Nursing Fundamentals Exam 1 Practice Test and Comprehensive Exam Study Guide, Exams of Nursing

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A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe healthcare? (Select all that apply). [23]

1. Information provided by the head nurse
2. Policies and procedures of the employing hospital
3. State Nurse Practice Act
4. Regulations identified in the Joint Commission's manual.
5. The American Nurses Association standards of practice. - ans2, 3, 4, 5 A nurse is sued for failure to monitor a patient appropriately after a procedure,. Which of the following statements are correct about this lawsuit? (Select all that apply) [23]
6. The nurse represents the plaintiff.
7. The defendant must prove injury, damage, or loss.
8. The person filing the lawsuit has the burden of proof.
9. The plaintiff must prove that a breach in the prevailing standard of care caused an injury. - ans3, 4 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]
10. The nurse's auto insurance
11. The nurse's homeowner's insurance
12. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence.
13. The Patient Care Partnership, which may grant immunity from suit if the injured party contends. - ans A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with the possible risks, complications, and benefits? [23]
14. Family member
15. Surgeon
16. Nurse
17. Nurse Manager - ans A woman who is a Jehovah's Witness has severe, life-threatening injuries and is hemorrhaging following a car accident. The healthcare 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. What is the nurse's responsibility? [23]
18. Obtain a court order to give the blood
19. Coerce the husband into giving the blood
20. Call security and have the husband removed from the hospital
21. Abide by the husband's wishes and inform the healthcare provider - ans 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 the nurse will follow? [23]
22. A living will allows an appointed person to make health care decisions when the patient is in

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an incapacitated state.

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2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
3. The patient can not make changes in the advance directive once admitted to the hospital.
4. 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. - ans 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 nursing manager because this action is a violoation of which act? [23]
5. Mental Health Parity Act
6. Patient Self-Determination Act (PSDA)
7. Health Insurance Portability and Accountability Act (HIPPA)
8. Emergency Medical Treatment and Active Labor Act - ans 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.) [23]
9. Taking and selling controlled substances
10. Refusing to provide health care information to a patient's child
11. Reporting suspected abuse and neglect of children
12. Applying physical restraints without a written physician's order. - ans1, 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]
13. Discussing the patient conditions in the nursing report room at the change of shift
14. Allowing nursing students to review patient charts before caring for patients to whom they are assigned
15. Posting medical information about the p - ans 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]
16. Failure to document a change in assessment data
17. Failure to provide discharge instructions

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3. Failure to follow the six rights of medication administration

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4. Failure to use proper medical equipment ordered for patient monitoring
5. Failure to notify a health care provider abou - ans1, 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? [23]
6. Health Insurance Portability and Accountability Act (HIPPA)
7. Americans with Disabilities Act (ADA)
8. Patient Self-Determination Act (PSDA)
9. Emergency Medical Treatment and Active Labor Act (EMTALA) - ans You are the night shift nurse and are caring for a newly admitted patient who appears confused. The family asks to see the patient's medical record. What is the first nursing action to take? [23]
10. Give the family the record
11. Give the patient the record
12. Discuss the issues that concern the family with them
13. Call the nursing supervisor - ans A home health nurse notices significant bruising on the 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? [23]
14. Document her findings and treat the patient
15. Instruct the mother on safe handling of a 2-year-old child
16. Contact a child abuse hotline
17. Discuss this story with a colleague - ans A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply) [23]
18. "I am thinking about joining the health committee at my church."
19. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health."
20. "I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing."
21. "Nurses do not have very much voice in legislation in Washington, D.C. because of the shortage of nurses." - ans1, 2 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]
22. Call the nursing supervisor to discuss the situation
23. Discuss the problem with a colleague
24. Leave the nursing unit and go home
25. Say nothing and begin your work - ans

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The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? [31]

1. Call the pharmacist to interpret the order
2. Call the physician to have the order clarified
3. Consult the unit manager to help interpret the order
4. Ask the unit secretary to interpret the physician's handwriting - ans The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? [31]
5. 2 mL
6. 5 mL
7. 16 mL
8. 30 mL - ans A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? [31]
9. Outward
10. Back
11. Upward and back
12. Upward and outward - ans A patient is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? [31]
13. 1/2 tablet
14. 1 tablet
15. 1 1/2 tablets
16. 2 tablets - ans A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? [31]
17. Give the medication
18. Identify the patient using two identifiers
19. Withhold the medications and verify the medication orders
20. Provide medication education to the mother to help her better understand her child's medications - ans A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? [31]
21. Set up the follow-up appointments with the physician for the patient
22. Ensure that someone will provide housekeeping for the patient at home
23. Ensure that the home care agency is aware of medication and health teaching needs.

