Fundamentals of Nursing Test Bank: Quizzes and Solutions, Exams of Nursing

Download Fundamentals of Nursing Test Bank: Quizzes and Solutions and more Exams Nursing in PDF only on Docsity! FUNDAMENTALS OF NURSING TEST BANK QUIZZES AND SOLUTIONS ALL 100% CORRECT 2024-2025 LATEST AND APPROVED. What is the most influential factor that has shaped the nursing profession? 1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation - Solution 3 Which of the following is an example of an illness prevention activity? Select all that apply. 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet - Solution 3 Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession - Solution 1 All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel - Solution 1 Which statement pertaining to Benners practice model for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage. 2) Progression through the stages involves continual development of thinking and technical skills. 3) The nurse must have experience in many areas before being considered an expert. 4) The nurses progress through the stages is determined by years of experience and skills. - Solution 2 Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images of nurses. 2) There are constant changes in healthcare and the activities of nurses. 3) There is disagreement among the different nursing organizations. 4) Is removed from many components of direct patient care that have been delegated to the NAP 4) Still maintains responsibility for the patient care given by the NAP - Solution 2 An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility - Solution 4 The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1) Functional 2) Primary 3) Case method 4) Team - Solution 3 Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social worker 2) Occupational therapist 3) Physicians assistant 4) Technologist - Solution 1 Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1) Health maintenance organization 2) Integrated delivery network 3) Preferred provider organization 4) Employment-based private insurance - Solution 3 A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a 1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model - Solution 1 Which member of the healthcare team typically serves as the case manager? 1) Occupational therapist 2) Physician 3) Physicians assistant 4) Registered nurse - Solution 4 Which of the following is considered a primary care service? 1) Providing wound care 2) Administering childhood immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair - Solution 2 Which of the following nursing activities represent direct care? Choose all that apply. 1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift - Solution 1 An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare - Solution 2 Which of the following are examples of a health-promotion activity? Select all that apply. 1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2) Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures. 2) Nurses work with other healthcare team members. 3) Nurses care for clients who have multiple health problems. 4) Nurses have to be flexible and work variable schedules. - Solution 3 The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention - Solution 4 How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1) Terminology for the clients disease or injury 2) A part of the clients medical diagnosis 3) The clients presenting signs and symptoms 4) A clients response to a health problem - Solution 4 Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give. - Solution 2 What do critical thinking and the nursing process have in common? 1) They are both linear processes used to guide ones thinking. 2) They are both thinking methods used to solve a problem. 3) They both use specific steps to solve a problem. 4) They both use similar steps to solve a problem. - Solution 2 A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem - Solution 1 The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1) Determine whether she has gathered enough assessment data. 2) Judge whether the interventions achieved the stated outcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patients condition. - Solution 2 In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge - Solution 1 The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process - Solution 2 Which aspects of healthcare are affected by a clients culture? Select all that apply. 1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities - Solution 1 When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient - Solution 4 Which of the following is an example of an open-ended question? 1) Have you had surgery before? 2) When was your last menstrual period? 3) What happens when you have a headache? 4) Do you have a family history of heart disease? - Solution 3 Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening - Solution 4 Which of the following is an example of the most basic motivation in Maslows hierarchy of needs? 1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood - Solution 2 What makes a nursing history different from a medical history? 1) A nursing history focuses on the patients responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information. - Solution 1 Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies - Solution 4 What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of Care. - Solution 1 Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious - Solution 3 A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? 