathtub. B. Wait for the patient to calm down, and then give them a towel bath. C. Allow the patient to go without bathing for about a week. D. Ask another staff member to attempt the tub bath.

B

A patient with tuberculosis is admitted to the hospital. Which precautions must the nurse institute when caring for this patient? A. Droplet transmission B. Airborne transmission C. Direct contact D. Indirect contact

B

After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: A. Pediculosis. B. Alopecia. C. Dandruff. D. Vellus hair.

B

An 18-year-old is accepted to nursing school in another state. The adolescent states to their parents, "I know I am going away to college, but I am nervous about going." Which type of stressor is the student most likely experiencing? A. External B. Developmental C. Situational D. Biophysical

B

An adult client attends a smoking-cessation class. The client tells the nurse, "Even though I smoke, I don't smoke around children, in my car, or in my house." Which defense mechanism does the nurse recognize the client is exhibiting? A. Displacement B. Rationalization C. Denial D. Repression

B

As a general rule, what is the minimum amount of liquid antiseptic solution in milliliters (mL) the nurse would use for effective handwashing? A. 2 B. 3 C. 6 D. 7

B

During morning rounds, a male patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should take which action? A. Have him sign a permission form. B. Check to see whether he is taking anticoagulants. C. Tell him that only a family member may shave a patient. D. Position him flat in bed.

B

How should the nurse remove the disposable breakfast tray of a patient who requires airborne isolation? A. Move the tray to a specially marked trashcan inside the patient's room. B. Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. C. Return the tray with a note to dietary services so that it can be cleaned and reused for the next meal. D. Carry the tray to an isolation trash receptacle located in the dirty utility room, and dispose of it there.

B

Many healthcare providers define illness as pathology; however, people experience illness rather than define it as a pathology. In which manner do most people experience illness? A. "Feeling lousy," a true sense of not being all right B. A change in the way they feel or a disruption in their typical life C. Something to be dreaded and avoided, if at all possible D. An experience that offers a potential for learning and spiritual growth

B

The mother of a 6-year-old child says to the pediatric nurse, "My son had such a bad case of the measles. I hope he doesn't get them again." What is the most appropriate response by the nurse? A. "It sounds like he was very sick. Let's hope he doesn't get them again." B. "Measles is a disease that once you've had it, you won't get it again. The body has learned to make cells that will fight off any future exposures." C. "Would you like me to prepare a plan for you with ways you can prevent future episodes of measles?" D. "It will be important for you to keep your son away from other children with measles, as he is now more susceptible."

B

The new graduate nurse is working with a nurse mentor. Which advice from the mentor is best suited when the new graduate is preparing to interact with the first patient? A. Be maximally attentive to the patient at all times. B. Take a few moments to settle into the situation. C. Accept the patient regardless of background. D. Create a broad attitude of enjoyment of the patient.

B

The nurse asks, "Why do some of my patients get a headache when they have stress but others cry?" Which is the most appropriate response to the nurse's question? A. "All patients react to stress differently." B. "Stress responses can be physical, mental, behavioral, and spiritual." C. "Some patients are more emotional than others." D. "Some patients overreact to the stress they are experiencing."

B

The nurse assessing the mobility of a patient with Parkinson's disease might expect to observe which type of gait? A. Antalgic B. Propulsive C. Scissors D. Steppage

B

The nurse documents in a client's plan of care that wound treatment to the client's left foot resulted in wound healing. The nurse then removes the skin integrity diagnosis from the plan of care. Which aspect of the nursing process is the nurse performing? A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions

B

The nurse documents that the patient with diarrhea, incontinence of liquid stool, now has excoriated skin on the buttocks. Which finding by the nurse led to this documentation? A. The skin was softened from prolonged exposure to moisture. B. The superficial layers of the skin were absent. C. The epidermal layer of the skin was rubbed away. D. A lesion caused by tissue compression was present.

B

The nurse is aware the client's risk of breast cancer is dramatically increased because both her sister and her mother had breast cancer. Which of the multidimensional aspects of health does this scenario illustrate? A. Personal relationships B. Biological factors C. Lifestyle choices D. Environmental factors

B

The nurse is providing care for a patient with a terminal illness. Which is particularly valuable in helping a patient with a terminal illness maintain a view of wellness? A. Family relationships B. Spiritually C. Nutrition D. Sleep and rest

B

The nurse is providing care to a client with a history of schizophrenia who is diagnosed with a urinary tract infection. The nurse recognizes that which of the following is the most significant barrier this patient will face? A. Chronic urinary incontinence B. Stigma associated with mental illness C. Risk for recurring infections D. Auditory hallucinations ("hearing things")

B

The nurse is removing personal protective equipment (PPE). Which item should be removed first? A. Gown B. Gloves C. Face shield D. Hair covering

B

The nurse researcher is conducting a research study on the association between aging male populations and the development of prostate cancer. The nurse uses a sample of 50 males older than 80 years of age. The quantitative research finds that many of the participants developed cancer after age 80 years. Which is the flaw in this research if the nurse reports all males over 80 years of age will most likely develop prostate cancer? A. The problem statement does not provide enough information. B. Sample size is too small to make a generalization. C. The research is only valuable to those working with aging males. D. The research design is most likely inappropriate for the type of study.

B

The nurse understands the term "paradigm" is the worldview of a discipline. Which paradigm relates to nursing? A. Focuses on an in-depth look at parts of a person. B. Involves a broader perspective of the entire person. C. Includes the purpose of providing legal equality. D. Represents the theories used to define society.

B

The nurse uses the concept of the wellness-illness continuum for developing a nursing plan of care. Which plan for a chronically ill patient does the nurse select? A. Educate the patient about every possible complication associated with the specific illness. B. Encourage positive health characteristics within the limits of the specific illness. C. Limit activities because of the progressive deterioration associated with chronic illnesses. D. Recommend activity beyond the scope of tolerance to prevent early deterioration.

B

The nurse uses the non-nursing theory of Maslow's hierarchy of needs when providing care. Which client intervention does the nurse develop to address physiological needs? A. A client is placed on fall precautions due to physical limitations. B. A client will begin cardiac rehabilitation to promote complete recovery. C. Clients will use recognition from others as a motive to improve health. D. A client will fulfill cognitive needs effectively through patient education

B

The nurse works in a public health department. Which nursing function is considered a primary-care service? A. Providing wound care B. Administering childhood immunizations C. Providing drug rehabilitation D. Providing outpatient hernia repair

B

The parent of a child who is participating in a research study using high-dose steroids wishes to withdraw the child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the parent does not change their mind. Which right is the parent exercising by withdrawing the child from the study? A. Not to be harmed B. To self-determination C. To full disclosure D. Of confidentiality

B

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G (IgG)? A. Cell-mediated B. Passive C. Secondary defense D. Active

B

Which action would the nurse take when removing and cleaning a hearing aid? A. Wash only the external surfaces, not the canal portion. B Clean the top part of the canal portion of the device. C. Insert a wax loop or toothpick into the hearing aid itself. D. Gently submerge the hearing aid in warm water.

B

Which action, when demonstrated by the patient with osteoporosis, would indicate to the nurse that teaching was effective? A. Taking a calcium supplement every day and increasing their phosphorus intake B. Participating in an aerobic barbell strength class at the gym three times a week C. Using a wheelchair to reduce the risk of spontaneous fractures to their legs and feet D. Seeking healthcare by scheduling a follow-up examination with bone-density testing

B

Which is the best treatment to protect the skin of the patient who is frail, malnourished, and immobile and confined to a bed? A. Offering the patient six small meals a day B. Turning the patient at least every 2 hours C. Assisting the patient to sit in a chair three times a day D. Administering fluid boluses as directed by the healthcare provider

B

Which of the following is the most commonly reported incident in hospitals? A. Equipment malfunction B. Patient falls C. Laboratory specimen errors D. Treatment delays

B

While bathing a patient, the nurse observes that they have dry skin. The best action by the nurse is to: A. Bathe the patient more frequently. B. Use an emollient. C. Massage the skin with warm water. D. Discourage fluid intake.

