Unit One Chapter Questions

You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a healthcare provider's order for one of your patient's medications. You have heard from more experience nurses that this healthcare provider does not like to be called, and you know that another of the healthcare providers patience is very unstable. What is the most appropriate next step for you to take? 1. Call the healthcare provider to clarify the order. 2. Talk with your preceptor to help you interpret the order. 3. Refer to a medication manual before giving the medication. 4. Use your best judgment and critical thinking and administer the dose you think the healthcare provider ordered.

Call the healthcare provider to clarify the order.

A healthcare provider write the following order for a patient who is opioid naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every three days." On the basis of this order, the nurse takes the following action: 1. Calls the healthcare provider and questions the order. 2. Applies the patch the third postoperative day. 3. Applies the patch as soon as the patient reports pain. 4. Places the patch as close to the hip dressing as possible.

Calls the healthcare provider and questions the order.

A patient is evaluated in the emergency department after causing an automobile accident while under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4, "It will be OK. No one was seriously hurt in the accident."

"Tell me what happened before, during, and after the automobile accident tonight."

Which statement made by a new graduate nurse about the teach back technique requires intervention and further instruction by the nurse is preceptor? 1. "After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient's understanding." 2. "The Teach Back technique is an ongoing process of asking patients for feedback." 3. "Using Teach Back will help me identify explanations and communication strategies that my patients will most commonly understand." 4. "Using pictures, drawings, and models can enhance the effectiveness of the Teach Back technique."

"After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient's understanding."

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are defining characteristics that support a nursing diagnosis of "spiritual distress related to the loss of the family member"s? Select all that apply. 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

"I have nothing to live for now." "Why would my God do this to me?"

What statement made by a four-year-old patient's mother indicates that she understands how to administer her son's eardrops? 1. "To straighten his ear canal, I need to pull the outside part of his ear down and back." 2. "I need to straighten his ear canal before administering the medication by pulling is your upward and outward." 3. I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." 4. After I'm done giving him his eardrops I need to make sure that my son remain sitting straight up for at least 10 minutes.""

"I need to straighten his ear canal before administering the medication by pulling is your upward and outward."

A patient who is recovering from a bilateral amputation of the legs below the knee shows transcendence when she states: 1. "My pain medicine helps me feel better." 2. "I know I'll get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sunset at night." 4. "I have had a great life and a good marriage. My husband has been so helpful in my healing."

"I see God's grace and become relaxed when I watch the sunset at night."

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurses best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "What do you mean when you say you can't go on any longer?"

"What do you mean when you say you can't go on any longer?"

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. Which of the following statements indicates the patient is beginning to cope with the diagnosis? Select all that apply. 1. "I'm going to learn to drive a car so that I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

"I'm going to let the occupational therapist assess my home to improve efficiency." "I'm going to attend a support group to learn more about multiple sclerosis."

The patient asks a nurse what the patient centered care model for the hospital means. What is the nurses best answer? 1. "This model ensures that all patients have private rooms when they are admitted into the hospital." 2. "In this model you in the healthcare team or full partners and decisions related to your health." 3. "This model focuses on making the patient experience a good one by providing amenities such as restaurant style food service." 4. "Patients and families sign a document providing them full access to their medical charts."

"In this model you in the healthcare team or full partners and decisions related to your health."

Nurse prepares to contact the patient's physician about a change in patient condition. But the following statements in the correct order using SBAR communication. 1. "She is a 53-year-old female who was admitted to days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of like Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night."

"The patient started complaining of nausea yesterday evening and has vomited several times during the night." "She is a 53-year-old female who was admitted to days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." "The patient reported feeling very nauseated after her dose of like Levaquin an hour ago." "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?"

A nurse is assigned to a 42-year-old mother of four who weighs 300 pounds, has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurses cultural competence in assessing the patient's care problems? 1. "I can tell that your eating habits have led you to diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how over eating its affects their health."

"You have four children; do you have any concerns about going home and caring for them?"

A 10-year-old girl was playing on a slide at the playground during the summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10 year old is happy in the treatment room, eating a popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents? 1. "Can I contact someone to help you?" 2. "Your daughter is happy in the treatment room, eating a popsicle and picking out the color of her cast." 3. "I'll have the doctor come out and talk to you as soon as possible." 4."Let me help you to calm down a bit so I can take you to your daughter."

"Your daughter is happy in the treatment room, eating a popsicle and picking out the color of her cast." "Let me help you to calm down a bit so I can take you to your daughter." "I'll have the doctor come out and talk to you as soon as possible." "Can I contact someone to help you?"

You are caring for a hospitalized patient who is Muslim and has diabetes. Which of the following items do you need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream. 2. A dozen red grapes. 3. Bacon and eggs. 4. Garden salad with ranch dressing.

Bacon and eggs.

A healthcare provider ordered an enalapril (vasotec) 2 mg IV push for a patient with hypertension. The pharmacy sent vials marked 1.25 mg enalapril/mL. How many milliliters does the nurse administer?

1.6 mL

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and less requiring thorough bathing in skin care? 1. A 44-year-old female who has had removal of breast lesion and is having her menstrual period. 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line. 3. A 60 year old female who experienced a stroke with right sided paralysis and has had orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been in continent of stool.

A 70-year-old patient who has diabetes and dementia and has been in continent of stool.

Which of the following are examples of problems with the healthcare system that contribute to health disparities? Select all that apply. 1. A healthcare provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for the missed visits. 2. The discharge nurse at a hospital uses Teach Back with a patient to ensure that she has communicated the discharge instructions clearly. 3. A community hospital lacks an adequate staff of social workers who are able to ensure patients access to resources they need to take care of their health. 4. A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow up appointment. 5. A nurse uses a family member as an interpreter to explain the patient's medication. 6. The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities.

A healthcare provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for the missed visits. A community hospital lacks an adequate staff of social workers who are able to ensure patients access to resources they need to take care of their health. A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow up appointment. A nurse uses a family member as an interpreter to explain the patient's medication. The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities.

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who has just returned to the nursing unit from a diagnostic test. 2. A patient who prefers a bath in the evening when his wife visits and can help him. 3. A patient who is experiencing frequent in continent diarrheal stools and urine. 4. A patient who has been awake all night because of pain eight out of 10.

A patient who is experiencing frequent in continent diarrheal stools and urine.

A 72-year-old male patient comes to the health clinic for an annual follow up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and ask him, "Tell me where your pain is." Which of the following assessments approaches does the scenario described? 1. Review of systems approach. 2. Use of structured database format. 3. Back channeling. 4. A problem oriented approach.

A problem oriented approach.

Discussing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? 1. The amount of family support. 2. A three day diet recall. 3. A thorough physical assessment. 4. Threats to safety in her home.

A thorough physical assessment.

During an encounter with an elderly patient, the nurse recognizes that a thorough cultural assessment is necessary because the patient has recently come to United States from Russia and has never been hospitalized before. The nurse wants to discuss cultural similarities between her self and the patient. Which step of the LEAR in mnemonic is this? 1. Listen. 2. Explain. 3. Acknowledge. 4. Recommended treatment. 5. Negotiate agreement

Acknowledge.

Assisting patient with oral care

Activity of daily living

A nurse administered an antibiotic 30 minutes ago and returned to the patient's room to determine if the patient is having any unexpected symptoms. This is an example of assessing for a:

Adverse reaction

Which example demonstrates a nurse performing the skill evaluation? 1. The nurse explains the side effects of the new blood pressure medication ordered for the patient. 2. The nurse asked patient to rate pain on a scale of 0 to 10 before administering the pain medication. 3. After completing the teaching, the nurse observed patient draw up in administering insulin injection. 4. The nurse change is a patient's leg ulcer dressing using aseptic technique.

After completing the teaching, the nurse observed patient draw up in administering insulin injection.

Patient states that he does not believe in a higher power but instead believes that people bring meaning to what they do. This patient most likely is an: 1. Academic. 2. Atheist. 3. Agnostic. 4. Anarchist.

