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NSG3130/ NSG3130 Exam 1 – Fundamentals &
Skills for Nursing Practice II 2025/2026 | Galen |
Practice Questions & Verified Answers
What intervention should be initiated first by a nurse assigned to care for a culturally diverse patient with significant body odor? a. Seek information to determine the underlying cause of the body odor. b. Approach the patient with washcloths and towels ready to give a bath. c. Contact family members or friends to learn more about their situation d. Ask the patient to bathe prior to conducting an admission assessment. a Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? a. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea b. Crab salad on a croissant, vegetables with dip, potato salad, milk c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice d. Pork roast, rice, vegetables, mixed fruit, milk c The nurse is caring for a surgical patient who speaks only Mandarin Chinese. The nurse will: (Select all that apply.) a. consider the body structure of the patient for rehabilitation needs. b. use the translation services of the institution for communication of the care plan. c. determine the patient's role and functions within the family. d. ask a family member to translate so the patient doesn't get charged for an interpreter.
e. explore the cultural practices for foods, eye contact, and body space for care provision. a, b, c, e A nurse gives a resident in a nursing home a choice about which color shirt to wear. Which level of needs, according to Maslow's Hierarchy of Needs, has the nurse just met? a. love and belonging b. self-esteem c. physiological d. safety and security b The nurse is caring for a newly admitted patient. The nurse collects the following data and reviews the patient's clinical record. Vital Signs: T99.8° F, Pulse 110, RR 24 bpm, B/P 128/80, Pain 9 out of 10 on a scale of 0 - 10 with patient stating pain is in the lower left abdominal quadrant that started 3 days ago. Patient is a 65 year old female that smokes 1 pack of cigarettes a day for 45 years. She drinks alcohol socially on weekends. Her husband died 1 year ago of cancer and she states that she "misses him a lot." Daughter wants her to move in with her, but patient states she wants to remain independent. Patient participates in a sewing group at her church to make pillows for hospitalized children Which level is the priority for this patient according to Maslow's Hierarchy of Needs? a. Self-esteem b. love and belonging c. Safety and security d. Physiological c
a. adaptive b. Eudaimonistic c. Health-Wellness Continuum d. Clinical Which of the following external variables should be addressed with a patient when providing education during a routine health care visit? Select all that apply. a. Use of tobacco b. Lack of physical activity c. Gender d. High fat diet e. Age a, b, d A mother brings her infant son in for routine immunizations. What level of health care prevention is this patient participating in? a. Primary b. Tertiarv c. Essential d. Secondary a The nurse has assessed that the patient has confidence in the ability to take action. What is this concept is called? a. Perceived benefits b. Self-efficacy c. Perceived severity
d. Cues to action b A nurse gives a resident in a nursing home a choice about which color shirt to wear. Which level needs, according to Maslow's Hierarchy of Needs, has the nurse just met? a. love and belonging b. safety and security c. physiological. d. self-esteem d When communicating with a client who speaks a different language, which best practice should the nurse implement? a. Arrange for an interpreter to translate b. Speak to the client and the family together c. Stand close to the client and speak loudly d. Speak loudly and slowly a Which action by a health care facility would demonstrate a commitment to providing culturally competent care? a. Providing continuing education events focused on delivery of linguistic services b. Delegation of all patient and family care to health care professionals that are of the same ethnicity c. Providing hospital signage in several languages to help patients and families navigate d. Referral of cultural diverse patients for counseling to help them communicate more clearly a
where the air quality is poor. According to Dunn's wellness grid, what category does this patient fall into? a. Protected poor health in a favorable environment b. Emergent high level wellness c. Poor health in unfavorable environment d. high level of wellness in favorable environment a A nurse is caring for a patient who suffered a spinal cord injury following a motor vehicle accident. The patient, although a paraplegic from his accident, participates in the Paralympics, is a motivational speaker, and has a family with kids. The patient considers himself healthy. What model of health is this patient demonstrating? a. Adaptive b. Eudaemonistic c. Health-wellness contimuum d. Clinical a A nurse is explaining the different levels of prevention for a client with a family history of colon cancer. Which of the following is an example of primary prevention? a. The patient participates in an ostomy support group b. The patient has a segment of his colon removed that contains cancerous cells and receives a temporary ostomy. c. The patient gets a colonoscopy every 5 years instead of every 10 because of his family history. d. the patient avoids a diet high in fat and red meat d
A patient prefers to seek acupuncture for pain relief before taking prescribed medication. What response by the nurse is most appropriate? a. Require that the patient take the ordered pain medication. b. Recognize that alternative forms of treatment can be effective. c. Have the patient's family get the patient to take the medication. d. Refer the patient for professional pain relief counseling. b The nurse notices a nursing staff member from another unit is reading the chart of one of the unit's patients. What action by the nurse is most appropriate? a. Inform the staff person that he/she may not read records of patients not assigned to them. b. Tell the patient that someone from off the unit was reading the record. c. Ask the charge nurse if this person is allowed to read the record. d. Don't worry since this staff member has a hospital ID badge. a Legal issues related to medical records include which of the following? (Select all that apply.) a. Medical record entries can be altered or erased to increase accuracy. b. In the event of litigation, the medical record is often the only available evidence. c. The medical record is the legal documentation of care provided to a patient. d. Medical record documentation should be based strictly on facts, not opinions. e. The nurse cannot make corrections at all to the record.