B

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is more than 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? A. Continue using the gloves inside the package because the package is intact. B. Remove the gloves from the sterile field, and use a new pair of sterile gloves. C. Throw away all supplies that were to be used, and begin again. D. Use the gloves and make sure the yellow edges of the package do not touch the client.

B

While teaching a safety session at the local library, the nurse instructor emphasizes that according to the National Weather Service, the leading cause of weather-related fatalities is: A. Floods. B. Heat. C. Hurricanes. D. Tornadoes.

B

The patient who is on extended bedrest and experiencing constipation requests a fiber supplement. Which statement by the nurse is most appropriate? A. "I will need to see if you have any allergies before I order a fiber supplement for you." B. "That is a good choice to manage constipation. I will contact the physician." C. "A fiber supplement won't be very effective; we need to get you moving soon." D. "A stool softener could be used in place of a fiber supplement. Let's try that medication now."

B A nurse can not order supplements without a physician or nurse practitioner's orders.

A patient who has a temperature of 100°F (37.8°C) most likely requires: A. Acetaminophen. B. Increased fluids. C. Bedrest. D. A hot bath

B Acetaminophen is not necessary for a low grade fever, but fever commonly increases fluid loss.

When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? A. Take a calcium supplement twice a day. B. Start a weight-bearing exercise program. C. Perform strenuous activity that puts stress on bones. D. Schedule regular healthcare checkups.

B Calcium supplements can assist to prevent bone loss, but does not promote bone strength. Weight beating exercise is the most important.

A nurse has been asked to design an exercise program with the goal of increasing a client's muscular strength and endurance. Which exercise program would specifically focus on meeting that goal? A. Flexibility training B. Resistance training C. Aerobic conditioning D. Anaerobic conditioning

B Resistance training involved movement against resistance, which increases muscular strength and endurance.

An 82-year-old patient is unsteady on their feet when walking around the room. They report feeling a little sore but have no complaints of weakness. Which is the appropriate piece of equipment to use when helping them ambulate? A. Crutches B. Transfer belt C. Cane D. Walker

B This allows the greatest amount of independence.

The community-health nurse is preparing a teaching plan for infection control in the home. Which instructions will the nurse include in the plan for the home setting? Select all that apply. A. Keep a supply of broad-spectrum antibiotics. B. Use a clean technique for urinary catheterization. C. Wash hands before preparing food. D. Share personal items routinely. E. Mix 10 parts bleach with 25 parts water for a cleaning solution.

B and C

The nurse in the intensive care unit is experiencing an excessive amount of job-related stress. The nurse visits the employee health nurse and states, "I feel nervous and stressed all the time. Even when I go home, I don't feel better. What am I going to do?" Which are the most appropriate responses from the health nurse? Select all that apply. A. "If you are doing the best you can and still feel this way, maybe you need to find another job." B. "I'm happy to see you are here and asking for help dealing with your anxiety." C. "Have you talked to some of your colleagues about the way you feel?" D. "I will make a list for you of some coping strategies that may be helpful." E. "I suggest you see your physician for a prescription of anti-anxiety medication."

B and C

Which of the following are the benefits of bathing? Select all that apply. A. Constricts blood vessels B. Increases depth of respirations C. Provides opportunity for assessments D. Reduces sensory input E. Prevents buildup of plaque

B and C

During the alarm stage of general adaptation syndrome (GAS), which metabolic changes occur? Select all that apply. A. Rate of metabolism decreases. B. The liver converts more glycogen to glucose. C. Use of amino acids decreases. D. Amino acids and fats are more available for energy. E. Physiological responses will last at least 24 hours.

B and D

The nurse is aware that which situations can lead to the family caregiver's feeling of "burnout"? Select all that apply. A. Caring for an infant during the eruption of a first tooth B. Caring for an adolescent child with schizophrenia C. Caring for a child being treated for a broken leg D. Caring for a spouse with Alzheimer's disease E. Caring for grandchildren once a week, as needed

B and D

Which of the following patients would you expect to be at risk for decreased activity? Select all that apply. A. Older adult who walks at the mall for physical activity B. Someone living in a skilled nursing facility C. Healthy adult who works as a computer programmer D. Obese child who enjoys video games E. The patient with impaired arterial circulation

B, C, D, and E

The nurse is teaching a safety class for campers. Which statements by the participants indicate understanding of the safety measures against ticks? Select all that apply. A. "I will wash the tick repellent off the next morning." B. "I will apply sunscreen first and then the tick repellent." C. "I will wear a long-sleeved shirt, tucked in." D. "I will look over my whole body, even my hair, for ticks." E. "I will not stay around old tires filled with water."

B, C, and D

The nurse on the pediatric unit is preparing a teaching plan related to small children and drowning. Which sources of drowning will the nurse include in the plan? Select all that apply. A. Empty bathtub B. Water-filled wading pool C. Toilet D. Mop bucket filled with water E. Unfilled hot tub

B, C, and D

Which of the following body systems must interact to produce mobility and locomotion? Select all that apply. A. Digestive system B. Muscles C. Skeleton D. Nervous system E. Endocrine system

B, C, and D

Which of the following points should the nurse include when teaching safety precautions to the parent of a toddler? Select all that apply. A. Make sure the child sleeps supine (on the back) at night. B. Keep the telephone number of the poison control center accessible. C. Use a rear-facing car seat placed in the back seat of the car. D. Keep syrup of ipecac on hand in case of accidental poisoning. E. Remove philodendron and English ivy plants from the house.

B, C, and E

In which situation would using standard precautions be adequate? Select all that apply. A. While interviewing a client with a contagious productive cough B. While helping a client perform their own hygiene care C. While taking vital signs for a client who has smallpox D. While inserting a peripheral intravenous catheter E. While assessing sutures in an abdominal incision

B, D, and E

Two days after a patient undergoes abdominal surgery, the surgical incision is red and slightly edematous and a small amount of serosanguinous (pink-tinged serous) fluid is noted on the dressing. On the basis of these data, at which conclusion will the nurse arrive? Select all that apply. A. The wound is most likely infected. B. There is a vascular response to inflammation. C. Damaged cells are being regenerated. D. Exudate formation is occurring. E. The wounds are progressing as expected.

B, D, and E

The nurse educator in the local hospital is developing a plan to implement research into nursing care practices. Which are some of the barriers the nurse educator may encounter in the implementation process? Select all that apply. A. Not enough nursing research has been published. B. There is a negative attitude toward research. C. There is a lack of support from the employing hospital. D. Most nursing research is not relevant to hospital practice. E. Nurses are reluctant to change nursing practice.

B, c, and E

A client approaches the nurse in the health clinic and states, "I have been dealing with my spouse's illnesses for years. Now my children want me to start babysitting my grandchildren. I don't know whether I can handle all this." Which is the nurse's most accurate interpretation of the client's statements? A. Some events are producing more stress for the client than other events. B. Coping abilities are extended to the limit, and the client is unable to cope. C. Many stressors or prolonged stressors make adaptation more likely to fail. D. Coping strategies used in the past are no longer successful for the client.

C

A male patient in the emergency department is angry, yelling, cursing, and waving both arms when the nurse comes into the treatment room to provide care. Which action taken by the nurse is advisable? A. Reassure the patient by entering the room alone. B. Ask the patient whether he is carrying any weapons. C. Stay between the patient and the door while keeping the door open. D. Stand close to the patient to establish rapport and trust.

C

A nurse identifies a patient's nursing diagnosis as "Diarrhea related to stress." Which nursing intervention does the nurse include in the nursing care plan to help the patient relieve the cause of the diarrhea? A. Monitor and record the frequency of stools on the graphic record. B. Administer antidiarrheal medications, as needed. C. Encourage the patient to verbalize about stressors and anxiety. D. Provide oral fluids on a regular schedule.

