Textbook questions for test 1

A nurse is caring for a patient with a painful, non-healing surgical wound. The patient does not request pain medication because they do not want to be a burden. What actions will the nurse implement to improve pain relief? Select all that apply. Reestablishing the pain level the patient finds acceptable as the pain management goal Obtaining a dry-erase board to remind the patient of the plan of care Assessing the patient's pain and offering analgesia during hourly rounding Placing the analgesic underneath other medications and quickly handing it to the patient Asking the family members to speak to the patient about pain relief

A, B, C. The nurse reassesses the patient's knowledge and acceptance of the plan of care, including the level of pain the patient finds acceptable. Using a dry-erase board and hourly rounding further communicate and reinforce the care plan. The nurse develops a compassionate and trusting relationship with the patient; the nurse and patient mutually determine the plan for pain management, not their family.

Nursing programs prepare students for safe clinical practice. As a student nurse, why is a basic understanding of NCSBN's Clinical Judgment Measurement Model (CJMM) important? Select all that apply. Successful completion of the NCLEX is required for professional licensure in the United States. Nurse educators use the CJMM model and NCLEX test plans to develop exam questions. Students should be intimately familiar with theoretical models of education to answer questions. Appreciation of the core principles assists students in understanding the structure and intent of nursing exams. There is overlap in the core components of clinical judgment models, measurement models, and the nursing process.

A, B, D, E. Nurses in the United States must pass NCLEX prior to being issued a license to practice as a professional nurse. To help students achieve this goal, nurse educators model course exams on the NCSBN's NCLEX test plan in terms of content and style. Understanding the why (rationale for actions) is often helpful when students are engaged in studying, working to apply the information they have learned, and developing test-taking strategies. There is overlap between the models and processes identified as foundational to nursing education, which demonstrates the importance of fundamental concepts. A deep understanding of theoretical and philosophical models is not necessary for student nurses.

Nursing students enrolled in a medical-surgical nursing course are learning about infection control measures. They have learned that nurses use droplet precautions for patients with which infections? Select all that apply. A. Rubella B. Herpes simplex C. Varicella D. Tuberculosis E. MRSA F. Adenovirus

A, B, F. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-droplet particles; droplet precautions and standard precautions are indicated. Airborne precautions refer to small, infectious particles spread through the air; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

The nurse collects subjective and objective data during a patient assessment. When documenting, which data points will the nurse include as subjective data? Select all that apply. A. Feeling nauseated B. Edematous ankles C. Feeling anxious about test results D. Report of left arm tingling E. Pain rated 7 on a scale of 1 to 10 F. Oral temperature of 101°F

A, C, D, E. Subjective data are information perceived only by the affected person. Examples of subjective data are feeling nauseated, anxious, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Examples of objective data are fever or 101°F or edema.

A nursing unit has multiple patients with MRSA infections requiring contact isolation. In which situations is it appropriate for the nurses to use an alcohol-based hand sanitizer to decontaminate their hands? Select all that apply. A. Before providing a bed bath B. Having visibly soiled hands after patient contact C. Removing gloves after patient care D. Inserting a urinary catheter E. Assisting with a surgical placement of a cardiac stent F. Removing old magazines from a patient's table

A, C, D, F. An alcohol-based handrub is used in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices not requiring surgical placement; before donning sterile gloves prior to an invasive procedure; when moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. It is essential to note that handrubs are not appropriate for use after caring for a patient with C. diff infection.

The nurse assessing a patient plans to use the OLD CARTS mnemonic to organize their questions. What questions will the nurse include in the assessment? Select all that apply. A. "Can you tell me when the problem began"? B. "Where were you sitting when this started?" C. "Have your symptoms stopped and/or started again?" D. "Would you describe your pain as sharp, dull or burning?" E. "What do you believe has caused this problem?"

A, C, D. The nurse uses Maslow's hierarchy of needs to prioritize assessing the patient with hypoxemia, manifested by a pulse oximetry reading of 89%. The postoperative patient is reporting moderate pain; the patient with pneumonia has normal WBCs; the adolescent patient with a burn to the face is stable for discharge. These patients can be seen as soon as possible.

A nurse has finished providing care for a patient in contact isolation for a MRSA infection. Place the steps the nurse should follow to remove PPE in the correct order. A. Untie gown at the front waist B. Remove mask C. Remove gloves D. Remove gown E. Remove goggles

A, C, E, D, B. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask. Hands should be washed thoroughly after the equipment has been removed and before leaving the room.

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

A, C, E. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for confidentiality of care with transparency for the patient and designated individuals, rather than secrecy is used.

During orientation to the critical care unit, a nurse learns that staff follow existing clinical practice guidelines, also called standards, for patient care. Which activities does the nurse expect to be included in these guidelines? Select all that apply. Monitoring vital signs and pulse oximetry every hour Using intuition to troubleshoot patient problems Repositioning a patient on bed rest every 2 hours Becoming a nurse mentor to a student nurse Administering pain medication prescribed by the health care provider Becoming involved in community nursing events

A, C, E. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, repositioning a patient on bed rest every 2 hours, and administering pain medication prescribed by the health care provider. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not included in patient care standards.

Nurses on an oncology unit plan to adopt use of critical pathways for patients receiving chemotherapy. What positive features of this system will the nurses anticipate? Select all that apply. Accessible computerized practice standards, easily individualized for patients Binary decision tree for stepwise assessment and intervention Ability to measures the cause-and-effect relationship between pathway and patient outcomes Research-based practice recommendations that may or may not have been tested in clinical practice Preprinted provider prescriptions, using standards validated through research, to streamline care Outcomes with suggested time frames for achievement

A, C, F. Critical pathways represent a sequential, interdisciplinary, minimal practice standard for a specific patient population, that provide flexibility to alter care to meet individualized patient needs. They provide the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

During a nursing staff meeting to discuss delayed documentation, the nurses unanimously agree that they will ensure all vital signs are reported and charted within 15 minutes following assessments. This decision is consistent with which characteristics of effective communication? Select all that apply. A. Group decision making B. Group leadership C. Group power D. Group identity E. Group patterns of interaction F. Group cohesiveness

A, D, E, F. Solving problems involves group decision making; ascertaining the task is important and agreeing to complete the task on time is characteristic of group identity. Group patterns of interaction involve honest communication and member support; cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and appropriately used to accomplish group outcomes.

A nurse is caring for a group of patients. Which actions are appropriate to include in the implementation phase of care? Select all that apply. Changing the dressings on a burn victim's arm Assessing a patient's nutritional intake Formulating a nursing diagnosis for a patient with epilepsy Turning a patient in bed every 2 hours to prevent pressure injuries Checking a patient's insurance coverage at the initial interview Determining availability of community resources for a patient with dementia

A, D, F. During the implementing step of the nursing process, nursing actions that were formulated during the planning process are carried out. The purpose of the implementation phase is to assist the patient in achieving valued health outcomes, for example promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient's nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing/analyzing step.

