Evidence-Based Practice in Nursing Care, Exams of Nursing

Download Evidence-Based Practice in Nursing Care and more Exams Nursing in PDF only on Docsity! Fundamentals of Nursing 11th Edition by Potter Perry Test Bank 2023/2024 VERSION/GRADED A+ A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale? for the nurse's behavior? a. EBP is a guide for nurses in making clinical decisions. b. EBP is based on the latest textbook information. c. EBP is easily attained at the bedside. d. EBP is always right for all situations. - ANSWER>>>a In caring for patients, what must the nurse remember about evidence-based practice (EBP)? a. EBP is the only valid source of knowledge that should be used. b. EBP is secondary to traditional or convenient care knowledge. c. EBP is dependent on patient values and expectations. d. EBP is not shown to provide better patient outcomes. - ANSWER>>>c A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? a. Read all the articles found on the Internet. b. Make a general search of the Internet. c. Use a PICOT format for the search. d. Start with a broad question. - ANSWER>>>c A nurse has collected several research findings for evidence- based practice. Which article will be the best for the nurse to use? a. An article that uses randomized controlled trials (RCT). b. An article that is an opinion of expert committees. c. An article that uses qualitative research. d. An article that is peer-reviewed. - ANSWER>>>a The nurse is reviewing a research article on a patient care topic. Which area should entice the A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? a. An article about the number of falls after use of no side rails b. An article about infection rates after use of a new wound dressing c. An article about the percentage of new admissions on a new floor d. An article about emotional needs of dying patients and their families - ANSWER>>>d A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the ―C‖? a. After surgery. b. Who listen to music? c. Who receive standard nursing care? d. Achieve better control of their anxiety and pain. - ANSWER>>>c The nurse uses a PICOT question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more evidence than is available at this time. What is the nurse's best option? a. Conduct a pilot study to investigate findings. b. Drop the idea of making the change at this time. c. Insist that management hire the needed staff to facilitate the change. d. Seek employment in another institution that may have the staff needed. - ANSWER>>>a The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting? a. Nonexperimental research b. Experimental research c. Qualitative research d. Evaluation research - ANSWER>>>c In conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. Which concept is the nurse researcher fulfilling? a. Bias b. Confidentiality c. Informed consent b. Implement the changes as a pilot study. c. Wait a month before implementing the changes. d. Communicate to staff the results of this project. - ANSWER>>>d A nurse is developing a care delivery outcomes research project. Which population will the nurse study? a. Nurses b. Patients c. Administrators d. Health care providers - ANSWER>>>b . A nurse is implementing an evidence-based practice project regarding infection rates. After reviewing research literature, which other evidence should the nurse review? a. Quality improvement data b. Inductive reasoning data c. Informed consent data d. Biased data - ANSWER>>>a . A nurse is using the research process. Place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. a. 3, 4, 5, 2, 1 b. 4, 3, 5, 2, 1 c. 3, 5, 4, 2, 1 d. 4, 5, 3, 2, 1 - ANSWER>>>a The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which methods will provide the nurse with the right kind of data? (Select all that apply.) a. Surveys b. Phenomenology c. Grounded theory d. Evaluation research e. Nonexperimental research MULTIPLE CHOICE - ANSWER>>>A,D,E MULTIPLE CHOICE Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.) a. Gives complete information about the purpose. b. Allows free choice to participate or withdraw. c. Understands how confidentiality is maintained. d. Identifies risks and benefits of participation. realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs - ANSWER>>>A A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members - ANSWER>>>B The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs - ANSWER>>>B A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices - ANSWER>>>A The nurse is admitting a patient diagnosed with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood glucose levels. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on adherence. b. A person's adherence is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures. - ANSWER>>>B The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? Upon completing a history, the nurse finds that a patient has risk factors for developing lung disease. How should the nurse interpret this finding? a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. Risk modification will have no effect on disease prevention. d. The disease is guaranteed not to develop if the risk factor is controlled. - ANSWER>>>B The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and will never quit smoking. b. The patient must pick up the attempt right where the patient left off. c. The patient will return to the contemplation or precontemplation phase. d. The patient will need to adopt a new lifestyle for change to be effective. - ANSWER>>>C The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for ―detox.