C

A nurse is assessing a healthy older adult patient for an exercise program that is offered at the local hospital. During the evaluation, the nurse notes the following vital signs: pulse (P) = 72 beats/min; respiratory rate (RR) = 16 breaths/min; blood pressure (BP) = 132/70 mm Hg. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, "I have to stop. I can't do this anymore." The nurse measures his vital signs again: P = 152 beats/min; RR = 40 breaths/min; BP = 172/98 mm Hg. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? A. Anxiety B. Orthostatic hypotension C. Limited activity tolerance D. Respiratory distress

C

A patient admitted to the cardiac unit is going for a cardiac catheterization. The patient tells the nurse, "I am so anxious about this. I am afraid the procedure might trigger a heart attack." Which is the first action by the nurse? A. Contact the physician for an anti-anxiety medication prior to the procedure. B. Assure the patient this is a very common procedure for cardiac patients. C. Instruct the patient prior to the procedure about what to expect of the procedure. D. Offer the patient some stress-reducing techniques to use before the procedure.

C

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. The patient's condition has stabilized, and their temperature has returned to normal. Which stage of infection is the patient most likely experiencing? A. Incubation B. Prodromal C. Decline D. Illness

C

A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of activity intolerance. Which type of bath is preferred for this patient? A. Tub bath B. Complete bed bath C. Towel bath D. Therapeutic

C

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform? A. Comprehensive B. Ongoing C. Initial focused D. Special needs

C

A patient develops localized heat and erythema over an area on the lower leg. These findings are primarily indicative of which secondary defense against infection? A. Phagocytosis B. Lysozyme C. Inflammation D. Immunity

C

A patient who is 30 years of age has been experiencing joint pain for several months and is diagnosed with rheumatoid arthritis. The patient tells the nurse, "This can't be happening to me. I don't understand this." Which statement best describes the nurse's understanding of the patient's comments? A. The patient is too young to possess the ability to cope with this diagnosis. B. The patient is exhibiting a state of denial related to the illness diagnosis. C. The patient's developmental stage affects the ability to cope with stressors. D. The patient's statements indicate an inability to accept an ongoing illness.

C

A teenage boy was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, "Our son is just staring off into space; he won't talk to us. He isn't acting like himself." Which response by the nurse is most appropriate? A. "I will inform his doctor and see whether we can get your son started on an antidepressant medication." B. "He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse." C. "Your son had a major injury, and his immobility might be causing him to feel isolated and depressed." D. "He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to do."

C

After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of general adaptation syndrome (GAS) does the nurse recognize the patient is most likely experiencing? A. Alarm B. Resistance C. Exhaustion D. Recovery

C

Dunn believes that an individual's state of health should be evaluated in the context of the person's environment. Which is an approach that illustrates Dunn's belief? a. An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individual's health. B. Adequate income, food, and shelter create a healthful environment and always improve physical health status. C. Physical environment, family, and social support may help or hinder the health status of an individual. D. The environment that should always be assessed is the client's immediate surroundings; extended boundaries do not apply in an ill state.

C

For which of the following patients can the nurse safely delegate morning care to an experienced unlicensed assistive personnel (UAP)? A. A 32-year-old just admitted with a closed head injury B. A 76-year-old admitted with septic shock C. A 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago D. A 23-year-old recently admitted with an exacerbation of asthma with dyspnea on exertion

C

Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient who had hip replacement surgery and who also has a history of emphysema. A. Activity intolerance related to injury B. Impaired mobility related to weakness C. Risk for injury related to the medical condition D. Ineffective breathing pattern related to illness

C

The new nurse working on a surgical unit observes some patients developing a low-grade fever of 99°F (37.2°C) a few hours after surgery. Which action is appropriate for the nurse to take to gain a better understanding of the observation? A. Explore previous patient records for additional data. B. Talk to the nurse manager about starting a research study. C. Formulate a searchable question, and research the literature. D. Speak to the surgeon whose patients are exhibiting symptoms.

C

The nurse in a clinical setting states, "I keep up with the latest nursing trends on the Internet." Which factor causes another nurse to question the statement? A. The Internet provides rapid and ongoing updates. B. Publishing on the Internet is strictly monitored. C. It may be difficult to do a research appraisal on the material. D. There is no reason for concern because Web sites are reliable sources.

C

The nurse in the intensive care unit is providing care for only one patient, who was admitted with a diagnosis of septic shock. Based on this information, which care and delivery model is this nurse following? A. Functional B. Primary C. Case method D. Team

C

The nurse is aware that when a patient becomes alarmed, the body will release a substance to promote a sense of well-being. Which substance is released? A. Aldosterone B. Thyroid-stimulating hormone C. Endorphins D. Adrenocorticotropic hormone

C

The nurse is caring for an admitted patient with a history of dementia. Which action by the nurse is appropriate when providing hygiene care for this patient? A. Bathe the patient quickly. B. Use cool water for bathing. C. Provide care in short intervals. D. Turn up the brightness of the lights.

C

The nurse is counseling a patient about behaviors to reduce stress. Which goal should the nurse put on the care plan? A. "The patient will limit fat intake to 15% of the daily calories consumed." B. "The patient will eat three meals at approximately the same time each day." C. "The patient will limit the intake of sweet and salty foods." D. "The patient will consume no more than three alcoholic beverages a day."

C

The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly, they state, "I feel so light-headed and weak," as their knees begin to buckle. Which is the best action by the nurse at this time? A. Instruct the patient to grab the rail in the hallway while the nurse calls for assistance. B. Immediately release the transfer device and place a wheelchair behind the patient. C. Assist the patient to slide down the nurse's leg as the nurse guides them to a seated or lying position. D. Grasp the patient under the arms and across the chest to hold them up as the nurse calls for assistance.

C

The nurse is invited to a childcare center for a safety class. An employee comes running into the class and says to the nurse, "I think one of the children swallowed a poisonous chemical from our storage area." What is the first action by the nurse? A. Identify the poison; then call 911 or the local emergency number. B. Assess for signs and symptoms; then call 911 or the local emergency number. C. Call 911 immediately, even if the child has no symptoms. D. Induce vomiting in the child; then call 911.

C

The nurse is planning to initiate a research project that involves adult patients as participants. The nurse accepts moral and legal responsibility to protect research participants from physical or emotional harm. Which mechanism will the nurse utilize for participant protection? A. The research facility board of directors B. The research facility board of medical advisors C. The institutional review board (IRB) at the research facility D. The U.S. Department of Health and Human Services

C

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client's spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview? A. Provide enough chairs for the family to sit facing the client. B. Ask the client's preference for how to be addressed by the nurse. C. Ask if the client is willing to answer questions after the family leaves. D. Give the client the option of having the interview while the family watches television.

C

The nurse is presenting a workshop on stress and adaptation to adolescents at the local high school. A teenager tells the nurse, "Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think?" Which is the most appropriate response by the nurse? A. "No amount of stress is healthy, especially if your heart is going faster." B. "As long as you are getting through the test, I think you will be just fine." C. "A little stress is not necessarily a bad thing. It can help you to focus." D. "You may need to develop some additional stress-reducing activities."

C

The nurse is providing care for a 55-year-old client with severe respiratory disease. Using Neuman's continuum as a resource, which stage of illness is the nurse most likely to identify as being applicable to this client? A. Moderate energy related to the resiliency of age B. High energy related to available treatment C. Low energy related to compromised breathing D. Extremely low energy due to impending death

C

The nurse is providing care for a client who is 76 years of age and experiencing chronic illness related to genetic-linked anemia. The client does not eat a balanced diet and admits preferring sweets to meat and vegetables. Which dimension of health is the nurse most likely to influence with teaching and counseling? A. Age-related changes B. Genetic anemia C. Eating habits D. Gender-related issues

C

The nurse is providing care for a patient in an acute care facility. The patient tells the nurse, "Ever since we experienced an earthquake, I keep having flashbacks of the event. I can't sleep for fear of another one happening during the night." Which condition does the nurse associate with the patient's statements? A. Anxiety B. Lack of coping skills C. Post-traumatic stress disorder (PTSD) D. Crisis

C

The nurse is ready to bathe a female patient who has an intravenous (IV) line with no two-way, needle-free connector and needs to remove the patient's gown. The nurse should take which action? A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown. B. Cut the gown with scissors to allow the patient's arm to be easily removed from the gown. C. Thread the bag and tubing through the gown sleeve, keeping the line intact. D. Disconnect the tubing, thread it through the gown, and reconnect the tubing.

