Fundamentals of Nursing Exam 1 Review: Chapters 1, 2, 3, 8, 9, 10, 15, 23, 30, 31, Exams of Nursing

Download Fundamentals of Nursing Exam 1 Review: Chapters 1, 2, 3, 8, 9, 10, 15, 23, 30, 31 and more Exams Nursing in PDF only on Docsity!

Fundamentals of Nursing Exam 1 Review for

Chapters 1, 2, 3, 8, 9, 10, 15, 23, 30, 31 Questions

and Answers.

Which action by the nurse demonstrates implementation of Florence Nightingale's original theories about nursing care? A. The patient is gently bathed and given fresh linens after giving birth. B. The nurse forms a close therapeutic relationship with the patient. C. The nurse helps the patient conserve energy for healing processes. D. The nurse views the patient as a unique, ever-changing energy field. - Correct Answer A. The patient is gently bathed and given fresh linens after giving birth. The nurse is mandated by the state to complete 25 contact hours of nursing education before the nursing license may be renewed. Which term best describes this requirement? A. In-service education B. Advanced Education C. Continuing education D. Certification Education - Correct Answer C. Continuing education The nurse is caring for a patient who suddenly becomes acutely short of breath. The nurse elevates the head of the patient's bed, checks the patient's pulse oximetry, and administers 2 L of oxygen before notifying the patient's physician. Which term best describes the actions of the nurse? a. Accountability b. Autonomy c. Licensured. d. Certification - Correct Answer B. Autonomy Which type of program is appropriate to educate staff about new fall prevention protocols that are to be implemented on the nursing unit? a. In-service education b. Advanced education c. Continuing education d. Certification Education - Correct Answer a. In-service education

Which program is appropriate for a nurse who wishes to become an expert in ostomy and wound care? a. Specialty certification b. Master of Science program c. Doctoral degree program d. Continuing education program - Correct Answer A. Specialty certification Which action of the nurse demonstrates coordination of care for the patient? a. The nurse creates a warm, therapeutic relationship with the patient by actively listening to what the patient has to say. b. The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair. c. The nurse educates the patient about energy conservation techniques to increase activity tolerance. d. The nurse uses clear and objective language when documenting assessment findings in the patient's medical record. - Correct Answer B. The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair. The nurse feels that an assigned duty is outside the scope of nursing practice. Which document is the best source to answer the nurse's concern? a. ANA Code of Ethics b. State Nurse Practice Act c. QSEN Initiative Act d. Nurse's Bill of Rights - Correct Answer B. State Nurse Practice Act Which professional nursing organization ensures that nursing programs adequately prepare students to enter the nursing profession? a. Federal Nurses Association (FNA) b. International Council of Nurses (ICN) c. National League for Nursing (NLN) d. National Student Nurses Association (NSNA) - Correct Answer C. National League for Nursing

Which actions of the nurse demonstrate the nursing role of leader? (Select all that apply.) a. The nurse implements a new skin-care protocol to reduce decubitus ulcers. b. The nurse develops a therapeutic relationship with the patient's family members. c. The nurse ensures that the patient assignments are created fairly for each shift. d. The nurse works to meet the patient's cultural preferences for personal care. e. The nurse clearly communicates expected standards of care for the patients. - Correct Answer A, C, E Which actions of the nurse demonstrate the nursing role of educator? (Select all that apply.) a. The nurse teaches the patient's family how to perform sterile dressing changes. b. The nurse includes the patient in clinical decision making whenever possible. c. The nurse provides written teaching materials in the patient's preferred language. d. The nurse speaks about diabetes management at a professional conference. e. The nurse assesses for adequate protein intake for a patient on a vegetarian diet. - Correct Answer A, C, D Which nursing actions incorporate informatics into nursing practice? (Select all that apply.) a. The nurse uses written materials to teach a patient who is hard of hearing. b. The nurse uses an online database to learn more about the patient's disease. c. The nurse uses a bar-code scanner to prevent medication administration errors. d. The nurse teaches the patient's family how to perform range of motion. e. The nurse checks the electronic record to review the patient's medical history. - Correct Answer B, C, E