Agnostic

What is the most effective way to control transmission of infection? 1. Isolation precautions. 2. Identifying the infectious agent. 3. Hand hygiene practices. 4. Vaccinations.

Hand hygiene practices.

While administering medication, a nurse realize is that a prescribed dose of medication was not given. The nurse asked by completing an incident report and notifying the patient's healthcare provider. The nurse is exercising: 1. Authority. 2. Responsibility. 3. Accountability. 4. Decision making.

Accountability.

You are working in the health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly to a female patient for birth control. You look up this medication in a reference manual and determine that it is a viscous and injections can be painful. On the basis of this information, you plan which of the following one administering this medication? Select all that apply. 1. Inject the medication over three minutes to reduce pain associated with the injection. 2. Administer the medication in the ventral gluteal site. 3. Use the Z track method when administering the medication. 4. Use the deltoid site for medication administration. 5. Ask the patient questions about her major in which classes she is taking during injection to provide a distraction.

Administer the medication in the ventral gluteal site. Use the Z track method when administering the medication. Ask the patient questions about her major in which classes she is taking during injection to provide a distraction.

The staff on the nursing unit are discussing implementing interprofessional rounding. Which of the following statements correctly describe interprofessional rounding? Select all that apply. 1. Allows team members to share information about patients to improve care. 2. Provides an opportunity for early patient discharge planning. 3. Improves communication among healthcare team members. 4. Allows each of the healthcare team members to identify separate patient goals. 5. Allows each healthcare provider and opportunity to delegate a task.

Allows team members to share information about patients to improve care. Provides an opportunity for early patient discharge planning. Improves communication among healthcare team members.

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: 1. A situational crisis. 2. A maturational crisis. 3. An adventitious crisis. 4. A developmental crisis.

An adventitious crisis.

A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? 1. A medication cup. 2. A teaspoon. 3. A 5 mL syringe. 4. An oral dosing syringe.

An oral dosing syringe.

When using ice massage for pain relief, which of the following is correct? Select all that apply. 1. Apply ice using firm pressure over skin. 2. Apply ice for five minutes or until numbness occurs. 3. Apply ice no more than three times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular study massage.

Apply ice using firm pressure over skin. Apply ice for five minutes or until numbness occurs. Use a slow, circular study massage.

Pediatric nurse take some medicine to a 12-year-old female patient. The patient tells the nurse to take it away because she's not going to take it. What is the nurses next action? 1. Ask the patient's for reason for refusal. 2. Consult with the patient's parents for advice. 3. Take the medication away and chart the patient's refusal. 4. Tell the patient that her healthcare provider knows what is best for her.

Ask the patient's for reason for refusal.

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? Select all that apply. 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

Assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily. Clean between toes after bathing.

A 62-year-old patient has had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? Select all that apply. 1. Assess the condition of skin before making the call. 2. Rely on the nurse specialist to know the type of surgery the patient likely had. 3. Explain the patient's response emotionally to the repeated leaking of stool. 4. Describe the type of bag being used and how long it lasts before leaking. 5. Order extra colostomy bags currently being used.

Assess the condition of skin before making the call. Explain the patient's response emotionally to the repeated leaking of stool. Describe the type of bag being used and how long it lasts before leaking.

After receiving an intramuscular injection in the deltoid, the patient states, "My arm really hurts. It's been burning and tingling where I got my injection." What should the nurse do next? Select all that apply. 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's healthcare provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal findings so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.

Assess the injection site. Notify the patient's healthcare provider of assessment findings. Document assessment findings and related interventions in the patient's medical record.

A nurse accidentally gives a patient the medication's that were ordered for the patient's roommate. What is the nurses first priority? 1. Complete an occurrence report. 2. Notify the healthcare provider. 3. Informed the charge nurse of the error. 4. Assess the patient for adverse effects.

Assess the patient for adverse effects.

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? Select all that apply. 1. Check for needed adaptive equipment. 2. Exaggerate lip movement to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep the communication short into the point. Communicate only through written information.

Check for needed adaptive equipment. Give the patient time to respond to questions. Keep the communication short into the point.

A patient is prescribed morphine patient controlled analgesia. Arrange the following steps for administering PCA in the correct order. 1. Program computerized PCA pump to deliver prescribe medication dose and lock out interval. 2. Check the label of medication three times: when removed from storage, when brought to bedside, when preparing for assembly. 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into ejection port nearest patient.

Check the label of medication three times: when removed from storage, when brought to bedside, when preparing for assembly. Identify patient using two identifiers. Program computerized PCA pump to deliver prescribe medication dose and lock out interval. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. Insert and secure needleless adapter into ejection port nearest patient. Administer loading dose of analgesia as prescribed.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? Select all that apply. 1. Checks scientific literature or policy and procedure. 2. Reassess the patient's condition. 3. Collects all necessary equipment. 4. Delegates the procedure to a more experienced nurse. 5. Considers all possible consequences of the procedure.

Checks scientific literature or policy and procedure. Reassess the patient's condition. Collects all necessary equipment. Considers all possible consequences of the procedure.

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. He is experiencing allostatic load. As a result, which of the following would be present during complete patient assessment? Select all that apply. 1. Post traumatic stress disorder. 2. Rise of hormone levels. 3. Chronic illness. 4. Return vital signs to normal. 5. Depression.

Chronic illness. Depression.

A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying: 1. Organizational skills. 2. Use of resources. 3. Priority setting. 4. Clinical decision making.

Clinical decision making.

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength of both of the patients legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is in an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing.

Clinical inference.

Before consulting with a physician about a female patients need for urinary catheterization, the nurse consider is the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exist, but none has been effective, and that before surgery the patient was forwarding normally. This scenario is an example of which implementation scale? 1. Cognitive. 2. Interpersonal. 2. Psychomotor. 4. Consultative.

Cognitive.

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? Select all that apply. 1. Collaboration between staff members from sending and receiving departments. 2. Require that the patient visit the facility before a transfer is arranged. 3. Using a standardized transfer policy and transfer tool. 4. Arranging all patient transfers during the same time each day. 5. Relying on family members to share information with the new facility.

Collaboration between staff members from sending and receiving departments. Using a standardized transfer policy and transfer tool.

Which of the following examples are steps of nursing assessment select all that apply? 1. Collection of information from patients family members. 2. Recognition that further observations are needed to clarify information. 3. Comparison of data with another source to determine data accuracy. 4. Complete documentation of observational information. 5. Determining which medications to administer based on a patient's assessment data.

Collection of information from patients family members. Recognition that further observations are needed to clarify information. Comparison of data with another source to determine data accuracy.

To whom do you go for support in times of difficulty?

Community

Discussing a patient's options in choosing palliative care

Counseling

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the healthcare facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurses review of the situation? 1. Critical thinking. 2. Managing an adverse event. 3. Exercising self-discipline. 4. Time management.

Critical thinking.

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? Select all that apply. 1. Use of cough drops. 2. Immunosuppression. 3. Radiation therapy. 4. Dehydration. 5. Presence of oral airway.

Radiation therapy. Dehydration.

The nurse interviewed and conducted a physical examination of the patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while laying flat, and pursed lip breathing. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

Data cluster.

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurses compares the defining characteristics for "ineffective coping" with those for "readiness for enhanced coping" and selects "ineffective coping" as the correct diagnosis. This is an example of the nurse avoiding an error in: Select all that apply. 1. Data collection. 2. Data clustering. 3. Data interpretation. 4. Making a diagnostic statement. 5. Goal setting.

Data collection. Data interpretation

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? Select all that apply. 1. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs. 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves. 3. Helps nurses focus on the scope of nursing practice. 4. Creates practice guidelines for collaborative health care activities 5. Builds and expands nursing knowledge.

Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs. Helps nurses focus on the scope of nursing practice. Builds and expands nursing knowledge.

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, the hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last six months. Which defense mechanism is the patient using? 1. Denial. 2. Conversion. 3. Dissociation. 4. Displacement

Denial.

