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Questions & Answers (Grade A+)
The nurse is educating the patient on guided imagery. Which statement indicates the patient requires more education? a. "This technique will help decrease my stress." b. "This technique will help alleviate my anxiety." c. "This technique will help me eliminate my infection." d. "This technique will help me reduce my pain." - correct answer โ
C Guided imagery can help reduce stress, anxiety, and pain levels, but it cannot eliminate an infection. The nurse hesitates to report a critical laboratory value to a physician for fear of receiving an angry, inappropriate response. By waiting for the next shift, the nurse does not promote which of the following Healthy Work Environment Initiatives? a. Appropriate staffing b. Meaningful recognition c. Skilled communication
Questions & Answers (Grade A+)
d. Authentic leadership - correct answer โ
C Failing to report the value is a violation of true communication. Staffing is not the problem unless the reason was "too busy" to report. This is not a recognition issue. Although authentic leadership would support the nurse, the main issue is communication. Which care management tools can be modified by the nurse to individualize patient care? (Select all that apply.) a. Algorithms b. Practice alerts c. Order sets d. Protocols e. Nursing standards - correct answer โ
A,B,C Algorithms are decision trees that help the nurse decide on appropriate interventions for patients based on needs and responses. Practice alerts and order sets
Questions & Answers (Grade A+)
There is no description of a quality improvement project, and an informatics project is not represented. A nurse has been having difficulty sleeping since the death of a patient who had a stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse's symptoms could be signs of what problem? a. Moral confusion b. Immoral distress c. Moral distress d. Change fatigue - correct answer โ
C This scenario depicts moral distress. Although change fatigue could also cause some of the symptoms, that is not the case described here. Immoral distress and moral confusion are not applicable in this situation. The family of a patient who is receiving mechanical ventilation for respiratory distress associated with an inoperable brain tumor asks that the patient be
Questions & Answers (Grade A+)
extubated to "allow natural death" to occur. This is an example of what situation? a. Withholding treatment b. Rationing care c. A criminal act d. Withdrawing treatment - correct answer โ
D Withdrawing is the removal of treatment in the event of medical futility. Withholding would have been not to place the patient on the ventilator in the first place. Rationing care and a criminal act are not accurate. The nurse observes a coworker diverting narcotics by administering normal saline to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse? a. Autonomy b. Justice c. Nonmaleficence
Questions & Answers (Grade A+)
(ANA) publishes the Code of Ethics, contacting the organization would not be appropriate. The policy and procedure committee would be responsible for writing policy but not enforcing it. A patient with metastatic cancer tells the nurse, "I am tired and do not want to be put on a breathing machine." The patient's out-of-town son wants "everything done for my mother" when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply.) a. Autonomy b. Nonmaleficence c. Justice d. Beneficence e. Paternalism - correct answer โ
A,B,D The patient's autonomy is in danger. Harm (nonmaleficience), in the form of complications from a treatment that the patient does not want, is also involved. Doing the right thing (beneficence) for the
Questions & Answers (Grade A+)
patient is in question, owing to the patient's wishes and the prognosis of her illness. The principle of justice means that there is an equitable distribution of limited resources. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient or by disregarding the patient's preferences. This scenario does not involve the principle of justice or the concept of paternalism. The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case? a. Yes. Even though there were no damages, the nurse failed to follow hospital protocol. b. No. There were no damages associated with failure to document. c. Yes. Failure to document always results in negligence. d. No. Documentation is not part of the duty of nurse.
correct answer โ
B
Questions & Answers (Grade A+)
The nurse failed to properly assess and analyze the patient's need to be transported with a cardiac monitor and professional staff. Misdiagnosis and lack of communication were not the issues. There is not enough evidence to determine whether postponing the examination would have prevented the event. On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to "bother the physician this early." During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform? a. Assessment b. Planning c. Implementation d. Evaluation - correct answer โ
C The nurse failed to communicate critical laboratory values to the physician in a timely manner. Because the laboratory report was available, this was not an issue with assessment, planning, or evaluation.