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4. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care. - ans A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? [31]
5. Only the patient's physician can give this information
6. The student provides the name of the medication and a description of its desired effect
7. Information about medications is confidential and cannot be shared
8. He has to speak with his assigned nurse about this - ans The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's best course of action? [31]
9. Ask the prescriber to change the order
10. Crush the pill with a mortar and pestle
11. Hide the capsule in a piece of solid food
12. Open the capsule and sprinkle it over pudding - ans The nurse takes a medication to a patient, and the patient tells him or her to take it way because she is not going to take it. What is the nurse's next action? [31]
13. Ask the patient's reason for refusal
14. Explain that she must take the medication
15. Take the medication away and chart the patient's refusal
16. Tell the patient that her physician knows what's best for her - ans The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines that the appropriate route for administering the diuretic according to: [31]
17. Hospital policy
18. The prescriber's orders
19. The type of medication ordered
20. The patient's size and muscle mass - ans A patient is receiving an IV push medication. If the drug infiltrates into the outer tissues, the nurse: [31]
21. Continues to let the IV run
22. Applies a warm compress to the infiltrated site
23. Stops the administration of the medicine and follows agency policy
24. Should not worry about this because vesicant filtration is not a problem - ans If a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: [31]
25. Sepsis
26. Phlebitis
27. Infiltration

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4. Fluid overload - ans

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After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: [31]

1. Follow ISMP guidelines for safe medication abbreviations
2. Explain to the physician that the order needs to be given to a registered nurse
3. Write the order on the patient's order sheet and read it back to the physician
4. Ensure that the six rights of medication administration are followed when giving the medication - ans A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: [31]
5. Complete an occurence report
6. Notify the healthcare provider
7. Inform the charge nurse of the error
8. Assess the patient for adverse effects - ans A patient is taking albuterol through a pressurized metered-dose inhaler that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the inhaler last? [31] days. - ans The nurse's first action after discovering an electrical fire in a patient's room is to: [27]
9. Activate the fire alarm
10. Confine the fire by closing all doors and windows
11. Remove all patients in immediate danger
12. Extinguish the fire by using the nearest fire extinguisher - ans A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? [27]
13. Give the child milk
14. Give the child syrup of ipecac
15. Call the poison control center
16. Take the child to the emergency department - ans The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? [27]
17. Activity intolerance
18. Impaired bed mobility
19. Acute pain
20. Risk for falls - ans A couple is with their adolescent daughter for a school physical and state they are worries about all the saftey risks affecting this age. What is the greatest risk for injury to an adolescent? [27]
21. Home accidents
22. Physiological changes of aging

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3. Poisoning and child abduction

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4. Automobile accidents, suicide, and substance abuse - ans The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) [27]
5. Insert a urinary catheter
6. Leave a night light on in the bathroom
7. Ask the physician to order a restraint
8. Keep the bed in low position with upper and lower side rails up
9. Assign a staff member to stay with the patient
10. Provide scheduled toileting during the night shift
11. Keep the pathway from the bed to the bathroom clear - ans2, 6, 7 The family of a patient who is confused and ambulatory insist that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) [27]
12. Contact the nursing supervisor
13. Restrict the family member's visiting privileges
14. Ask the family to stay with the patient if possible
15. Inform the family of the risks associated with side-rail use
16. Thank the family for being conscientious and put the four rails up
17. Discuss alternatives with the family that are appropriate for this patient - ans3, 4, 6 A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. [27]
18. Explain what you plan to do
19. Wrap a limb restraint around a wrist or ankle with soft part toward skin and secure
20. Determine that restraint alternatives fail to ensure the patient's safety
21. Identify the patient using proper identifier
22. Pad the patient's wrist - ans3, 4, 1, 5, 2 A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? [27]
23. Begin cardiopulmonary resuscitation
24. Restrain the child to prevent injury
25. Place a tongue blade over the tongue to prevent aspiration
26. Clear the area around the child to protect the child from injury - ans A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: [27]
27. A safe environment promotes patient activity
28. Assessment focuses on environmental factors only
29. Teaching home safety is a difficult to do in the hospital setting

