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EXAM 1 FOR PN 101 QUESTIONS
WITH ANSWERS RATED A+
The nurse describes 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 ANS: C In planning the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes. A nurse assesess a patients 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 ANS: B Autotomy is an essential element of the professional nursing that involves the initiation of independent nursing interventions without medical orders. A nurse identifies the gaps between local and best practices. Which quality and safety education for nurses (QSEN) competency is the nurse demonstrating? A) Safety B) Patient- centered care C) Team work and collaboration - ANSWER ANS: C Quality improvement identifies gaps between local and best practices. Safety minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Patient- centered care recognizes the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. Teamwork and collaboration allows effective functioning within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision making. An example of a violation to criminal law by a nurse is: A) Taking a controlled substance from agency supply for personal use. B)Accidentally administering a drug to the wrong
C) Advising a patient to sue the doctor for a supposed mistake the doctor made D) Writing a letter to the newspaper outlining questionable or unsafe hospital practices - ANSWER ANS: A Theft of a controlled substance is a federal crime and consequently a crime against society A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, "I have no idea what is going to happen. I couldn't ask any questions." The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying? a. Manager b. Patient educator c. Patient advocate d. Clinical nurse specialist - ANSWER ANS: C As a patient advocate, the nurse protects the patient's human and legal rights, including the right of the patient to understand procedures before signing permits. Although nurses can be educators, it is the responsibility of the surgeon to provide education for the patient in preparation for surgery, and it is the nurse's responsibility to notify the health care provider if the patient is not properly educated. Managers coordinate the activities of members of the nursing staff in delivering nursing care, and clinical nurse specialists are experts in a specialized area of nursing practice in a variety of settings 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 ANS: B The nurse practice acts regulate the scope of nursing practice and protect public health, safety, and welfare. They do not protect the nurse, provider, or hospital 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 ANS: A The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. The Standards of Practice describe a competent level of nursing care. The ANA Standards of
A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical chart to take, because it is her personal property. An appropriate response would be: A) Certainly, This hospital doesn't need to keep is if you are leaving and will not be returning here. B) You are entitled to the information in your chart, but the chart is the property of the hospital. I will see about having a copy made for you. C) The information in your chart is confidential, and you cannot leave this facility with it. D) Because you are leaving against medical advice of your physician, you may not have the chart. - ANSWER ANS: B The chart is the property of the facility, but the patient has a legal right to the information in it even if she is leaving AMA. A nurse enters a notation in a patients chart but then discovers that the notation was made in the wrong chart. The nurse correctly: A) draws a single line through the notation so that it is still readable and writes mistaken entry, his signature, and the date and time. B) removes the page on which the error is written and rewrites the other correct notes C) blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin wrong patient, his signature, and the date and time. D) whites out the wrong entry and writes the note in the chart of the correct patient. - ANSWER ANS: A When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as ________ data. A) Objective B) Medical C) Subjective D) Adjunct - ANSWER ANS: C Subjective data are symptoms that only the patient can identify. During the assessment phase of the nursing process, the nurse___________ A) Develops a care plan to meet the patients nursing needs. B) Begins to formulate plans for providing nursing interventions C) Establishes a nursing diagnosis for the nursing care plan D) Gathers, organizes, and document data in a logical database. - ANSWER ANS: D Gathering and organizing data is the first step in the assessment phase of the nursing process. the nurse takes into consideration that the difference between a sign and a symptom is that a sign is:
A) Subjective data B) unreliable because it depends on translation C) Can be verified by examination D) Something a patient reports that is verified by a relative - ANSWER ANS: C Signs are objective data that can be confirmed by examination, assessment, or observation. Signs are reliable research- based data The nurse clarifies that nursing orders are also called: A) Goals B) Qualifiers C) Interventions D) Measurement criteria - ANSWER ANS: Nursing orders are called nursing interventions and follow the same requirements when placed in a nursing care plan. The nurse understands that an expected outcome should be: (select all that apply) A) Realistic B) Approved by the physician C) Attainable D) Within a defined time E) Included after patient collaboration - ANSWER ANS: A,C,D,E AN expected outcome should be realistic and attainable and should have a defined time line after collaboration with the patient the nurse can best ensure that communication is understood by: A) Speaking slowly and clearly in the patients native language B) Asking the family member whether the patient understands C) Obtaining feedback from the patient that indicates accurate comprehension D) Checking for signs of hearing loss or aphasia before communicating. - ANSWER ANS C: The best way to determine understanding is to ask the patient. Factors such as anxiety, hearing acuity, language, aphasia, or lack of familiarity with medical jargon or routines can all contribute to misunderstanding. The nurse recognizes a verbal response when the patient: A) Nods her head when asked whether she wants juice B) Writes the answer to a question asked by the nurse C) Begins sobbing uncontrollably when asked about her daughter D) is moaning and restless and appears to be in pain - ANSWER ANS: B Verbal communication involves words, either written or spoken. Nodding, sobbing and moaning are nonverbal communication A nurse using active listening techniques would:
