NUR 102 Exam 1 Study Guide NUR 102 Fundamentals of Nursing Exam 1 Test Bank,Complete answ, Exams of Nursing

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NUR 102 Exam 1 Study Guide NUR 102

Fundamentals of Nursing Exam 1 Test

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A new nurse is caring for a client who has a rx for a stool specimen analysis. As the nurse performs the procedure in the image, the charge nurse walks in to the clients bathroom and observes the bew nurse obtaining a specimen. what is next priority action by the charge nurse? - Correct Answer inform the new nurse to wear gloves when obtaining specimens that contain bodily fluids the nurse begins a task and then realizes that ppe is needed. what is the correct action by the nurse? - Correct Answer stop and obtain appropriate ppe the nurse is caring for a client with a latex sensitivity. which resource would be most appropriate for the nurse to access when developing the client's plan of care? - Correct Answer policy for clients with latex sensitivity which nursing action demonstrates safe injection practice? - Correct Answer use sterile single-use disposable syringes for each inj the nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. what is the nurse's next action? - Correct Answer open a new sterile kit an older adult woman has been in the hospital for more than 1 week. while assessing her IV catheter port, the nurse finds a staph infection, which developed in the past day or so. This infection is an example of which type of infection? - Correct Answer healthcare-associated infection the nurse is caring for a client with HIV who currently has no signs or symptoms of the disease. which important information about being an HIV carrier does the nurse teach the client? - Correct Answer HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk the nurse conducting an in-service on hand hygiene determines that additional eduction is needed when a participant states- - Correct Answer I do not need to wash my hands if I am using gloves when accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. what is the appropriate action by the nurse? - Correct Answer perform hand hygiene after removing the glove

a nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. what would be the most appropriate action to take in order to maintain a sterile field? - Correct Answer stop the procedure, remove damaged glove, perform hand washing, and open new sterile gloves the nurse is monitoring a student who is performing surgical hand asepsis. which student actions indicate the need for further education from the nurse? - Correct Answer wearing a gold wedding band - using at least 5 strokes for cleansing each area (10)- dropping hands to side when the wash is complete the nurse reviews principles of infection prevention during yearly safety training. which actions would the nurse use as an example of safe practice? - Correct Answer sterilizing any item entering the vascular system- Donning gloves and gowns as a substitute for handwashing in some circumstances the nurse provides care for an adolescent who is diagnosed with mono. which crucial information foes the nurse include in client education about the condition? - Correct Answer because mono is spread through saliva, do not share food drinks or silverware- it is important to practice safe sex bc a form of mono can be transmitted through sex- mono is called the kissing disease so refrain from kissing- cover coughs sneezes to reduce the risk of spreading- EBV causes mono a nurse is changing the dressings of a client in the burn unit. which actions should the nurse perform to maintain asepsis and client comfort? - Correct Answer keep nails short with no polish utilize isolation precautions including gloves gown and face mask wash hand thoroughly and then don sterile gloves ensure family visitors know they cannot bring flowers or fresh fruit to the client practice good personal hygiene including showering before each shift. the nurse is caring for a client in protective isolation due to neutropenia as a result of chemo. what priority precaution should the nurse implement in this client? - Correct Answer monitor client for depression and loneliness a nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs? - Correct Answer soil a client with an upper respiratory infection tells the nurse,"i am so angry bc the NP would not give me antibiotics ". what would be the most appropriate response by the nurse? - Correct Answer antibiotics have no effect on viruses a woman tests positive for HIV antibody but has no symptoms. she is considered a carrier. what component of the infection cycle does the woman illustrate? - Correct Answer a reservoir

a man on an airplane is sitting by a woman who is coughing and sneezing. if she has an infection, what is the most likely means of transmission from the woman to the man? - Correct Answer airborne route a nurse is educating a rural community group on how to avoid contracting west nile virus by using approved insect repellent and wearing proper coverings when outdoors. by what means is the pathogen involved in west nile virus transmitted? - Correct Answer vector a nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. the woman has diabetes. does this pose a risk to the client?