Which action of the nurse demonstrates patient-centered care? (Select all that apply.) a. The nurse elevates the head of the bed when the patient becomes short of breath. b. The nurse and patient work together to determine the patient's health goals. c. The nurse checks the patient's name and birthdate before giving medications. d. The nurse maintains privacy when conversing with the patient and providing care. e. The nurse respects the patient's choice to refuse transfusion of blood products. - Correct Answer B, D, E Which statement by the patient indicates to the nurse that the patient is in the preparation stage of smoking cessation? a. "I don't ever want to quit smoking." b. "I hope to quit smoking sometime before I die." c. "I am really working hard to stop smoking." d. "I stocked up on nicotine patches and gum." - Correct Answer d. "I stocked up on nicotine patches and gum." Which patient assessment finding must be addressed first according to Maslow's hierarchy of needs? a. The patient is cyanotic and feels short of breath. b. The patient refuses to participate in physical therapy. c. The patient verbalizes anxiety about upcoming surgery. d. The patient is unable to reposition in bed without assistance. - Correct Answer a. The patient is cyanotic and feels short of breath. Which patient action demonstrates the concept of health promotion? a. The patient receives the influenza vaccination every year. b. The patient participates in cardiac rehabilitation after a heart attack. c. The patient has yearly mammograms to screen for breast cancer. d. The patient follows a macrobiotic, vegetarian diet with organic foods. - Correct Answer d. The patient follows a macrobiotic, vegetarian diet with organic foods.

4. Which assessment finding is an example of an internal variable that influences the patient's health beliefs? a. The patient's spiritual beliefs prohibit the use of blood transfusions.

b. The patient's family is homeless after being evicted from their apartment. c. The patient relies on a pharmacy assistance program to pay for medications. d. The patient and community prefer natural medicines over prescription drugs. - Correct Answer a. The patient's spiritual beliefs prohibit the use of blood transfusions. Which action by the patient best represents primary prevention? a. The patient utilizes a cane when walking to prevent falls. b. The patient receives the influenza vaccination every year. c. The patient participates in physical therapy after having a stroke. d. The patient takes prescribed blood pressure medication every morning. - Correct Answer b. The patient receives the influenza vaccination every year. Which assessment finding is a modifiable risk factor for disease? a. The patient has a family history of breast cancer. b. The patient smokes two packs of cigarettes every day. c. The patient was born with a congenital heart defect. d. The patient's childhood home contained high levels of radon. - Correct Answer b. The patient smokes two packs of cigarettes every day. Which is an example of an acute illness? a. Type 2 diabetes b. Multiple sclerosis c. Alcohol addiction d. Bacterial meningitis - Correct Answer d. Bacterial meningitis The diabetic patient sees the podiatrist regularly to prevent the development of ulcers in the feet. Which term best describes this action of the patient? a. Health promotion b. Primary prevention c. Secondary prevention d. Tertiary prevention - Correct Answer c. Secondary prevention Which statement indicates the patient's perception of susceptibility to illness as described by the Health Belief Model? a. "I am never going to get lung cancer so I refuse to stop smoking." b. "Cancer is no big deal with all of the new treatments available now."

c. "I have been smoking for so many years that I will never be able to quit." d. "I cannot afford the nicotine patches so I might as well keep on smoking." - Correct Answer a. "I am never going to get lung cancer so I refuse to stop smoking." Which action by the patient reflects a cultural influence on health practices? a. The patient uses seaside purification rituals to ease arthritis pain. b. The patient refuses to take blood pressure medicine due to the side effects. c. The patient has annual mammograms to screen for breast cancer. d. The patient avoids eating red meat due to a family history of heart disease. - Correct Answer a. The patient uses seaside purification rituals to ease arthritis pain. Which is an example of how a psychosocial variable affects the patient's health beliefs? a. The patient was diagnosed with rheumatoid arthritis as a young child. b. The patient has always been terrified of needles and so never goes to the doctor. c. The patient's neighborhood has few opportunities to buy fresh fruits or vegetables. d. The patient requires three antihypertensive medications to control blood pressure. - Correct Answer b. The patient has always been terrified of needles and so never goes to the doctor. Which statement by the nurse will help the patient progress to the preparation stage for smoking cessation? a. "You will die of emphysema or lung cancer if you do not stop smoking." b. "Research has shown that smoking causes emphysema and lung cancer." c. "The physician will give you nicotine patches to help you start to quit smoking." d. "You need to avoid people who smoke so you will not be tempted to start again." - Correct Answer c. "The physician will give you nicotine patches to help you start to quit smoking." Which is an example of a Healthy People 2020 goal? a. Women and men will receive equally aggressive care for suspected heart attack.