C

The nurse works at a busy trauma center and needs to establish a relationship of caring, respect, and understanding with clients during a time of extreme physical and emotional stress. Which behavior from the nurse is most likely to convey a sense of compassion? A. Extend kindness to the client and family. B. Display competency during procedures. C. Provide a healing presence. D. Remain professionally aloof.

C

The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient's artificial eye. What should the nurse ask the patient to do to best position them for this procedure? A. Lean forward and rest the arms on the overbed table. B. Sit back in the chair and tilt the head back. C. Move to the bed and lie down. D. Stand up and lean over the bed.

C

The patient with a spinal cord injury is experiencing autonomic dysfunctions. Which of the following is an important aspect of care to assist in managing these dysfunctions? A. Hold the patient upright if they begin to fall until assistance arrives. B. Ask the patient to assist with turning by holding the side rails of the bed. C. Place the patient in a high-back reclining wheelchair, which can be lowered. D. Ask the patient if a transfer belt would be helpful to support assisted walking.

C

The quality and risk nurse at the local hospital is performing a hospital survey on sentinel events. Which statement would the nurse use to accurately describe a sentinel event? A. An event that can cause serious injury to a patient that should never happen in a hospital B. Specific events that enable a hospital to maximize reimbursement C. An unexpected event involving death or serious physical or psychological injury D. Operating room event involving the use of unsafe equipment

C

To achieve balance, body mass must be distributed around which point? A. Line of gravity B. Center of balance C. Center of gravity D. Base of support

C

What action is most important in preventing the nurse's risk of back injuries? A. Use good body mechanics at all times. B. Develop a lift team at the clinical site. C. Avoid manual lifting by using assistive devices as often as possible. D. Work with another nurse or an aide when lifting and turning patients.

C

When taking care of patients on the medical-surgical unit, what is the most important action the nurse can take in preventing falls? A. Raise the two side rails for each patient's bed. B. Place a fall risk sign on the front of the patient's door. C. Identify those patients who are at risk for falls. D. Use bed alarms for patients prone to falls.

C

Which action by the nurse indicates an understanding of the most effective method to prevent the spread of infection among institutionalized patients? A. Place patient on airborne precautions B. Prevent contact with contaminated equipment C. Perform hand hygiene routinely D. Decrease exposure to infections from family members

C

Which activity provides evidence-based support for the contribution made by advanced practice nurses (APNs) within healthcare? A. Reduced use of diagnostics using advanced technology B. Decreased the number of unnecessary visits to the emergency department C. Improved patient compliance with prescribed treatments D. Increased use of complementary and alternative therapies

C

Which behavior by the nurse indicates the highest potential for spreading infections among clients? A. Disinfects dirty hands with antibacterial soap B. Rubs alcohol-based hand gel for 20-30 seconds C. Washes hands primarily after leaving each room D. Uses warm water for medical asepsis

C

Which is the most important reason for nurses to be critical thinkers? A. Nurses need to follow policies and procedures. B. Nurses work with other healthcare team members. C. Nurses care for clients who have multiple health problems. D. Nurses have to be flexible and work variable schedules.

C

Which theorist developed the nursing theory known as the science of human caring? A. Florence Nightingale B. Patricia Benner C. Jean Watson D. Nola Pender

C

While eating in the hospital cafeteria, a nurse sees a visitor display the "universal sign of choking." Which action should the nurse take first? A. Page a "Code Blue" emergency. B. Immediately perform five abdominal thrusts. C. Assess the situation by asking, "Are you choking?" D. Deliver four sharp back blows between the scapulae.

C

The nurse is caring for a client with Clostridium difficile infection. The nurse is caring for which client? A. A neonate just born to a mother with a sinus infection B. A young adult with vancomycin-resistant enterococci C. A 78-year-old male taking antibiotics for cellulitis D. A 45-year-old female taking hormonal medications

C Elders and long term treatment with antibiotics is at great risk for developing C. Diff

The nurse is providing care to a patient who expresses feelings of dread and of vague uneasiness. Nursing assessment reveals the patient's heart rate is elevated. Which nursing diagnosis is most appropriate for this patient? A. Anger B. Fear C. Anxiety D. Hopelessness

C NANDA defines anxiety as a vague, uneasy feeling of discomfort or dread.

The nurse providing care to a patient with a fracture explains how bones heal. Which type of cells will the nurse indicate repairs damaged bone and builds new bone to keep the skeleton strong? A. Amphiarthroses B. Articular cartilage C. Osteoblasts D. Osteoclasts

C Osteoblasts build Osteoclast breakdown

A newly hired nurse is working with an experienced nurse on the oncology unit. The newly hired nurse expresses interest in helping patients and making their hospital stay a better experience. Which is the most appropriate response for the experienced nurse to make? Select all that apply. A. "This takes time. Once you have worked on the unit for a while, it will become clear to you." B. "Find your best approach to patient care, and then use this approach with every patient." C. "One of the very best ways is to listen to your patient and be attentive to their needs." D. "It is helpful to consider your strengths and weaknesses and how you cope with illness." E. "Just remember to apply all your nursing knowledge when you interact with a patient."

C and D

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. A. Question the order because the patient must remain in isolation. B. Place an N-95 respirator mask on the patient, and transport to the test. C. Place a surgical mask on the patient and transport to CT lab. D. Notify the CT department about precautions prior to transport. E. Apply a sterile gown and face shield over the patient before leaving the room.

C and D

The mother of 6-year-old twins says to the pediatric nurse, "My husband and I keep a gun in our home. Do you have any safety tips for us?" The most appropriate responses by the nurse are which of the following? Select all that apply. A. "I do not recommend owning a firearm when children are living in the home." B. "Be careful not to allow your children into the homes of others who own firearms." C. "Be sure to keep your gun unloaded and in a secure and locked cabinet." D. "Ammunition for your gun should be stored in a different location from the gun." E. "I can't believe your family owns a gun, especially when you have twins."

C and D

A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. They live independently and have developed strong upper-body strength to maximize their independence. Which transfer device should be used when transferring them from the bed to their wheelchair? A. Mechanical lift B. Transfer belt C. Draw sheet D. Transfer board

D

A female client comes to the clinic for her annual physical. During the examination, the nurse palpates a lump in the left breast and informs the client of the finding. The client responds, "Yes, I found it a few months ago but just didn't want to think about it." The nurse recognizes the client is using which approach to coping with the lump? A. Altering B. Adapting C. Changing D. Avoiding

D

A healthy 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. Based on the U.S. Department of Health and Human Services recommendations, which advice should the nurse offer him? A. Exercising once weekly for 20 to 30 minutes is essential to increase strength. B. Thirty minutes of moderate physical activity three times a week is appropriate. C. Moderately intense exercise for 1 hour three times a week will be adequate. D. Moderate physical activity 150 to 300 minutes or more per week is needed.

D

A newly graduated nurse is working on a medical-surgical unit and appears to have difficulty identifying what needs to be done, as well as selecting interventions and setting goals. Which advice from the nurse manager is most helpful? A. Follow an experienced nurse for a week. B. Contact a former instructor for help and guidance. C. Discuss each shift's responsibility with the nurse manager. D. Review and discuss the use of clinical practice theories.

D

A nurse was recently hired at an acute care facility. During orientation, the nurse is given a chart describing each person's role in the assigned unit. The chart reflects that registered nurses are responsible for all admission and discharge assessments and patient treatments. Licensed practical nurses (LPNs) administer medications, and certified nursing assistants (CNAs) obtain vital signs and perform personal care. Which model of care does the nurse recognize? A. Case method B. Team C. Primary D. Functional

D

A nursing instructor asked their nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? A. "I find it difficult to avoid using phrases like 'patient tolerated the procedure well.'" B. "It's confusing to have to remember which abbreviations this hospital allows." C. "I need to work on charting assessments and interventions right after they are done." D. "My patient was really quiet and didn't say much, so I charted that they acted depressed."