• Correct Answer yes, these can obstruct lower extremity circulation a nurse is planning hygiene for a client with dementia. the nurse understands the need to provide an environment that will aid her in the care of this client. which actions will she perform? - Correct Answer create a calming environment with little stimuli the nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. which will the nurse document on the EHR? - Correct Answer during bed bath, slight bruising noted on left thigh. 5cm hard lump palpated on anterior surface of the thigh a femal client in a reproductive health clinic tells the NP that she douches every day. should the nurse tell the client to continue this practice? - Correct Answer no. douching removes normal bacteria a nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. what action will the nurse use to facilitate the client's self-care and safety? - Correct Answer obtain a shower chair so the client can take a sit-down shower the nurse provides care for a female client having difficulty urinating after vaginal hysterectomy. which strategies does the nurse use to assist the client with urinary elimination? - Correct Answer turn on the water in the bathroom -pour warm water over the perineum -place client in sitting position -provide a sitz bath a nurse is preparing to perform oral care for a client who has full dentures. which actions should the nurse take? - Correct Answer provide privacy while the client removes dentures from the mouth -use a toothbrush and paste to gently brush surfaces -rinse the dentures with water or normal saline if the client is dehydrated -place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning

a client with a stroke has left-sided paralysis. which actions does the nurse take to ensure proper positioning and support for this client? - Correct Answer - place small pillow under client's waist -straighten the left elbow and support in a pillow

• place the left leg far enough in front of the body to prevent the client rolling onto the back
• bend the left knee and support the left leg on a pillow a client has a NG tube following abdominal surgery. which intervention does the nurse perform to prevent alterations in the client's oral health? - Correct Answer - offer water to rinse every hr
• apply lubricant to lips and nostrils
• encourage the clieny to swallow saliva naturally
• assist the client to brush teeth at least every 4 hrs the nurse is providing oral care to a hospitalized client. which outcome of this intervention is the priority? - Correct Answer decreasing the incidence of hospital acquired pneumonia the home health nurse is providing care to a number of clients. which client assessed by the nurse will require hospitalization related to complications associated with the feet? - Correct Answer the client with peripheral vascular disease the nurse assists the client to the bathroom sink to perform morning care. the nurse observes the client wash his face, arms, abdomen, and legs. the nurse washes the client's back and rectal area and applies soap to the back. the client brushes his teeth and ambulates to a chair in his room with assistance. hiw will the nurse describe morning care on the chart? - Correct Answer partial care upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. what is an appropriate consideration when assisting the client with morning hygiene? - Correct Answer provide the client with an electric shaver the nurse has completed an assessment of a client's typical hygiene practices. how should the nurse best document the findings of this assessment in the chart? - Correct Answer client normally bathes and washes her hair every other day, applies moisturizer to dry areas on her elbows and forearms an older adult resident of a long term care facility has recurring problems with dry skin. which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? - Correct Answer use a nonsoap cleaning agent a nurse is providing foot care to an elderly client who has diabetes and decreased mobility. what technique would the nurse employ when providing foot care? - Correct Answer use an antifungal powder on the client's feet if necessary

which client would be at greatest risk for injury to the skin and mucous membranes? - Correct Answer man 77 years of age with diabetes a student has been assigned to provide morning care to a client. the plan of care includes information that the client requires partial care. what will the student do? - Correct Answer provide supplies and assist with hard to reach areas before a long term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. what rationale supports placing dentures in water? - Correct Answer to prevent drying and warping of plastic a nurse is providing oral care to a client with dentures. what action would the nurse perform first? - Correct Answer don gloves a nurse has an order to take the core temperature of a client. at which site would a core body temp be measured? - Correct Answer rectal the nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. the client asks why it is so important to do this. what is the nurse's best response? - Correct Answer monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk of heart attacks and stroke what organ is the primary site of heat loss in the body? - Correct Answer skin a client who is an avid runner has been monitoring her pulse at home. recently, her pulse has been below the normal range of 60-100 bpm for adults. today her pusle is 58. the client asks the nurse at her annual screening if she should be concerned. what is the most appropriate response? - Correct Answer well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise a nurse is measuring the apical pulse of a client. where should she place the diaphragm of her stethoscope i. this assessment? - Correct Answer over the space between the fifth and sixth ribs on the left midclavicular line while assessing for orthostatic hypotension, the nurse follows which steps when taking the BP? - Correct Answer - check and record blood pressure taken while the client is in bed