1) My patient is a young adult, so I plan to talk to her without her parents in the room. 2) Because my patient is old enough to be my grandfather, I will call him Mr. 3) When reading my patients health record, I thought of a few questions to ask. 4) When I give my patient his pain medication, I will have time to ask questions. - Solution 4 A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs - Solution 3 Introduce yourself and ask, Dear, what name do you prefer to go by? before asking any questions. 3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions. 4) Ask the client if you can talk with her while her family is watching the television. - Solution 3 Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) How did this happen to you? 2) What was your first symptom? 3) Why didnt you seek healthcare earlier? 4) When did you start having symptoms? - Solution 1,2,4 A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Associations Scope and Standards of Practice - Solution 1,4 Which of the following are cues rather than inferences? Choose all Solutions. 1) Ate 50% of his meal 2) Patient feels better today 3) States, I slept well 4) White blood cell count 15,000/mm3 - Solution 1,3,4 Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection - Solution 2 Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 - Solution 1 Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference - Solution 3 How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop. - Solution 2 Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician. - Solution 4 Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the clients family confirm it. - Solution 3 What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities - Solution 3 What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom. 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic. - Solution 2 Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours - Solution 3 The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook. - Solution 3 The clients weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I dont like to take supplements, and I think I could really improve my nutrition. Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition - Solution 4 The patient verbalizes an overwhelming lack of energy. He says, I still feel exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily activities or sleep during the day. Ive been a little depressed lately, too. The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy - Solution 1 Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, On a scale of 1 to 5, its a 5. 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever - Solution 1 Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms - Solution 2,3,5 Using Maslows hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation - Solution 4,2,1,3 For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 1) Use the incentive spirometer when awake 2) Walk two times during day and evening shifts 3) Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy - Solution 3 How are critical pathways and standardized nursing care plans similar? Both 1) Specify daily, or even hourly, outcomes and interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions - Solution 3 How is NOC different from the Omaha System? 1) NOC can be used to write health restoration outcomes. 2) NOC can be used in all specialty and practice areas. 3) NOC can be used for individuals, families, or groups. 4) NOC formulates goals based on nursing diagnoses. - Solution 2 How are short-term goals different from long-term goals? Short-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/dates 4) Specify desired client responses to interventions - Solution 1 What do standardized nursing care plans and individualized care plans have in common? They both 1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group of patients 3) Address a patients individual needs 4) Provide detailed nursing interventions - Solution 4 The nurse is individualizing Mr. Wus plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe 1) Desired changes in the patients health status 2) Specific patient responses to medical interventions 3) Specific nursing behaviors to improve a patients health 4) Criteria to evaluate the appropriateness of a nursing diagnosis - Solution 1 Which of the following outcome statements contains the best example of performance criteria? The patient will 1) Turn herself in bed frequently while awake 2) Understand how to use crutches by day 2 3) State that pain is decreased after being medicated 4) Eat 75% of each meal without complaint of nausea - Solution 4 Which of the following is true for goals/outcomes for collaborative problems? 1) They are monitored only by other disciplines. 2) They are usually sensitive to nursing interventions. 3) They state that a complication will not occur. 4) They state only broad performance criteria. - Solution 3 How are NANDA-I problem labels and NOC outcome labels alike? Both describe 1) Health status in terms of human responses 2) Patient response before interventions are done 3) Patient response in positive terms 4) A pattern of related cues - Solution 1 The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan? 1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memory loss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements with meals - Solution 2 A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient? 1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awakeD. Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the clientJ. Smith, RN - Solution 1 A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay? 1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the clients dietary concerns - Solution 3 Which definition best describes a critical pathway? 