D) white blood cell count of 19,000 - ANSWER ANS: B another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. What objective data should the nurse include after a patient assessment? A) Headache of 3 days duration B) Severe stomach cramps C) Flatulence D) Anxiety - ANSWER ANS: C objective data are observable and measurable by people other than the patient What is classified as information provided by the family when a patient is unable to provide data during assessment? A) Primary B) Secondary C) Unreliable D) Biased - ANSWER ANS: B Secondary sources include family members. What framework does the establishment of priorities of care during the planning phase of the nursing process often use? A) Erickson's developmental tasks B) Piagets cognitive table C) Maslow's hierarchy of needs D) Freuds classifications - ANSWER ANS: C A useful framework to guide prioritization is maslow's hierarchy of needs When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? A) Assessment B) Planning C) Implementation D) Evaluation - ANSWER ANS: B During the planning phase, the nurse connects nursing interventions to nursing orders. Which are acceptable secondary sources for data? (Select all that apply) A) Patient B) Family members C) Other health professionals D) Diagnostic reports E) Textbooks - ANSWER ANS: B,C,D,E A patient is not a secondary source. Which are considered phases of the nursing process? (Select all that apply) A) Diagnosis B) Prediction C) Assessment D) Evaluation
E) Implementation - ANSWER ANS: A,C,D,E The nursing process consists of five dynamic and interrelated phases: diagnosis, assessment, evaluation, implementation, planning. Predication is not a phase of the nursing process. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: A) Malpractice B) harm to the patient C) Negligence D) Failure to follow the nurse practice act - ANSWER ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? A) Physical assessment B) Interview C) Informed consent D) Surgical checklist - ANSWER ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. The new LPN is concerned regarding what should or should not be done for patients. What resource will best provide this information? A) Nurse practice act B) Standards of care C) Scope of nursing practice D) Professional organizations - ANSWER ANS: B Standards of car define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? A) Administering a stronger dose of drug than was ordered B) Refusing to give a patient daughter information over the phone C) Informing the patient medical power of attorney of a medication change D) Leaving a copy of the patients history and physical in the photocopier - ANSWER ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patients daughter information over the phone is appropriate practice
C) Implementation D) Evaluation - ANSWER ANS: D A nurse evaluates the effectiveness of interventions based on the patients ability to meet established goals and outcomes Who is the legal owner of the patients medical records? A) Patient B) Physician C) Institution D) State - ANSWER ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the physician in the case of private office visits. When a student nurse performs a nursing skill, it is expected that the student: A) Performs the skill as quickly as the license nurse B) Achieves the same result as the licensed nurse C) Not be held to the same standard as the licensed nurse. D) Always be directly supervised by an instructor. - ANSWER ANS: B Students are not expected to perform skills as quickly or as smooth as experienced nurses, but should be done in the same safe manner and result in the same way. If a patient indicates that he is unsure if he needs the surgery he is scheduled for later that morning, the nurse would best reply: A) "Your doctor explained all of that yesterday when you signed the consent" B) "Your doctor is in the operating room; she cant talk to you now" C) "You should have the surgery; your doctor recommended that you have it"
- ANSWER The nurse takes into consideration that of all the physical changes that the elderly experience, the most common cause of most problems is that of: A) Visual disturbance B) Hearing deficit C) Loss of muscle mass D) Impaired mobility - ANSWER ANS: D Constipation, urinary incontinence, and alteration in nutrition and depression are all problems that are complicated or caused by impaired mobility. An elderly patient is too weak to walk independently after surgery. Based on the services available on the rehabilitation unit, the nurse should work collaboratively with a(n): A) Exercise physiologist B) Nutritionist C) physical therapist