• assist client to standing position and wait 2-3 mins before taking bp
• record measurements and note if the drop is greater than 25 mmHg systolic and 10 mmHg diastolic
• keep the bp cuff attached the whole time

over the course of a day, a burse encounters many different clients whose pulse rates she must measure. for which clients should she measure apical pulse? - Correct Answer - a client who is on a medication 5hat has dysrhythmia as a side effect

• a healthy 8 yr old girl
• an older adult client, whose pulse when measured peripherally is found to be extremely rapid which pathologic condition would result in release of ADH by the posterior pituitary? - Correct Answer hemorrhage a nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. what type of pulse rate would the client most likely exhibit? - Correct Answer tachycardia a nurse is conducting a health history for a client with a chronic respiratory problem. what question might the nurse ask to assess for orthopnea? - Correct Answer how many pillows do you sleep on at night to breathe better? what population is at greatest risk for hypertension? - Correct Answer indigenous Australians, maori and Pacific islander peoples You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code?

1. Improves self-health care
2. Protects the patient's confidentiality
3. Ensures identical care to all patients
4. Defines the principles of right and wrong to provide patient care - Correct Answer 4. Defines the principles of right and wrong to provide patient care An 18 year old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?
5. Diagnosis
6. Evaluation
7. Assessment
8. Implementation - Correct Answer 3. Assessment A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed?
9. Planning
10. Evaluation
11. Assessment

4. Implementation - Correct Answer 4. Implementation A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's
5. Educator
6. Advocate
7. Caregiver
8. Case manager - Correct Answer 2. Advocate The nurse spends time with the patient and family reviewing the dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role?
9. Educator
10. Advocate
11. Caregiver
12. Case manager - Correct Answer 1. Educator The examination for RN licensure is exactly the same in every state in the United States. This examination
13. Guarantees safe nursing care for all patients
14. Ensures standard nursing care for all patients
15. Ensures that honest and ethical care is provided
16. Provides a minimal standard of knowledge for an RN in practice - Correct Answer 4. Provides a minimal standard of knowledge for an RN in practice Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.) A. Caregiver B. Autonomy and accountability C. Patient advocate D. Health promotion E. Lobbyist - Correct Answer 1, 2, 3, 4 Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform?
17. Moving from an acute illness to a health promotion, illness prevention model
18. Moving from an illness prevention to a health promotion model
19. Moving from an acute illness to a disease management model
20. Moving from a chronic care to an illness prevention model - Correct Answer 1. Moving from an acute illness to a health promotion, illness prevention model

A nurse meets with the registered dietician and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?

1. patient-centered care
2. safety
3. teamwork and collaboration
4. informatics - Correct Answer 3. teamwork and collaboration A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which QSEN competency?
5. Patient-centered care
6. safety
7. teamwork and collaboration
8. informatics - Correct Answer 4. informatics The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career?
9. clinical nurse specialist
10. nurse administrator
11. nurse educator
12. nurse researcher - Correct Answer 4. nurse researcher Nurses in an acute care hospital are attending a unit based education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education?
13. continuing education
14. graduate education
15. in-service education
16. professional registered nurse education - Correct Answer 3. in-service education Which of the following Internet resources can help consumers compare quality care measures? (Select all that apply.)
17. WebMD
18. Hospital compare
19. Magnet recognition program
20. Hospital Consumer assessment of healthcare
21. The American Hospital Association's webpage - Correct Answer 2, 4 The components of the nursing metaparadigm include:
22. Person, health, environment, and theory
23. Health, theory, concepts, and environment
24. Nurses, physicians, health, and patient needs