D

A patient diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? A. Precrisis B. Impact C. Crisis D. Adaptive

D

A patient who is 80 years old arrives in the emergency department experiencing a severe heart attack. The patient's condition is deteriorating and the physician informs the spouse that the patient is not expected to survive. The spouse becomes distraught and tells the nurse, "We have been married for 60 years. What am I going to do?" Which is the most appropriate response by the nurse? A. "You had a good life together. You just need to understand that death is part of life, too." B. "I understand how you feel, but living to 80 years of age is a good long life." C. "I will get a social worker to see you for some help you may need at home." D. "I understand that this is an incredible and unexpected loss for you."

D

A patient with a history of seizures who takes phenytoin is at risk for which oral problem? A. Dryness of the mouth B. Brownish pigmentation of the gums C. Demineralization of the tooth enamel D. Gingival hyperplasia

D

According to the U.S. Department of Health and Human Services 2018 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct? A. Lesser amounts of activity provide little to no health benefits. B. Physical activity in excess of recommendations for age is harmful. C. The risks of participating in physical activity outweigh the health benefits. D. Physical activity should be enjoyable, and a variety will improve adherence.

D

The home-care nurse is providing care for a patient. After several visits and review of the plan of care, the nurse notices the patient does not follow the prescribed diet and exercise regimen. Which is the most appropriate action by the nurse? A. Discharge the patient from home care because of noncompliance to the medical regimen. B. Continue to teach and reinforce the importance of the diet and exercise regimen. C. Notify the healthcare provider of the patient's refusal to follow the diet and exercise regimen. D. Identify why the patient is not following the plan, and revise the plan in collaboration with the patient.

D

The nurse assigned to teaching a new parent about proper infant car seat positioning will explain that it is recommended that the child be placed in a forward-facing car seat at which age at the oldest? A. 2 years B. 3 years C. 4 years D. 5 years

D

The nurse assigns a nursing assistant the task of ambulating a group of patients on the medical-surgical unit. Later in the morning, the nursing assistant tells the nurse, "Some of my patients feel very sick but want to get out of bed. Others say they feel well but don't want to get out of bed. What should I do?" Which is the most appropriate response by the nurse? A. "All patients are supposed to be out of bed today, so do the best you can with them." B. "This is not uncommon. Sometimes you have to push some patients more than others." C. "All patients may respond to illness differently. Explain that they must be out of bed today." D. "Get the patients up if they want to get up, and help the others to ambulate later in the day."

D

The nurse attempts to transfer a totally dependent patient from a stretcher to a bed. What is the best action to reduce the musculoskeletal risk factors for the nurse? A. Use a mechanical lift to transfer the patient. B. Use a wide base of support when transferring. C. Ask a coworker to help transfer the patient. D. Use a transfer roller sheet when transferring.

D

The nurse has been teaching a student how to perform mouth care for an unconscious patient. The student shows evidence of understanding when they place the patient in which of the following positions? A. Supine B. Prone C. Semi-Fowler's D. Side-lying

D

The nurse is admitting a 62-year-old patient with a diagnosis of hypertension to the hospital. Which question by the nurse is most important when performing the initial assessment interview? A. "What medications do you take at home?" B. "Do you have any environmental, food, or drug allergies?" C. "Do you have an advance directive?" D. "What greatest concern are you dealing with today?"

D

The nurse is admitting a patient with heart disease to the cardiac unit. When answering questions related to health history, the patient's responses are lengthy and time-consuming. Which is the most appropriate action by the nurse? A. Recognize that the patient may be lonely and just wants to talk to someone. B. Set a time limit, and inform the patient of your time frame to complete the assessment. C. Anticipate the patient's answers, and quickly go on to the next question. D. Be attentive, focus on what the patient has to say, and respond accordingly.

D

The nurse is attending to a 76-year-old patient who is being admitted for an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary, and the patient agrees and signs the informed consent form. Which stage of illness behavior does the nurse identify the patient experiencing? A. Sick-role behavior B. Seeking professional care C. Experiencing symptoms D. Dependence on others

D

The nurse is delegating the foot care of a patient with congestive heart failure to the UAP. At which temperature would the nurse tell the UAP to prepare the water? A. 99°F (37.2°C) 1B. 02°F (38.9°C) C. 103°F (39.4°C) D. 105°F (40.6°C)

D

The nurse is providing care for a client who has been hospitalized for 6 weeks. Which nursing intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization? A. Providing skin care every shift to prevent skin breakdown B. the patient to get up in a chair to eat meals C. Assisting the patient to ambulate in the hallway for several minutes each day D. Designating a corner of the patient's room to display personal mementos

D

The nurse is providing care for a patient who is in crisis. After assessing the situation, which action does the nurse perform first? A. Determine the imminent cause of the crisis. B. Intervene to relieve the patient's anxiety. C. Decide on the type of help needed. D. Ensure the safety of both nurse and the patient.

D

The nurse is providing care for a patient who sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process does the nurse expect the patient to experience first? A. Cellular inflammation B. Exudate formation C. Tissue regeneration D. Vascular response

D

The nurse is providing care for a patient with numerous physiological complaints. A family member shares that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. The nurse recognizes which somatoform disorder this patient is most likely experiencing? A. Hypochondriasis B. Somatization C. Somatoform pain disorder D. Malingering

D

The nurse is teaching a UAP how to give a complete bed bath. Which instruction should the nurse include? A. "Cleanse only those areas likely to cause odor." B. "Provide the patient with warm water for washing the perineum." C. "Wash the patient's back, buttocks, and perineum first." D. "Bathe the patient from head to toe, cleanest areas first."

D

The nurse will teach the patient that the most common causes of death related to a house fire are: A. Explosions. B. Falls from second-story windows. C. Thermal damage to skin and body surfaces. D. Smoke inhalation injuries.

D

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which initial antibody would most likely be elevated in a test of immunoglobulin (Ig) levels? A. IgA B. IgE C. IgG D. IgM

D

To ensure effectiveness, when should the nurse stop rubbing antiseptic hand gel over all surfaces of the hands? A. When fingers feel sticky B. After 5 to 10 seconds C. Before leaving the client's room D. Once fingers and hands feel dry

D

When encouraging a fitness program for healthy older adults, what must the nurse consider? A. Older adults should engage in 75 to 150 minutes of moderate physical activity per week. B. More than 150 minutes of moderate-intensity physical activity can be harmful to bones. C. Structured fitness programs achieve greater health benefits for older adults. D. Older adults at risk for falling should do activities that maintain or improve balance.

D

When making an occupied bed, which action is most important for the nurse to do? A. Keep the bed in a low position. B. Raise the side rails on both sides of the bed. C. Move back and forth between the sides of the bed when adjusting linens. D. Use a bath blanket or sheet to maintain patient warmth and privacy.

D

When the use of a restraint is necessary, what task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Assessing the patient's status B. Determining the need for restraint C. Evaluating the patient's response to restraints D. Applying and removing the restraints

D

Which condition listed below is not considered a chronic disease? A. Diabetes B. Kidney disease C. Arthritis D. Mononucleosis

D

Which intervention would be appropriate for a patient who has an eye infection with a moderate amount of discharge? A. Cleansing the eye with hydrogen peroxide B. Wiping from the outer canthus to the inner canthus C. Positioning the patient on the same side as the eye to be cleansed D. Using a different wipe to cleanse each eye

D

Which of the following instructions is most important for the nurse to include when teaching a 3-year-old's parent about protecting their child against accidental poisoning? A. Store medications on countertops out of the child's reach. B. Purchase medication in child-resistant containers. C. Take medications in front of the child, and explain that they are for adults only. D. Never leave the child unattended around medications or cleaning solutions

D

Which sutures between cranial bones are which type of joint? A. Diarthroses B. Synovial C. Amphiarthroses D. Synarthroses

D

Which term should the nurse use to describe a patient infected with a virus but who does not have any outward signs of the disease? A. Pathogen B. Fomite C. Vector D. Carrier

D

A frail, elderly patient is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, they are to begin ambulating with a walker but must avoid weight bearing on their left lower leg. What is the best intervention to help them use the walker? A. Aerobic exercise with deep breathing B. Quadriceps and gluteal repetitions C. Isometric toning of lower legs D. Arm resistance training

D Arm strength is necessary for ambulating with a walker and other assistive devices.