1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something - Solution 1 A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowlers position. - Solution 1 Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse - Solution 3 A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written. - Solution 2 The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patients individual needs. What should the nurse do? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give her recommendation. 4) Restart the computer; it is probably a program malfunction. - Solution 1 Which statement(s) about nursing interventions is/are true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client. - Solution 1,3 An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is The client will maintain urine output of at least 30 mL/hour. Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer IV fluids as prescribed. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking - Solution 2 Which intervention depends almost entirely on the clients adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet - Solution 4 The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the clients main concerns about his diabetes - Solution 4 Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway - Solution 1 Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) Record how much the patient drinks today, please. 2) Take the patients vital signs every 2 hours today. 3) Take the patients temperature every 4 hours; notify me if it is greater than 100.5F (38.1C). 4) Assist the patient with all of her meals. - Solution 3 Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift - Solution 1 Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care. - Solution 3 Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30. - Solution 2 When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour - Solution 4 Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process - Solution 1 Which of the following is the most valid criterion for determining the status of a patients anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Virginia Henderson 2) Imogene Rigdon 3) Katherine Kolcaba 4) Florence Nightingale - Solution 4 A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse if her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is utilizing the theory developed by which nurse theorist? 1) Betty Neuman 2) Dorothea Orem 3) Callista Roy 4) Madeline Leininger - Solution 4 According to Maslows hierarchy of needs, which patient need should the nurse address first? 1) Protecting the patient against falls 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change - Solution 3 A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next? 1) Perform a literature review. 2) Develop a conceptual framework. 3) Formulate the hypothesis. 4) Define the study variables. - Solution 1 The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? The right 1) Not to be harmed 2) To self-determination 3) To full disclosure 4) Of confidentiality - Solution 2 After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslows hierarchy of needs, cardiac rehabilitation most directly addresses which need? 1) Safety and security 2) Physiological 3) Self-actualization 4) Self-esteem - Solution 2 In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include 1) Cognitive and aesthetic needs 2) Love and belonging needs 3) Safety and security needs 4) Physiological and self-esteem needs - Solution 1 The PICO question reads, Is TENS effective in the management of chronic low-back pain in adults? Which part of this question comes from the I in PICO? 1) Adults 2) Management 3) Pain 4) TENS - Solution 4 While reading a journal article, the nurse asks herself these questions: What is this about overall? Is it true in whole or in part? Does it matter to my practice? What is this nurse doing? 1) Reading the article analytically 2) Performing a literature review 3) Formulating a searchable question 4) Determining the soundness of the article - Solution 1 In an effort to promote health, the home health nurse opens the clients bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people? 1) Jean Watson 2) Jurgen Moltmann 3) Florence Nightingale 4) Explaining treatment options in terms she can understand 4) Providing a healing presence by listening and being attentive - Solution 4 Which statement best describes the health/illness continuum? 1) Health is the absence of disease; illness is the presence of disease. 2) Health and illness are along a continuum that cannot be divided. 3) Health is remission of disease; illness is exacerbation of disease. 4) Health is not having illness; illness is not having health. - Solution 2 Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)? 1) A healthy diet 2) Physical activity 3) Restful sleep 4) Comfortable room temperature - Solution 3 A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization? 1) Providing skin care every shift to prevent skin breakdown 2) Encouraging the patient to get up in a chair to eat meals 3) Assisting the patient to ambulate in the hallway for several minutes each day 4) Designating a corner of the patients room to display personal mementos - Solution 4 Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self? 1) Family relationships 2) Spirituality 3) Nutrition 4) Sleep and rest - Solution 2 A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces? 1) Chronic urinary incontinence 2) Stigma associated with mental illness 3) Risk for recurring infections 4) Auditory hallucinations (hearing things) - Solution 2 A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior? 1) Sick-role behavior 2) Seeking professional care 3) Experiencing symptoms 4) Dependence on others - Solution 4 Many health providers define illness as pathology; however, people experience, rather than define, illness. Which of the following is how most people experience illness? 