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Nursing Fundamentals Practice Final Exam Extra Study Guide, Exams of Nursing

A study guide for nursing fundamentals practice final exam. It contains 386 questions and answers related to nursing standards of care, legal issues, patient care, medication administration, and IV therapy. The questions are designed to help nursing students prepare for their final exam and test their knowledge of nursing fundamentals. The document covers various scenarios and provides correct answers with explanations. It also includes the latest updates for the 2023/2024 academic year.

Typology: Exams

2023/2024

Available from 12/28/2023

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GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

LATEST UPDATE 2023/2024 BEST EXAM FOR NURSING

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. - correct answers 2, 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. - correct answers 3, 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.

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. The Patient Care Partnership, which may grant immunity from suit if the injured party contends. - correct answers 3 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]
  2. Family member
  3. Surgeon
  4. Nurse
  5. Nurse Manager - correct answers 2 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]
  6. Obtain a court order to give the blood
  7. Coerce the husband into giving the blood
  8. Call security and have the husband removed from the hospital
  9. Abide by the husband's wishes and inform the healthcare provider - correct answers 4 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]
  10. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state.

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
  2. The patient can not make changes in the advance directive once admitted to the hospital.
  3. 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 answers 2 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]
  4. Mental Health Parity Act
  5. Patient Self-Determination Act (PSDA)
  6. Health Insurance Portability and Accountability Act (HIPPA)
  7. Emergency Medical Treatment and Active Labor Act - correct answers 3 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]
  8. Taking and selling controlled substances
  9. Refusing to provide health care information to a patient's child
  10. Reporting suspected abuse and neglect of children
  11. Applying physical restraints without a written physician's order. - correct answers 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

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. Discussing the patient conditions in the nursing report room at the change of shift
  2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned
  3. Posting medical information about the p - correct answers 3 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]
  4. Failure to document a change in assessment data
  5. Failure to provide discharge instructions
  6. Failure to follow the six rights of medication administration
  7. Failure to use proper medical equipment ordered for patient monitoring
  8. Failure to notify a health care provider abou - correct answers 1, 5

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. Health Insurance Portability and Accountability Act (HIPPA)
  2. Americans with Disabilities Act (ADA)
  3. Patient Self-Determination Act (PSDA)
  4. Emergency Medical Treatment and Active Labor Act (EMTALA) - correct answers 4 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]
  5. Give the family the record
  6. Give the patient the record
  7. Discuss the issues that concern the family with them
  8. Call the nursing supervisor - correct answers 3 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]
  9. Document her findings and treat the patient
  10. Instruct the mother on safe handling of a 2-year-old child
  11. Contact a child abuse hotline
  12. Discuss this story with a colleague - correct answers 3

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. "I am thinking about joining the health committee at my church."
  2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health."
  3. "I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing."
  4. "Nurses do not have very much voice in legislation in Washington, D.C. because of the shortage of nurses." - correct answers 1, 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]
  5. Call the nursing supervisor to discuss the situation
  6. Discuss the problem with a colleague
  7. Leave the nursing unit and go home
  8. Say nothing and begin your work - correct answers 1 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]
  9. Call the pharmacist to interpret the order
  10. Call the physician to have the order clarified
  11. Consult the unit manager to help interpret the order
  12. Ask the unit secretary to interpret the physician's handwriting - correct answers 2

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? [31]

  1. 2 mL
  2. 5 mL
  3. 16 mL
  4. 30 mL - correct answers 4 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]
  5. Outward
  6. Back
  7. Upward and back
  8. Upward and outward - correct answers 4 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]
  9. 1/2 tablet
  10. 1 tablet
  11. 1 1/2 tablets
  12. 2 tablets - correct answers 4

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. Give the medication
  2. Identify the patient using two identifiers
  3. Withhold the medications and verify the medication orders
  4. Provide medication education to the mother to help her better understand her child's medications - correct answers 3 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]
  5. Set up the follow-up appointments with the physician for the patient
  6. Ensure that someone will provide housekeeping for the patient at home
  7. Ensure that the home care agency is aware of medication and health teaching needs.
  8. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care. - correct answers 3 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]
  9. Only the patient's physician can give this information
  10. The student provides the name of the medication and a description of its desired effect
  11. Information about medications is confidential and cannot be shared
  12. He has to speak with his assigned nurse about this - correct answers 2