When performing a dressing change requiring surgical asepsis, a nurse opens sterile supplies and dons sterile gloves. What additional action by the nurse is appropriate? A. Avoiding splashing while pouring irrigant onto the sterile field B. Covering the nose and mouth with gloved hands if a sneeze is imminent C. Using forceps soaked in a disinfectant to place dressings on the sterile field D. Considering the outer 1 inch of the sterile field sterile

A, D. Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

The nurse is admitting a pregnant patient to the hospital for treatment of pregnancy-induced hypertension. The patient asks the nurse, "Why are you doing a history and physical exam when the doctor just did one?" What statements will the nurse use to explain the primary purpose of the nursing assessment? Select all that apply. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." "It's hospital policy. I know we ask a lot of questions, but I will try to make this quick." "As a nursing student, I need to develop assessment skills about your health status and need for nursing care." "This validates that your responses with the medical exam are consistent and that all our data are accurate." "I will check your health status and see what kind of nursing care you may need." "This is to determine the necessity for referring

A, E, F. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to actual and potential health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage their own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the finding(s) to the health care provider or collaborate with other health care professionals where indicated. Citing hospital policy or student learning is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the main reason for a nursing history and assessment. The assessment augments the medical examination but is not performed to check its accuracy.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and grunting sounds. Based on these nonverbal cues, what action will the nurse take next? A. Assess for pain and the need for analgesia. B. Ask the patient if they feel anxious. C. Offer to sit with the patient and listen to their feelings. D. Suggest the patient increase their fluid intake to prevent constipation.

A. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and grunting sounds is most likely communicating pain. The nurse should clarify this nonverbal behavior.

A school nurse determines that a student who has lost weight is at risk for an eating disorder and would benefit from a nutritional assessment. What action will the nurse take? A. Perform a focused nutritional assessment B. Seek direction from the student's health care provider C. Suggest the student visit the nurse-run clinic D. Request a consultation with a nutritionist

A. A school nurse determines that a student who has lost weight is at risk for an eating disorder and would benefit from a nutritional assessment. What action will the nurse take? Perform a focused nutritional assessment Seek direction from the student's health care provider Suggest the student visit the nurse-run clinic Request a consultation with a nutritionist

A nursing student obtains a blood pressure reading of 148/100. To determine the significance of this reading, what action will the nurse take first? A. Comparing this reading to standards and trends in the medical record B. Checking the taxonomy of nursing diagnoses for a pertinent label C. Checking a medical text for the signs and symptoms of high blood pressure D. Consulting with experienced nurse colleagues

A. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared within the same class or category. When interpreting the significance of a patient's blood pressure reading, the nurse uses normative values for the patient's age group, race, and illness category and compares these to the patient's recent results. Identifying the reason for deviation from a norm gives direction to the etiology of a health problem (e.g., insufficient knowledge, nutrition, stress, and coping, or other).

A nursing unit has adopted use of a care bundle for insertion of central venous catheters. During the procedure, which action by a nurse requires the charge nurse to intervene? A. They discard the sterile drapes in the insertion kit. B. The primary nurse reminds everyone in the room to wear a mask. C. The team includes every item in the bundle during the procedure. D. The nursing student states using the bundle improves patient outcomes.

A. Care bundles are sets of evidence-based interventions that, when performed together and consistently, improve the process of care and patient outcomes. Discarding sterile drapes from the insertion kit circumvents this process.

A nurse writes the outcome for a patient who is trying to lose weight: "The patient will explain the relationship between weight loss, increased exercise, and decreased calorie intake." This outcome reflects which domain of learning? A. Cognitive B. Psychomotor C. Affective D. Physical changes

A. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nursing student tells the primary nurse that their patient has not had a bowel movement for 2 days and suggests adding the health problem "Constipation" to the care plan. How would the nurse best respond? A. "Did you assess the patient's usual bowel patterns and appearance of the last stool?" B. "This early diagnosis will help us manage the problem before it becomes severe." C. "Have you determined if this is an actual or a possible diagnosis?" D. "This condition requires a medical diagnosis."

A. Patient health problems are derived from clusters of related data and patterns, rather than a single cue. The nurse determines if this is the patient's usual bowel pattern, or whether an underlying reason exists for the lack of a bowel movement. Constipation is a health problem the nurse can resolve with independent or interdependent nursing actions.

A nurse works in a long-term care facility where standing orders are in place for influenza vaccines for all residents. What is the nurse's priority, when carrying out the prescriptions? A. Assessing whether the patient previously received the vaccine B. Refusing to give the vaccine without a written prescription C. Determining if the standing orders are inappropriate for their unit D. Calling the nursing supervisor to determine if this is a permitted action

A. Standard orders empower the nurse to initiate actions ordinarily requiring the order, prescription or supervision of a health care provider. The nurse first assesses whether the patient has already received the vaccine. The standing order is a valid prescription given to cover common, recurring actions the nurse can use when indicated.

The charge nurse tells a nursing student to change a surgical dressing while they take care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What action should the student take? Tell the charge nurse that they lack the technical competencies to change the dressing independently Assemble the equipment for the procedure and follow the steps in the procedure manual Ask another student nurse to work collaboratively with them to change the dressing Tell the clinical instructor they have not had experience with the delegated task

A. Student nurses should notify their nursing instructor or nurse preceptor if they believe they lack any competencies needed to safely implement the care plan. Once educated and technically prepared, the nursing student may perform a dressing change.

The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene? A. "I am sure everything will be fine; you have nothing to worry about." B. "When you return from surgery, you'll need to cough and deep breathe." C. "Many people on this unit have had that procedure with good success." D. "You seem fearful, can I answer any questions about the procedure?"

A. Telling a patient that everything will be fine is a cliché. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.

A student nurse walks into a patient room, introduces themselves, and begins to complete a full head-to-toe assessment. The clinical faculty member enters the room, introduces themselves, and asks the student to step out of the room for a moment. The student meets the faculty member in the hallway and is asked to identify 15 cues or observations they noted during their initial contact with the patient and the patient's environment. Although the student is unable to reach 15 observations, the faculty guides the student to recognize the linen on the floor, old dinner tray on the windowsill, empty water pitcher, twisted oxygen tubing, the patient's pallor, and several other things requiring action. What is the value of engaging in this kind of activity with students in the clinical setting? Developing situational awareness is important to risk prevention, timely implementation of interventions, and prioritizing acti

A. The case represents a concrete example of how students develop situational awareness and how that awareness develops with experience. Cognitive load management occurs in many ways; the use of mental images may not facilitate cognitive load management. Although an environmental scan is important, it is generally not documented in the EHR. Patient satisfaction is not the priority when completing the initial assessment; rapport formation, solid assessments, and good patient outcomes are associated with patient satisfaction.

A nursing student tells the clinical instructor that their patient is fine and has "no complaints." Which question by the faculty coaches the student to provide evidence that supports their assessments? A. "Could you tell me how you validated this?" B. "Do you think your patient feels free to share their concerns?" C. "That's good to hear. Tell me about the care you provided." D. "Please reassess the patient; they were admitted with a serious problem."

A. The instructor is reminding the student that all data must be validated. Questioning the use of the word "fine" allows the nurse to determine if this is a social and reflexive response, and there may be another need the nurse can meet. Concluding that the patient does not trust the student is premature and is based on an invalidated inference. Saying "That's good to hear" and asking the student to describe the care provided is incorrect because it accepts the invalidated inference. Telling the student to reassess the patient because they were admitted with a serious problem is incorrect because it is possible that the condition is resolving.