1) Feeling lousy, a true sense of not being all right 2) A change in the way they feel or a disruption in their typical life 3) Something to be dreaded and avoided if at all possible 4) An experience that offers the potential for learning and spiritual growth - Solution 2 Dunn believes that an individuals state of health should be evaluated in the context of the persons environment. This approach illustrates that 1) An unhealthy physical environment, characterized by poor living conditions, always has a negative effect on an individuals health 2) Adequate income, food, and shelter create a healthful environment and always improve physical health status 3) Physical environment, family, and social support may help or hinder the health status of an individual 4) The environment that should always be assessed is the clients immediate surroundings; extended boundaries do not apply in an ill state - Solution 3 Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a persons level of hardiness. How can you apply this knowledge to your nursing care? 1) You cannot use this information at all. People are innately hardy or not. This is something that you must merely recognize. 2) You should encourage all people to develop some level of hardiness in order to get through difficult physical and emotional times. 3) You should assess for your own level of hardiness: If you are hardy, you will be a better nurse; if you are not, you can learn more about hardiness. 4) You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable. - Solution 4 2) Patient Self-Determination Act (PSDA) 3) Health Insurance Portability and Accountability Act (HIPAA) 4) Health Care Quality Improvement Act (HCQIA) - Solution 3 Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patients arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? 1) Good Samaritan Law 2) Mandatory Reporting Law 3) Nurse Practice Act 4) Nursing Standards of Practice - Solution 2 Nursing codes of ethics support which of the following? 1) Patients can receive emergency treatment regardless of their ability to pay. 2) Nurses will educate patients about advance directives. 3) Nurses with HIV must disclose their condition to their employer. 4) Patients have the right to dignity, privacy, and safety. - Solution 4 The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following? 1) Malpractice 2) Incompetence 3) Negligence 4) Abandonment - Solution 3 In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient? 1) The patient is confused and cannot understand or sign the consent form. 2) The patient is brought to the emergency department in cardiac arrest; no family is present. 3) The surgeon requests that the patient be sent to the surgical suite before you get the consent form signed. 4) An unconscious patient is admitted to your unit; he is alone. - Solution 2 A 4-year-old child is brought to the emergency department by his mother. He has a large bruise in his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four items should the nurse do first? 1) Notify the nursing supervisor of the suspected physical abuse. 2) Complete a physical assessment of the child. 3) Obtain an order for pain medication. 4) Notify Child Protective Services of the suspected abuse. - Solution 2 You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, Im leaving this hospital. Remove my IV and surgical drains or I will do it myself. In order to keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following? 1) Assault and battery 2) Felony 3) False imprisonment 4) Quasi-intentional tort - Solution 3 A registered nurse forgot to put the side rails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurses situation is that her insurance policy will: 1) Not cover her. 2) Pay $4 million. 3) Pay $2 million. 4) Pay 75% of the $2 million - Solution 3 A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? 1) Disciplinary action against the nurses license to practice 2) Criminal misdemeanor charges against the nurse 3) Medical malpractice lawsuit against the nurse 4) Employment release from the institution - Solution 1 Which of the following are examples of invasion of privacy by nurses? Choose all that apply. Review the following: 38 years old; growth in height to 52; female gender; weight gain of 15 pounds. This list can be referred to as which of the following? 1) Information 2) Knowledge 3) Data 4) Patient record - Solution 1 CINAHL is a(n): 1) Popular periodical. 2) Internet site. 3) Scholarly journal. 4) Literature database - Solution 4 A nurse is entering a pharmacy request for patient medication in the patients electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches her and asks her to access another patients EHR so that he can look at the patients laboratory report. Which of the following is the best action for the nurse to take? 1) Access the lab report for the physician. 2) Log off the computer before proceeding. 3) Quickly finish the pharmacy requisition before the physician logs on. 4) Allow the physician to access the laboratory report without logging out. - Solution 2 What is (are) the primary benefit(s) of computer physician order entry (CPOE)? 1) Increased privacy 2) Improved access to patient data 3) Cost savings 4) Reduced medication errors - Solution 4 Which of the following are main functions of a computer? Choose all that apply. 