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient has lost 10 pounds in six weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect older adults oral health? Select all that apply. 1. Dentures do not always fit properly. 2. Most older adults have an increase in salivary of secretions. 3. With aging the periodontal membrane becomes tight and painful. 4. Many older adults are in edentulous, and remaining teeth are often decayed. 5. The teeth of elderly patients are more sensitive to hot and cold.

Dentures do not always fit properly. Many older adults are in edentulous, and remaining teeth are often decayed.

Which of the following signs or symptoms in a patient who is opioid naïve is of greatest concern to the nurse when assessing the patient one hour after administering an opioid? 1. Oxygen saturation is at 95%. 2. Difficulty arousing the patient. 3. Respiratory rate of 10 breaths per minute. 4. Pain intensity rating a five on a scale of 0 to 10.

Difficulty arousing the patient.

Which type of personal protective equipment or staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? Select all that apply. 1. Disposable gown. 2. N 95 respirator mask. 3. Face shield or goggles. 4. Surgical mask. 5. Gloves

Disposable gown. N 95 respirator mask. Gloves

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report a frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is the correct PES format? 1. Disturbed sleep pattern evidence by frequent awakening. 2, Disturbed sleep pattern related to family caregiving responsibilities. 3. Disturbed sleep pattern related to need to improve sleep habits. 4. Disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested.

Disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested.

A patient is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation. 2. Droplet precautions. 3. Standard precautions. 4. Contact precautions..

Droplet precautions.

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what ways can the nursing student make the goal of improving the patient's activity tolerance a patient centered effort? 1. Engage the patient in setting mutual outcomes for distance he's able to walk. 2. Confirm with the patient's healthcare provider about ambulation goals. 3. Have physical therapy assist with ambulation. 4. Refer to medical record regarding nature of face patient's physical problem.

Engage the patient in setting mutual outcomes for distance he's able to walk.

A home health nurse visit a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over two weeks. The patient has had diabetes for over 10 years. The ulcer has not been healing; it has drainage with a foul smelling odor. As the nurse examines the patient, she learns that the patient is not following the order diabetic diet. Which of the following is considered a low priority goal for the patient? 1. Achieving wound healing of the foot ulcer. 2. Enhancing patient knowledge about the effects of diabetes. 3. Providing a dietitian consultation for diet retraining. 4. Improving patient adherence to a diabetic diet.

Enhancing patient knowledge about the effects of diabetes.

A nurse assesses a 78-year-old patient who weighs 240 pounds and is partially immobilized because of a stroke. The nurse turns the patient finds that the skin over the sacrum is very red and the patient does not feel sensation in that area. The patient has had a fecal incontinence on and off for the last two days. The nurse identifies the nursing diagnosis as "risk for impaired skin integrity". Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every two hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.

Erythema of skin will be mild to none within 48 hours.

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used to encourage openness and allow the patient to "tell his story." This is an example of which step in the nursing process? 1. Planning. 2. Assessment. 3. Intervention. 4. Evaluation.

Evaluation.

The patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provided dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading.

Explain the reasons for isolation procedures and provide meaningful stimulation.

After seeing a patient, the healthcare provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: 1. Follow ISMP guidelines for safe medication abbreviations. 2. Explain to the healthcare provider that the order needs to be given to a registered nurse. 3. Write down the order on the patients order sheet and read it back to the healthcare provider. 4. Ensure that the six rights of medication administration are followed when giving the medication.

Explain to the healthcare provider that the order needs to be given to a registered nurse.

Which of the following changes can help create a more inclusive environment for lesbian, gay, bisexual, and transgender patients? Select all that apply. 1. Explicitly including sexual orientation and gender identity and non-discrimination policies. 2. Displaying art that reflects LGBT community. 3. Modifying healthcare forms to provide opportunities for gender identity and sexual orientation disclosure. 4. Not asking patients about their gender identity and sexual orientation to avoid making them uncomfortable. 5. Ensuring access to unisex or single stall bathrooms.

Explicitly including sexual orientation and gender identity and non-discrimination policies. Displaying art that reflects LGBT community. Modifying healthcare forms to provide opportunities for gender identity and sexual orientation disclosure. Ensuring access to unisex or single stall bathrooms.

Tell me if you have a higher power or authority that helps you act on your beliefs

Faith

At 1200 the registered nurse says to the nursing assistive personnel, "You did a good job walking Mrs. Taylor by 0930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500." Which characteristics of positive feedback did the RN use when talking to the nursing assistant? Select all that apply. 1. Feedback is given immediately. 2. Feedback focuses on one issue. 3. Feedback offers concrete details. 4. Feedback identifies ways to improve. 5. Feedback focuses on changeable things. 6. Feedback is specific about what is done incorrectly only.

Feedback focuses on one issue. Feedback offers concrete details. Feedback identifies ways to improve. Feedback focuses on changeable things.

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? Select all that apply. 1. Gaining an understanding of patient's motivations. 2. Focusing on opportunities to avoid poor health choices. 3. Recognizing patient's strengths and supporting our efforts. 4. Providing assessment data that can be shared with families to promote change. 5. Identifying differences in patient's health goals and current behaviors.

Gaining an understanding of patient's motivations. Recognizing patient's strengths and supporting our efforts. Identifying differences in patient's health goals and current behaviors.

The nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? Select all that apply. 1. Encourage family members to practice in this exercise. 2. Have patient identify quiet room in the home that has minimal interruptions. 3. Suggest you have a quiet fan running in the bedroom. 4. Explain that it is best to meditate about five minutes four times a day. Show the patient 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on prayer.

Have patient identify quiet room in the home that has minimal interruptions. Suggest you have a quiet fan running in the bedroom. Show the patient how to sit comfortably with the limitation of his arthritis and focus on prayer.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over six months since you've been here, but your appointment was set for every two months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurses assessment covers which of Gordon's functional health patterns? 1. Value belief pattern. 2. Cognitive perceptual pattern. 3. Coping stress tolerance pattern. 4. Health perception health management pattern.

Health perception health management pattern.

A registered nurse is providing care to a patient who had abdominal surgery two days ago. Which task is appropriate to delegate to the nursing student? 1. Helping the patient ambulate in the hall. 2. Changing surgical wound dressing. 3. Irrigating the nasogastric tube. 4. Providing brochures for the patient on health diet.

Helping the patient ambulate in the hall.

Which task is appropriate for a registered nurse to delegate to a nursing student? 1. Explaining to the patient that preoperative preparation before the surgery in the morning. 2. Administering the ordered anabiotic to the patient before surgery. 3. Obtaining the patient signature on the surgical informed consent. 4. Helping the patient to the bathroom before leaving for the operating room.

Helping the patient to the bathroom before leaving for the operating room.

A nurse is preparing to perform a cultural assessment of a patient. Which of the following questions is an example of a contrast question? 1. Tell me about your ethnic background. 2. Have you had this problem in the past? 3. Where do other members of your family live? 4. How different is this problem from the one you had previously?

How different is this problem from the one you had previously?

A nurse getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and history of not being able to manage his health. Which of the following questions reflects the nurses cultural competence and making an accurate diagnosis? Select all that apply. 1. How was your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar?

How was your diabetic diet affecting you and your family? What worries you the most about having diabetes? What do you believe will help you control your blood sugar?

A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and I want to learn how to better meet your health care needs." Which therapeutic communication technique to the nurse used in the situation? 1. Validation. 2. Empathy. 3. Sarcasm. 4. Humility.

Humility.

A nursing student is reporting during handoff to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to the end of the hall and back with no shortness of breath. Mr. Rourke said he slept better last night after I closed the door and gave him a chance to be uninterrupted. I change the dressing over his intravenous site and started a new bag D 1/2 NS." Which intervention is a dependent intervention? 1. Reporting hand off at change of shift. 2. Ambulating patient down hallway. 3. Sleep hygiene. 4. IV fluid administration.

IV fluid administration.

Nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. For which of the following reasons is this in incorrectly stated diagnostic statement? 1. Identifying the clinical sign instead of an etiology. 2. Identifying a nursing I gnosis on the basis of prejudicial judgment. 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study. 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Identifying the medical diagnosis instead of the patient's response to the diagnosis.