Questions & Answers (Grade A+)
A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a "no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates the patient. The nurse states she was unware of the "no code" order. What part of the nursing process did the nurse fail to perform? a. Assessment b. Planning c. Implementation d. Evaluation - correct answer โ
A The nurse failed to ascertain and follow the patient's wishes. Nurses caring for acutely and critically ill patients have a legal and ethical obligation to act in accordance with a patient's wishes with regard to self- determination. This is not an issues with planning, implementation, or evaluation. Which action would be considered a breach of the standard of care for the registered nurse, thus
Questions & Answers (Grade A+)
The nurse is discussing the patient's home medications. Which question will elicit the most information from the patient regarding the patient's understanding of the diuretic? a. "Is this what you take at home?" b. "When do you take this pill at home?" c. "Why are you taking this pill?" d. "Do you really take this pill at home?" - correct answer โ
C "Why are you taking this pill?" is an open-ended question that will allow the patient to describe the medication in his or her own words. "Is this what you take at home?" is a "yes" or "no" question. "When do you take this pill at home?" is narrow and will elicit only a time from the patient. "Do you really take this pill at home?" sounds accusing and will also elicit only a "yes" or "no" response. What are the advantages to performing preoperative patient and family teaching about the recovery phase of surgery? (Select all that apply.) a. The family will not bother the nurse after surgery.
Questions & Answers (Grade A+)
b. The patient will experience less stress when waking up from anesthesia by knowing what to expect. c. The family will be prepared for how the patient will look after surgery and not be frightened. d. The physician will not have to talk to the family after surgery. e. The patient will be more likely to follow the postoperative plan of care if it has been discussed ahead of time. - correct answer โ
B,C,E The patient will experience less stress when waking up from anesthesia by knowing what to expect, the family will be prepared for how the patient will look after surgery and not be frightened, and the patient will be more likely to follow the postoperative plan of care if it has been discussed ahead of time are advantages of preoperative teaching. It is untrue that the family will not bother the nurse after surgery and the physician will not have to talk to the family after surgery. Adult learners are sensitive about making mistakes, so it is important for the nurse to include which of the
Questions & Answers (Grade A+)
c. The patient needs to use the bedpan. d. The patient has a new magazine. e. The patient has been sitting up in the chair for the first time and is tired. - correct answer โ
A,C,E The blood sugar level and the need to use the bedpan are physiologic needs that will interfere with teaching. Being tired will interfere with the teaching because of the patient's lack of concentration. Blood pressure is normal, and the magazine is a higher level need that can wait until after the teaching has occurred. The patient is a visual learner and will be discharged with a new colostomy pouch. List the appropriate educational strategies that can be used for teaching the care of the new appliance. (Select all that apply.) a. Provide a pamphlet with pictures. b. Show the patient an instructional video. c. Provide a demonstration and return demonstration. d. Give the patient a brief lecture.
Questions & Answers (Grade A+)
e. Have the patient listen to audiotape on colostomies.
correct answer โ
A,B,C A pamphlet with pictures, showing the patient an instructional video, and providing a demonstration and return demonstration are strategies that can be used successfully with visual learners. A lecture and listening to an audiotape would work better with auditory learners. Many patients experience stress when they are admitted to the intensive care unit. Which statement about stress is accurate? a. Stress of any type can elicit the same physical responses. b. Stress overload does not have to be differentiated from other stresses of the critical care experience. c. Stress overload occurs because the patient or family members have coping deficiencies or psychologic disorders. d. The appropriate nursing response to a patient at risk for stress overload is to maintain stressors to enable the patient to use adequate coping
Questions & Answers (Grade A+)
To decrease the patient's sense of powerlessness the nurse should ask before moving the patient's personal belongings as this allows the patient some control over the environment. Having the spouse complete the patient's diet request form, scheduling physicial therapy without asking the patient's preference and conducting hand-off outside of the patient's room all deny the the patient control and may enhance the patient's sense of powerlessness. A patient has been admitted with the symptoms of alcohol withdrawal syndrome (AWS). The nurse would expect which finding when the patient is assessed? a. Bradycardia b. Fatigue c. Hallucinations d. Hypotension - correct answer โ
C The signs and symptoms of AWS are easily confused with other conditions. Patients with AWS exhibit altered concentration, tremulousness, autonomic
Questions & Answers (Grade A+)
hyperarousal, hallucinations, disorientation, psychosis, tachycardia, hypertension, low-grade fever, agitation, diaphoresis, and delirium tremens. A patient has been displaying apathy, anxiety, and the inability to perform basic activities of daily living. When asked the patient states "I just can't do it." What psychosocial problem is the patient displaying? a. Identity disturbance b. Low self-esteem c. Ineffective coping d. Spiritual distress - correct answer โ
C Ineffective coping is defined as the impairment of a person's adaptive behaviors and problem-solving abilities when meeting life's demands and necessary roles. Manifestations of ineffective coping in critical illness include verbalization of an inability to cope, anxiety, and being unable to meet basic needs. The patient may display apathy or destructive behavior toward self and others. Patients experiencing spiritual distress may question the meaning of suffering and death in relation to their personal belief system.