4. Person, health, environment, and nursing - Correct Answer 4. Person, health, environment, and nursing Theory is essential to nursing practice because it: (Select all that apply)
5. Contributes to nursing knowledge
6. Predicts patient behaviors in situations
7. Provides a means of assessing patient vital signs
8. Guides nursing practice
9. Formulates health care legislation
10. Explains relationships between concepts - Correct Answer 1, 2, 4, 6 A nurse ensures that each patient's room is clean, well ventilated, and free from clutter, excessive noise, and extremes in temperature. Which theorist's work is the nurse practicing in this example?
11. Henderson
12. Orem
13. King
14. Nightingale - Correct Answer 4. Nightingale The nurse is caring for a patient admitted to the neurological unit with the diagnosis of a stroke and right-sided weakness. The nurse assumes responsibility for bathing and feeding the patient until the patient is able to begin performing these activities. The nurse in this situation is applying the theory developed by:
15. Neuman
16. Orem
17. Roy
18. Peplau - Correct Answer 2. Orem Which of the following statements related to theory-based nursing practice are correct? (Select all that apply.)
19. Nursing theory differentiates nursing from other disciplines
20. Nursing theories are standardized and do not change over time
21. Integrating theory into practice promotes coordinated care delivery.
22. Nursing knowledge is generated by theory
23. The theory of nursing process is used in planning patient care
24. Evidence-based practice results from theory-testing research. - Correct Answer 1,3,4, A nurse is caring for a patient who recently lost a leg in a motor vehicle accident. The nurse best assists the patient to cope with this situation by applying which of the following theories?
25. Roy
26. Levine
27. Watson
28. Johnson - Correct Answer 1. Roy

Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing.

1. Self-actualization
2. Air, water, and nutrition
3. Safety
4. Esteem and self-esteem needs - Correct Answer 2. Air, water, and nutrition Which of the following categories of shared theories would be most appropriate for a patient who is grieving the loss of a spouse?
5. Biomedical
6. Leadership
7. Psychosocial
8. Developmental - Correct Answer 3. Psychosocial While working in a rehabilitation facility, it is important to obtain nursing histories and develop a therapeutic nurse-patient relationship. Which of the following lists in correct order the phases of Peplau's theory as applied in this setting. The nurse:
9. Ensures that the patient has access to appropriate community resources for long- term care.
10. Collaborates with the patient to identify specific patient needs
11. Collects essential information from the patient's health record.
12. Works with the patient to develop a plan for resolving patient issues. - Correct Answer 3, 2, 4, 1 Nurses have developed theories in response to: (Select all that apply.)
13. Changes in health care.
14. Prior nursing theories.
15. Changes in nursing practice.
16. Research findings.
17. Government regulations.
18. Theories from other disciplines.
19. Physician opinions. - Correct Answer 1,2,3,4, Which of the following types of theory influence the "evidence" in current "evidence- based practice"?
20. Grand theory
21. Middle range theory
22. Practice theory
23. Shared theory - Correct Answer 2. Middle range theory A nurse is preparing to begin intravenous fluid therapy for a patient. Which category of theory would be most helpful to the nurse at this time?
24. grand theory
25. middle-range theory
26. practice theory
27. shared theory - Correct Answer 3. practice theory

Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? A. Keep a journal B. Participate in a unit meeting to discuss feelings about the patient deaths C. Ask the nurse manager to assign you to less difficult patients D. Review the policy and procedure manual on proper care of patients after death - Correct Answer 2. Participate in a unit meeting to discuss feelings about the patient deaths A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: A. Creativity. B. Fairness. C. Clinical reasoning. D. Applying ethical criteria. - Correct Answer 4. Applying ethical criteria A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of:

1. Accuracy
2. Reflection
3. Risk taking
4. Basic critical thinking - Correct Answer 4. Basic critical thinking A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude:
5. Responsible
6. Complete
7. Accurate
8. Broad - Correct Answer 1. Responsible A nurse on a busy medicine unit is assigned to four patients. It is 10am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.)
9. Consider availability of assistive personnel to obtain the specimen
10. Combine activities to resolve more than one patient problem