b. The patient will participate in a physical therapy program after suffering a stroke. c. The nurse will identify and address stressors unique to multicultural families. d. The nurse will organize mobile mammograms for female patients in the local area. - Correct Answer a. Women and men will receive equally aggressive care for suspected heart attack. Which action of the nurse addresses Maslow's need for love and belongingness? a. The nurse uses a gait belt and assists the patient to use a walker for ambulation. b. The nurse encourages a widowed patient to join a bereavement support group. c. The nurse plans daily care to allow for rest periods for the patient as needed. d. The nurse reorients the patient to time and place during periods of acute confusion. - Correct Answer b. The nurse encourages a widowed patient to join a bereavement support group. Which action by the nurse helps to meet the aesthetic needs of the patient as described by Maslow? a. The nurse uses a drawsheet to carefully reposition the patient in bed. b. The nurse puts a beautiful handmade quilt on the bed for the patient to enjoy. c. The nurse collaborates with the health care team when scheduling care activities. d. The nurse assesses the patient's readiness to learn before beginning teaching. - Correct Answer b. The nurse puts a beautiful handmade quilt on the bed for the patient to enjoy. Which action by the nurse helps to meet the cognitive needs of the patient as described by Maslow? a. Encouraging early ambulation after surgery to prevent formation of blood clots. b. Providing a calm environment when the patient becomes agitated and confused. c. Teaching the patient's family how to perform sterile dressing changes.

d. Performing careful perineal care to avoid development of a urinary tract infection. - Correct Answer b. Providing a calm environment when the patient becomes agitated and confused. Which action of the nurse demonstrates the concept of the Holistic Health Model? a. The nurse incorporates the patient's religious restrictions, economic status and personal preferences when developing the nutrition plan. b. The nurse has the patient demonstrate how to perform a sterile dressing change after teaching about the procedure. c. The nurse consistently uses a 0-10 objective pain rating scale to achieve consistent pain management for the patient. d. The nurse assists the patient to sit up slowly when getting out of bed to avoid fainting from orthostatic hypotension. - Correct Answer a. The nurse incorporates the patient's religious restrictions, economic status and personal preferences when developing the nutrition plan. Which is an example of an environmental risk factor? a. The patient's drinking water contains high levels of lead. b. The patient has a strong family history of autoimmune diseases. c. The patient carefully follows a lactose-free, gluten-free diet. d. The patient drinks one glass of red wine every night before bed. - Correct Answer a. The patient's drinking water contains high levels of lead. Which assessment finding indicates that the family processes were interrupted by the patient's illness? a. The patient must now follow a gluten-free, low-carbohydrate diet. b. The patient must use a walker for ambulation to prevent a fall or injury. c. The patient's spouse had to return to work to maintain the family's income. d. The patient must take three antihypertensive drugs to control high blood pressure - Correct Answer c. The patient's spouse had to return to work to maintain the family's income. Which assessment finding indicates that the patient's body image has been altered due to illness?

a. The patient developed a strong dislike for any kind of spicy foods. b. The patient feels uncomfortable wearing a swimsuit after colostomy surgery. c. The patient refuses to take antihypertensive medications due to the side effects. d. The patient drinks six glasses of cranberry juice daily to prevent bladder infections. - Correct Answer b. The patient feels uncomfortable wearing a swimsuit after colostomy surgery. Using the Health Promotion Model while rendering care enables a nurse to do which of the following: (Select all that apply.) a. Help the patient attain better health b. Detect the presence of illness c. Promote health behaviors in a patient d. Assess a family's response to illness e. Stimulate relational transcendence - Correct Answer A, C Which is an example of tertiary care? a. The patient has annual mammograms to screen for breast cancer. b. The patient sees the podiatrist monthly to prevent diabetic foot ulcers. c. The patient is seen at an urgent care clinic to treat a badly sprained wrist. d. The patient is treated in the intensive care unit following a gunshot injury.