A public health nurse is leaving the home of a young mother who has an infant with special needs. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response? A. "New mothers need support." B. "The lack of a father is difficult." C. "How are you today?" D. "It is a very sad situation."

A. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. "How are you today?" is dismissive of the neighbor's question.

A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship? A. "Let's review the progress you've made in meeting your goals." B. "I'd like to review your medication schedule with you." C. "I need to document today's teaching session in the electronic health record." D. "Should we include your family in today's session?"

A. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed.

A nurse is caring for a patient who presents with dyspnea, tachypnea, productive cough, fever, and low oxygen saturation. When developing the nursing care plan, which health problems might the nurse identify for this patient? Select all that apply. A. Bronchial pneumonia B. Impaired gas exchange C. Impaired Respiratory System Function D. Altered breathing pattern E. Impaired Thermoregulation

B, C, D, E. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent or interdependent nursing interventions. These include Impaired gas exchange, supported by low oxygen saturation; Impaired Respiratory System Function; Altered breathing pattern, supported by dyspnea and tachypnea; and Impaired Thermoregulation. Pneumonia is a medical diagnosis.

The nurse on a medical-surgical unit is admitting a patient with a diagnosis of active tuberculosis. Which infection control precautions will the nurse put in place? A. Wearing sterile gloves for patients with visible body fluids B. Placing the patient on airborne precautions C. Wearing an N95 respirator mask when in the room D. Placing the patient in a single-occupancy room E. Ensuring the room provides positive pressure F. Restricting visitors for the duration of the patient's stay

B, C, D. Airborne precautions are used for patients who have infections with small particles that spread through the air, for example, tuberculosis, varicella, and rubeola. An N95 respirator mask is worn and the patient placed in a private room, preferably with negative air pressure. Sterile gloves are used for procedures requiring surgical asepsis. Standard precautions are for all patient care when contact with blood or body fluids, nonintact skin, and mucous membranes are likely. Visitors must wear PPE, including a mask.

A nurse is planning care for a patient admitted to the hospital for treatment of a drug overdose. What actions will the nurse take during the outcome identification and planning step of the nursing process? Select all that apply. A. Formulating nursing diagnoses B. Identifying expected patient outcomes C. Selecting evidence-based nursing interventions D. Explaining the nursing care plan to the patient E. Assessing the patient's mental status F. Evaluating the patient's outcome achievement

B, C, D. During the outcome identification and planning step of the nursing process, the nurse, patient, and family collaborate to establish priorities and identify and write expected patient outcomes. The nurse selects evidence-based nursing interventions, and communicates the care plan. These steps may overlap; however, formulating and validating nursing diagnoses are typically performed during the diagnosing step. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

An RN working on a hospital unit frequently delegates patient care to assistive personnel (AP). Which activities are appropriate for the nurse to safely delegate? Select all that apply. A. Performing patient assessments B. Making patient beds C. Giving patients bed baths D. Administering oral medications E. Ambulating patients F. Assisting patients with meals

B, C, E, F. AP assist the RN to provide care as delegated by and under their supervision. Typical tasks delegated include actions for stable patients (e.g., vital signs hygiene, bed-making, ambulating patients, and helping to feed patients). Performing the initial patient assessment and administering medications are the responsibility of the RN.

During morning huddle, a nurse manager and some nurses are identifying patients on the unit who are at risk for hospital-acquired infections (HAIs). Which patients will the nurses identify? Select all that apply. A. Smoker, two packs of cigarettes daily B. White blood cell count of 2,000/mm3 C. Indwelling urinary catheter in place D. Vegetarian and slightly underweight E. Central venous catheter present F. Postoperative colostomy

B, C, E, F. Leukopenia (low white blood cell count), indwelling urinary catheters, central venous catheters, and surgeries in which the wound is classified as dirty have been implicated in most HAIs. Cigarette smoking and a vegetarian diet have not been implicated as risk factors for HAIs.

A nurse on a mother-baby unit engages in informal planning while providing ongoing nursing care. What actions are included in this type of planning? Select all that apply. Sitting down with a patient and prioritizing existing diagnoses Assessing a woman for postpartum depression during patient education Planning interventions for a patient with a risk for bleeding Taking time to speak with a new mother who just received bad news Reassessing a patient who reports their pain medication is not working Coordinating home care for a patient being discharged later today

B, D, E. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response, often while rearranging priorities. Examples of this include the nurse integrating assessment for postpartum depression during patient care, providing a therapeutic presence for a patient who received bad news, or reassessing a patient for pain during rounding. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A registered nurse is formulating nursing diagnoses for a patient with multiple fractures. Which actions does the nurse take during this step of the nursing process? Select all that apply. A. Conducting a nursing interview to collect patient data B. Analyzing data collected in the nursing assessment C. Developing a care plan for the patient D. Pointing out the patient's strengths E. Assessing the patient's mental status F. Identifying community resources to help the family cope

B, D, F. Diagnosing includes identifying actual or potential health problems for individuals, groups, or communities; identifying factors that contribute to or cause health problems (etiologies); and identifying resources or strengths the individual, group, or community can draw on to prevent or resolve problems. The nurse assesses and collects patient data in the assessment step and develops the care plan during the planning phase of the nursing process.

A nursing student is performing hand hygiene after providing care to a patient who is in isolation for C. diff related to antibiotic therapy. Which actions by the nursing student will the primary nurse need to correct? Select all that apply. Removing all jewelry including a platinum wedding band Decontaminating the hands with an alcohol-based hand sanitizer Using approximately 1 teaspoon of liquid soap Keeping hands higher than elbows when placing under the faucet Using friction motion when washing for at least 20 seconds Rinsing thoroughly with water flowing toward the fingertips

B, D. After caring for patients with C. diff infection, proper handwashing includes using soap and water, then rinsing thoroughly with water flowing toward fingertips. Proper hand hygiene permits a plain wedding band to be worn; other jewelry is removed. The nurse uses about 1 teaspoon (5 mL) of liquid soap, using friction motion for at least 20 seconds, washing to 1 inch above the wrists using friction.

A nurse is updating the plan of care with nurse-initiated interventions. Which intervention is appropriate to include? A. Administering acetaminophen for a headache B. Offering emotional support to a patient C. Consulting with a physical therapist D. Attending a team meeting for care planning

B. A nurse-initiated intervention is related to the nursing diagnosis and projected outcome. It is an autonomous action based on scientific rationale. The physician or health care provider uses a physician-initiated interventions or order in response to the medical diagnosis: nurses execute these interventions safely and effectively. Collaborative interventions are initiated by other providers including pharmacists, respiratory therapists, or physician assistants.

When developing the admission care plan for a patient with multiple sclerosis and quadriplegia, the nurse formulates the patient problem: Impaired Tissue Integrity: Impaired Skin Integrity. What action will the nurse take next? A. Elevate the patient's heels off the bed using a pillow B. Develop a goal that the patient will consume protein at each meal C. Delegate assessment of the skin on the patient's back to the AP D. Teach the patient to turn themselves in bed every hour

B. After the health problem is developed, the nurse begins the planning phase of the nursing process, which includes goal development. Elevating the heels and teaching the patient to turn are interventions used during the implementation phase. Delegating an assessment to the AP is an incorrect activity; assessment falls within the role and scope of practice of the professional nurse. In addition, the nurse must perform the skin assessment to develop the problem and plan care.