‖ What should the nurse do next? a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Teach the patient that choices will have to change. d. Instruct the patient that relapses will not be tolerated. - ANSWER>>>A A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action - ANSWER>>>B Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Action - ANSWER>>>B The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support - ANSWER>>>C,D,E A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system. b. Identifies actual and potential risk factors. c. Has coined the term ―illness behavior.‖ d. Minimizes the effects of illnesses. e. Experiences compassion fatigue. - ANSWER>>>A,B,D A nurse is teaching about the goals of Healthy People 2030. Which information should the nurse include in the teaching concerning what leading health indicator (LHI)? (Select all that apply.) a. Food insecurity b. Healthcare costs c. Adolescent obesity d. Suicide prevention e. Illness care - ANSWER>>>A,C,D A nurse is caring for a patient in pain. Which nursing approach is priority? a. Patient-centered b. Technology-centered c. High tech-centered d. Family-centered - ANSWER>>>A A nurse is providing pain medication to patients after surgery. Which component is key for the nurse's personal philosophy of nursing? a. Caring b. Technology c. Informatics d. Therapeutics - ANSWER>>>A A nurse attends a seminar on nursing theories for caring. Which information from the nurse indicates a correct understanding of these theories? a. Benner identifies caring as highly connected involving patient and nurse. b. Swanson develops four caring processes to convey caring in nursing. c. Watson's transcultural caring views inclusion of culture as caring. d. Leininger's theory places care before cure and is transformative. - ANSWER>>>A The patient has a colostomy but has not yet been able to look at it. The nurse teaches the A nurse is providing presence to a patient and the family. Which nursing action does this involve? a. Focusing on the task that needs to be done b. Providing closeness and a sense of caring c. Jumping in to provide patient comfort d. Being there without an identified goal - ANSWER>>>B The patient is afraid to have a thoracentesis at the bedside. The nurse sits with the patient and asks about the fears. During the procedure, the nurse stays with the patient, explaining each step and providing encouragement. What is the nurse displaying? a. Providing touch b. Providing a presence c. Providing family care d. Providing a listening ear - ANSWER>>>B The patient has a terminal diagnosis and is very near death. When the nurse assesses the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating? a. Caring touch b. Protective touch c. Therapeutic touch d. Task-oriented touch - ANSWER>>>B Which action indicates a nurse is using caring touch with a patient? a. Inserts a catheter. b. Rubs a patient's back. c. Prevents a patient from falling. d. Administers an injection. - ANSWER>>>B The nurse is caring for a patient who has been sullen and quiet for the past 3 days. Suddenly, the patient says, ―I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family.‖ What should the nurse do first? a. Assure the patient that everything will be all right. b. Tell the patient that there is no need to worry. c. Listen to the patient's concerns and fears. d. Inform the patient a social worker is available. - ANSWER>>>C The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure and stops to listen. Which response by the nurse may be most beneficial? Which actions by the nurse indicate compassion and caring to patients? (Select all that apply.) a. Saying ―I'm here‖ b. Including the family in care c. Staying with the patient during a bedside test d. Relying on monitors and technology e. Refining work processes on the unit - ANSWER>>>A,B,C Which nurse most likely kept records on sanitation techniques and the effects on health? a. Florence Nightingale b. Mary Nutting c. Clara Barton d. Lillian Wald - ANSWER>>>A The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? a. Assessment b. Diagnosis c. Planning d. Implementation - ANSWER>>>C An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? a. Novice b. Proficient c. Competent d. Advanced beginner - ANSWER>>>A A nurse assesses a patient's fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating? a. Licensure b. Autonomy c. Certification d. Accountability - ANSWER>>>B A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing? a. Educator b. Manager c. Advocate d. Caregiver - ANSWER>>>B The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend? a. Doctor of Nursing Science degree (DNSc) d. Clinical nurse specialist - ANSWER>>>C The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse-midwife, the patient asks for a referral to a pediatrician for the newborn. Which action should the nurse-midwife take initially? a. Provide the referral as requested. b. Offer to provide the newborn care. c. Refer the patient to the supervising provider. d. Tell the patient that is not allowed to make referrals. - ANSWER>>>B The nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). Which activity is appropriate for a CRNA? a. Manages gynecological services such as PAP smears. b. Works under the guidance of an anesthesiologist. c. Obtains a PhD degree in anesthesiology. d. Coordinates acute medical conditions. - ANSWER>>>B A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts? a. Protects the