1) Process 2) Storage 3) Memory 4) Output - Solution 1,2,4 Which of the following aspects of a computer determine its power? Choose all that apply. 1) User friendliness 2) Speed of operations 3) Accessibility for the user 4) Data storage capacity - Solution 2,4 Which of the following health information is protected in the electronic health record? Choose all that apply. 1) Social Security number 2) Insurance information 3) Physicians name 4) Laboratory results - Solution 1,2,4 The nurse is preparing to pass the 0900 medications prescribed for her patients. She removes the medications from the automated dispensing unit. When scanning the medication, an alert notifies the nurse that the patient is allergic to this medication. What action should the nurse take? Choose all that apply. 1) Override the alert and administer the medication. 2) Confirm the patients allergies and type of reaction. 3) Notify the prescriber of the patient medication allergy. 4) Be sure an antidote is available at the patients bedside. - Solution 2,3 A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The clients condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1) Study the discharge plan. 2) Check the graphic data for vital signs. 3) Examine the history and physical. 4) Look for an advance directive. - Solution 4 A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1) It involves a cooperative effort among various disciplines. 2) The system requires diligence in maintaining a current problem list. 3) Data may be fragmented and scattered throughout the chart. 4) It allows the nurse to provide information in an unorganized manner. - Solution 3 A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1) Hypertension 2) Rheumatoid arthritis 3) Postoperative colon resection 4) Follow all three plans - Solution 3 The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4) 09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN - Solution 2 A patient refuses a dose of medication. How should the nurse document the event? 1) Patient is uncooperative and refuses the prescribed dose of digoxin. 2) Patient refuses the 0900 dose of digoxin. 3) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4) 0900 dose of digoxin not given. - Solution 2 The nurse makes a mistake while documenting in the patients health record. Which action should the nurse take? 1) Use an opaque white fluid to cover the documentation error. 2) Completely cover the documentation error with black ink. 3) Draw a line through the error and initial the change. 4) Use correction tape to make the documentation correct. - Solution 3 At 1000 on 11/14/10, the nurse takes a telephone order for metoprolol 5 mg intravenously now. What is the latest date and time the nurse will expect the prescriber to countersign the order? 1) 11/14/13 at 1200 2) 11/14/13 at 2200 3) 11/15/13 at 1000 4) 11/16/13 at 1000 - Solution 3 The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1) Repeat the order to the prescriber even if she believes she understood the order correctly. 2) Immediately notify the pharmacy of the order and verify it with a pharmacist. 3) Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4) Transcribe the order onto note paper and verify the dosage in a drug handbook. - Solution 1 A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patients care? 1) Every 2 weeks 2) Every shift 3) Every week 4) Every 3 months - Solution 2 What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1) 14 days 2) 3 days 3) 2 days 4) 24 hours - Solution 1 A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1) The Minimum Data Set (MDS) for assessment 2) Situation-background-assessment-recommendation (SBAR) for reporting 3) Healthcare Financing Administration guidelines prior to surgery 4) Joint Commission guidelines for discharge planning - Solution 1 The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeons order? The nurse 1) Performs oral care 1) Leaving patient data displayed on a computer screen where others may view it 2) Remaining logged on to the computer system after documenting patient care 3) Faxing a patient report to the nurses station where the patient is being transferred 4) Informing the nurse manager of a change in the patients condition - Solution 1,2 Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1) I can wait until the end of the shift to document my care. 2) Charting every 2 hours is the most appropriate way to document nursing care. 3) I find it easier to chart before I go to lunch and then after my shift report. 4) I should chart as soon as possible after nursing care is given. - Solution 1,2,3 The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1) Facilitate evidence-based nursing practice 2) Promote efficient use of the nurses documentation time 3) Reduce the opportunity for interdisciplinary collaboration 4) Ensure improved client safety and outcomes - Solution 1,2,4 In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1) Teaching performed 2) Any change in client status 3) Treatments administered 4) Hygiene measures performed - Solution 1,2,3 Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) Small group 2) Interpersonal 3) Group 4) Intrapersonal - Solution 2 During admission to the unit, a patient states, Im not worried about the results of my tests. Im sure Ill be all right. As he observes the patient, the nurse notes that the patient is shaky and tearful and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following actions is most appropriate for the nurse to establish when returning to the patient? Patient will 1) Explain the reason for his incongruent statements 2) Engage in diversional activities to cope with stress 3) Express his concerns to his primary care provider 4) Discuss his concerns and fears with the nurse - Solution 4 The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? 