• Correct Answer d. The patient is treated in the intensive care unit following a gunshot injury. Which agency would be most appropriate for a patient who requires rehabilitation services for right-sided hemiplegia after a stroke? a. Respite center b. Primary care center c. Restorative care center d. Assisted-living center - Correct Answer c. Restorative care center Which form of insurance is appropriate for a single mother who is unable to work and her three children? a. State Medicaid b. Federal Medicare c. Private insurance d. Managed care program - Correct Answer a. State Medicaid

Which is an example of a patient-centered medical home team? a. Occupational and physical therapists come to the patient's home to provide rehabilitation services. b. The patient's primary care physician coordinates care with the patient's social worker and respiratory therapist. c. The nurse assesses the patient's home environment for irritants that can worsen the patient's respiratory status. d. A home care company is employed to provide the patient with a nebulizer and supplemental oxygen equipment. - Correct Answer b. The patient's primary care physician coordinates care with the patient's social worker and respiratory therapist. Which is an example of a tertiary health care provider? a. An outpatient rehabilitation center b. A nurse-managed urgent care clinic c. A university-based research hospital d. A community center offering adult day care services - Correct Answer c. A university-based research hospital Which assessment question allows an administrator to determine the level of patient satisfaction after hospitalization? a. "Did the nursing staff treat you with respect and maintain your privacy?" b. "Were you able to keep the follow-up appointment with your physician?" c. "Did you have any difficulty filling your prescriptions after discharge?" d. "Has the occupational therapist come to your home to start therapy yet?"

• Correct Answer a. "Did the nursing staff treat you with respect and maintain your privacy?" The patient is nauseated and vomiting when the nurse attempts to provide discharge teaching. Which is the most appropriate action of the nurse? a. Administer antinausea medication and provide discharge teaching later. b. Provide written materials to the patient to read when the nausea has subsided. c. Provide discharge teaching to the family members while the patient rests.

d. Assist the patient with mouth care and proceed with the discharge teaching. - Correct Answer a. Administer antinausea medication and provide discharge teaching later. How will the hospital be reimbursed by Medicare for an elderly patient admitted with pneumonia? a. Based upon the DRG for pneumonia b. Based upon the cost of the patient's care c. Based upon the patient's length of stay d. Based upon the types of therapies required - Correct Answer a. Based upon the DRG for pneumonia Which is an example of capitation in health care? a. The patient's rheumatologist is reimbursed for services provided at each consultation appointment with the patient. b. The discharge planner arranges for a home respiratory care company to deliver home oxygen supplies before the patient leaves the hospital. c. The patient's care is managed by a nurse practitioner rather than an attending physician. d. The patient's primary care physician is paid a flat monthly fee no matter how many appointments are scheduled with the patient. - Correct Answer d. The patient's primary care physician is paid a flat monthly fee no matter how many appointments are scheduled with the patient. A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use? a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care - Correct Answer b. Preventative care The nurse has taught the patient about how to perform sterile dressing changes. Which action by the nurse best assesses whether or not the patient's discharge teaching was effective?

a. The nurse watches the patient perform the sterile dressing change and provides feedback as needed. b. The nurse provides additional written instructions as a reminder of how to correctly perform the procedure. c. The nurse includes the patient's spouse when teaching the patient how to perform the sterile procedure. d. The nurse asks the patient and spouse if they have any further questions about how to perform the procedure. - Correct Answer a. The nurse watches the patient perform the sterile dressing change and provides feedback as needed. Which patient will be treated in a Critical Access Hospital (CAH)? a. The cancer patient who requires a bone marrow transplant b. The victim of a serious car accident that occurred in a remote area c. The pregnant patient whose baby will require neonatal intensive care d. The patient who requires minimally invasive heart valve replacement - Correct Answer b. The victim of a serious car accident that occurred in a remote area Which type of patient is an appropriate candidate for restorative care services? a. A patient who uses supplemental oxygen for emphysema b. A patient who is actively dying of metastatic cancer c. A patient with right-sided hemiplegia after a recent stroke d. A patient with depression who tried to commit suicide - Correct Answer c. A patient with right-sided hemiplegia after a recent stroke Which information is included in the Minimum Data Set? a. The patient has a history of gout and macular degeneration. b. The average length of stay for pneumonia is 3 days in the hospital. c. The hospital has a 14% nosocomial urinary tract infection rate. d. Approximately 40% of American adults exercise at least 30 minutes daily. - Correct Answer a. The patient has a history of gout and macular degeneration. Which patient is appropriate for an assisted-living agency?