D) Occupational therapist - ANSWER ANS: C Physical therapists can assist patients with mobility and teach them to use assistive devices as needed, such as walkers and canes. The nurse adds to the nursing care plan for a resident with presbycusis. To better communicate with the patient, the staff should use: A) Written notes B) A slower speed of speech C) A lower, deeper voice. D) Hand signals - ANSWER ANS: C Speaking in a lower, deep voice will allow the person with presbycusis to hear better since these persons have difficulty picking up higher-pitched sounds and spoken words. The nurse is aware that the newly admitted resident has age-related macular degeneration (AMD). Th nurse will modify the care plan to accommodate the patients: A) Loss of central vision B) lack of ability to focus on near objects C) Inability to adjust from light to dark environments D) Increasing pressure in the eye with progressive blindness - ANSWER ANS: A AMD causes loss of central vision as well as color perception For a patient with visual impairment who wishes to continue to eat independently, the nurses most helpful intervention would be to: A) describe positions of foods on the plate by clock position B) tell the patient to eat all foods that are firmest first. C) raise the over-the-bed table so that all food is within 3 inches of the eyes. D) have the patient use a spoon instead of a fork - ANSWER ANS: A It is helpful to describe the position of the foods on the plate. The texture of the food has nothing to do with visual impairment. It is not helpful or realistic to raise the over-the-bed table so that the plate is 3 inches away from the eyes. Using a spoon will not help the patient identify foods on the plate. A nurse who is assisting a blind patient to ambulate should: A) Hold the patients arm firmly to gently put him in the proper directions B) Hold the patient by a strap around the patients waist to prevent his falling. C) Offer the patient an arm for guidance D) Acquire a cane for the patient. - ANSWER ANS:C Offering the patient an arm or walking in front of the patient with the patients hand on the shoulder gently guides the visually impaired A nurse is caring for an 86-year-old patient who still takes pride in the fact that he drives. The nurse suggests that his driving be limited to: A) Back roads B) large shopping centers
C)Increased sensitivity to touch D)Increased sensitivity to taste - ANSWER ANS: A Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase. Which factors in a health history place a patient at risk for hearing loss? Choose all that apply. A)Being an older adult B)Childhood chickenpox C)Frequent otitis media D)Diabetes mellitus - ANSWER ANS: A, C Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss The nurse will choose the best time to continue postoperative teaching regarding wound care and dressings, which would be: A) Immediately after the patient has been medicated for pain B) just before the patient is discharged , so the information is current. C) when the patient is comfortable and receptive to the teaching D) the last thing in the evening, after visitors have left, before bedtime. - ANSWER ANS: C A patient who is in pain, sedated from pain medication, or fatigued at the end of the day after visitors leave will not be receptive to teaching. An 80-year-old patient is to be taught the process of colostomy irrigation and reattachment of the colostomy bag. The nurses initial assessment prior to instruction should address the patients: A) understanding of the process of irrigation B) Familiarity with the irrigation materials C) Manual dexterity D) Motivation to learn - ANSWER ANS: D The patients motivation to learn a new skill is essential to the success of the instruction. Some patients need to see the advantage of independence to motivate them to learn. Manual dexterity and basic understanding of materials and process are important, but initially the motivation needs to be assessed. The nurse can assess her patients ability to read and comprehend written instructions by doing which of the following? A) Asking the patient, "Did you graduate from high school?"
B) Giving the patient a printed instruction sheet and saying, "Some people have difficulty with written instructions. Others find them helpful. Would these be helpful to you?" C) Asking the patient, "Are you able to read?" D)Giving the patient some printed materials and saying, "After you have read this, Ill ask you some questions about whats in them, to see if youve learned it." - ANSWER ANS: B Graduation from high school does not guarantee reading comprehension. Actually reading allows the nurse to know if the patient can read as well as comprehend. The nurse evaluates the effectiveness of teaching relative to how to use an eye shield after eye surgery is to: A) have the patient tell the nurse what he is going to do. B) have the patient demonstrate that he can secure the eye shield. C) Ask the patient if he has any questions related to the use of the shield. D) Call the patient at home in 3 days and ask if he has been wearing the shield - ANSWER ANS: B A return demonstration and explanation by the patient will evaluate whether the patients learning needs are met. Having the patient describe the process and ask questions might be helpful but does not show that the patient can place the shield correctly (a psychomotor skill). Evaluation of teaching should be done to allow time to revise the teaching plan if the patient is unable to meet the behavioral objectives. Calling after discharge is too late to correct problems The best way for a nurse to reinforce learning during a return demonstration by the patient is for the nurse to: A) give recognition and praise for the parts the patient does well and to assist or teach when the patient becomes confused or forgetful B) watch quietly until the return demonstration is finished and then list the errors. C) instruct the patient to read the written material again when an error is made. D) stop the patient each time he makes a mistake and have jhim start again after the nurse reviews the procedure with him. - ANSWER ANS: A Praise and walking through the procedure reinforces learning A nurse is showing a diabetic patient how to draw insulin out of a syringe. The mode of learning that the nurse is using is____ learning. A) auditory B) visual C) kinesthetic D) oral - ANSWER ANS: B Visual learning is based on learning through what the learner sees. The nurse will plan to offer the teaching session in a quite area in order to: A) Ensure that the patient can hear what the nurse says.