When you care for a patient who does not speak English, it is necessary to call on a professional interpreter. Which of the following are proper principles for working with interpreters? Select all that apply. 1. Expect the interpreter to interpret your statements word for word so there's no misunderstanding by the patient. 2. If you feel an interpretation is not correct, stop and address the situation directly with the interpreter. 3. Place a conversation so there is time for the patient's response to be in interrupted. 4. Direct your questions to the interpreter. 5. Ask the patient for feedback and clarification at regular intervals.

If you feel an interpretation is not correct, stop and address the situation directly with the interpreter. Place a conversation so there is time for the patient's response to be in interrupted. Ask the patient for feedback and clarification at regular intervals.

Review the following problem focused nursing diagnoses and identify the diagnoses that are stated correctly. Select all that apply. 1. Impaired skin integrity related to physical immobility. 2. Fatigue related to heart disease. 3. Nausea related to gastric distention. 4. Need for improved oral mucosa integrity related to inflamed mucosa. 5. Risk for infection related to surgery

Impaired skin integrity related to physical immobility. Nausea related to gastric distention.

Your illness has kept you from attending church. Is that a problem for you?

Importance of spirituality

Register nurse performs the following four steps and delegating a task to a nursing assistant. Place the steps in the order of appropriate delegation. 1. Do you have any questions about walking Mr. Malone? 2. Before you take him for his walk to the end of the hallway in back, please take and record his pulse rate. 3. In the next 30 minutes please assess Mr. Malone in room 418 with her afternoon walk. 4. I will make sure that I check with you in about 40 minutes to see how the patient did.

In the next 30 minutes please assess Mr. Malone in room 418 with her afternoon walk. Before you take him for his walk to the end of the hallway in back, please take and record his pulse rate. I will make sure that I check with you in about 40 minutes to see how the patient did. Do you have any questions about walking Mr. Malone?

New nurse complaint to her preceptor has no time for therapy communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

Include communication while performing tasks such as changing dressings and checking vital signs.

A patient with type two diabetes is experiencing a lot of work related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevated, and his doctors want him to attend some stress management classes. He says "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? Select all that apply. 1. Increases an antidiuretic hormone. 2. Increases in cortisol. 3. Increases in aldosterone. 4. Increases in adrenocorticotropic hormone. 5. Increases in epinephrine.

Increases in cortisol. Increases in adrenocorticotropic hormone. Increases in epinephrine.

Which principle is most important for the nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline. 2. Reviewing the evidence used to develop the guideline. 3. Individualizing how to apply the clinical guideline for a patient. 4. Explaining to a patient the purpose of the guideline.

Individualizing how to apply the clinical guideline for a patient

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of deficit fluid volume." The lead charge nurse immediately goes to the patient's room with a student to assess the patient's orientation, heart rate, skin turgor, and urine output for the last eight hours. The lead charge nurse suspects that the student has made which type of diagnostic error? 1. Insufficient cluster of cues. 2. Disorganization. 3. Insufficient number of cues. 4. Evidence that another diagnosis is more likely.

Insufficient number of cues.

A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient? 1. Low priority. 2. High priority. 3. Intermediate priority. 4. Nonemergency priority

Intermediate priority.

Describe which activities give you comfort spiritually

Interventions to adress spiritual needs

Patient has indwelling urinary catheter. Why does an indwelling urinary catheter present a risk of a urinary tract infection? Select all that apply. 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's dry skin dry. 5. The outer surface of the catheter is not considered sterile.

It allows migration of organisms into the bladder. It obstructs the normal flushing action of urine flow.

The nurse uses long, firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulation. 2. It covers a large area of the leg. 3. It completes care in a timely fashion. 4. It prevents blood clots in legs.

It promotes venous circulation.

Staff nurse is talking with the nursing supervisor about the stress that she feels on the job. Which of the following are true about work related stress? Select all that apply. 1. Job-related stress can affect the quality of patient care. 2. Stress can affect nurses' efficiency and decision-making. 3. Nurses who talk about feeling stressed or unprofessional and should calm down. 4. Nurses frequently experience stress with the rapid changes in healthcare technology. 5. Nurses cannot resolve job-related stress.

Job-related stress can affect the quality of patient care. Stress can affect nurses' efficiency and decision-making. Nurses frequently experience stress with the rapid changes in healthcare technology.

Which of the following actions by the nurse comply with core principles of surgical a sepsis? Select all apply. 1. Set up sterile field before patient and other staff come in to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm or 1 inch of the sterile field as contaminated. 4. Only healthcare personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed.

Keep the sterile field in view at all times. Consider the outer 2.5 cm or 1 inch of the sterile field as contaminated.

Which of the following are considered social determinants of health? Select all that apply. 1. Lack of primary healthcare providers is in a ZIP Code. 2. Poor quality public school education that prevents a person from developing adequate reading skills. 3. Lack of affordable health insurance. 4. Employment opportunities that do not provide paid vacation or sick leave. 5. . The number of times a person exercises during a week. 6. Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home.

Lack of primary healthcare providers is in a ZIP Code. Poor quality public school education that prevents a person from developing adequate reading skills. Lack of affordable health insurance. Employment opportunities that do not provide paid vacation or sick leave. Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home.

Protecting a violent patient from injury

Life-saving measure

A nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? Select all that apply. 1. Listen attentively to the patient story. 2. Use gestures to reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the patient's fatigue.

Listen attentively to the patient story. Use gestures to reinforce your questions or comments. Maintain direct eye contact.

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? Select all that apply. 1. Providing mouth care every four hours. 2. Maintaining intravenous infusion at 100 mL/hour. 3. Administering Prochlorperazine via rectal suppository. 4. Consulting with dietitian on initial foods to offer patient. 5. Controlling aversive odors or unpleasant visual stimulation that triggers nausea.

Maintaining intravenous infusion at 100 mL/hour. Consulting with dietitian on initial foods to offer patient.

A nurse is conferring with another nurse about the care of a patient with stage two pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcers management. The use of a standardized guideline achieves which of the following? Select all that apply. 1. Makes it quicker and easier for nurses to intervene. 2. Sets a level of clinical excellence for practice. 3. Eliminates need to create an individualized care plan for the patient. 4. Delivers evidence based interventions for stage two pressure ulcer. 5. Summarizes the various approaches used for the practice concern a problem

Makes it quicker and easier for nurses to intervene. Sets a level of clinical excellence for practice. Delivers evidence based interventions for stage two pressure ulcer.

A nurse is visiting a patient in the home and is assessing the patient's adherence to medication's. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how the nurse will make clinical decisions about how to implement care for this patient? Select all that apply. 1. Reviewing the family caregivers availability during medication administration times. 2. Making a judgment of the value of improved adherence for the patient. 3. Reviewing the number of medications and time each is to be taken. 4. Determining all consequences associated with the patient missing specific medicines. 5. Reviewing the therapeutic actions of the medication.

Making a judgment of the value of improved adherence for the patient. Determining all consequences associated with the patient missing specific medicines.

In the United States, there's never been a president of Asian or Hispanic culture. This is is an example of: 1. Social inequality. 2. Marginalization. 3. Under inclusion. 4. Social location

Marginalization.

What is the importance of the hospital consumer assessment of healthcare providers and systems survey? 1. Measures of nurses competency in interdisciplinary care. 2. Measures the number of adverse events in a hospital. 3. Measures quality of care within hospitals. 4. Measures referrals to a healthcare agency.

Measures quality of care within hospitals.

When a nurse conducts an assessment, data about a patient often comes from which of the following sources. Select all that apply 1. Mission of how a patient turns and moves in bed. 2. The unit policy and procedure manual. 3. The care recommendations of a physical therapist. 4. The results of a diagnostic x-ray film. 5. Your experiences in caring for other patients with similar problems.

Mission of how a patient turns and moves in bed. The care recommendations of a physical therapist. The results of a diagnostic x-ray film.