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. Ask the prescriber to change the order
  2. Crush the pill with a mortar and pestle
  3. Hide the capsule in a piece of solid food
  4. Open the capsule and sprinkle it over pudding - correct answers 1 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]
  5. Ask the patient's reason for refusal
  6. Explain that she must take the medication
  7. Take the medication away and chart the patient's refusal
  8. Tell the patient that her physician knows what's best for her - correct answers 1 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]
  9. Hospital policy
  10. The prescriber's orders
  11. The type of medication ordered
  12. The patient's size and muscle mass - correct answers 2

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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A patient is receiving an IV push medication. If the drug infiltrates into the outer tissues, the nurse: [31]

  1. Continues to let the IV run
  2. Applies a warm compress to the infiltrated site
  3. Stops the administration of the medicine and follows agency policy
  4. Should not worry about this because vesicant filtration is not a problem - correct answers 3 If a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: [31]
  5. Sepsis
  6. Phlebitis
  7. Infiltration
  8. Fluid overload - correct answers 2 After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: [31]
  9. Follow ISMP guidelines for safe medication abbreviations
  10. Explain to the physician that the order needs to be given to a registered nurse
  11. Write the order on the patient's order sheet and read it back to the physician
  12. Ensure that the six rights of medication administration are followed when giving the medication - correct answers 2 A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: [31]

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. Complete an occurence report
  2. Notify the healthcare provider
  3. Inform the charge nurse of the error
  4. Assess the patient for adverse effects - correct answers 4 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. - correct answers 16 The nurse's first action after discovering an electrical fire in a patient's room is to: [27]
  5. Activate the fire alarm
  6. Confine the fire by closing all doors and windows
  7. Remove all patients in immediate danger
  8. Extinguish the fire by using the nearest fire extinguisher - correct answers 3 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]
  9. Give the child milk
  10. Give the child syrup of ipecac
  11. Call the poison control center
  12. Take the child to the emergency department - correct answers 3

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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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]

  1. Activity intolerance
  2. Impaired bed mobility
  3. Acute pain
  4. Risk for falls - correct answers 4 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]
  5. Home accidents
  6. Physiological changes of aging
  7. Poisoning and child abduction
  8. Automobile accidents, suicide, and substance abuse - correct answers 4 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]
  9. Insert a urinary catheter
  10. Leave a night light on in the bathroom
  11. Ask the physician to order a restraint
  12. Keep the bed in low position with upper and lower side rails up
  13. Assign a staff member to stay with the patient
  14. Provide scheduled toileting during the night shift

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. Keep the pathway from the bed to the bathroom clear - correct answers 2, 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]
  2. Contact the nursing supervisor
  3. Restrict the family member's visiting privileges
  4. Ask the family to stay with the patient if possible
  5. Inform the family of the risks associated with side-rail use
  6. Thank the family for being conscientious and put the four rails up
  7. Discuss alternatives with the family that are appropriate for this patient - correct answers 3, 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]
  8. Explain what you plan to do
  9. Wrap a limb restraint around a wrist or ankle with soft part toward skin and secure
  10. Determine that restraint alternatives fail to ensure the patient's safety
  11. Identify the patient using proper identifier
  12. Pad the patient's wrist - correct answers 3, 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]

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. Begin cardiopulmonary resuscitation
  2. Restrain the child to prevent injury
  3. Place a tongue blade over the tongue to prevent aspiration
  4. Clear the area around the child to protect the child from injury - correct answers 4 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]
  5. A safe environment promotes patient activity
  6. Assessment focuses on environmental factors only
  7. Teaching home safety is a difficult to do in the hospital setting
  8. Most accidents in the older adult are caused by lifestyle factors - correct answers 1 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]
  9. Place a bed alarm device on the bed
  10. Place the patient in a belt restraint
  11. Provide one-on-one observation of the patient
  12. Apply wrist restraints - correct answers 1 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]