To plan the day, a nurse is prioritizing patient diagnoses according to Maslow's hierarchy of human needs. What patient problem will the nurse address first? A. Altered body image perception B. Impaired gas exchange C. Grief D. Situational low self-esteem

B. Because basic needs must be met before a person can focus on higher ones, Maslow's hierarchy of needs sets the priorities as: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. Answer (b) is an example of a physiologic need, (a and d) are examples of a self-esteem need, and (c) is an example of a love and belonging need.

A nurse enters the patient's room to perform pin-site care for a patient wearing a halo vest to stabilize the cervical spine. What action will the nurse take first? A. Administer pain medication B. Reassess the patient C. Prepare the equipment D. Explain the procedure to the patient

B. Before implementing any nursing action, the nurse returns to the first step of the nursing process, reassessing whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

A nurse is developing a clinical outcome for a patient who is an avid runner and is recovering from a stroke resulting in right-sided paresis. Which clinical outcome is most appropriate to include in the care plan? After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/25, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/25, patient will verbalize feeling sufficiently prepared to participate in running events.

B. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

An outbreak of measles has occurred at the local elementary school. The parents of a child in the prodromal phase of the illness are told the child should stay home until well. What is important for the nurse to teach the parents about the prodromal phase? The organisms enter the body and multiply while the patient is asymptomatic. A person typically has vague, nonspecific symptoms and is highly contagious. The presence of infection-specific signs and symptoms develop, manifesting as local or systemic responses. The signs and symptoms of the illness disappear, and the person returns to their preillness state.

B. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and symptoms are more specific and apparent during the full stage of illness, disappearing in the convalescent period.

A nurse says to their nurse manager, "I need the day off, and you didn't give it to me!" The manager replies, "I wasn't aware you needed the day off, and it isn't possible since staffing is inadequate." How could the nurse best modify the communication for a more positive interaction? "I placed a request to have 8th of August off for a doctor's appointment, but I'm scheduled to work." "Could I make an appointment to discuss my schedule with you? I requested the 8th of August off for a doctor's appointment." "I will need to call in on the 8th of August because I have a doctor's appointment." "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B. Effective communication involves sending clear, nonthreatening, and respectful information to the receiver. The nurse identifies the subject of the meeting and determines a mutually agreed upon time.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" and, "What do you do to keep yourself healthy?" These questions reflect what model for organizing data? A. Maslow's hierarchy of needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

B. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A nursing student is performing a nursing history for the first time. The student asks the primary nurse how anyone learns all the questions needed to get complete baseline data. What would be the nurse's best reply? "There's a lot to learn at first, but once it becomes part of you, you just ask the same questions over and over in each situation until you can do it in your sleep!" "You make the basic questions a part of you and apply critical thinking to modify them, to help you plan quality care." "It is really hard to learn how to do this well, as each history is different. I often feel like I'm starting fresh with each new patient." "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B. Once a nurse learns what constitutes the minimum data set, it can be adapted to each patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice individualize their questions to each patient and situation. When using a standard facility assessment tool the nurse must still use critical thinking to individualize questions or follow up on patient information.

As part of a hospital-wide quality-assurance program, an electronic medical record review for the last 6 months reveals a higher incidence of falls on a specific unit. The nurse authoring the study refers to the review as what type of evaluation? A. Quality by inspection B. Retrospective evaluation C. Concurrent study D. Quality by indicator

B. Quality by inspection focuses on finding deficient workers and removing them. Concurrent evaluation uses direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met. Retrospective evaluation may use post discharge questionnaires, patient interviews (by telephone or face to face), or chart review (nursing audit) to collect data. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment thriving on teamwork, with people sharing the skills and lessons they have learned.

Nurses note that allowing patients to choose the time of their breakfast to improve patient satisfaction has resulted in medication delays for patients who have prescriptions for medications taken on an empty stomach. Which action will direct the nurses to the best outcome? Asking the pharmacy to dispense the medication at bedtime Suggesting a quality improvement project piloting a 6:00 AM administration Requesting that the health care provider prescribe the medication for midnight Telling the nurse manager that patients are getting their medications late

B. Quality improvement or continuous quality improvement involves systematic, continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. Quality-assurance programs enable nursing to be accountable for the quality of nursing care. Making changes without gathering needed data may prove unsafe or a waste of time. Reporting to the nurse manager does not reflect professional commitment to improving processes.

A nursing program uses Tanner's Clinical Judgment Model, a research-based model that accounts for differences in the patient, environment, and individual student nurse. What makes Tanner's reflection step unique? The emphasis is on noticing, interpreting, and responding; reflection is less important. Reflection occurs both in-action (in the moment) and on-action (after the situation). Reflection occurs first in the model that is focused on rapid decision making and patient outcomes. Reflection is the last step in a linear model and is designed to minimize bias in the student nurse.

B. Reflection drives the clinical judgment cycle and allows for the integration of new knowledge that will inform future situations. Reflection is as important in Tanner's model as the other elements of noticing, interpreting, and responding. The focus of the model is the development of clinical judgment, rather than rapid decision making; as clinical judgment is developed, decision making improves and may lead to better patient outcomes. Tanner's model is cyclic, not linear; although bias may be addressed as part of the development of clinical judgment, it is not the focus.

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

B. The Nursing Interventions Classification (NIC) Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

When caring for a patient who sustained a spinal cord injury, the nurse formulates the health problem: Impaired Tissue Integrity Etiology: sensory and motor deficit Signs and symptoms: difficulty turning, reddened areas on heels and sacrum Which phrase gives direction to the underlying cause of the problem? A. Impaired Tissue Integrity B. Sensory and motor deficit C. Signs and symptoms D. Reddened areas of skin on the heels and back

B. The etiology, sensory and motor deficits, identifies the contributing or causative factors of the problem. The problem, "Impaired Tissue Integrity: Impaired Skin Integrity," states the undesirable health condition, life processes, or human response. The phrase, "Signs and symptoms: non-blanchable reddened areas on heels and back," contains the defining characteristics of the problem.

A nurse notices a patient crying after meeting with the health care provider. Prior to formulating a health problem of difficulty coping, the nurse seeks to further support the problem by gathering which data? A. Abnormal vital signs B. Underlying cause of the tears C. Admitting diagnosis D. Patient's support system

B. The nurse continues gathering data, determining the presence of a problem of grief, impaired coping, etc., by determining the underlying cause of the tears. If the patient received news that a biopsy was free from cancer, perhaps no problem exists. If the patient was told they have a terminal illness, the nurse can continue to gather data and plan to support the patient's physical and emotional needs.