a. A patient who requires tube feeding and frequent tracheostomy suctioning after a massive stroke b. A patient with dementia who requires supervision during the day when family members are at work c. A patient with severe depression who has made three suicide attempts in the last 6 months d. A patient who can perform activities of daily living independently but requires assistance with daily medications - Correct Answer Which patient is the highest priority for the discharge planner? a. A patient who will require home IV antibiotics for the next 6 weeks b. A patient who will be taking antihypertensive medications after discharge c. A patient who will be discharged after routine tonsillectomy surgery d. A patient who will be returning to a local skilled nursing facility - Correct Answer a. A patient who will require home IV antibiotics for the next 6 weeks Which is an example of respite care? a. A patient with dementia attends an adult day care center so that the patient's family can go to work. b. The respiratory therapist comes to the patient's house to ensure that the oxygen equipment is functioning correctly. c. The nurse teaches the patient's spouse how to check blood sugar levels and administer insulin to the patient. d. The patient is seen in an urgent care clinic for stitches and wound care after being bitten by a dog. - Correct Answer a. A patient with dementia attends an adult day care center so that the patient's family can go to work. Which is the expected action of the nurse who is caring for a patient in a hospice agency? a. The nurse teaches the patient how to administer home IV antibiotics through an

intravenous line. b. The nurse educates the patient's family about what to expect as the patient progresses through the dying process. c. The nurse reviews the patient's daily laboratory results before preparing to administer the next dose of chemotherapy. d. The nurse teaches the patient about the importance of swallow precautions to avoid the development of aspiration pneumonia. - Correct Answer b. The nurse educates the patient's family about what to expect as the patient progresses through the dying process.

19. Which is an example of a diagnosis-related group (DRG)? a. Patients recovering from orthopedic surgery are placed on the same nursing unit. b. Specialty hospitals are utilized to treat patients with life-threatening illnesses. c. The speech therapist is consulted to see every patient admitted with dysphagia. d. Hospitals will be paid $4500 to care for patients with uncomplicated pneumonia - Correct Answer d. Hospitals will be paid $4500 to care for patients with uncomplicated pneumonia Which is a responsibility of the Centers for Medicare and Medicaid (CMS)? a. Create teaching materials to educate health care professionals. b. Research evidenced-based practices to improve health care for patients. c. Accredit and certify hospitals in order to ensure safe health care for patients. d. Manage health insurance coverage for elderly, disabled, and low-income patients. - Correct Answer d. Manage health insurance coverage for elderly, disabled, and low-income patients. Which action by the nurse helps to achieve the goals of the Hospital Readmissions Reduction Program? a. The nurse ensures that the patient understands how to take prescribed medications correctly. b. The nurse develops a close therapeutic relationship with the patient and provides

privacy when care is provided. c. The nurse uses therapeutic touch to promote relaxation, reduce anxiety, and promote healing. d. The nurse elevates the head of the patient's bed and administers oxygen when the patient feels short of breath. - Correct Answer a. The nurse ensures that the patient understands how to take prescribed medications correctly. Which is an example of a Bundled Payment for Care Improvement? a. The insurance company combines services for several patients into one single payment. b. The hospital is paid a predetermined lump sum for all costs related to the patient's open-heart surgery. c. The hospital is paid an additional bonus if the patient's surgical outcome exceeds national standards. d. The insurance company will withhold all payments for the patient until accreditation is achieved. - Correct Answer b. The hospital is paid a predetermined lump sum for all costs related to the patient's open-heart surgery. Which feature of the hospital enables it to qualify for Magnet Recognition Program? a. The hospital cafeteria is open 24 hours to accommodate staff on every shift. b. The nurses utilize evidence-based practice and flexible staffing plans. c. The hospital radiology technicians have received additional certifications. d. The hospital physicians provide mentoring services for interns and residents. - Correct Answer b. The nurses utilize evidence-based practice and flexible staffing plans The patient uses a special telephone connection to allow the cardiologist to assess the patient's pacemaker function while the patient stays at home. Which term is used to describe this type of health care? a. Capitation b. Telemedicine