A nurse in a mother-baby clinic learned that a 16-year-old has given birth to her first child and has not been to a well baby class yet. The nurse's assessment reveals that the infant cries when breast-feeding and has difficulty latching onto the nipple. The infant has not gained weight over the last two weeks. The nurse identifies the patients nursing diagnosis as an "ineffective breast-feeding". Which of the following is the best "related to" factor? 1. Crying at breast. 2. Infant unable to latch onto the breast correctly. 3. Mothers deficient knowledge. 4. Lack of infant weight gain.

Mothers deficient knowledge.

A nurse is conducting a patient centered interview. Place the statements from the interview in correct order, beginning with the first statement a nurse would ask. 1. You say you've lost weight. Tell me how much weight you've lost in the last month. 2. My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history. 3. I have no further questions. Thank you for your patience. 4. Tell me what brought you into the hospital. 5. So, to summarize you've lost about 6 pounds in the last month, and your appetite has been poor, correct?

My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history. Tell me what brought you into the hospital. You say you've lost weight. Tell me how much weight you've lost in the last month. So, to summarize you've lost about 6 pounds in the last month, and your appetite has been poor, correct? I have no further questions. Thank you for your patience.

A nurse is caring for a patient with a seriously advanced infection who asked to have a spiritual care provider come you can offer Blessingway, a practice that attempts to remove ill health. This patient is likely a member of which religion or culture? 1. Hinduism. 2. Navajo. 3. Sikhism. 4. Judaism

Navajo.

Patient receiving chemotherapy experienced stomatitis. The nurse advised the patient to use: 1. Community mouthwash. 2. Alcohol-based mouth rinse. 3. Normal saline rinse. 4. Firm toothbrush

Normal saline rinse.

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? Select all that apply 1. Numbered order of diagnosis on the basis of severity. 2. Notion of urgency for nursing action. 3. Symptom pattern recognition suggesting a problem. 4. Mutually agreed on priority set with the patient. 5. Time when a specific diagnosis was identified.

Notion of urgency for nursing action. Symptom pattern recognition suggesting a problem. Mutually agreed on priority set with the patient.

The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following characteristics or traits of transformational leadership displayed by award winner? Select all that apply. 1. Nurse manager regularly rounds on staff to gather input on unit decisions. 2. The nurse manager sends thank you notes to staff and recognition of a job well done. 3. The nurse manager send memos to staff about decisions that the manager was made regarding unit policies. 4. The nurse manager has an innovation idea box to which staff are encouraged to submit ideas for unit improvements. 5. The nurse developed a philosophy of care for the staff.

Nurse manager regularly rounds on staff to gather input on unit decisions. The nurse manager sends thank you notes to staff and recognition of a job well done. The nurse manager has an innovation idea box to which staff are encouraged to submit ideas for unit improvements.

Which of the following are components of interprofessional collaboration? Select all that apply 1. Interprofessional education does not impact the collaboration among interprofessional team members. 2. Nurses are often viewed as a team leader because of their coordination of patient care. 3. Effective interprofessional collaboration requires mutual respect and trust from all team members. 4. Open communication improves the collaboration among the interprofessional team members. 5. The goal of interprofessional collaboration is to improve the quality of patient care.

Nurses are often viewed as a team leader because of their coordination of patient care. Effective interprofessional collaboration requires mutual respect and trust from all team members. Open communication improves the collaboration among the interprofessional team members. The goal of interprofessional collaboration is to improve the quality of patient care.

A nurse is talking with a young adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medication?" This exchange is an example of which element of the transactional communication process? 1. Message. 2. Obtaining feedback. 3. Channel. 4. Referent

Obtaining feedback.

A student nurse is developing a plan of care for a 74-year-old female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? Select all that apply. 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might help have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine if her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise.

Older adults achieve spiritual resilience through frequent expressions of gratitude. Have the patient determine if her husband left a legacy behind. Offer the patient her choice of rituals or participation in exercise.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on patient controlled analgesia of morphine? Select all that apply. 1. Only the patient should push the button. 2. Do not use the PCA until pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse from the button is pushed. 5. Do not push the button to go to sleep.

Only the patient should push the button. The PCA system can set limits to prevent overdoses from occurring. Do not push the button to go to sleep.

Which type of interview question does the nurse first use when assessing the reason for a patient seeking healthcare? 1. Probing. 2. Open ended. 3. Problem oriented. 4. Confirmation.

Open ended.

A patient with chronic low back pain who took an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He's now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal.

Opioid withdrawal.

Goal: patient will achieve pain relief by discharge.

Outcome: patient expresses fewer nonverbal signs of discomfort within 24 hours.

Goal: patient will be injury free for one month.

Outcome: patient identifies barriers to remove in the home within one week.

Goal: patient will achieve 5 pound weight gain in one month.

Outcome: patient increases calorie intake to 2500 daily.

Goal: patient will ambulate independently in three days.

Outcome: patient walks 20 feet using the walker in 24 hours.

As a nurse, you were assigned to four patients. Which patient do you need to see first? 1. The patient who is it had an abdominal surgery two days ago who is requesting pain medication. 2. Patient admitted yesterday with atrial fibrillation with decreased level of consciousness. 3. Patient with a wound drain who needs teaching before discharge in the early afternoon. 4. A patient going to surgery for a mastectomy and three hours who has a question about the surgery.

Patient admitted yesterday with atrial fibrillation with decreased level of consciousness.

A patient rates his pain as a six on a scale of 0 to 10, with zero being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing pain? 1. Patient self-report. 2. Behaviors. 3. Surrogate (wife) report. 4. Vital signs changes.

Patient self-report.

The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. Patient will take stool softener every four hours. 4. Patient will report stool soft and formed with each defecation.

Patient will report stool soft and formed with each defecation.

A nurse is checking a patient intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient health management values.

Patient's level of function.

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in a policy manual. The nurse raises the patients bed and adjust the rooms lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources in care delivery did the nurse omit? 1. Environment. 2. Personnel. 3. Equipment. 4. Patient.

Patient.

The nurse is caring for 50-year-old woman visiting the outpatient medicine clinic. The patient has had type one diabetes since 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with their chronic illness, which of the following principles should the nurse apply in practice? Select all that apply. 1. Pay attention to the patient spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient story each visit to the clinic and offer a compassionate presence. 4. When the patient questions the reason for her longtime suffering quote, try to provide answers. 5. Consult with a spiritual care advisor and have the advisor recommend useful interventions.

Pay attention to the patient spiritual identity throughout the course of her illness. Listen to the patient story each visit to the clinic and offer a compassionate presence.

A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the healthcare provider about need for immunization. 4. Perform hand hygiene after care and are handling contaminate equipment or materials.

Perform hand hygiene after care and are handling contaminate equipment or materials.

Using safe patient handling during positioning of a patient

Physical care technique

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1. Physical care technique. 2. Activity of daily living. 3. Indirect care measure. 4. Life-saving measure.

Physical care technique.

A nurse begins the night shift being a sign to five patients. She learns that the floor will be a registered nurse short as a result of a colon. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on a patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stopped her in the hallway to ask about another patient. Which factors in the nurse's unit environment will affect her ability to set priorities? Select all that apply 1. Policy for conducting hourly rounds. 2. Staffing level. 3. Interruption by staff nurse colleague. 4. RNs years of experience. 5. Competency of patient care technician.

Policy for conducting hourly rounds. Staffing level. Interruption by staff nurse colleague.

When doing an assessment of a young woman who was a victim of a home invasion three months earlier, the nurse learns that the woman has vivid images of the crash whenever she hears a loud yelling or a sudden noise. The nurse recognizes this as

Post traumatic stress disorder.

The nursing diagnosis "impaired parenting" related to mothers developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem focused nursing diagnosis. 3. Health promotion and nursing diagnosis. 4. Wellness nursing diagnosis.

Problem focused nursing diagnosis.

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurses the silence? Select all that apply. 1. Prevent the nurse from saying the wrong thing. 2. Prompt the patient to talk when here she is ready. 3. Allow the patient time to think and gain insight. 4. Allow time for the patient to drift off to sleep. 5. Determine if the patient would prefer to talk with another staff member.