A visiting nurse is following up with a patient who was given a prescription for a diuretic and told to chart her weight daily. The patient's weight has increased 5 lb since the nurse's last visit. What actions will the nurse take first? Explain to the patient that it is clear she is not adhering to her prescription and the health care provider will be notified Document the 5-lb weight gain and ask the patient about sodium intake and medication side effects Terminate the plan of care while determining the cause for the weight gain Encourage the patient to continue the prescription and return in 1 week

B. The nurse documents the goal has not yet been achieved and also suspects the patient has not adhered to the prescription, perhaps due to frequent urination or other side effects. The nurse further assesses the patient's understanding of the medication's purpose and effects, understanding of the disease process and complications.

A nursing student is preparing to administer morning care to a patient. What question by the student is most important to ask? A. "Would you prefer a bath or a shower?" B. "May I help you with a bed bath now or later this morning?" C. "I will be giving you your bath. Do you use soap or shower gel?" D. "I prefer a shower in the evening. When would you like your bath?"

B. The nurse should ask permission to assist the patient with a bath. This allows for patient preferences and consent for care that involves entering the patient's personal space.

A nurse is caring for a patient with dehydration who has a prescription to encourage oral fluids. Which outcome statement will best direct nursing interventions? A. Offer patient 60 mL of fluid every 2 hours while awake. B. During the next 24-hour period, patient's fluid intake will total at least 2,000 mL. C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/25. D. At the next visit on 12/23/24, patient will know to drink at least 3 L of water per day.

B. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/25." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

A nurse is writing outcomes for a patient admitted with a cardiac condition causing fluid overload and edema. Which reflects an appropriately worded outcome? A. Offer to elevate the patient's legs on a stool while out of bed B. Patient will restrict fluids to 1,500 mL per 24-hour period C. Monitor the patient's intake and output D. Weigh the patient each morning prior to breakfast

B. The terms goal, objective, and outcome are often used interchangeably to refer to the expected conclusion to the patient's health problem or expectation. Nurses use the phrase expected outcomes to refer to the more specific, observable, and measurable changes. Options a, c, and d are stated as interventions, rather than outcomes.

The nurse manager of a unit with an excellent safety record meets with staff to present the findings of a recent audit. The manager states, "We're doing well, but I believe we can do better. Who's got an idea to foster increased patient well-being and satisfaction?" This leader has demonstrated they value which process? A. Quality assurance B. Quality improvement C. Process evaluation D. Outcome evaluation

B. Unlike quality assurance, quality improvement (QI) is internally driven. QI focuses on patient care rather than organizational structure and processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

A nurse administering an injection to a patient who tested positive for HIV sustains a needlestick. What action should the nurse take first? A. Report the incident to the nurse manager and file an injury report B. Wash the exposed area with warm water and soap C. Consent to postexposure prophylaxis (PEP) at the appropriate time D. Set up counseling sessions regarding safe practice to protect self

B. When a needlestick injury occurs, the nurse should wash the affected area immediately with warm water and soap, report the incident to the nurse manager or appropriate person and complete an injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others.

After assessing a patient recovering from a stroke in a rehabilitation facility, the nurse's initial analysis suggests a potential health problem of situational low self-esteem. How will the nurse record the problem when they believe more data are needed? A. No problem B. Possible problem C. Actual nursing diagnosis D. Clinical problem other than nursing

B. When a possible problem exists, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion, "no problem," indicates no nursing response is required. When an actual problem is identified, the nurse continues using the steps of the nursing process by planning, goal setting, implementing, and evaluating care to resolve the problem. A clinical problem other than nursing diagnosis requires a collaborative approach with the appropriate health care professionals.

During a change-of-shift report, a nurse receives information that a patient admitted with hypertensive emergency has prescriptions for antihypertensive medications given at 8 AM and due at 8 PM. During the 8:00 PM assessment, the patient's blood pressure is 90/60, and they report slight dizziness upon standing. After returning the patient to bed, what action will the nurse take? Exhibit: Electronic health record, vital signs 8:00 AM 182/100 12:00 PM 168/98 4:00 PM 160/88 Record the BP in the electronic health record Notify the health care provider Administer the 8:00 PM medications Place the patient flat in bed

B. When assessment findings reveal a critical change in the patient's health status, the nurse reports the data (verbally) immediately. The nurse verifies the BP and notifies the health care provider, who may prescribe withholding blood pressure medications, assessment of orthostatic vital signs, among other actions. There is no indication the patient needs to lie flat at this time.

During an assessment, the nurse on a neurologic unit finds the patient confused to time and place but able to state their name. How will the nurse best record this in the electronic health record? A. Is more confused than yesterday B. States the year is 1975 and they are at a wedding C. Disoriented to person, time, and place D. Patient's speech is garbled

B. While the patient is confused, it is most important to clearly describe the behavior for comparison to past and future behavior. Citing the actual year and events (orientation to time and place) provides context; "patient confused" is open to misinterpretation. Garbled speech refers to speech that is unclear; the patient may have difficulty with pronunciation or speak slowly, which is not necessarily reflective of confusion.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after hearing the plan of care. How does the nurse best respond? Select all that apply. Fill the silence with lighter conversation directed at the patient. Use the time to perform the care that is needed uninterrupted. Discuss the silence with the patient to ascertain its meaning. Allow the patient time to think and explore inner thoughts. Determine if the patient's culture requires pauses between conversation. Arrange for a counselor to help the patient cope with emotional issues.

C, D, E. Appropriate use of silence allows the patient to initiate or to continue speaking; the nurse can reflect on what has been shared while observing the patient without having to concentrate simultaneously on conversation. In due time, the nurse might discuss the meaning of silence with the patient. The nurse considers whether the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to excessive talking by the nurse, displacing focus from the patient. The nurse should not assume silence requires a consult with a counselor.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which reflect these types of actions? Select all that apply. Administering an antibiotic to a patient with pneumonia Consulting with a psychiatrist for a patient who misuses opiates Checking the skin of bedridden patients for skin breakdown Ordering a kosher meal for an orthodox Jewish patient Recording a patient's intake and output Preparing a patient for surgery according to facility protocol

C, D, F. Nurse-initiated interventions, or independent nursing actions, include nurse-prescribed interventions resulting from their assessment of patient's actual or potential health problems. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A nursing student is presenting their concept map care plan for a patient with sickle cell anemia in post-conference. How does the student best describe the "concepts" that are being diagrammed in the plan? A. Protocols for treating the patient's medical problem B. Evidence-based treatment guidelines C. Synthesis of the patient's problems and treatment Clinical pathways reflecting evidence-based treatment for sickle cell D. anemia

C. A concept map care plan is a diagram synthesizing patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and provide a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

A nurse is changing a patient's bed linens after drainage from an infected abdominal wound leaked. Which nursing action reflects proper use of medical asepsis? A. Carrying soiled bed linens close to the body to prevent spreading microorganisms into the air B. Placing soiled bed linens and hospital gowns on the floor when making the bed C. Moving the patient table away from the body when wiping it off D. Cleaning the most soiled items at the bedside first, followed by cleaner items

C. According to the principles of medical asepsis, the nurse should move equipment and soiled items away from the body to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first, then move to the more soiled ones to prevent contamination.