3. Analyze the diagnoses / problems and decide which are most urgent based on patients' needs
4. Plan a family conference for tomorrow to make decisions about resources the patient will need to go home
5. Identify the nursing diagnoses for the patient going home - Correct Answer 1,2, By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
6. Curiosity
7. Adequacy
8. Discipline
9. Thinking independently - Correct Answer 3. Discipline A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called
10. reflection
11. perseverance
12. intuition
13. problem solving - Correct Answer 1. reflection Place the steps of the scientific method in their correct order with number 1 being the first step of the process.
14. Formulate a question or hypothesis.
15. Evaluate results of the study.
16. Collect data.
17. Identify the problem.
18. Test the question or hypothesis. - Correct Answer 4,3,1,5, A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Select all that apply.) A. Clinical inference B. Basic critical thinking C. Complex critical thinking Correct D. Experience Correct E. Reflection - Correct Answer 3, 4

Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.)

1. Initiative in reading current evidence from the literature
2. Application of nursing theory
3. Reviewing policy and procedure manual
4. Considering holistic view of patient needs
5. Previous time caring for a specific group of patients - Correct Answer 1,2, An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient?
6. Working in multiple health care settings
7. Learning good communication skills
8. Spending time establishing relationships with patients
9. Relying on evidence in practice - Correct Answer 3. Spending time establishing relationships with patients In which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.)
10. The nurse thinks back about a personal experience before administering a medication subcutaneously.
11. The nurse uses a pain-rating scale to measure a patient's pain.
12. The nurse explains a procedure step by step for giving an enema to a patient care technician.
13. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis
14. A nurse offers support to a colleague who has witnessed a stressful event. - Correct Answer 1, 2, 4 A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of: A. Inference. B. Basic critical thinking. C. Evaluation. D. Diagnostic reasoning. - Correct Answer 4. Diagnostic reasoning Which of the following examples are steps of nursing assessment? (Select all that apply.)
15. Collection of information from patient's family members
16. Recognition that further observations are needed to clarify information
17. Comparison of data with another source to determine data accuracy
18. complete documentation of observational information

5. Determining which medications to administer based on a patient's assessment data - Correct Answer 1, 2, 3 A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?
6. Value-belief pattern
7. cognitive-perceptual pattern
8. coping-stress-tolerance pattern
9. health perception-health management pattern - Correct Answer 4. health perception - health management pattern When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
10. An observation of how a patient turns and moves in bed
11. The unit policy and procedure manual
12. The care recommendations of a physical therapist
13. The results of a diagnostic x-ray film
14. Your experiences in caring for other patients with similar problems - Correct Answer 1, 3, 4 The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of
15. Cue
16. Reflection
17. Clinical inference
18. Probing - Correct Answer 3. clinical inference A 72 year old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe?
19. Review of systems approach
20. Use of a structured database
21. back channeling
22. a problem-oriented approach - Correct Answer 4. a problem-oriented approach The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep?" This series of questions would likely occur during which phase of a patient-centered interview?
23. orientation

2. working phase
3. data validation
4. termination - Correct Answer 2. working phase A nurse is assigned to a 42 year old mother of 4 who weighs 136.2kg (300 pounds), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems?
5. "I can tell that your eating habits have led to your diabetes. Is that right?"
6. "It's been difficult for people to find jobs. Is that why you work part time?"
7. "You have four children; do you have any concerns about going home and caring for them?
8. "I wish patients understood how overeating affects their health." - Correct Answer 3. "You have four children; do you have any concerns about going home and caring for them?" Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
9. Probing
10. Open-ended
11. problem-oriented
12. confirmation - Correct Answer 2. Open-ended A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16]
13. The skin around the wound is tender to touch
14. Fluid intake for 8 hours is 800 mL
15. Patient has a heart rate of 78 and regular
16. Patient has drainage from surgical wound
17. Body temperature is 101F (38.3 C)
18. Patient asks, "I'm worried that I won't return to work when I planned." - Correct Answer 1, 4, A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
19. patient's level of function
20. patient's willingness to perform self-care
21. patient's level of consciousness
22. patient's health management values - Correct Answer 1. patient's level of function A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61 year old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a

chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply)