The nurse is aware that after a patient has an argument with their spouse, the patient becomes verbally abusive to the nurse who is providing care. Which coping mechanism does the nurse recognize the patient is exhibiting? A. Reaction formation B. Displacement C. Denial D. Conversion

D Displacement means transferring emotions towards someone or thing else.

Some people readily become ill when under stress, while others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person's level of hardiness. In which manner does the nurse apply this knowledge to nursing care? A. The nurse cannot use the presented information. People are innately hardy or not, a state that the nurse must merely recognize. B. Nurses need to encourage all people to develop some level of hardiness to help them get through difficult physical and emotional times. C. Nurses need to assess for their own level of hardiness. If nurses are hardy, they will be better nurses; if not, nurses can learn more about hardiness. D. Nurses assessing for hardiness in patients can encourage hardy patients to learn about their illness as a means for them to be more comfortable.

D Hardiness is a personality trait that helps many to cope with stress and illness.

A patient fractured their right ulna 8 weeks ago and has just had their cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises complies with the surgeon's orders? A. Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds, and repeat 5 to 10 times. B. Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times. C. Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. D. Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times.

D Isometric exercise involved muscle contractions without movement.

The PICOT question reads, "Is transcutaneous electrical nerve stimulation (TENS) effective in the management of chronic low-back pain in adults?" Which part of this question comes from the "I" in PICOT? A. Adults B. Management C. Pain D. TENS

D The I in PICOT is the Intervention part of a research question. TENS is the Intervention in the PICOT system.

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate? A. The client's weight is 185 lb (83.9 kg) at the clinic. B. The client's liver function test results are elevated. C. The client states that blood pressure (BP) of 160/94 mm Hg is typical. D. The client reports eating processed foods on a low-sodium diet.

D Validation does not need to be done on labs or when subjective and objective agree with each other.

Complete the statement: A 56-year-old patient diagnosed with acute myocardial infarction (heart attack) makes inappropriate sexual comments to the licensed practical nurse/licensed vocational nurse (LPN/LVN). The LPN/LVN is visibly upset. The RN assigned to the patient informs the patient that the behavior is unacceptable and will not be tolerated. The RN is demonstrating ____________________ nursing.

Mechanistic

Complete the statement: The unit committee in the intensive care unit is designing a research study to see whether the spiritual needs of patients are being met. The study will involve patient interviews after discharge. After the interview process, the staff will examine patient statements for recurring themes. The unit committee is conducting ____________________ research.

Qualitative

A patient experiences pain after undergoing surgery. The nurse forms a mental image of pain based on the nurse's own experiences with pain. Which term describes this mental image? A. Phenomenon B. Concept C. Assumption D. Definition

B Concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience.

The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data? A. Prioritizes collection of assessment data B. Organizes and clusters data efficiently C. Separates subjective and objective data D. Identified both primary and secondary data

B During assessment, nurse is still collecting data.

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives the notification of another client's admission to the unit. Which professional body influences the nurse's decision about who will be assigned to perform the assessment of the second client? A. The state board for nursing-assistant testing B. The American Nurses Association (ANA) C. The facility policy and procedure committee D. The bargaining committee for facility nurses

B The ANA Scope and Standards of Practice identifies assessment to a professional responsibility.

The nurse manager in an acute care facility is orienting new graduate nurses. While reviewing the Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with the Joint Commission? A. Nutritional status B. Functional ability C. Cultural D. Wellness

B The Joint Commission requires an initial functional ability assessment that is based on the patient's condition. 3 assessment tools the Karnofsky Performance Scale, the Katz Index, and the Lawton Instrumental Activities of Daily Living.

Each U.S. state has its own state board of nursing responsible for protecting the health, safety, and welfare of the general public. The state boards of nursing meet these responsibilities by performing which functions? Select all that apply. A. Advocating for nursing student issues B. Determining the nurse's scope of practice C. Enforcing the rules that govern nursing D. Writing the laws that regulate nursing E. Regulating the number of licensed nurses

B and C

The nurse is providing care for a pediatric patient in an acute care facility. The patient's parents express concern about the cost of medical care. The parents state, "We have jobs, but we don't make a lot of money and have no insurance." Which medical assistance program does the nurse recognize as being most appropriate for this family? A. Children's Health Insurance Program (CHIP) B. Medicare C. Medicaid D. Local charity

A

The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history? A. A nursing history focuses on the effects the health problem has on the patient. B. The medical history gathers information about the current problem. C. A nursing history is gathered by using a specific format. D. A medical history collects more in-depth information.

A

Which activities indicate the implementation of direct nursing care? Select all that apply. A. Bathing a patient B. Administering a medication C. Teaching a patient to change a wound dressing D. Making work assignments for the shift E. Evaluating patient progression toward goals

A, B, and C

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. Which action does the nurse take to develop a nursing diagnosis? A. Analyze the assessment data. B. Refer to the standards of patient care. C. Select appropriate patient care interventions. D. Ask the client's perceptions of the health problem.

A

A nurse working in a rehabilitation facility has a physician's order to contact therapists as required by patient needs. A patient has started to have difficulty with bathing and grooming. Which therapist does the nurse contact to assist the patient to regain these skills? A. Physical therapist B. Occupational therapist C. Speech-language pathologist D. Respiratory therapist

A

An older adult patient is preparing for discharge and tells the case manager, "I don't know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me." Which is the most appropriate response by the case manager? A. "We can have a social worker see you when you get home." B. "Medications are expensive, but you will need to take them." C. "I will check if some of the medications can be discontinued." D. "The home-health nurse will address this when they see you."

A

In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike? A. Health status is expressed in terms of human responses. B. Patient response is expressed before interventions are done. C. Patient responses are always expressed in positive terms. D. Both methods reveal patterns of related cues.

A

The nurse gathers assessment data and notes several significant changes in the client's health status. The client's weight has increased by 5 pounds (2.27 kg) over the past 24 hours, the client is short of breath, and crackles are auscultated at both lung bases. To which step of the nursing process should the nurse proceed after organizing the data? A. Diagnosis B. Planning C. Implementation D. Evaluation

A

The nurse is assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse develops a plan of care. Which action will the nurse initially perform? A. Make an assessment B. Make a diagnosis C. Plan outcomes D. Plan interventions

A

The nurse is caring for a patient with diabetes mellitus and impaired skin integrity. When preparing a plan of care, the nurse uses knowledge of the patient's medical condition and the latest guidelines for providing skin care. Appropriate interventions are initiated, and the nurse begins regular monitoring for intervention effectiveness. Which nursing concept is being used? A. Full-spectrum nursing B. Critical thinking C. Nursing process D. Nursing knowledge

A

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment? A. Obtaining a patient's temperature 1 hour after giving acetaminophen B. Examining a patient's throat after soreness with swallowing is reported C. Requesting a patient to rate pain intensity level on a scale of 0 to 10. D. Asking a patient the details of a plan to return to normal exercise activities.

A Ongoing assesement occurs when a previously identified problem is being reassessed.

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is most appropriate when gathering data about headaches? A. "When did your migraines begin?" B. "Tell me about your family history of migraines." C. "What are the things that trigger your headaches?" D. "Describe for me what your headaches feel like."

A For someone who is anxious, it is best to used closed-ended questions.