A nurse is writing nursing outcomes in the affective domain for a patient who is trying to stop smoking. Which outcome statement will the nurse include in the care plan? "The patient will state the relationship between smoking and coronary artery disease." "After the teaching session, the patient will redemonstrate the proper application of a nicotine patch." "The patient will state they value a healthy body sufficiently to stop smoking prior to discharge." "The patient will state that any changes in cough should be reported to the health care provider"

C. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nurse has performed an admission assessment on a patient. What step does the nurse perform after clustering the data? A. Developing interventions B. Nursing judgments C. Diagnosing and analyzing D. Concept mapping

C. After clustering the data, the nurse analyzes the data and formulates a nursing diagnosis. Interventions are based on and developed after goal setting. Nursing judgments are outcomes based on critical thinking and clinical reasoning. A concept map is a diagram or pictorial representation of the (student) nurse's understanding of the interactions and relationships of the patient's problems and plan of care.

A nursing student is nervous and concerned about working at a clinical facility. Which action would best decrease anxiety and help ensure successful delivery of patient care? A. Determining the established goals of the institution B. Ensuring that verbal and nonverbal communication is congruent C. Engaging in self-talk to plan the day and decrease fear D. Speaking with fellow colleagues about how they feel

C. By engaging in positive self-talk, or intrapersonal communication, the nursing student can plan the day, decrease fear and anxiety, and enhance clinical performance.

A nurse in the emergency department is assessing a young adult who has cognitive disability and is reporting severe abdominal pain. The patient is accompanied by the director of the group home where they live. When collecting data from this patient, which action reflects best practice? Ask the assessment questions of the director. Wait for the young adult's parents to arrive before performing the assessment. Ask the young adult questions and validate with the adult present. Perform the physical assessment, then the intake interview when the family arrives.

C. Children and people with decreased mental capacity or impaired verbal ability should be encouraged to respond to interview questions as best as they can. This communicates support of the patient's autonomy, expression of their needs, and respect for their abilities. The information is then validated with family members or guardians as appropriate.

The nurse on a medical-surgical unit attends a class on the seven crucial conversations in health care. After observing a colleague administer an incorrect dose of medication without reporting it, which action will the nurse take? Speak to the nurse privately and tell her if she does not complete an event report, you will report her to the unit manager Tell the nurse you overheard her discussing giving too much medication, and she must complete an event report or you will Explain that you are aware of the medication incident, and you can assist her in notifying the health care provider for patient safety Give the nurse a copy of the handout from the class and explain that this class in crucial conversations was very helpful

C. Crucial Conversations for Healthcare, addresses "undiscussable" communication breakdowns and gaps that can result in patient harm, medical errors, and staff turnover. When nurses feel unsafe to report problems or are not heard, dangerous shortcuts, incompetence, and disrespect may ensue. Threatening the nurse with reporting them is unprofessional and inconsistent with the crucial conversations. Providing a handout is passive aggressive and does not clearly relate the medication error to this concept.

The development of clinical judgment requires intentional focus and a willingness to grow and change both personally and professionally. How can a nursing student best foster the development of clinical judgment? Engaging in learning that only appeals to their preferred learning style Focusing on knowledge acquisition that is straightforward and clear Developing a model for learning that integrates feedback and reflection Focusing inward to develop emotional intelligence and communication skills

C. Each nursing student is in charge of their learning, including integrating feedback from exams, clinical experiences, simulations, and other assignments—reflecting on what has been learned and integrating new learning. Adaptability is key. Classroom and clinical learning presents information in myriad ways and in different settings. Students should learn what they can from each situation and adapt their studying style as needed. Nursing knowledge, like patient care, is rarely straightforward and clear. Picking up on cues, emphasizing the correct element, answering the question being asked, and maintaining a person-centered focus that is individualized and nuanced requires practice and time. Students must give themselves the space and grace needed to learn and apply information in various situations. There is a reciprocity in learning that requires and inward and outward combination. Engagement with others and the environment is essential for shaping thinking and development of clinical judgment.

A nurse and health care provider are preparing for insertion of a central venous catheter when the patient accidentally touches the sterile field. What action will the nurse take next? Ask another nurse to hold the patient's hand and continue setting up the field Remove any objects the patient touched and resume setting up the sterile field Have someone hold the patient's hand, discard the supplies, and prepare a new sterile field No action since the patient has touched their own sterile field

C. If a patient touches a sterile field, the nurse should discard all supplies and prepare a new sterile field. If the patient is restless or confused, the nurse obtains an assistant to hold the patient's hands and explain what is happening.

Nurses on a hospital unit work to improve staff communication, as outlined in The Joint Commission's National Patient Safety Goals. What process will best provide for continuity of the plan of care? Checking two patient identifiers, such as name and date of birth, prior to administering medications Ensuring two nurses check doses of high-risk medications such as anticoagulants or insulin Giving handoff report in the patients' rooms to update the next nurse on the plan of care Obtain a patient sitter for a confused individual who has fallen trying to get out of bed

C. One of the published standards and requirements for accreditation and certification required by The Joint Commission is to "improve staff communication." Communicating the plan of care with the patient and oncoming and off going nurses meets this goal. Using patient identifiers relates to the goal of safely identifying patients, checking high-risk medications relates to decreasing medication errors, and obtaining a patient sitter relates to general safety and fall reduction.

Nursing students and those studying other health sciences (medicine, pharmacy, physical therapy, etc.) are often engaged in competency-based education. What is the value of competency-based education? It provides comprehensive skills checklists for students to check their progress and move on to other elements. It allows for student individualization based on their unique experience and preferences. It provides specific guidance on the expected level of performance that integrates knowledge, skills, abilities, and judgment. Like most other education models, it is a high-level way of thinking that is not related to clinical judgment.

C. The definition of a competency included in the Nursing: Scope and Standards of Practice (ANA, 2021) identified includes knowledge, skills, abilities, and judgment. Competency-based education is more than a checklist and often requires repeated exposure to concepts for mastery in a variety of contexts. Although the delivery of education can flex to meet the needs of students, testing is standardized to address core competencies. Competency-based education is very direct and concrete; the development of competence requires clinical judgment.

A nurse is caring for a patient recovering from a stroke that paralyzed the dominant arm. The nursing assistant reports that the patient was unable to bathe, comb their hair, or brush their teeth. Which health problem should the nurse add to the care plan? A. Lack of motivation to complete self-care activities B. Risk for: Activities of Daily Living Deficit C. ADL deficit: impaired dressing and grooming D. Impaired musculoskeletal system function: paralysis

C. The nurse clusters the data that demonstrates the patient's (actual) inability to perform bathing and grooming. For that reason, a "potential problem" or "risk" is not appropriate. There is no evidence the patient lacks motivation, and paralysis is not a problem the nurse can resolve.

The nurse notes a temperature of 102°F in a patient scheduled for surgery in 30 minutes. As the patient has been afebrile and asymptomatic until now, what action will the nurse take next? A. Inform the charge nurse B. Notify the surgeon C. Reassess the temperature D. Document the finding in the electronic health record

C. The nurse validates assessment findings that deviate from normal patterns or are unsupported by other data. Should the initial measurement be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse must be sure that all data are accurate prior to documenting and reporting. If there is a question about accuracy, the data should be validated before documenting.