1. The nurse asks the patient to rate his pain on a scale from 0 to 10.
2. The nurse asks the patient what caused his fall.
3. The nurse asks the patient if he has had pain in his back in the past.
4. The nurse assesses lower limb strength.
5. The nurse asks the patient what pain medication is most effective in managing his pain. - Correct Answer 1, 4 A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess?
6. health perception-health management pattern
7. value-belief pattern
8. cognitive-perceptual pattern
9. self-perception-self-concept pattern - Correct Answer 4. self-perception-self- concept pattern A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.
10. You say you've lost weight. Tell me how much weight you've lost in the last month.
11. My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history.
12. I have no further questions. Thank you for your patience.
13. Tell me what brought you to the hospital.
14. So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor --correct? - Correct Answer 2, 4,1, 5, During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?
15. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct?
16. Have you taken anything for your headaches?
17. Tell me what makes your headaches begin.
18. Uh huh, tell me more. - Correct Answer 3. Tell me what makes your headaches begin. The nurse enters the room of an 82 year old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.)
19. listen attentively to the patient's story

2. use gestures that reinforce your questions or comments
3. stand back away from the bedside
4. maintain direct eye contact
5. ask questions quickly to reduce the patient's fatigue - Correct Answer 1, 2, 4 The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principles are at work in this case, list the principles from highest to lowest priority.
6. Accountability: You as the nurse are accountable for the well being of this patient.
7. Respect for autonomy: This patient's autonomy will be violated if he does not receive the liver transplant.
8. Ethics of care: The caring thing that a nurse could provide this patient is resources for a liver transplant.
9. Justice: The greatest question in this situation is how to determine the just distribution of resources. - Correct Answer 4, 2, 3, 1 A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation?
10. fidelity
11. beneficence
12. nonmaleficence
13. respect for autonomy - Correct Answer 2. beneficence When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain?
14. fidelity
15. beneficence
16. nonmaleficence
17. respect for autonomy - Correct Answer fidelity A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy?
18. Seeking out the nursing supervisor to talk with the patient
19. Documenting patient fears in the medical record in a timely manner
20. Working to change the hospital environment
21. Assessing the patient's point of view and preparing to articulate it - Correct Answer 4. Assessing the patient's point of view and preparing to articulate it.

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why?

1. Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values.
2. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism
3. Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism
4. Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure. - Correct Answer 2. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? (Select all that apply.)
5. Ethics of care pays attention to the environment in which caring occurs.
6. Ethics of care pays attention to the stories of the people involved in the ethical issue
7. Ethics of care is used only in nursing practice
8. Ethics of care focuses only on the code of ethics for nurses.
9. Ethics of care focuses only on understanding relationships. - Correct Answer 1, 2, 5 In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?
10. Nurses understand the principle of autonomy to guide respect for a patient's self- worth.
11. Nurses have a scope of practice that encourages their presence during ethical discussions.
12. Nurses develop a relationship with the patient that is unique among all professional health care providers.
13. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient are. - Correct Answer 3. Nurses develop a relationship with the patient that is unique among all professional health care providers. Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma?
14. List the actions that could be taken to resolve the dilemma
15. Agree on a statement of the problem or dilemma that you are trying to resolve.
16. Agree on a plan to evaluate the action over time.
17. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma
18. Take time to clarify values and distinguish between facts and opinions - your own and those of others involved.
19. Negotiate a plan - Correct Answer 4,5,2,1,6,

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principle, if you participate in a public online social network such as FB, could you post images of a patient's xray film if you obscured or deleted all patient identifiers?