c. Magnet Recognition Program d. Utilization review - Correct Answer b. Telemedicine Which is an example of health care disparity? a. The physician treats cardiac patients with insurance more aggressively than noninsured patients. b. The patient takes longer to recover from surgery due to a history of aggressive rheumatoid arthritis. c. The nurse prioritizes care so that additional time is spent with patients who require more intensive interventions. d. The registered nurse is able perform more advanced interventions than the licensed practical nurse. - Correct Answer a. The physician treats cardiac patients with insurance more aggressively than noninsured patients. Which type of health care agency is appropriate for a patient who sustained a back injury while at work? a. Respite care center b. Skilled nursing facility c. Occupational health clinic d. Outpatient surgical center - Correct Answer c. Occupational health clinic Which goals are appropriate for a patient in a restorative care agency? (Select all that apply.) a. The patient will be able to transfer to the wheelchair with one person assist. b. The patient's family will verbalize understanding of the dying process. c. The patient will be able to eat independently using specially molded utensils. d. The patient will be transferred to a trauma hospital within 1 hour of arrival. e. The patient's family will verbalize feeling of relief from strains of caregiving. - Correct Answer A, C

Which health care professionals will participate in discharge planning for the patient? (Select all that apply.) a. Registered nurse b. Radiology technician c. Social worker d. Physical therapist e. Laboratory technician - Correct Answer A, C, D The nurse is caring for a patient who is having severe pain despite regular doses of narcotic pain medication. The nurse suspects that the patient may be experiencing neuropathy and obtains an order for gabapentin which relieves the patient's pain. Which term most accurately describes the action of the nurse? a. Intuition b. Reflection c. Perseverance d. Critical thinking - Correct Answer d. Critical thinking A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during the shift. The nurse remembers that this was similar to a situation that happened in the past when a patient developed an internal bleed. Which term most accurately describes the thought process of the nurse? a. Reflection b. Curiosity c. Discipline d. Confidence - Correct Answer a. Reflection The nurse suspects that a patient is being abused by the spouse based on the presence of many unexplained bruises and the nonverbal behavior of the patient. Which critical thinking technique was used by the nurse? a. Intuition b. Humility c. Curiosity d. Fairness - Correct Answer a. Intuition Which behavior demonstrates basic critical thinking expected of beginning nursing students? a. Creating a personalized bowel elimination program for a patient with constipation

due to narcotic pain medications b. Elevating the patient's leg and applying ice packs when the patient's postoperative pain is not relieved with prescribed pain medications c. Asking the instructor for assistance when having difficulty inserting the urinary catheter into the male patient's bladder d. Advocating for delay in the patient's discharge when the nurse suspects that a serious surgical complication has developed - Correct Answer c. Asking the instructor for assistance when having difficulty inserting the urinary catheter into the male patient's bladder The nurse becomes very skilled at feeding patients with dysphagia after working on a rehabilitation unit for many years. Which component of critical thinking allows the nurse to function at this high level of practice? a. Integrity b. Experience c. Risk taking d. Responsibility - Correct Answer b. Experience The nurse feels strongly that the patient may be suffering from physical abuse. The nurse reports the situation to protective services even though the physician insists that the patient is simply accident-prone. Which component of critical thinking leads the nurse to file the report even though the physician believes it is not needed? a. Fairness b. Creativity c. Discipline d. Confidence - Correct Answer d. Confidence The nurse comes up with creative methods to help soothe agitated patients with dementia when the usual approaches fail. Which term best describes the action of the nurse? a. Concept mapping b. Diagnostic reasoning c. Scientific method d. Effective problem solving - Correct Answer d. Effective problem solving The experienced trauma nurse determines that the patient may have suffered a cervical spinal cord injury as the patient is unable to feel or move

the arms or legs. Which term best describes the nurse's ability to make this conclusion? a. Data collection b. Clinical inference c. Scientific method d. Standardized criteria - Correct Answer b. Clinical inference The nurse implements interventions to address risk for falls after noting that the patient is unsteady when getting out of bed. The nurse is using which skill in this situation? a. Medical diagnosis b. Scientific method c. Diagnostic reasoning d. Data collection - Correct Answer c. Diagnostic reasoning Which action of the nurse demonstrates clinical decision making? a. The nurse performs a detailed health history and physical assessment when the patient is admitted to the unit. b. The nurse determines that the patient is at risk for constipation due to use of postoperative narcotic pain medication. c. The nurse applies a hydrocolloid dressing to the patient's decubitus ulcer as ordered by the physician. d. The nurse assesses the patient's oral mucus membranes each morning to check for candida infection or ulceration. - Correct Answer b. The nurse determines that the patient is at risk for constipation due to use of postoperative narcotic pain medication. Which patient's need constitutes the highest priority for the nurse? a. The patient who is waiting for discharge teaching in order to go home b. The constipated patient who has not had a bowel movement in 3 days c. The patient with sudden onset of slurred speech and right-sided weakness d. The patient who requires linen changes after being incontinent of urine and stool - Correct Answer c. The patient with sudden onset of slurred speech and right-sided weakness