A nurse develops a care plan for an adolescent patient who gave birth to a premature infant. When presented with the collaborative care plan, including home health care visits, the patient states, "We will be fine on our own. I don't need any more care." What is the nurse's best response? "You know your personal situation better than I do; I will respect your wishes." "If you don't accept these services, your baby's health will suffer." "Let's take a look at the plan again and see if we can adjust it to fit your needs." "I'm going to assign your case to a social worker who can explain the services better."

C. When a patient rejects the care plan, the nurse works to identify the underlying barriers. If the nurse determines that the care plan is adequate, the nurse works with the patient to formulate mutually developed goals and interventions.

The care plan for a patient just diagnosed with diabetes contains the expected outcome: "the patient will correctly measure the insulin dose and self-administer the injection, using correct technique by 12/12/24." The nurse observes the client fumbled with the syringe and drew up less insulin than prescribed. What action will the nurse take first? Document that the plan of care was unsuccessful State continuation of the care plan is indicated Assess the patient's vision and dexterity and revise the plan Designate a family member to administer the insulin

C. When an outcome is not achieved, the nurse can (1) delete or modify a diagnosis; (2) revise the diagnosis, making it more realistic; (3) adjust the time criteria, or (4) modify the nursing interventions. This outcome was not successfully met; further assessment and revision is indicated. It is inappropriate for the nurse to designate a family member to take over insulin administration without additional assessment and patient permission.

A nurse in the psychiatric clinic is developing a problem list for a patient. What statement best reflects a correctly written, two-part problem? Difficulty Coping: Impaired Family Coping Etiology: inability to maintain marriage Difficulty Coping: Impaired Acceptance of Health Status Etiology: anger management issues Impaired Cognition: Distorted Thought Process Etiology: psychosis as evidence by hallucinations Impaired Cognition: Decisional Conflict Etiology: placement of parent in a long-term care facility

D A correctly written two-part problem statement includes the health problem and the etiology or cause. The problem statement and etiology should avoid signs and symptoms, medical diagnoses, and something that cannot be changed. Inability to maintain marriage and anger issues do not identify the underlying cause of the problem and may themselves reflect the true problem. Psychosis is a medical diagnosis, which should not be used to support a patient problem.

When performing sterile wound irrigation and dressing change for a postoperative patient, a new graduate nurse creates a sterile field. Which actions require correction by the preceptor? Select all that apply. Placing the bottle cap for the irrigating solution off the sterile field with the edges down Holding the bottle of irrigating solution inside the edge of the sterile field Applying the second sterile glove by lifting it from beneath the cuff with the thumb held away from the glove Pouring the irrigating solution into a sterile container from a height of 4 to 6 inches (10 to 15 cm) Opening packages of sterile gauze dressings, prior to applying sterile gloves

D, E. To add a sterile solution to a sterile field, the nurse opens the solution container according to directions and places the cap on the table away from the field with the edges up. The nurse then holds the bottle outside the edge of the sterile field with the label side facing the palm of the hand and pours from a height of 4 to 6 inches (10 to 15 cm) to prevent splashing.

A nurse is caring for a patient who had abdominal surgery yesterday. The nurse observes the patient guarding the area with hands and a pillow, refusing to move, and grimacing. What information does the nurse use to formulate the health problem statement? A. Symptoms B. Diagnostic statement C. Etiology D. Cue

D. A cue denotes significant data or "red flags," that, when occurring in a pattern or cluster, point to the existence of a health problem.

A nursery nurse notifies the nurse practitioner (NP) that a newborn has signs of jaundice. The NP performs a brief skin assessment, then orders a blood test for bilirubin levels. Which type of assessment has the NP performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

D. A quick priority assessment (QPA) is a short, focused assessment to obtain the most important information first. A comprehensive initial assessment is performed shortly after admission. The time-lapsed assessment is used to compare a patient's current status to baseline data obtained earlier.

A nurse is developing outcomes in the affective domain for a patient with a foot ulcer related to diabetes. Which outcome best addresses this domain? Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to foot ulcer after discharge. By 6/12/25, the patient will correctly demonstrate application of wet-to-dry dressing on the foot ulcer. By 6/19/25, the patient's pressure ulcer will decrease in size from 3 to 2.5 inches. By 6/12/25, the patient will verbalize they value their health sufficiently to control diabetes and prevent recurrence of diabetic ulcers.

D. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse is developing a problem list for a care plan. Which reflects a correctly written three-part problem statement? Select all that apply. Difficulty Coping: Impaired Family Coping: Etiology: lack of knowledge about tube feeding Signs and symptoms: child needing tube feeding discharged to home Impaired Nutritional Status: Impaired Nutritional Intake Etiology: striving for perfect weight, wishes to excel in gymnastics Signs and symptoms: 20-lb weight loss in 1 month Need to learn how to care for child on ventilator at home Etiology: discharge of child after 3-month hospital stay Signs and symptoms: repeated comments, "I know I'll harm her because I'm not a nurse." and "I can't do medical things." Impaired Spiritual Status Etiology: inability to accept diagnosis of terminal illness Signs and symptoms: comments such as, "I don't deserve this"; "I've tried to live my life well"; and "How co

D. Correctly written problem statements contain a problem the nurse can treat with independent or interdependent interventions, a clearly stated etiology or cause of the problem, and supporting signs and symptoms. Option (a) may be more easily resolved with the problem statement, knowledge deficiency. Option (a) further states the tube feeding is the underlying cause of the problem; it is a factor that cannot be changed. Option (c) is written in terms of needs and not an unhealthy response. Option (e), while written in three parts, places blame or implies negligence, which is legally inadvisable and should be avoided. A clear etiology is not stated in option (e), impeding direction for appropriate interventions or outcomes.

A nurse is caring for a patient who refuses to look at or care for a new colostomy. The patient states, "I don't care what I look like anymore. I'm not washing up, let alone touching or changing this bag!" The nurse formulates the health problem: Difficulty Coping: Impaired Acceptance of Health Status, reflecting which type of health problem? A. Collaborative B. Interdisciplinary C. Medical D. Nursing

D. Difficulty Coping: Impaired Acceptance of Health Status is a nursing problem, falling within the scope of independent nursing practice. Collaborative and interdisciplinary problems are resolved through a teamwork approach with other health care professionals. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A nurse is caring for a patient who has been admitted the second time this month for hypertensive emergency. The care plan contains the health problem: Nonadherence Etiology: lack of knowledge of purpose of medications Signs and symptoms: BP, 220/112; readmitted for hypertensive crisis after 2 weeks When meeting the patient, which action will the nurse take first? Teach the patient that nonadherence may lead to stroke and heart disease Discuss what will motivate the patient to adhere to the medication regimen Explain that these medications are essential to their health and illness prevention Determine the patient's knowledge about the medications and their side effects

D. Patient health problems are derived from clusters of related data and patterns, rather than a single cue. The nurse determines if this is the patient's usual bowel pattern, or whether an underlying reason exists for the lack of a bowel movement. Constipation is a health problem the nurse can resolve with independent or interdependent nursing actions.

During shift report, a nurse says that a patient has no integumentary changes or skin care needs. During assessment, the nurse observes reddened areas over bony prominences. What action will the nurse take? A. Correct the initial assessment form B. Redo the initial assessment and document current findings C. Conduct and document an emergency assessment D. Perform and document a focused assessment of skin integrity

D. Perform a focused skin assessment for the new problem, documenting the current date. The initial assessment was entered in the permanent health record, correct at the time, and cannot legally be rewritten. An emergency assessment is performed for a life-threatening problem.