Prompt the patient to talk when here she is ready. Allow the patient time to think and gain insight.

Which of these statements are true regarding disinfection and cleaning? Select all that apply. 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing the medical devices and equipment involve the same procedures.

Proper cleaning requires mechanical removal of all soil from an object or area. General environmental cleaning is an example of medical asepsis. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. Checking distal pulses. 2. Providing range of motion exercises to extremities. 3. Determining type of treatment for stage one pressure ulcer. 4. Changing the dressing over an intravenous site.

Providing range of motion exercises to extremities.

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with a patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If a patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise the bed, lower side rail, and position patient close to side of bed with the head of the bed raised up to 30°. 3. Using a brush moistened with chlorhexedine paste, clean chewing and inner tooth surface is first. 4. For patients without teeth, use a toothette moistened and chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex

Raise the bed, lower side rail, and position patient close to side of bed with the head of the bed raised up to 30°. Remove partial plate or dentures if present. If a patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. Using a brush moistened with chlorhexedine paste, clean chewing and inner tooth surface is first. Gently brush tongue but avoid stimulating gag reflex For patients without teeth, use a toothette moistened and chlorhexidine rinse to clean oral cavity.

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. Place the following steps of review and revision in the correct order. 1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses.

Reassess the patient. Compare assessment findings to validate existing nursing diagnoses. Decide if the nursing interventions remain appropriate. Modify care plan as needed.

A patient signals the nurse by turning on the cold light. The nurse enters the room and finds that the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous line and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing. 2. Inspect the condition of the IV dressing. 3. Obtain the next IV fluid bag from the medication room. 4. Explain when the healthcare provider is likely to visit.

Reconnect the drainage tubing.

Nurses must communicate effectively with the healthcare team for which of the following reasons? Select all that apply. 1. Improve the nurses status with the health team members. 2. Reduce the risk of errors to the patient. 3. Provide optimum level of patient care. 4. Improve patient outcomes. 5. Prevent issues that need to be reported to outside agencies.

Reduce the risk of errors to the patient. Provide optimum level of patient care. Improve patient outcomes.

A crisis intervention nurse is working with a mother who is down syndrome child has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in special school classes during hospitalization. Which strategies are effective in helping this mother cope with the stressors? Select all that apply. 1. Referral to social service process reestablishing the child's disability payment. 2. Sending the child home in 72 hours and having a child return to school. 3. Coordinating hospital-based in home-based schooling with a child's teacher. 4. Teaching the mother signs and symptoms of respiratory tract infection. 5. Telling the mother that the stress will decrease in six weeks when everything is back to normal.

Referral to social service process reestablishing the child's disability payment. Coordinating hospital-based in home-based schooling with a child's teacher. Teaching the mother signs and symptoms of respiratory tract infection.

How can a nurse work on developing cultural awareness? Select all that apply. 1. Reflect on his or her past learning about health, illness, race, gender, and sexual orientation. 2. Develop greater self knowledge about personal biases. 3. Recognize consciously the multiple factors that influence as her own worldview. 4. Engage in an in-depth self examination of his or her own background. 5. Learn as many facts as possible about an ethnic group.

Reflect on his or her past learning about health, illness, race, gender, and sexual orientation. Develop greater self knowledge about personal biases. Recognize consciously the multiple factors that influence as her own worldview. Engage in an in-depth self examination of his or her own background.

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top then bought a mask strings and remove from face. 5. Untie tie waist and neck strength of gown. Remove gown, rolling it onto itself without touching the contaminated side.

Remove gloves. Remove eyewear or goggles. Untie tie waist and neck strength of gown. Remove gown, rolling it onto itself without touching the contaminated side. Untie top then bought a mask strings and remove from face. Perform hand hygiene.

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find out the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the healthcare provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

A patient with a three day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to 4 tablets per day before her stroke for arthritic pain. The healthcare provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastronomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

Request to have the order changed to around the clock for the first 48 hours.

When you were assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? Select all that apply. 1. Oxygen saturation. 2. Heart rate. 3. Respirations. 4. Gag reflex. 5. Response to painful stimulus.

Respirations. Gag reflex.

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of the stress response? 1. Results in neurophysiological a response. 2. Reduce body temperature. 3. Causes a person to be hypervigilant. 4. Reduce level of consciousness to conserve energy.

Results in neurophysiological a response.

Nursing student is administering ampicillin PO. The expiration date on the medication rapper was yesterday. What is the appropriate action for the nursing student to take next? 1. Ask the nursing professor for advice. 2. Return the medication to pharmacy and get another tablet. 3. Call the healthcare provider after discussing the situation with the charge nurse. 4. Administer the medication since medication's are good for 30 days after the expiration date.

Return the medication to pharmacy and get another tablet.

A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three healthcare providers who have ordered a total of 13 medication's. What is the most appropriate action for the nurse to take next? 1. Give the medication's after identifying the patient using 2 patient identifiers. 2. Provide medication education to the patient to help with adherence to the medical plan. 3. Review the list of medication's with the healthcare providers to ensure that the patient needs all 13 medications. 4. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital.

Review the list of medications with the healthcare providers to ensure that the patient needs all 13 medication's.

A nurse is assigned a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step. 1. Considers context of the patient's health problem and selects a related factor. 2. Reviews assessment data, noting objective and subjective clinical information. 3. Clusters clinical cues that form a pattern. 4. Chooses diagnostic label

Reviews assessment data, noting objective and subjective clinical information. Clusters clinical cues that form a pattern. Chooses diagnostic label Considers context of the patient's health problem and selects a related factor.

A nurse asks a nursing assistive personnel to help the patient in room 418 walk to the bathroom right now. The nurse tells the NAP that the patient needs the assistance of one person and the use of a walker. The nurse also tells in a NAP that the patient's oxygen can be removed while he goes to the bathroom but to make sure that it is put back on at 2L. The nurse also instructed the NAP to make sure the side rails are up in the bed alarm is reset after the patient gets back in bed. Which of the following components of the five rights of delegation were used by the nurse? Select all that apply. 1. Right task. 2. Right circumstances. 3. Right person. 4. Right direction/communication. 5. Right supervision/evaluation.

Right task. Right circumstances. Right person. Right direction/communication.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced the most commonly by adolescence include which of the following? 1. Loss of autonomy caused by health problems. 2. Physical parents, family, friends, and school. 3. Self-esteem issues, changing family structure. 4. Search for identity with peer groups and separation from family.

Search for identity with peer groups and separation from family.

The nurse is administering an intravenous push medication to a patient who has a compatible IV fluid running through intervenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port for IV tubing closest to patient. Whenever possible, injection port should except a need a list syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdrawal syringe and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needle is tip or small gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with anti-septic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

Select injection port for IV tubing closest to patient. Whenever possible, injection port should except a need a list syringe. Use IV filter if required by medication reference or agency policy. Clean injection port with anti-septic swab. Allow to dry. Connect syringe to port of IV line. Insert needle is tip or small gauge needle of syringe containing prepared drug through center of injection port. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. After injecting medication, release tubing, withdrawal syringe and recheck fluid infusion rate.

A patient who visits the surgery clinic four weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then ask the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? 1. Health perception health management pattern. 2. Value belief pattern. 3. Cognitive perceptual pattern. 4. Self perception self-concept pattern.

Self perception self-concept pattern.

A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her and inner self, including her values and principles. The instructor explains that this is an example of: 1. Faith. 2. Community. 3. Interpersonal communication. 4. Self transcendence.

Self transcendence.

A nurse is caring for a complicated patient three days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? Select all that apply. 1. Is willing to challenge other members ideas because the nurse disagrees with their rationale. 2. Show us competence and how to monitor patient's clinical status and inform the physician of critical changes. 3. Asks a more experienced nurse to attend the conference. 4. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly. 5. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

Show us competence and how to monitor patient's clinical status and inform the physician of critical changes. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? Select all that apply. 1. Prone position 2. Sims position. 3. Semi-Fowler's position with head to side. 4. Trendelenburg position. 5. Supine position.