The nurse knows the following descriptions are most closely related to the primary goal(s) of evidence-based practice (EBP)? Select all that apply. A. Presents the most effective treatments B. Identifies the most cost-effective treatments C. Includes all patient and family preferences D. Creates standardized facility clinical pathways E. Adds more studies to support an intervention

A and B EBP uses firm scientific data to present the most effective treatments that are also cost effective.

Caring is a central concept in nursing. Which of the following exemplifies a nurse exhibiting the concept of caring and the use of critical-thinking attitudes? Select all that apply. A. Treating clients as unique individuals B. Responding compassionately to client needs C. Acting in ways to preserve human dignity D. Connecting with others to give and receive help E. Using the communication skill of active listening

A, B, C, D, and E

The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply. A. "How did this happen to you?" B. "What was your first symptom?" C. "Why didn't you see healthcare earlier?" D. "When did you start having symptoms?" E. "Why did you decide to seek help now?"

A, B, and D Ask how, what and when. Why questions can be deemed offensive.

Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply. A. Assessment is a professional nursing responsibility. B. Assessment helps the nurse identify problems and priorities. C. Assessment helps the nurse formulate the medical diagnosis. D. Assessment of pain is focused on patients indicating the presence of pain. E. Assessments can be delegated according to state practice acts and agency policies.

A, B, and E All patients are assessed for pain, so that is not specific.

According to the American Nurses Association, which statements best describe the characteristics of registered nursing? Select all that apply. A. Nursing practice is individualized. B. Nursing practice is similar to medical practice. C. Caring is central to the practice of the registered nurse. D. Nurses coordinate care by establishing partnerships. E. Nurses promote health through political involvement.

A, C, and D

The nurse is preparing a presentation for nursing students about the processes of thinking and implementation that apply to nursing. Which topics will the nurse include? Select all that apply. A. Critical thinking B. Pain evaluation C. Clinical judgment D. Problem-solving E. Sterile technique

A, C, and D

Which of the following are cues rather than inferences? Select all that apply. A. Patient ate 50% of the meal. B. Patient feels better today. C. Patient states, "I slept well." D. Patient's white blood cell (WBC) count is 15,000/mm3 E. Patient does not appear to be in pain.

A, C, and D Cues are what the nurse observes and the client says.

What are the benefits for nursing practice in using a standardized nursing language when writing nursing diagnoses? Select all that apply. A. Defines and communicates nursing knowledge B. Assists the nurse in understanding medical diagnoses C. Facilitates better understanding of nursing research D. Helps nurses provide consistent interventions for all patients E. Promotes understanding of nursing functions

A, C, and E

The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior? A. Taking frequent notes B. Asking for more details C. Leaning toward the patient D. Sitting comfortably with legs crossed

C Active listening includes leaning towards client, facing patient, exhibiting open, relaxed posture without crossing arms or legs and maintaining eye contact).

Which commonality is shared by both critical thinking and the nursing process? A. They are both linear processes used to guide one's thinking. B. They are both thinking methods used to solve a problem. C. They both use specific steps to solve a problem. D. They both use similar steps to solve a problem.

B

A few nurses on a unit have proposed to the nurse manager changes in the process for documenting care on the unit. The nurses describe a completely new system. For which reason is it important for the nurse manager to have a critical attitude? A. All the possible advantages and disadvantages and must be considered. B. An open mind about the proposed change needs to be maintained. C. The nursing process needs to be applied to the proposed change. D. Past experience with documentation needs to be applied to the decision.

B

A patient in an ambulatory clinic tells the nurse, "Every visit costs me $10, even though I have insurance." Which is the most appropriate response by the nurse? A. "I am not involved in your insurance; you need to contact the insurance company." B. "Let's check if this is a co-payment described by your insurance plan for each visit." C. "Healthcare is expensive, and insurance companies can't pay all of the costs." D. "This charge is actually part of the insurance premium that you pay monthly."

B

A patient who is 80 years of age is in an acute care facility because of a fractured hip resulting from a fall. Previously, the patient lived at home and managed activities of daily living independently. The patient's goal is to return to the previous living style. The patient is to be discharged because of insurance regulations. If the patient cannot walk or provide self-care, to which type of facility will the patient be transferred? A. Nursing home B. Rehabilitation center C. An outpatient therapy center D. None of these; they should receive home-healthcare

B

After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data? A. The client's blood pressure reading is 132/68 mm Hg, and their heart rate is 88 beats/min. B. The client's cholesterol is elevated, and they admit to liking and eating fried food. C. The client reports having trouble sleeping and admits drinking coffee in the evening. D. The client verbally reports having frequent headaches and taking aspirin for the pain.

B

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? A. Psychomotor B. Interpersonal C. Cognitive D. Critical thinking

B

The nurse develops a plan of care for a patient who is at risk for impaired skin integrity. Interventions include changing the patient's position every 2 hours and keeping the skin clean and dry. During the evaluation phase of the nursing process, which finding validates the effectiveness of the plan of care? A. Documentation reflects the performance of care interventions. B. Reassessment indicates maintenance or improvement of the condition. C. Intervention performance is verbally validated by the assigned personnel. D. Patient states that care was provided in an effective and timely manner.

B

The nurse in an acute care facility is appointed to a committee that reviews the delivery of patient care. Which primary purpose of using the full-spectrum nursing model does the nurse recognize A. The model assists nurses in testing. B. Implementation has a positive effect on client health outcomes. C. The model adequately uses all aspects of the nursing process. D. The implementation enables nurses to complete their work on time.

B

The nurse is providing care for an older adult patient in an acute care setting for various age-related health issues. When planning for discharge, the patient states concern about being able to adequately provide for health maintenance and self-care needs. Which type of facility does the nurse recognize for this patient? A. Skilled nursing facility B. Assisted-living facility C. Nursing home facility D. Independent living facility

B

The nurse is providing care to a patient who has left-sided weakness related to a recent stroke. Which type of special needs assessment is most important for the nurse to perform? A. Family B. Functional C. Community D. Psychosocial

B

The nurse works on a postsurgical unit with a broad and rapidly changing patient census. Which critical-thinking attitude is most likely to best serve this nurse? A. Possesses an extensive knowledge of principles and theories B. Has a lively curiosity and enjoys learning new ways to do things C. Applies the problem-solving process taught in nursing school D. Responds to patients on the basis of what is socially approved

B

The nursing instructor is considering becoming a member of the National League for Nursing (NLN). Which primary goal of the NLN will most strongly impact the nurse's decision to become a member? A. Emphasizing the necessity for registered nurses to promote patient safety B. Establishing and maintaining identified standards for nursing education C. Supporting global health policies and improving health worldwide D. Fostering nursing scholarship, leadership, and service to improve health

B

For which reason does the nurse use nondirective interviewing as an assessment technique? A. Allows the nurse to have control of the interview B. Is an efficient way to interview a patient C. Facilitates open communication D. Helps focus the attention of patients who are anxious

C

In the United States, each state enacts its own nurse practice acts. Which agency is responsible for nurse practice acts? A. American Nurses Association B. Institute of Medicine C. State Board of Nursing D. National League for Nursing

C

Nurses are constantly confronted by situations and conditions requiring the application of various types of knowledge. Which is an example of practical knowledge? A. The tricuspid valve is located between the right atrium and the ventricle. B. The pancreas does not produce enough insulin in type 1 diabetes. C. When assessing the abdomen, you should auscultate before palpating. D. Pain medication given intravenously acts faster than medication given by other routes.

C

Nursing education does not override or diminish self-knowledge. Which is the most important reason for nurses to develop an awareness of individual self-knowledge? A. Can be used to hide personal cultural biases B. Assists in directing patients to self-understanding C. Helps identify errors in nurse's thinking D. Aids the nurse in protecting personal beliefs

C

The nurse enters a room to find the client sitting up in the chair and crying. Which action by the nurse best displays both a critical-thinking and caring attitude? A. Telling the client the nurse will return to chat after seeing other clients. B. Contacting the family to request someone to come and sit with the client. C. Using communication skills to determine the reasons for the client's crying. D. Placing a "do not disturb" sign on the door to protect the client's privacy.