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4. Most accidents in the older adult are caused by lifestyle factors - ans

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The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: [27]

1. Place a bed alarm device on the bed
2. Place the patient in a belt restraint
3. Provide one-on-one observation of the patient
4. Apply wrist restraints - ans To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply) [27]
5. Smoking is prohibited around oxygen
6. Demonstrate how to adjust the oxygen flow rate based on patient symptoms
7. Do not use electrical equipment around oxygen
8. Special precautions may be required when traveling with oxygen - ans1, 3, 4 How does the nurse support a culture of safety? (Select all that apply) [27]
9. Completing incident reports when appropriate
10. Completing incident reports for a near miss
11. Communicating product concerns to an immediate supervisor
12. Identifying the person responsible for an incident - ans1, 2, 3 You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply) [27]
13. Smokes a pack a day
14. Used a cane to walk at home
15. Takes antihypertensives and diuretics
16. History of recent fall
17. Neglect, spatial and perceptual abilities, impulsive
18. Requires assistance with activity, unsteady gait
19. IV line, urinary catheter - ans3, 4, 5, 6, 7 At 3am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? [27]
20. Prepare for an influx of patients
21. Contact the American Red Cross
22. Determine how to restore essential services
23. Evacuate patients per the disaster plan - ans

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If an infectious disease can be transmitted directly from one person to another, it is a: [28]

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1. Susceptible host
2. Communicable disease
3. Port of entry to a host
4. Port of exit from the reservior - ans Which is the most likely means of transmitting infection between patients? [28]
5. Exposure to another patient's cough
6. Sharing equipment between patients
7. Disposing of soiled linen in a shared linen bag
8. Contact with a health care worker's hands - ans Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. [28]
9. Illness stage
10. Convalescence
11. Prodromal stage
12. Incubation period - ans Which of the following is the most effective way to break the chain of infection? [28]
13. Hand hygiene
14. Wearing gloves
15. Placing patients in isolation
16. Providing private rooms for patients - ans A family member is providing care to a loved care who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? [28]
17. Wear gloves before eating or handling food
18. Place any soiled materials into a bag and double bag it
19. Have the family member check with the doctor about need for immunization
20. Perform hand hygiene after care and/or handling contaminated equipment or material - ans A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? [28]
21. Provide a dark, quiet room to calm the patient
22. Reduce the level of precautions to keep the patient from angry
23. Explain the reasons for isolation procedures and provide meaningful stimulation
24. Limit family and other caregiver visits to reduce the risk of spreading infection - ans The nurse wears a gown when: [28]
25. The patient's hygiene is poor
26. The nurse is assisting with medication administration
27. The patient has AIDS or hepatitis
28. Blood or body fluids may get onto the nurse's clothing from a task that he or she plans to

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perform - ans

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The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? [28]

1. Leave the gloves on to administer the medication
2. Remove gloves and administer the medication
3. Remove gloves and perform hand hygiene before administering the medication
4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room - ans When a nurse is performing surgical hand asepsis, the nurse must keep hands: [28]
5. Below elbows
6. Above elbows
7. At a 45-degree angle
8. In a comfortable position - ans What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? [28]
9. Use an autoclave
10. Use boiling water
11. Use ethylene oxide gas
12. Use chemicals for disinfection - ans A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? [28]
13. It keeps an incontinent patient's skin dry
14. It can get caught in the linens or equipment
15. It obstructs the normal flushing action of urine flow
16. It allows the patient to remain hydrated without having to urinate - ans Put the following steps for removal of protective barriers after leaving an isolation room in order: [28]
17. Untie top, then bottom mask strings and remove from face
18. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side
19. Remove gloves
20. Remove eyewear or goggles
21. Perform hand hygiene - ans3, 4, 2, 1, 5 Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? [28]
22. Wash them with soap and water
23. Use an alcohol-based hand cleaner
24. Rinse them and use the alcohol-based cleaner
25. Wipe them with a paper towel - ans A patient's surgical wound has become swollen, red, and tender. You note that the patient has a

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new fever and leukocytosis. What is the best immediate intervention? [28]