Sims position. Semi-Fowler's position with head to side.

A nurse begins a night shift, assuming care for critically ill patient who is resuscitated earlier in the day from cardiac arrest. He survived and is physically stable, alert, oriented, and responding appropriately to the nurses questions. Knowing that the patient experienced a period when his heart stopped beating, what would be the best approach for the nurse to use with him? 1. Have family come to visit and focus discussion about their gratitude that the patient survived. 2. Change the subject when the patient begins talking about entering a dark tunnel when the doctors were resuscitating him. 3. Sit and encourage the patient to share what he experienced during resuscitation. 4. Provide the patient the opportunity to have passages from the Bible read.

Sit and encourage the patient to share what he experienced during resuscitation.

A patient has just learned that she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. Do you have cared for her for only two hours but have a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care advisor. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patients Bible from her bedside cabinet drawer to the top of her over bed table. 4. Ask the patient if she would like to learn more about the implications of having this type of tumor.

Sit down and talk with the patient; have her discuss her feelings and listen attentively.

A nurse gathers the following assessment data. Which of the following cues together form a pattern suggesting a problem? Select all that apply 1. Skin around the wound is tender to touch. 2. Fluid intake for eight hours is 800 mL. 3. The patient has a heart rate of 78 bpm and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 101°F. 6. Patient states, "I'm worried that I won't be able to return to work when planned"

Skin around the wound is tender to touch. Patient has drainage from surgical wound. Body temperature is 101°F.

Which of the following nursing diagnoses a stated correctly? Select all that apply. 1. Fluid volume excess related to heart failure. 2. Sleep deprivation related to sustained noisy environment. 3. Impaired bed mobility related to postcardiac catheterization. 4. Ineffective protection related to inadequate nutrition. 5. Diarrhea related to frequent, small, watery stools.

Sleep deprivation related to sustained noisy environment. Ineffective protection related to inadequate nutrition.

Groups have unequal access to resources, services, and positions.

Social inequality

One's place in society is based on membership in a social group that determines access to resources.

Social location

A patient is being discharged home on and around the clock opioid for chronic back pain. Because of this order, the nurse anticipate an order for which class of medication? 1. Opioid antagonist. 2. Antiemetics. 3. Stool softeners. 4. Muscle relaxants.

Stool softeners.

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? 1. TENS works by causing distraction. 2. TENS therapy does not require a healthcare providers order. 3. TENS requires an electrical source for use. 4. TENS electrodes are applied near or directly on the side of pain.

TENS electrodes are applied near or directly on the side of pain.

A new nurse is experience lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior. 2. Talk with the department secretary and ask if there has been a problem for other nurses. 3. Talk with a preceptor or manager and ask for assistance in handling the issue. 4. Say nothing and hope things get better.

Talk with a preceptor or manager and ask for assistance in handling the issue.

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time. 2. Talking with the patient about her past experiences with illness. 3. Talking with a patient about her concerns and acknowledging her sense of unfairness. 4. Beginning instruction on post operative procedures.

Talking with a patient about her concerns and acknowledging her sense of unfairness.

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing healthcare acquired infections? Select all that apply. 1. Teaching correct hand washing to assigned patients. 2. Using correct procedures in starting and caring for an intravenous infusion. 3. Providing perineal care to a patient with an indwelling urinary catheter. 4. Isolating a patient who has just been diagnosed as having tuberculosis. 5. Decreasing a patient's environmental stimuli to decrease nausea

Teaching correct hand washing to assigned patients. Using correct procedures in starting and caring for an intravenous infusion. Providing perineal care to a patient with an indwelling urinary catheter.

Bring a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headache sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had these headaches periodically in the last week and sometimes they caused you to feel nauseated, correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches again. 4. Uh huh, tell me more.

Tell me what makes your headaches again.

The nurse reviews the patient's medical administration record and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every three hours for the past three days. What concerns the nurse the most? 1. The patient's level of pain. 2. The potential for addiction. 3. The amount of daily acetaminophen. 4. The risk for gastrointestinal bleeding.

The amount of daily acetaminophen.

What does it mean when a patient is diagnosed with multidrug resistant organism in his or her surgical wound? Select all that apply. 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics that the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of anabiotic to kill the organism. 4. The organism has developed a resistance to one or more broad spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any anabiotic options available to treat the patients infection.

The antibiotics that the patient has received are not strong enough to kill the organism. The organism has developed a resistance to one or more broad spectrum antibiotics, indicating that the organism will be hard to treat effectively.

The nurse enters a patient's room and find that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin and applies skin barrier ointment to the peroneal area. The nurse consult the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurses actions? Select all that apply. 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an independent care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activities of daily living. 5. Inspecting the skin is a direct care activity.

The call to the ostomy and wound care specialist is an independent care measure. The cleansing of the skin is a direct care measure.

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of disturbed sleep pattern related to noisy home environment in choosing an intervention for enhancing the patients sleep? Select all that apply. 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one that you've used with other patients in the past.

The intervention should be directed at reducing noise. The intervention should be one shown to be effective in promoting sleep on the basis of research. The intervention should be one acceptable to the patient.

A nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61 year old patient from Chile. He fell at home and hurt his back three days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a six, and move slowly as he transfers to a chair." What can the nurse who is beginning a shift due to validate the previous nurses assessment findings when she conducts rounds on the patient? Select all that apply. 1. The nurse asked the patient to write his pain on a scale of 0 to 10. 2. The nurse asked patient what caused his fall. 3. The nurse asked the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower limb strength. 5. The nurse asked patient what pain medication is most effective in managing his pain.

The nurse asked the patient to write his pain on a scale of 0 to 10. The nurse assesses the patient's lower limb strength.

A new nurse is caring for a hospitalized obese patient who is homeless. This is the first time the patient has been admitted to the hospital, and the patient is scheduled for surgery. Which of the following is a universal skill that would help the nurse work effectively with this patient? 1. "The nurse shifts her focus to understanding the patient by asking her, "Describe for me the course of your illness." 2. "The nurse tells the patient, your choices of foods and unwillingness to exercise are adding to your health problems." 3. The nurse asked the patient, "Tell me about the main problems you have had with your health from not having a home." 4. The nurse explains, "Because you have obesity, it is important to know the effects it has on the wound healing because of reduced tissue perfusion."

The nurse asked the patient, "Tell me about the main problems you have had with your health from not having a home."

Select the three factors that are evident when I healing relationship develops between a nurse and patient. 1. The nurse being able to realistically mobilize hope for the patient. 2. The patient being able to share fears of loss with significant others. 3. Finding an interpretation or understanding of the patient's illness that is acceptable to the patient. 4. Understanding your own beliefs about spirituality. 5. Helping the patient you spiritual resources that here she chooses.

The nurse being able to realistically mobilize hope for the patient. Finding an interpretation or understanding of the patient's illness that is acceptable to the patient. Helping the patient you spiritual resources that here she chooses.

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? Select all that apply. 1. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. 2. Determining what is the patient care technicians current workload. 3. The nurse chooses to get delegate the measurement of a stable patient vital signs and not the assessment of the patient arriving from a diagnostic test. 4. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. 5. The nurse confirms with another registered nurse about organizing priorities.

The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. The nurse chooses to get delegate the measurement of a stable patient vital signs and not the assessment of the patient arriving from a diagnostic test. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.

When should a nurse wear a mask? Select all that apply. 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an arrow aerosolizing respiratory procedure such a suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is a droplet precautions. 5. The nurse is assisting a healthcare provider and the insertion of a central line catheter.

The nurse is assisting with an arrow aerosolizing respiratory procedure such a suctioning. The patient is a droplet precautions. The nurse is assisting a healthcare provider and the insertion of a central line catheter.