1) You will need to remain NPO for the 4 hours prior to your CT scan. 2) You cannot have anything to eat or drink for 4 hours before your test. 3) You will need to be NPO and drink this contrast media before your test. 4) You may need to void before you go down to the department for your CT scan. - Solution 2 The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lung cancer 2) Middle-aged man experiencing the acute phase of myocardial infarction 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery - Solution 3 The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful? 1) This was a good idea to form a group; Ive been wanting to get to know some of the people working the other shifts. 2) It really helps me to share feelings about how hard it is to see pain and suffering every day. 3) I now have a group to help me when I need to work through situations in my own life causing me stress. 4) It feels good to have a chance to get away from the unit and talk on a regular basis. - Solution 2 2) If you lie still and relax, youll be fine in a little while. 3) Please try not to think about the pain as best as you can. 4) Dont worry; were going to take good care of you. - Solution 1 Which statement by the nurse indicates that the nurse-patient relationship is entering the termination phase? 1) Ill be admitting you to our nursing unit as soon as I obtain your health history. 2) You seem upset today. Would you like to talk about whatever is bothering you? 3) Im leaving for the day. Is there anything I can do for you before I leave? 4) Hello. My name is Leslie, and Im going to be your nurse today. - Solution 3 A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1) Short term 2) Ongoing 3) Self-help 4) Work-related social support - Solution 1 The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information? 1) Im going to insert an NG tube and connect it to low Gomco to keep your stomach empty. 2) Im going to insert a tube through your nose into your stomach to prevent you from vomiting. 3) Im going to insert an NG tube through your nares to suction your secretions and prevent emesis. 4) Lie still, please; I need to elevate the head of the bed and insert this tube. - Solution 2 A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patients nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patients room so he can rest quietly. - Solution 3 A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as a translator. 3) Request the services of a hospital translator. 4) Speak in English, but speak very slowly. - Solution 3 After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) If I were you, Id go with chemotherapy. 2) What do you think about radiation therapy? 3) Why dont you see what your wife thinks. 4) Ill give you some information about each option. - Solution 4 Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions - Solution 3 A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) Youre lucky you didnt have a stroke; you really need to take your medication. 2) Tell me more about your experience with your high blood pressure medication. 3) Why did you stop taking your high blood pressure medication? 4) Its very important to take your blood pressure medication. - Solution 2 The wife of an elderly patient begins crying after she is informed that he has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patients wife while she composes her thoughts. 2) Inform his wife that a chaplain is available if she would like to speak to him. 3) Remind his wife that her husband has lived a long and happy life. 4) Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only when leaving each room. 4) uses cold water for medical asepsis. - Solution 3 What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members - Solution 3 Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown - Solution 1 A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1) pathogen. 2) fomite. 3) vector. 4) carrier. - Solution 4 A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact - Solution 2 A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1) Endogenous nosocomial 2) Exogenous nosocomial 3) Latent 4) Primary - Solution 1 A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence - Solution 3 The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patients door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure - Solution 1 A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity - Solution 3 The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels? 1) IgA 2) IgE 3) IgG 4) IgM - Solution 4 What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) 2) After 5 to 10 seconds 3) When leaving the clients room 4) Once fingers and hands feel dry - Solution 4 A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1) Contact 2) Protective 3) Droplet 4) Airborne - Solution 2 While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from the sterile field and use a new pair of sterile gloves. 3) Throw all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client. - Solution 2 The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering - Solution 2 A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses actions, listing the most important one first. 