nurse. b. Protects the public. c. Protects the provider. d. Protects the hospital. - ANSWER>>>B A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. What should the nurse realize? a. Legislation is politics beyond the nurse's control. b. National programs have no bearing on state politics. c. The individual nurse can influence legislative decisions. d. Focusing on nursing care provides the best patient benefit. - ANSWER>>>C A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using? a. Code of ethics b. Standards of practice c. Standards of professional performance d. Quality and safety education for nurses - ANSWER>>>A A graduate of a baccalaureate degree program plans to start working as a registered nurse (RN) in the emergency department. Which action must the nurse take first? a. Obtain certification for an emergency nurse. b. Pass the National Council Licensure Examination. c. Take a course on genomics to provide competent emergency care. a. Master's degree b. Inservice education c. Doctoral preparation d. Continuing education e. National Council Licensure Examination retakes - ANSWER>>>B,D A nurse wants to become an advanced practice registered nurse. Which options should the nurse consider? (Select all that apply.) a. Patient advocate b. Nurse administrator c. Certified nurse-midwife d. Clinical nurse specialist e. Certified nurse practitioner - ANSWER>>>C,D,E The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will have to cancel one or two of its nurses. The orthopedic unit has agreed to ―float‖ two of its nurses to the oncology unit if oncology can ―float‖ a nursing assistant to the orthopedic unit to help with obtaining vital signs. Which concepts does this situation entail? (Select all that apply.) a. Autonomy b. Informatics c. Accountability d. Political activism e. Teamwork and collaboration - ANSWER>>>A,C,E A nurse is discussing the changing demographics of the US population. What is expected to be the fastest growing racial ethnic group by 2060? a. Hispanic b. Asian c. Multiracial d. Non-Hispanic Blacks - ANSWER>>>C A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate. - ANSWER>>>B A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases - ANSWER>>>A interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking. - ANSWER>>>B Which action indicates the nurse is meeting a primary goal of culturally competent care for marginalized patients? a. Provides care to transgender patients. b. Provides care to restore relationships. c. Provides care to patients that is individualized. d. Provides care to surgical patients. - ANSWER>>>A The nurse is caring for a Asian patient using the teach-back technique. Which action by the nurse indicates successful implementation of this technique? a. Asks, ―Does this make sense?‖ b. Asks, ―Do you think you can do this at home?‖ c. Asks, ―What will you tell your spouse about changing the dressing?‖ d. Asks, ―Would you tell me if you don't understand something, so we can go over it?‖ - ANSWER>>>C A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a. Caucasians b. Poor people c. Alaska Natives d. American Indians - ANSWER>>>B A nurse is assessing culturally diverse population groups for the risk of suicide. Which assessment question will provide the most culturally relevant information? a. ―Is suicide common in your culture?‖ b. ―How is suicide viewed in your culture?‖ c. ―Has anyone here every considered suicide?‖ d. ―Do you know anyone who as committed suicide?‖ - ANSWER>>>B A nurse is caring for a patient with limited English-speaking skills. What intervention should be implemented to best assist in educating the patient about their disease process? a. Request a trained medical interpreter. b. Provide information in graphic form when possible. c. Use handouts prepared in the patient's native language. d. Ask that a family member be present during educational teaching. - ANSWER>>>A A nurse is assessing a patient's ethnic history. Which question should the nurse ask? a. What language do you speak at home? c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions - ANSWER>>>A A nurse is using Campinha-Bacote's model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge e. Cultural encounters - ANSWER>>>A,B,D,E A nurse is attempting to establish a respectful relationship with a newly admitted patient from another county. Which actions should the nurse take? (Select all that apply.) a. Engage in face-to-face interactions. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures. - ANSWER>>>A,C A nurse is using the Campinha-Bacote model to determine the cause of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have? - ANSWER>>>B,C,E Which action should thenurse take when using critical thinking to make clinical decisions? a. Makes decisions based on intuition. b. Accepts one established way to provide care. c. Considers what is important in any given situation. d. Reads and follows theheath care provider's orders. - ANSWER>>>C Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a. Administering pain-relief medication according to what was given last shift b. Offering pain-relief medication based on thehealth care provider's orders c. Asking thepatient what pain-relief methods, pharmacological and nonpharmacological, have worked in thepast d. Explaining to thepatient that self-reporting of severe pain is not consistent with theminor procedure that was performed - ANSWER>>>C Which action indicates a registered nurse is being responsible for making clinical decisions? b. Experience c. Nursing