1. Yes because patient privacy would not be violated since patient identifiers were removed.
2. Yes because respect for autonomy implies that you have autonomy to decide what constitutes privacy.
3. No because even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work.
4. No because the principle of justice requires you to allocate resources fairly. - Correct Answer 3. No because even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work. What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in the correct order.
5. clarify values
6. ask the question, Is this an ethical dilemma?
7. verbalize the problem
8. gather information
9. identify course of action
10. evaluate the plan
11. negotiate a plan - Correct Answer 2,4,1,3,5,7, Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations B. To await new clinical orders from the physician C. To limit discussions about ethical principals D. To allow the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues - Correct Answer 1. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations It can be difficult to agree on a common definition of the work quality when it comes to quality of life. Why? (Select all that apply.)
12. Average income varies in different regions of the country.
13. Community values influence definitions of quality, and they are subject to change over time.
14. Individual experiences influence perceptions of quality in different ways, making consensus difficult

4. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures.
5. Statistical analysis is difficult to apply when the outcome cannot be quantified.
6. Whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life. - Correct Answer 2, 3, 4, 5 Which of the following properly applies an ethical principle to justify access to health care? (Select all that apply.)
7. Access to health care reflects the commitment of society to principles of beneficence and justice.
8. If low income compromises access to care, respect for autonomy is compromised.
9. Access to health care is a privilege in the United States, not a right.
10. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics.
11. Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability.
12. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it. - Correct Answer 1, 2, 4 A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.)
13. Information provided by the head nurse.
14. Policies and procedures of the employing hospital
15. State Nurse Practice Act
16. Regulations identified in The Joint Commission manual
17. The American Nurses Association standards of nursing practice - Correct Answer 2, 3, 4, 5 A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.)
18. The nurse does not need any representation.
19. The patient must prove injury, damage, or loss occurred.
20. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred.
21. The patient must prove that a breach in the prevailing standard of care caused an injury.
22. The burden of proof is always the responsibility of the nurse. - Correct Answer 2,3, A nurse stops to help in an emergency at at the scene of an accident. The injured party files a suit and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? [23]
23. The nurse's auto insurance

2. The nurse's homeowner's insurance
3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence.
4. The Patient Care Partnership, which may grant immunity from suit if the injured party contends. - Correct Answer 3. The Good Samaritan Laws, which grant immunity from suit if there is no gross negligence A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?
5. Family member
6. Surgeon
7. Nurse
8. Nurse manager - Correct Answer 2. Surgeon A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? A. Obtain a court order to give the blood B. Coerce the husband into giving the blood C. Call security and have the husband removed from the hospital D. More information is needed about the wife's preference and if the husband has her medical power of attorney - Correct Answer 4. More information is needed about the wife's preference and if the husband has her medical power of attorney The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow?
9. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state.
10. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
11. The patient cannot make changes in the advance directive once admitted to the hospital
12. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state. - Correct Answer 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act?
13. PPACA
14. PSDA
15. HIPAA
16. Emergency Medical Treatment and Active Labor Act - Correct Answer 3. HIPAA

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.)

1. Taking or selling controlled substances
2. Refusing to provide health care information to a patient's child
3. Reporting suspected abuse and neglect of children
4. Applying physical restraints without a written physician's order
5. Completing an occurrence report on the unit. - Correct Answer 1, 4 The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patient's medical diagnoses on the message board. Later in the day, the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPPA)? [23]
6. Discussing the patient conditions in the nursing report room at the change of shift
7. Allowing nursing students to review patient charts before caring for patients to whom they are assigned
8. Posting medical information about the p - Correct Answer 3. Posting medical information about the patient on a message board in the patient's room The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patient's experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply). [23]
9. Failure to document a change in assessment data
10. Failure to provide discharge instructions
11. Failure to follow the six rights of medication administration
12. Failure to use proper medical equipment ordered for patient monitoring
13. Failure to notify a health care provider abou - Correct Answer 1, 5 A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws?
14. HIPAA
15. ADA
16. PSDA
17. Emergency Medical Treatment and Active Labor Act - Correct Answer 4. Emergency Medical Treatment and Active Labor Act

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action?