A nurse is caring for a group of patients and needs to delegate assignments. Which of the following is not an efficient use of the 5 rights of delegation? a. The nurse asks the LPN to give a complete bed bath to the patient with C-Diff b. The nurse asks the UAP to obtain vital signs on a patient who will be discharged that afternoon. c. The nurse asks the unit secretary to page a doctor d. The nurse asks another RN to hang blood on a patient with a history of anemia a A nurse is using SBAR to speak to a doctor regarding an asthma patient. The nurse would be using this communication tool correctly if they did what for the "R" part a. Informs the provider that the patient has a elevated respiratory rate, low O2 sat, and is currently wheezing b. Requests an albuterol nebulizer treatment be ordered c. Introduced them self and asked if the physician is familiar with the patient they are calling about d. Reminded the physician that the patient was admitted 3 days ago for status asthmaticus. b A nurse is busy and assigns a LPN to a client with a new tracheostomy. During the shift, the trach dislodges and the client experiences respiratory distress. Which of the rights of delegation was violated in this scenario? a. Right task b. Right circumstances c. Right person d. Right direction b
The nurse assigns the UAP to teach her patient how to ambulate using crutches prior to discharge. a. Right task b. Right supervision and evaluation c. Right Person d. Right directions & communication e. Right circumstances a General delegation rules to follow for the RN:
- Always be familiar with your state board rules and regulations for delegation.
- Refer to you facility policies and procedures for roles and responsibilities for task delegation.
- NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN and/or UAP) have the training and skill set to complete the task delegated to them.
- Always validate! If you are unsure if a staff member does not have the knowledge or skills to complete a task, ask them to demonstrate by stating "Please show me how you would do this". UAP Delegation:
- Setting bed alarms, VS.
- Check patient status as directed by the RN- must report findings to the RN ("are you still having pain?").
- Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains, etc).
- Record meals/routines.
- Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give medication. LVN/LPN Delegations:
- Complete.
- Factual.
- NO slang or bias language-factual and objective.
- ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION. Documentation Standards:
- You can't look up a patient that you had the day before (HIPAA violation).
- If you are the interviewing nurse, you can access client's chart.
- You can document meds on the patient you gave meds to: do not document medications or tasks you did not complete.
- Only need a section witness on required meds.
- You can discuss care of a client with the nurse that is precepting you. Rules and Regulations with Documentation:
- Ethical and Legal Concerns.
- Confidentiality of all patient information.
- HIPAA updated April 14, 2003.
- Ensuring confidentiality of computer records. Source-oriented: Each profession has a separate section of the record in which to do narrative charting. Problem-oriented medical record (POMR): Integrates charting from the entire care team in the same section of the record.
Nurse's notes may be in a narrative format or in a problem-oriented structure, such as... PIE, APIE, SOAP, SOAPIE, SOAPIER, or CBE format. Charting by exception:
- Agencies develop standards of nursing practice.
- Documentation according to standards involves a check mark.
- Exceptions to standards described in narrative form on nurses' notes. Only chart what is significant or abnormal. Flow sheets:
- Graphic record.
- Intake and output, vital signs, and blood glucose.
- Medication administration record.
- Skin assessment record, daily weights.