process d. Specific knowledge base - ANSWER>>>D Which action by a nurse indicates application of thecritical thinking model to make thebest clinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on thecharge nurse to determine priorities of care d. Using thenursing process - ANSWER>>>D A nurse is using thecritical thinking skill of evaluation. Which action will thenurse take? a. Examine themeaning of data. b. Support findings and conclusions. c. Review theeffectiveness of nursing actions. d. Search for links between thedata and thenurse's assumptions - ANSWER>>>C The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. thenurse then auscultates an apical pulse and asks thepatient whether there is any history of heart problems. thenurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation - ANSWER>>>C A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. thenext dose of pain medicine is not due for another hour. What should thecritically thinking nurse do first? a. Explore other options for pain relief. b. Discuss thesurgical procedure and reason for thepain. c. Explain to thepatient that nothing else has been ordered. d. Offer to notify thehealth care provider after morning rounds are completed. - ANSWER>>>A Which action should thenurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all in-service opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences. - ANSWER>>>C While caring for a hospitalized older-adult female post hip surgery, thenurse is faced with thetask of inserting an indwelling urinary catheter, which involves rotating thehip into a A nurse is using professional standards to influence clinical decisions. What is therationale for thenurse's actions? a. Establishes minimal passing standards for testing. b. Utilizes evidence-based practice based on nurses' needs. c. Bypasses thepatient's feelings to promote ethical standards. d. Uses critical thinking for thehighest level of quality nursing care. - ANSWER>>>D A nurse who is caring for a patient with a pressure ulcer applies therecommended dressing according to hospital policy. Which standard is thenurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guidelines - ANSWER>>>D A nurse is reviewing care plans. Which finding, if identified in a plan of care, should theregistered nurse revise? a. Patient's outcomes for learning b. Nurse's assumptions about hospital discharge c. Identification of several actual health problems d. Documentation of patient's ability to meet thegoal - ANSWER>>>B Which findings will alert thenurse that stress is present when making a clinical decision? (Select all that apply.) a. Tense muscles b. Reactive responses c. Trouble concentrating d. Feeling very tired e. Managed emotions - ANSWER>>>A,B,C,D The nurse is using critical thinking skills during thefirst phase of thenursing process. Which action indicates thenurse is in thefirst phase? a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on priorities of patient care. d. Determines whether outcomes have been achieved. - ANSWER>>>A A nurse is using theproblem-specific approach to data collection. Which action will thenurse take first? a. Completing thequestions in chronological order b. Focusing on thepatient's presenting situation c. Making accurate interpretations of thedata d. Conducting an observational overview - ANSWER>>>B After reviewing thedatabase, thenurse discovers that thepatient's vital signs have not been d. Ordering medications - ANSWER>>>C A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will thenurse use that will best obtain this information? a. Carefully review lab results. b. Conduct thephysical assessment. c. Perform a thorough nursing health history. d. Prolong thetermination phase of theinterview - ANSWER>>>C While interviewing an older female patient of Asian descent, thenurse notices that thepatient looks at theground when ANSWERing questions. What should thenurse do? a. Consider cultural differences during this assessment. b. Ask thepatient to make eye contact to determine her affect. c. Continue with theinterview and document that thepatient is depressed. d. Notify thehealth care provider to recommend a psychological evaluation. - ANSWER>>>A A nurse has already set theagenda during a patient-centered interview. What will thenurse do next? a. Begin with introductions. b. Ask about thechief concerns or problems. c. Explain that theinterview will be over in a few minutes. d. Tell thepatient ―I will be back to administer medications in 1 hour.‖ - ANSWER>>>B The nurse is attempting to prompt thepatient to elaborate on thereports of daytime fatigue. Which question should thenurse ask? a. ―Is there anything that you are stressed about right now that I should know?‖ b. ―What reasons do you think are contributing to your fatigue?‖ c. ―What are your normal work hours?‖ d. ―Are you sleeping 8 hours a night?‖ - ANSWER>>>B A nurse is conducting a nursing health history. Which component will thenurse address? a. Nurse's concerns b. Patient expectations c. Current treatment orders d. Nurse's goals for thepatient - ANSWER>>>B While thepatient's lower extremity, which is in a cast, is assessed, thepatient tells thenurse about an inability to rest at night. thenurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for thenurse to take? reports increased pain and thefamily wants something done. c. The nurse immediately asks thehealth care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when thepatient reports decreased mobility - ANSWER>>>A While completing an admission database, thenurse is interviewing a patient who states, ―I am allergic to latex.