1. Contact employee health 2. Complete an incident report 3. Wash the exposed area 4. Report to another nurse that she is leaving the immediate area. 1) 1, 2, 3, 4 2) 2, 3, 4, 1 3) 3, 4, 1, 2 4) 4, 1, 2, 3 - Solution 3 In which situation would using standard precautions be adequate? Select all that apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter - Solution 3,4 Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week - Solution 1,3,4 The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) uses a paper towel to turn off the faucet. 2) holds fingertips above the wrists while rinsing off the soap. 3) removes all rings and watch before washing hands. 4) cleans underneath each fingernail. - Solution 1,3,4 Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial spores 3) Yeast 4) Mold - Solution 1,3,4 A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport. - Solution 3,4 The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription? 1) Chemical A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? 1) 0930 2) 1000 3) 1100 4) 1500 - Solution 4 Which factor in a patients medical history is most likely to prolong the half- life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use - Solution 2 The nurse receives a laboratory report that states her patients digoxin level is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take? 1) Notify the prescriber to reduce the dose. 2) Withhold the next dose of digoxin. 3) Administer the next dose as prescribed. 4) Notify the prescribing healthcare provider to increase the dose. - Solution 3 The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? 1) With the morning routine laboratory studies 2) Approximately 30 minutes before the next dose 3) Two hours after the next dose infuses 4) While the drug infuses - Solution 2 Teratogenic drugs should be avoided in which patient population? 1) Pregnant women 2) Elderly 3) Children 4) Adolescents - Solution 1 A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative - Solution 4 After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing? 1) Side effect 2) Adverse reaction 3) Toxic reaction 4) Supportive effect - Solution 1 While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? 1) Administer epinephrine IM. 2) Give bolus dose of intravenous fluids. 3) Stop the infusion of medication. 4) Prepare for endotracheal intubation. - Solution 3 A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? 1) Mild adverse reaction 2) Dose-related adverse reaction 3) Toxic reaction 4) Anaphylactic reaction - Solution 1 Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect? 1) Antagonistic drug interaction 2) Synergistic drug interaction 3) Idiosyncratic reaction 4) Drug incompatibility - Solution 1 1) Place the drug in the cheek and allow it to dissolve. 2) Place the drug under the tongue and allow it to dissolve. 3) Inject the drug superficially into the subcutaneous tissue. 4) Give the pill and water to the patient for him to swallow the tablet. - Solution 2 Which action should the nurse take immediately after administering a medication through a nasogastric tube? 1) Verify correct nasogastric tube placement in the stomach. 2) Auscultate the abdomen for presence of bowel sounds. 3) Immediately administer the next prescribed medication. 4) Flush the tube with water using a needleless syringe. - Solution 4 How should the nurse dispose of a contaminated needle after administering an injection? 1) Place the needle in a specially marked, puncture-proof container. 2) Recap the needle, and carefully place it in the trash can. 3) Recap the needle, and place it in a puncture-proof container. 4) Place the needle in a biohazard bag with other contaminated supplies. - Solution 1 The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection? 1) Ventrogluteal 2) Vastus lateralis 3) Deltoid 4) Dorsogluteal - Solution 2 Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? 1) Apply a warm compress. 2) Massage the site in a circular motion. 3) Apply a soothing lotion. 4) Have the client assume a sitting position. - Solution 4 The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate? 1) No action is necessary because an extra 5 mg of warfarin is not harmful. 2) Call the prescriber and ask her to change the order to 10 mg. 3) Document on the chart that the drug was given and indicate the drug was given in error. 4) Complete an incident report according to the facilitys policy. - Solution 4 The nurse must administer eardrops to an infant. How should she proceed? 1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling the drops. 3) Instill the drops directly; no special positioning is necessary. 4) Position the patient supine with the head of the bed elevated 30. - Solution 1 The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance? 1) Crush time-release capsules to put in his favorite food. 2) Give medication quickly before he knows what is happening. 3) Allow the child to eat a frozen pop before receiving the medication. 4) Mask the flavor of medication in a toddler cup with orange juice. - Solution 3 An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? 1) 18 gauge 2) 22 gauge 3) 24 gauge 4) 26 gauge - Solution 1 The nurse is drawing up a medication from an ampule. Arrange the following steps in the order in which they should be performed. A. Use an ampule opener to break ampule neck. B. Tap the ampule to remove medication trapped in the top of ampule. C. Invert the ampule, and draw up the medication. D. Dispose of the top and bottom of the ampule and filter needle in sharps container. E. Hold the syringe vertically, and tap it to remove air bubbles. - Solution B, A, C, E, D A nurse is administering a medication using a volume-control administration set (e.g., Buretrol, Volutrol). Arrange the following steps in the order in which they would be performed.