C

The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question? A. "Have you had surgery before?" B. "When was your last menstrual period?" C. "What happens when you have a headache?" D. "Do you have a family history of heart disease?"

C

The nurse is providing care for a client with skin breakdown in the coccyx area. The physician has prescribed a medication to be applied to the area. The nurse administers all medications as prescribed. Which specific aspect of the nursing process is the nurse performing? A. Assessment B. Planning interventions C. Implementation D. Evaluation

C

The nurse is providing care for a patient following a debilitating stroke. Which type of care will the nurse recognize as the best choice for this patient? A. Primary care B. Secondary care C. Tertiary care D. Preventive care

C

The nurse is working in a community health promotion clinic. Which is an example of an illness prevention activity? A. Encouraging the use of a food diary B. Joining a cancer support group C. Administering immunization for human papillomavirus (HPV) D. Teaching a diabetic patient about their diet

C

The nurse uses full-spectrum nursing and a critical-thinking model to organize patient care. If the nurse lacks facts about the patient's pathophysiology, a credible source is used for the information. The nurse considers alternative actions for implementing care, factoring in the unique qualities of the patient. Which critical-thinking concept is the nurse demonstrating? A. Following model guidelines for specific interventions B. Using linear processes to promote critical thinking C. Moving appropriately back and forth between steps D. Using self-knowledge in the decision-making process

C

The nursing staff on a surgical unit expresses to the manager concerns about not having enough time to complete all wound care and dressing changes. Which is the initial action the manager takes? A. Decrease the patient-to-nurse ratio within budget limits B. Offer an in-service session on time-management strategies C. Suggest a continuing quality improvement committee to assess the issue D. Report the concerns to the director of nurses at the next management meeting

C

The registered nurse is discharging a patient to an assisted living facility. Which statement by the nurse is most appropriate for the patient? A. "Therapists will work with you daily to help you regain your functional abilities." B. "You will be provided with 24-hour nursing care for the next 6 weeks." C. "Assistance with meals and housekeeping tasks is available to you." D. "A nurse will come to your home and provide you with nursing care."

C

Which statement best explains the importance of standards of practice in the nursing profession? A. Nurses have the same standards of practice as other healthcare professionals. B. Standards of practice are applied exclusively to nurses working in hospital settings. C. Standards of practice identify the components nurses need to provide safe-care. D. Standards of practice differ among registered nurses, based on the population they serve.

C

Which type of managed care provides patients with the greatest choice of in-network providers, medications, and medical devices? A. Health maintenance organization B. Integrated delivery network C. Preferred provider organization D. Employment-based private insurance

C

Which nursing activity is most reflective of the evaluation phase of the nursing process? A. Administering pain medication prior to changing a complex wound dressing B. Obtaining patient's blood pressure (BP) 30 minutes after administering BP medication C. Reporting three patient falls in the past month on the nursing unit D. Teaching the patient how to perform daily finger sticks for blood glucose readings

C Teaching is an intervention. Evaluation is a planned, ongoing, systematic activity in which the nurse makes judgements about patient progress towards desired health outcome, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting.

A patient is preparing to be discharged after total knee replacement. The patient tells the case manager, "I feel pretty good, but I am having a hard time getting in and out of the bathroom." Which is the most appropriate response by the case manager? A. "I'll be sure to teach your family how to help you with this." B. "Once you are home for a while, it will get easier." C. "I can have a recreational therapist help you take your mind off your concerns." D. "An occupational therapist can be ordered to assist you in this area."

D

A practicing nurse is aware that continuing education courses may be required for license renewal. Which organization can require nurses to obtain a specified amount of continuing education courses? A. American Nurses Association B. National League for Nursing C. Sigma Theta Tau D. State Board of Nursing

D

An experienced nurse uses knowledge of patient medical conditions and intuition to identify patient problems. The nurse often fulfills the role of a resource for other nurses on the unit. At this point, which stage of proficiency has this nurse achieved? A. Novice B. Advanced beginner C. Competent D. Expert

D

An older adult patient is diagnosed with type 1 diabetes mellitus. The patient can perform self-care activities but needs assistance with shopping, meal preparation, blood glucose monitoring, and insulin administration. Which type of healthcare facility is most appropriate for the patient? A. Acute care facility B. Ambulatory care facility C. Extended care facility D. Assisted-living facility

D

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed? A. Time constraints support small portions of assessment at a time. B. Validating an absence of change decreases the need to document. C. Critical changes are less likely to occur with constant observation. D. Systematic observation makes it less likely the nurse will miss an assessment area.

D

The nurse and other hospital personnel strive to keep the patient care area clean. The theory of which nursing theorist most directly illustrates these ideas? A. Virginia Henderson B. Imogene Rigdon C. Katharine Kolcaba D. Florence Nightingale

D

The nurse is administering pain medication to an assigned patient every 4 hours as prescribed and based on patient-stated pain levels. The nurse's actions are an example of which aspect of patient care? A. Assessment data B. Nursing diagnosis C. Patient outcome D. Nursing intervention

D

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that they have persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?" A. Comprehensive assessment B. Ongoing focused assessment C. Special needs assessment D. Initial focus assessment

D

The nurse is providing care for a patient originating from a country in the Middle East. The patient has a nasogastric (NG) tube for stomach decompression for a blocked bowel. Which statement by the nurse indicates use of the theory developed by Madeleine Leininger when the patient asks if a family member can bring in garlic to be administered through the NG tube? A. "I think the administration of garlic will cause gastric upset." B. "I am sure the physician would not be in favor of allowing this." C. "Let's give the physician's medical treatment a chance to work first." D. "Please explain the association between garlic and your condition."

D

The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning? A. A postpartum patient after the birth to her second child, who lives with her spouse and 18-month-old daughter B. A patient who is readmitted for exacerbation of chronic obstructive pulmonary disease (COPD) C. A patient who is 12 years of age being discharged home with a parent after outpatient surgery D. An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis

D

The nurse understands that the most important reason for the development of a definition for the profession of nursing is that it: A. Will result in more informed people being recruited as nurses. B. Is a means for evaluating the degree of role satisfaction in nurses. C. Helps dispel the stereotypical images about nurses and nursing. D. Differentiates the nursing role from those of other health professionals.

D

Which is the best description of the nursing process? A. A way to create nursing knowledge for use in practice B. A systematic view of a specific phenomenon in nursing C. A linear process for providing nursing care D. A systematic process for the delivery of nursing care

D

Which member of the healthcare team typically serves as the case manager? A. Social worker B. Physician C. Physician's assistant D. Registered nurse

D

A nurse makes a nursing diagnosis of acute pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write? A. Collaborative B. Interdependent C. Dependent D. Independent

D Independent nursing interventions do not require a physican's order.

During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information? A. To determine what type of therapies are acceptable to the client B. To identify whether the client has a nutritional deficiency C. To help the nurse understand the client's cultural and spiritual beliefs D. To be aware of potential interaction with prescribed medication

D Physical assessment and labs are needed to assess nutritional deficiency.

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction? A. "My patient is a young adult, so I plan to talk to them without their parents in the room." B. "Because my patient is old enough to be my grandfather, I will address him with Mr." C. "When reading my patient's health record, I thought of a few questions to ask." D. "When I give my patient their pain medication, I will have time to ask questions."

D Reading patient's health record does not require further instruction. Giving pain meds first will help calm patient before interviewing.

Which is the best example of a well-written nursing order? A. Provide emotional support to the patient and family, as needed. B. Assist with the performance of personal hygiene, if necessary. C. Follow the prescribed fluid restriction of 1,500 mL per day. D. Insert urinary catheter if the patient has not voided within 8 hours.

D Well written nursing orders include data, subject, action verb, time and limits, and a signature.

____________________ is a health program, administered by the state and funded by federal and state governments, to provide care for low-income people.

Medicaid

____________________ is a federal insurance program designed to fund healthcare for people age 65 years and older, persons with disabilities, and those with end-stage renal disease.

Medicare