- Used when a comparison is required or helpful. Documentation DO'S:
- Chart a change in client's condition and that follow up actions were taken.
- Read the nurses' notes prior to care.
- Be timely with documentation.
- Use objective, specific, and factual descriptions.
- An increased burden of disease, illness or injury and mortality depending on race, gender, culture, disability, location, etc.
- Increased incidence (new cases or diagnoses) of illness within a community or group.
- Always assess what is happening, what are the beliefs and perceptions of care and access points in communities and groups. Equity: This is about access:
- Access to care.
- Access to services.
- Access to medications, treatments.
- Facilities. Culture:
- The learned, shared, and transmitted knowledge of values, beliefs, and ways of life of a particular group that are generally transmitted from one generation to another and influence the individual's thinking, decisions, and actions in patterned or certain ways, which may change over time. Ethnicity:
- An individual's identification with or membership in a particular racial, national, or cultural group and observation of the group's customs, beliefs, and language. Culture competence:
- The ability to interact with and appreciate people of different cultures and beliefs.
- Divided into two major categories: individual cultural competence and organizational cultural competence.
Individual cultural competence:
- The care provided for an individual patient by one or more nurses, physicians, social worker, etc. Organizational cultural competence:
- Focuses on the collective competencies of the members of the organization and their effectiveness in meeting the diverse needs of their patients, staff, and community. Culturally congruent care:
- Uses culturally based knowledge in sensitive, creative, safe, and meaningful ways to promote the health and well-being of individuals or groups and improve their ability to face death, disability, or difficult human life conditions.
- When caring for the client, always ask about cultural consideration and for permission to be touched, after explaining what needs to be done. Transcultural Nursing:
- Focuses on human caring-associated differences and similarities among the beliefs, values, and patterned life ways of cultures to provide culturally congruent, meaningful, and beneficial health care.
- All nurses need to achieve increasing levels of cultural competence throughout their careers in order to provide unbiased, holistic are.
- Nurses and all healthcare providers must recognize and respect patients’ cultural beliefs and make every effort to incorporate these beliefs into their treatment plans, in order to provide patient-centered care. Discussing the plan of care with patients is a critical step to ensure patients/families feel valued and included from a cultural perspective.
- Obesity. Older adults: Lifestyle/medical concerns:
- Falls.
- Depression/suicide.
- Oral health.
- Smoking cessation/ daily activity to improve balance and strength. Risk factor reduction:
- Step-by-step improvement of individual health factors. These combined improvements lower the likelihood of developing a disease.
- If the client has risk factors for the development of a disease, they are at increased risk of developing the disease within the next 10 years.
- This does not mean you will not get the disease - rather that you are trying to control factors that increase risk.
- For example: you may still develop lung cancer even if you stopped smoking.
- Educating patients about risk allows the opportunity for them to reduce risks through lifestyle and other modifications. For example, a patient with obesity and high blood pressure can reduce the risk of CVD/stroke/heart attack by slow increase in activity and weight loss. Primary prevention:
- The goal is to modify risk factors to avoid the onset of disease and prevent pathologic processing from occurring.
- Health education: diet, exercise, using seatbelts, wearing helmets.
- Immunizations.
- Risk assessments for specific disease.
- Family planning services.
Secondary Prevention:
- Goal is early detection and diagnosis of health problems before patients exhibit symptoms of disease. Screening tests may be used to assess for latent disease in vulnerable populations.
- Screening: mammograms, PPD skin tests, fecal occult blood.
- Encouraging regular medical and dental checkups.
- Teaching self-examination for breast and testicular cancer.
- Prompt intervention to alleviate health problems. Tertiary Prevention:
- Restoration or rehab with the goal to restore the individual to an optimal level of functioning.
- Teaching a client who has diabetes to identify and prevent complications.
- Referring a client who has a colostomy to a support group.
- Referring a client with a spinal cord injury to a rehabilitation center. Holistic Health:
- Synergistic relationships between the body and environment. Healing therapies are used.
- Incorporates spirituality, emotional security, nutritional status, sleep patterns, energy level.
- The body knows how to heal itself when given the proper support. Maslow: Basic human needs model:
- Focuses on basic survival needs and the drive for personal growth and development.
- Deficits and deficiencies need to be met first!
- Lowest level: physical and physiologic needs.
- KNOW THE PYRAMID!