1. Give the family the record
2. Discuss the issues that concern the family with them
3. Call the nursing supervisor
4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information - Correct Answer 4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information A home health nurse notices significant bruising on a 2 year old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take?
5. Document her findings and treat the patient.
6. Instruct the mother on safe handling of a 2 year old child.
7. Contact a child abuse hotline
8. Discuss this story with a colleague - Correct Answer 3. Contact a child abuse hotline Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.)
9. I am thinking about joining the health committee at my church.
10. I need to read newspapers, watch news broadcasts, and search the Internet for information related to health.
11. I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing
12. Nurses do not have very much voice in legislation in Washington, D.C. because of the nursing shortage
13. I will go back to school as soon as I finish orientation. - Correct Answer 1, 2, 3 You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first? [23]
14. Call the nursing supervisor to discuss the situation
15. Discuss the problem with a colleague
16. Leave the nursing unit and go home
17. Say nothing and begin your work - Correct Answer 1. Call the nursing supervisor to discuss the situation. A manager is reviewing the nursing documentation entered by a staff nurse in patient's EMR and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?
18. Avoid rushing when documenting an entry in the medical record.
19. Use correction fluid to remove the entry.

3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about a patient in the medical record. - Correct Answer 4. Enter only objective and factual information about a a patient in the medical record. A preceptor observes a new graduate nurse discussing change in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some lab tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the EMR when a computer terminal is available. At this hospital new medication orders entered into the EMR can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse:
5. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone.
6. Documents the date and time of the phone conversation, the nam - Correct Answer 3. Gives a newly ordered medication before entering the order in the patient's medical record. As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient?
7. "The patient has a defiant attitude and is demanding test results."
8. "The patient appears to be upset with the nurse because he wants his test results immediately."
9. "The patient is demanding and is complaining about the doctor."
10. "The patient stated feelings of frustration from the lack of information received regarding test results." - Correct Answer 4. The patient stated feelings of frustration from the lack of information regarding test results The nurse is reviewing the HIPAA regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response?
11. HIPAA allows all hospital staff access to your medical record.
12. HIPAA limits the information that is documented in the medical record.
13. HIPAA provides you with greater protection of your personal health information.
14. HIPAA enables health care institutions to release all of your personal information to improve continuity of care. - Correct Answer 3. HIPAA provides you with greater protection of your personal health information. A patient states, "I would like to see what is written in my medical record." What is the nurse's best response?
15. Only your family can read your medical record.
16. You have the right to read your record.

3. Patients are not allowed to read their records.
4. Only health care workers have access to patient records. - Correct Answer 2. You have the right to read your record. Which of the following documentation entries is most accurate?
5. Patient walked up and down hallway with assistance, tolerated well.
6. Patient up, out of bed, walked down hallway, and back to room, tolerated well.
7. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.
8. Patient walked 50 feet and back down hallway with assistance from nurse. HR 88 and regular before exercise, HR 94 and regular following exercise - Correct Answer 4. Patient walked 50 feet and back down hallway with assistance from nurse. HR 88 and regular before exercise and 94 and regular following exercise. The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system?
9. Electronic health record
10. Clinical documentation
11. Clinical decision support system
12. Computerized physician order entry - Correct Answer 3. Clinical decision support system While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record, a physician notices that the only information documented in that section is WDL. The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this?
13. The nurse caring for the patient forgot to document on the pulmonary system.
14. The EMR uses a charting by exception format.
15. The computer shut down unexpectedly when the nurse was documenting the assessment.
16. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment. - Correct Answer 2. The EMR uses a charting by exception format. What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record?
17. Rip the papers up into small pieces and place the pieces into a standard trash can.
18. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit.
19. Place papers with patient information in a secure canister marked for shredding.
20. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit. - Correct Answer 3. Place papers with patient information in a secure canister marked for shredding.