A patient is admitted through the emergency department after a serious car accident. The nurse assesses the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which interventions would be appropriate at this time? Select all that apply. 1. The nurse requests a professional interpreter. 2. Since this is an emergent situation, the nurse will interpret and identify the patient's priority needs. 3. The nurse determines the interpreters qualifications and makes sure the interpreter can speak the patient's dialect. 4. The nurse uses short sentences to explain treatment provided by the emergency department. 5. The nurse direct questions to the patient by looking at the patient instead of the interpreter.

The nurse requests a professional interpreter. The nurse determines the interpreters qualifications and makes sure the interpreter can speak the patient's dialect. The nurse uses short sentences to explain treatment provided by the emergency department. The nurse direct questions to the patient by looking at the patient instead of the interpreter.

A nurse has worked in a home health agency for a number of years. She goes to visit a patient who has diabetes and he lives in a public housing facility. This is the first time the nurse has cared for the patient. The patient has four other family members who live with her in the one bedroom apartment. Which of the following, based on Campinha's-Bacotes model of cultural competency, is an example of cultural awareness? 1. The nurse begins a discussion with the patient by asking, "Tell me about your family members who live with you?" 2. The nurse asked, "What do you believe is needed to make you feel better?" 3. The nurse silently reflects about how her bias is regarding poverty can influence how she assesses the patient. 4. The nurse uses a therapeutic and caring approach to how she interacts with the patient..

The nurse silently reflects about how her bias is regarding poverty can influence how she assesses the patient.

In which of the following examples are nurses making diagnostic errors? Select all that apply. 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data. 2. The nurse who measures joint range of motion after the patient reports pain in left elbow. 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose. 4. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping. 5. The nurse who makes a diagnosis of ineffective airway clearance related to pneumonia

The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping. The nurse who makes a diagnosis of ineffective airway clearance related to pneumonia

A nursing student is administering medication to a patient through gastric tube. Which of the following actions taken by the nursing student requires the nursing instructor to intervene? 1. The nursing students places all the patient's medication and different medicine cups. 2. The nursing student evaluate each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach. 3. The nursing student flushes the tube with 30 mL of water between each medication. 4. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

A patient who has been isolated for c. diff. asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? Select all that apply. 1. The organism is usually transmitted through fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C diff dies quickly once outside the body.

The organism is usually transmitted through fecal-oral route. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. Everyone coming into the room must be wearing a gown and gloves.

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive compulsive behavior 2. Personal preferences. 3. The patient's cultural norm 4. Controlling behaviors

The patient's cultural norm

A post operative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral route.

The sedative administered may have helped him sleep, but it is still necessary to assess pain.

The new medical resident writes an order for oxycodone CR 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug. 2. The time interval. 3. The dose. 4. The route.

The time interval.

When a nurse delegates hygiene care for a male patient to a nursing assistant personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure. 2. Pneumonia. 3. Arthritis. 4. Thrombocytopenia.

Thrombocytopenia.

After a nurse receives a change of shift report on his assigned patients, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice? 1. Organizational skills. 2. Use of resources. 3. Time management. 4. Evaluation.

Time management.

Patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain is a six on a scale of 0 to 10. She received a dose of hydromorphone just 15 minutes ago. Which intervention may be beneficial for this patient at this time? Select all that apply. 1. Transcutaneous electrical nerve stimulation (TENS). 2. Administer naloxone (narcan) 2 mg intravenously. 3. Provide back massage. 4. Reposition the patient. 5. Withhold any pain medication and tell the patient that she is at risk for addiction.

Transcutaneous electrical nerve stimulation (TENS). Provide back massage. Reposition the patient.

A group has been overlooked and research and design of interventions.

Under inclusion

Patient who is Spanish-speaking does not appear to understand the nurses information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure. 2. Ask a fellow Spanish-speaking patient to explain the procedure. 3. Use a professional interpreter to provide wound care education in Spanish. 4. Ask the patient to write down questions that he or she has for the nurse.

Use a professional interpreter to provide wound care education in Spanish.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: Select all that apply. 1. Use antimicrobial toothpaste. 2. Brush teeth four times a day. 3. Use 0.12% chlorhexidine gluconate oral rinse. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

Use antimicrobial toothpaste. Use 0.12% chlorhexidine gluconate oral rinse. Use a soft toothbrush for oral care.

A patient surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the healthcare provider of the patient status. 2. Reassure the patient and re-check the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing.

Use aseptic technique to change the dressing. Reassure the patient and re-check the wound later. Notify the healthcare provider of the patient status. Support the patient's fluid and nutritional needs.

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses. 2. Follow recommendations of lens manufacturers when inserting the lenses. 3. Keep lenses moist or wet were not worn. 4. Use fresh solution daily when storing and disinfecting lenses.

Use tap water to clean soft lenses.

It is time for a nurse handoff between the night nurse and the nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question which of the following activities are strategies for an effective handoff? Select all that apply. 1. Using a standardized checklist for essential information. 2. Asking the wife to briefly leave the room. 3. Completing the handoff without inviting questions. 4. Doing pre-work such as checking laboratory results before giving a report. 5. Including the wife in the handoff discussion.

Using a standardized checklist for essential information. Doing pre-work such as checking laboratory results before giving a report. Including the wife in the handoff discussion.

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: Select all that apply. 1. Using analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one medication at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of a juveniles such as gabapentin to manage neuropathic typepain.

Using analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) along with opioids. The use of a adjuvants (co-analgesiacs) such as gabapentin to manage neuropathic type pain.

A nursing student is reporting during handoff to the registered nurse assuming her patients care. The student states, Mr. Rourke had a good day, his intravenous fluid is infusing at 124 mL per hour with a D 1/2 NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to the end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Rourke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Rourke was to improve activity tolerance, which expected outcomes were shared in the handoff? Select all that apply. 1. IV site was not tender. 2. Uses cane to walk. 3. Walked to the end of hall. 4. No shortness of breath. 5. Slept better during the night.

Walked to the end of hall. No shortness of breath.

Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of the nurses care plan, which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Were prayer or meditation helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

Were prayer or meditation helpful to you?

A nurse is caring for a 78-year-old patient with chronic multiple sclerosis. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patients trust and wants to assess her life satisfaction. Which of the following questions for the nurse ask? Select all that apply. 1. How often are you able to attend your synagogue? 2. What about your family makes you proudest? 3. What does your husband do for you at home? 4. Looking back, what is your greatest accomplishment? 5. How has your illness affected the way you live your life spiritually at home?

What about your family makes you proudest? Looking back, what is your greatest accomplishment?

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing developmental crisis. Which of the following questions provide information about the impact of this crisis? Select all that apply. 1. With whom do you talk on a routine basis? 2. What do you do when you feel lonely? 3. How is having diabetes affecting your life? 4. I know this must be hard for you. Let me tell you what might help. 5. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

With whom do you talk on a routine basis? What do you do when you feel lonely? Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in what phase of the nurse patient relationship? 1. Working phase. 2. Preinteraction phase. 3. Termination phase. 4. Orientation phase.

Working phase.

The nurse ask the patient, describe for me a typical night's sleep. "What do you do to fall asleep? Do you have difficulty falling or staying asleep?" This series of questions would likely occur during which phase of a patient centered interview? 1. Orientation. 2. Working phase. 3. Data validation. 4. Termination.

Working phase.

Your healthcare provider has informed a patient that he has colon cancer, the nurse enters the room to find a patient gazing out the window and thought. Which of the following are appropriate responses or actions of the nurse? Select all that apply. 1. I know another patient whose colon cancer was cured by surgery. 2. Straighten the patient's bed and room. 3. Have you thought about how you were going to tell your family? 4. Would you like for me to sit down with you for a few minutes so you can talk about this? 5. Sit quietly with the patient.

Would you like for me to sit down with you for a few minutes so you can talk about this? Sit quietly with the patient.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean dry and intact; therefore she selects the nursing diagnosis "impaired skin integrity". The faculty member explains that the student has made a diagnostic area for which of the following reasons? 1. Incorrect clustering. 2. Wrong diagnostic label. 3. Condition is a collaborative problem. 4. Premature closure of clusters.

Wrong diagnostic label.