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1. Notify the health care provider and use surgical technique to change the dressing
2. Reassure the patient and check the wound later
3. Notify the health care provider and support the patient's fluid and nutritional needs
4. Alert the patient and caregivers to the presence of an infection to ensure care after discharge - ans While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has been violated? [28]
5. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action
6. Fluid flows in the direction of gravity
7. A sterile field becomes contaminated by prolonged exposure to air
8. None of the principles were violated - ans A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, 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 have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? [16]
9. Value-belief pattern
10. Cognitive-perceptual pattern
11. Coping-stress-tolerance pattern
12. Health perception-health management pattern - ans The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? [16]
13. Setting the stage
14. Gather information about a patient's chief concerns
15. Collecting the assessment
16. Termination - ans What type of interview techiniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply) [16]
17. Active listening
18. Open-ended questioning
19. Closed-ended questioning
20. Problem-oriented listening - ans3, 4 What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16]
21. Active listening
22. Back channeling

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3. Validating

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4. Use of open-ended questions
5. Use of closed-ended questions - ans1, 2, 4 A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16]
6. The skin around the wound is tender to touch
7. Fluid intake for 8 hours is 800 mL
8. Patient has a heart rate of 78 and regular
9. Patient has drainage from surgical wound
10. Body temperature is 101F (38.3 C)
11. Patient asks, "I'm worried that I won't return to work when I planned." - ans1, 4, 5 The 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, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? [16]
12. The nurse is making an accurate clinical inference
13. The nurse has gathered cues to identify a potential problem area
14. The nurse has allowed stereotyping to influence her assessment
15. The nurse wants to validate her information with the other nurse - ans3 A nurse check a patient's IV line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? [16]
16. Agenda setting
17. Problem-focused
18. Objective
19. Use of structured database format - ans2 A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses his inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? [16]
20. Health perception- health management pattern
21. Value-belief pattern
22. Cognitive-perceptual pattern
23. Coping-stress tolerance pattern - ans1 A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16]

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1. "You say you've lost weight. Tell me how much weight you have lost in the past month."

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2. "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."
3. "I have no further questions. That you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor - correct?" - ans2, 4, 1, 5, 3 Which of the following are examples of data validation? (Select all that apply) [16]
6. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record
7. The nurse asks the patient if he is having pain and then asks the patient to rate the severity
8. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content
9. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement
10. The nurse asks the patient to describe a symptom by saying "Go on." - ans1, 4 A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? [16]
11. So you've had an upset stomach and began vomiting - correct?
12. Have you taken anything for your stomach?
13. Is anything else bothering you?
14. Have you taken any medication for your vomiting? - ans3 The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case, the finding of nausea is which of the following? [16]
15. An objective finding
16. A clinical inference
17. A validation
18. A concomitant symptom - ans4 During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply) [16]
19. Family report
20. Chest x-ray film
21. Physical examination with auscultation of the lungs
22. Medical record summary of x-ray film findings - ans3, 4 A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hosprial with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's

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knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply) [16]

1. A problem-focused approach
2. A structured comprehensive approach
3. Using multiple visits to gather a complete database
4. Focusing on the functional health pattern of the role-relationship - ans1, 3 A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply) [16]
5. Maintain a neutral facial expression
6. Lean forward when interacting with the patient
7. Acknowledge the patient's answers through head nodding
8. Limit direct eye contact - ans2, 3 The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format. [17] - ansAcute pain r/t incisional trauma evidenced by pain reported at 7, with guarding, and restricted turning and positioning. Review the following nursing diagnoses and identify the diagnoses that are correctly stated. (Select all that apply) [17]
9. Anxiety related to fear of dying
10. Fatigue related to chronic emphysema
11. need for mouth care related to inflamed mucosa
12. Risk for infection - ans1, 4 A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is example of the nurse avoiding an error in: [17]
13. data collection
14. data clustering
15. data interpretation
16. making a diagnostic statment - ans3 The nursing diagnosis readiness for enhanced communication is an example of a(n): [17]
17. Risk nursing diagnosis
18. Actual nursing diagnosis
19. Health promotion nursing diagnosis
20. Wellness nursing diagnosis - ans3 In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply) [17]

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1. The nurse who listens to lung sounds after a patient reports "difficulty breathing"