‖ Which action will thenurse take first? a. Immediately place thepatient in isolation. b. Ask thepatient to describe thetype of reaction. c. Proceed to thetermination phase of theinterview. d. Document thelatex allergy on themedication administration record. - ANSWER>>>B A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is thenurse's initial action in response to these observations? a. Proceed to thenext patient's room to make rounds. b. Determine thepatient does not want any pain medicine. c. Ask thepatient what causes thefacial grimacing with movement. d. Administer thepain medication ordered for moderate to severe pain. - ANSWER>>>C The nurse is interviewing a patient with a hearing deficit. Which area should thenurse use to conduct this interview? a. The patient's room with thedoor closed b. The waiting area with thetelevision turned off c. The patient's room before administration of pain medication d. The waiting room while theoccupational therapist is working on leg exercises - ANSWER>>>A A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. thepatient's daughter is present in theroom. Which action by thenurse will require follow-up by thecharge nurse? a. The nurse makes eye contact with thepatient. b. The nurse speaks only to thepatient's daughter. c. The nurse leans forward while talking with thepatient. d. The nurse nods periodically while thepatient is speaking. - ANSWER>>>B After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To determine the direction of nursing care c. To develop clinical judgment based on other's intuition d. To help nurses focus on the scope of medical practice - ANSWER>>>B A patient presents to the emergency department following a motor vehicle crash that causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety - ANSWER>>>C The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation - ANSWER>>>A A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a. Risk b. Problem focused c. Health promotion d. Collaborative problem - ANSWER>>>C A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient reports feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation - ANSWER>>>A A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing - ANSWER>>>B A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection - ANSWER>>>C A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a. Decreased cardiac output related to altered myocardial contractility. b. Patient needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort. - ANSWER>>>A A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database - ANSWER>>>C A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea - ANSWER>>>C Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. ―What types of foods do you think caused your upset stomach?‖ b. ―How many bowel movements a day have you had?‖ The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process? a. Assessment b. Diagnosis c. Planning d. Implementation - ANSWER>>>C A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient falls. Which initial action will the nurse take next to most effectively revise the plan of care? a. Consult physical therapy. b. Establish a new plan of care. c. Set new priorities for the patient. d. Assess the patient. - ANSWER>>>D Which information concerning a goal indicates a nurse has a good understanding of its purpose? a. It is a statement describing the patient's accomplishments without a time restriction. b. It is a realistic statement predicting any negative responses to treatments. c. It is a broad statement describing a desired change in a patient's behavior. d. It is a measurable change in a patient's physical state. - ANSWER>>>C A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient? a. Patient will increase activity level this shift. b. Patient will turn side to back to side with assistance every 2 hours. c. Patient will use the walker correctly to ambulate to the bathroom as needed. d. Patient will use a sliding board correctly to transfer to the bedside commode as needed - ANSWER>>>A The following statements are on a patient's nursing care plan. When creating a nursing care plan, which statement should the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased tolerance to activity over the next month. c. The patient will understand needed dietary changes by discharge. c. ―Decide on goals and outcomes you have chosen for the patients.‖ d. ―Begin with the highest priority diagnoses, then select appropriate interventions.‖ - ANSWER>>>D A patient's son decides to stay at the bedside while his father is experiencing confusion. When developing the plan of care for this patient, what should the nurse do to best meet the patient's needs? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible - ANSWER>>>D A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will walk unassisted to bathroom by the end of shift. c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift. - ANSWER>>>A The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent b. Independent c. Interdependent d. Physician-initiated - ANSWER>>>C A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent - ANSWER>>>D Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court. b. Implements interventions based on scientific research. c. Uses standardized care plans for all patients. d. Plans care based on tradition. - ANSWER>>>B A nurse is developing a care plan. Which intervention is most appropriate for the nursing