Which action by the nurse best demonstrates independent thinking? a. Removing and carefully cleaning the patient's dentures every night b. Initiating swallow precautions when the patient shows signs of aspiration c. Teaching the diabetic patient how to self-administer insulin injections d. Actively listening to the patient when recording the patient's health history - Correct Answer b. Initiating swallow precautions when the patient shows signs of aspiration Which action by the nurse is an example of a workaround? a. In order to save time, the nurse scans medication bar codes after administration to the patient. b. The nurse prioritizes care for patients so that the most urgent patient needs are addressed first. c. The nurse helps the nursing assistant to change the linens after a patient is incontinent of stool and urine. d. The nurse seeks assistance from another nurse when having difficulty advancing the urinary catheter into the bladder. - Correct Answer a. In order to save time, the nurse scans medication bar codes after administration to the patient. The nurse asks another nurse for assistance when trying to determine the best way to manage a postoperative patient's pain. Which critical thinking attitude is demonstrated by the nurse? a. Humility b. Confidence c. Risk taking d. Fairness - Correct Answer a. Humility The new nurse keeps a diary to record experiences, patient encounters, and feelings when beginning work in the nursing profession. Which critical thinking action is used by the nurse? a. Professional standards b. Nursing process c. Concept mapping d. Purposeful reflection - Correct Answer d. Purposeful reflection

Which is the best tool that the nurse can use to make sense of the patient's multiple medical diagnoses, assessment findings, and medications? a. Plan of care b. Concept map c. Reflective journal d. Intellectual standards - Correct Answer b. Concept map The nurse inappropriately assumed that the patient did not require pain medication due to a history of substance abuse. Which critical thinking concept did the nurse fail to use? a. Criticism b. Maturity c. Analysis d. Organization - Correct Answer c. Analysis A nurse uses personal experience as well as knowledge of body mechanics and medical equipment in order to determine the safest way to transfer the paraplegic patient from the bed to the wheelchair. Which critical thinking concept is demonstrated by the nurse? a. Evaluation b. Explanation c. Development d. Self-regulation - Correct Answer b. Explanation The nurse readily accepts an opportunity to become certified in wound care and ostomy management. Which critical thinking concept is demonstrated by the nurse? a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness - Correct Answer d. Inquisitiveness In a facility with an outbreak of Clostridium difficile, the nurse manager determines that staff members are continuing to use alcohol-based hand sanitizer when caring for patients with Clostridium difficile infection despite the policy which requires hand hygiene using soap and water. Which step of the scientific method was performed by the nurse manager? a. Identification of the problem b. Formation of the hypothesis c. Investigation of the hypothesis

d. Evaluation of the intervention - Correct Answer a. Identification of the problem Which action by the nurse demonstrates the use of fairness for critical thinking? a. Adherence to the six rights when administering medication to a patient b. Clarification of an unusually high dosage medication with the prescriber c. Effective pain management is provided for all patients regardless of background d. Development of a personalized swallowing precautions protocol for the patient - Correct Answer c. Effective pain management is provided for all patients regardless of background Which statement is true about critical thinking? a. It is the same thing as the nursing process. b. It is moving from writing a plan of care to thinking. c. It is a haphazard method of providing nursing care. d. It is a continuous process characterized by open-mindedness. - Correct Answer d. It is a continuous process characterized by open-mindedness. The nurse carefully performs a careful physical assessment and health history for the patient, making sure not to miss any body systems. Which attitude for critical thinking is demonstrated by the nurse? a. Integrity b. Planning c. Discipline d. Diagnosis - Correct Answer c. Discipline The nurse noted a rise in skin infections on the nursing unit. After a literature review was completed, a new bathing protocol using disposable wash basins and pH balanced skin cleansers was suggested. Which steps of the scientific process were used by the nurse? (Select all that apply.) a. Identify the problem. b. Collect the data. c. Answer the question. d. Evaluate the results. e. Publish findings. - Correct Answer A, B