A patient states, "I have been experiencing complications of diabetes." What question will the nurse use to elicit additional information? A. "Do you take two injections of insulin to prevent complications?" B. "Are you using diet and exercise to help regulate your blood sugar?" C. "Have you been experiencing the complications of neuropathy?" D. "Can you tell me about the complications you've experienced?"

D. Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.

A university student works with the student health nurse to develop a weight loss plan that includes increasing activity and avoiding empty calories. At the next session, the student has lost 1 lb instead of the projected 5 lb. What action will the nurse take next? Congratulate the student and continue the care plan Terminate the care plan since it is not working Give the student more time to reach the targeted outcome Modify the plan after discussing possible reasons for partial success

D. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. As the plan is not completely working as written, continuing without further assessment is contraindicated. It is premature to terminate the care plan before the outcome is met. The student may need additional support and time to reach the outcome.

A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the "A" portion of the SBAR communication? Exhibit: Electronic health record (EHR) Past medical history, Vital Signs, Peptic ulcer, T 98.8°F, P 111, RR 20, BP 98/50, Bleeding disorder, Pulse oximetry 96% Admitted with peptic ulcer and bleeding disorder Found vomiting in bathroom Anti-ulcer medication recommendation Vital signs, oxygen saturation, bright red emesis

D. The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.

The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate? A. "Please speak more quietly so you don't disturb the other patients." B. "Let me help you with your transfer technique." C. "When you are finished, be sure to apologize for shouting." D. "When your patient is safe and comfortable, meet me at the desk."

D. The charge nurse should direct the AP to see to the patient's safety, then address any concerns privately. The nurse then can discuss appropriate use of therapeutic communication.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is most correctly written? A. "Outcome met." B. "1/21/25—Patient reports no change in diet." C. "Outcome not met. Patient reports no change in diet or activity level." D. "1/21/25—Outcome met. Cholesterol level has decreased 10 mg."

D. The evaluative statement should contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

A nurse enters a patient's room and examines the patient's intravenous (IV) fluids and cardiac monitor. When asked, "who are you?", which response by the nurse is most appropriate? A. "I'm just the IV therapist checking your IV." B. "I've been transferred to this division and will be caring for you." C. "I'm sorry, my name is John Smith and I am your nurse." D. "I am John Smith, your nurse, and I'll be caring for you until 11 PM."

D. The nurse should identify themselves, ensure the patient knows what will be happening, and the duration of their relationship.

The nurse is assigned to care for a group of patients. Which patient will the nurse assess first? A. Postoperative patient reporting pain 4/10 B. Individual with pneumonia whose WBCs are now 7,000 C. Adolescent with a burn to the face who is going home tomorrow D. Patient's pulse oximetry reading 89%, as reported by AP

D. The nurse uses Maslow's hierarchy of needs to prioritize assessing the patient with hypoxemia, manifested by a pulse oximetry reading of 89%. The postoperative patient is reporting moderate pain; the patient with pneumonia has normal WBCs; the adolescent patient with a burn to the face is stable for discharge. These patients can be seen as soon as possible.

A nursing student on the surgical unit is assigned to perform a review of systems using the head-to-toe format on a patient admitted for a fractured femur. Using this format, what system will the student assess first? A. Genitourinary B. Neurologic C. Respiratory D. Musculoskeletal

D. The nursing physical assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe format called the review of systems (ROS). This assessment begins at the top of the body with the neurologic system and moves downward.

When a nurse enters the patient's room to begin a nursing history, the nurse notes the patient's spouse is present. After greeting them, what action will the nurse take? A. Thank the spouse for being present B. Ask the spouse if they want to remain C. Ask the spouse to leave D. Ask the patient if they would like the spouse to stay

D. The patient has the right to privacy and to determine who will be present during the nursing history and exam. The nurse does not presume the patient's preference, as the decision belongs to the patient, not their spouse.

After reviewing the admission SBAR and plan of care, the nurse begins to evaluate patient outcomes. Which statement reflects a clear evaluation of the patient's primary problem? Electronic health record (EHR) 8:00 AM Admission note S. Patient with profound wheezing, tachycardia, and anxiety B. Patient has history of asthma, for which she regularly uses inhalers and carries a rescue inhaler A. Pulse oximetry 89%, cyanosis of lips, dyspnea with increased work of breathing R. Admit to telemetry unit, add IV corticosteroids and mini-nebulizer treatments The patient states they were terrified when they were fighting to breathe and the wheezing would not stop. The nurse determines the patient's strengths include adherence to their medication regimen. The care plan includes the health problem of impaired gas exchange, etiology, bronchospasm. At 10:00 AM, no wheezing on auscultation, pulse oxime

D. The two-part evaluative statement includes a decision about how well the outcome was met, along with patient data or behaviors that support this decision. Outcomes may have been met, partially met, or not met. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." How will the nurse best communicate a therapeutic response? The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." The nurse places a hand on the patient's arm and states, "You feel so alone." The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." The nurse holds the patient's hand and asks, "Tell me what feeling so alone is like for you?"

D. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information? A. "Watching your child vomiting and in discomfort must have been scary." B. "This started yesterday, correct?" C. "Has this child has had anything to drink?" D. Could you tell me the color and approximate amount of the vomiting?

D. Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true.

A nursing student is prioritizing interventions for a patient with diabetes who needs diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. The patient states, "I must have my hair washed before I can do anything else; I'm ashamed of the way I look." How will the student best prioritize this patient's care? Explain to the patient that there is not enough time to wash their hair today because of the busy schedule Schedule the testing and meal planning first and complete hygiene as time permits Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last Wash the patient's hair and perform hygiene, schedule testing and counseling, then change the dressing

D. When time constraints and safety permit, priorities identified by the patient as most important are completed first. Washing the patient's hair and assisting with hygiene put the patient first, setting the tone for an effective nurse-patient partnership.

A nurse is using the classic elements of evaluation when caring for patients. Place the steps of evaluation in the proper order they are carried out. A. Interpreting and summarizing findings B. Collecting data to determine whether evaluative criteria and standards are met C. Documenting your judgment D. Terminating, continuing, or modifying the plan E. Identifying evaluative criteria and standards (i.e., expected patient outcomes)

E, B, A, C, D. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what the nurse looks for during evaluation, that is, expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

A nursing student is assigned to the emergency department (ED) to shadow the triage nurse. What activity will the student expect to perform? A. Acute and emergency interventions B. Daily care and assistance with ADLs C. Assessment and prioritization of care D. Care planning for return to home

c. The triage nurse screens patients to determine the extent and severity of their problems. They use highly specialized nursing knowledge and clinical reasoning and make clinical judgments to prioritize who must be seen immediately and who can wait. Patients in the ED are stabilized and transferred to the appropriate level of care; therefore, daily care, assistance with ADLs, planning for return home, and providing interventions are not part of the triage nurse's role. Should the patient need emergency interventions, the triage nurse moves the patient to the appropriate area in the ED.