The nurse carefully enters a new patient's medical history and current medication list into the agency's electronic health record (EHR). Which step of the nursing process is being performed by the nurse? a. Assessment b. Implementation c. Evaluation d. Diagnosis - Correct Answer a. Assessment The nurse is caring for a patient who has just arrived at the hospital with chest pain. Which is the most important question for the nurse to ask the patient? a. "Did your family doctor tell you to come to the hospital?" b. "When did your chest pain begin?" c. "Do you have a family history of heart disease?" d. "Did someone come to the hospital with you?" - Correct Answer b. "When did your chest pain begin?" The nurse is caring for a patient who came to the hospital with acute shortness of breath. What is the priority action of the nurse as the assessment process is started? a. Pull the curtain around the bed and ensure patient privacy. b. Listen to the patient's lung sounds and check the pulse oximetry level. c. Tell the patient that the physician will be in shortly to start treatment. d. Reassure the patient that the shortness of breath will be relieved shortly.

• Correct Answer b. Listen to the patient's lung sounds and check the pulse oximetry level. The nurse is caring for a nonverbal patient who just had surgery. The nurse notes that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. The nurse decides that the patient is in pain and decides to administer an analgesic. What is the correct term for this nursing action? a. Setting priorities b. Recognizing inconsistencies c. Using empathy d. Making inferences - Correct Answer d. Making inferences A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data?

a. The patient's catheter drained 400 mL of urine during the last 8 hours. b. The patient's incision is clean, dry, and intact with staples. c. The patient reports having sharp, burning pain with urination. d. The patient refused breakfast after vomiting 200 mL green emesis. - Correct Answer c. The patient reports having sharp, burning pain with urination. The nurse has just completed an assessment for a patient. Which data will the nurse categorize as objective? a. The patient felt less short of breath after receiving a nebulizer treatment. b. The patient's lung sounds are diminished bilaterally with expiratory wheezes. c. The patient worries that the insurance company will not pay the hospital bill. d. The patient wonders if supplemental oxygen at home would be beneficial. - Correct Answer b. The patient's lung sounds are diminished bilaterally with expiratory wheezes. The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident? a. The patient was found on the floor and his urinal was on the floor next to him. b. The patient's nurse assistant always took her time to answer his call lights. c. The patient probably urinated on the floor and slipped on the wet floor. d. The patient is grouchy and inappropriate, always causing trouble for the nurses. - Correct Answer a. The patient was found on the floor and his urinal was on the floor next to him. Every time the nurse asks the patient a question for the admission assessment, the patient's husband interrupts and answers the question for her. What is the best action of the nurse? a. Enter the husband's responses into the patient's chart. b. Request that the husband leave the room. c. Complete the admission assessment after the husband has gone home. d. Allow time for the patient to answer each question. - Correct Answer d. Allow time for the patient to answer each question.

The nurse is caring for a toddler who will be having surgery. Which will provide the best primary source of information about how to comfort the child after surgery is completed? a. Patient's chart b. Patient c. Parents d. Surgeon - Correct Answer c. Parents The nurse completes the assessment for a patient who has just been admitted to the hospital. The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over- the-counter medications. Which phase of the interview does this occur in? a. Orientation b. Working c. Reasoning d. Termination - Correct Answer b. Working The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient's health status? a. "How long have you been experiencing chest pain?" b. "Do you have a family history of heart disease?" c. "Are you having any difficulty breathing right now?" d. "What does your chest pain feel like?" - Correct Answer d. "What does your chest pain feel like?" Which question is the most appropriate for the nurse to use to start the health history assessment? a. "Does your family doctor know that you are here?" b. "Did you drive yourself to the hospital?" c. "What brings you to the hospital today?" d. "Did you give your insurance card to the receptionist?" - Correct Answer c. "What brings you to the hospital today?" Which statement by the nurse is an example of back-channeling? a. "I completely understand. Can you tell me more?" b. "When did you first seek health care for your symptoms?" c. "I am sure the doctor will answer all of your questions shortly." d. "Try not to worry. I'm sure that you will be just fine." - Correct Answer a. "I completely understand. Can you tell me more?"