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  1. Smoking is prohibited around oxygen
  2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms
  3. Do not use electrical equipment around oxygen
  4. Special precautions may be required when traveling with oxygen - correct answers 1, 3, 4 How does the nurse support a culture of safety? (Select all that apply) [27]
  5. Completing incident reports when appropriate
  6. Completing incident reports for a near miss
  7. Communicating product concerns to an immediate supervisor
  8. Identifying the person responsible for an incident - correct answers 1, 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]
  9. Smokes a pack a day
  10. Used a cane to walk at home
  11. Takes antihypertensives and diuretics
  12. History of recent fall
  13. Neglect, spatial and perceptual abilities, impulsive
  14. Requires assistance with activity, unsteady gait

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. IV line, urinary catheter - correct answers 3, 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]
  2. Prepare for an influx of patients
  3. Contact the American Red Cross
  4. Determine how to restore essential services
  5. Evacuate patients per the disaster plan - correct answers 1 If an infectious disease can be transmitted directly from one person to another, it is a: [28]
  6. Susceptible host
  7. Communicable disease
  8. Port of entry to a host
  9. Port of exit from the reservior - correct answers 2 Which is the most likely means of transmitting infection between patients? [28]
  10. Exposure to another patient's cough
  11. Sharing equipment between patients
  12. Disposing of soiled linen in a shared linen bag
  13. Contact with a health care worker's hands - correct answers 4 Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. [28]
  14. Illness stage

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  1. Convalescence
  2. Prodromal stage
  3. Incubation period - correct answers 3 Which of the following is the most effective way to break the chain of infection? [28]
  4. Hand hygiene
  5. Wearing gloves
  6. Placing patients in isolation
  7. Providing private rooms for patients - correct answers 1 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]
  8. Wear gloves before eating or handling food
  9. Place any soiled materials into a bag and double bag it
  10. Have the family member check with the doctor about need for immunization
  11. Perform hand hygiene after care and/or handling contaminated equipment or material - correct answers 4 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]
  12. Provide a dark, quiet room to calm the patient
  13. Reduce the level of precautions to keep the patient from angry

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. Explain the reasons for isolation procedures and provide meaningful stimulation
  2. Limit family and other caregiver visits to reduce the risk of spreading infection - correct answers 3 The nurse wears a gown when: [28]
  3. The patient's hygiene is poor
  4. The nurse is assisting with medication administration
  5. The patient has AIDS or hepatitis
  6. Blood or body fluids may get onto the nurse's clothing from a task that he or she plans to perform - correct answers 4 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]
  7. Leave the gloves on to administer the medication
  8. Remove gloves and administer the medication
  9. Remove gloves and perform hand hygiene before administering the medication
  10. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room - correct answers 3 When a nurse is performing surgical hand asepsis, the nurse must keep hands: [28]
  11. Below elbows
  12. Above elbows
  13. At a 45-degree angle
  14. In a comfortable position - correct answers 2

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? [28]

  1. Use an autoclave
  2. Use boiling water
  3. Use ethylene oxide gas
  4. Use chemicals for disinfection - correct answers 2 A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? [28]
  5. It keeps an incontinent patient's skin dry
  6. It can get caught in the linens or equipment
  7. It obstructs the normal flushing action of urine flow
  8. It allows the patient to remain hydrated without having to urinate - correct answers 3 Put the following steps for removal of protective barriers after leaving an isolation room in order: [28]
  9. Untie top, then bottom mask strings and remove from face
  10. 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
  11. Remove gloves
  12. Remove eyewear or goggles
  13. Perform hand hygiene - correct answers 3, 4, 2, 1, 5

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Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? [28]

  1. Wash them with soap and water
  2. Use an alcohol-based hand cleaner
  3. Rinse them and use the alcohol-based cleaner
  4. Wipe them with a paper towel - correct answers 1 A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? [28]
  5. Notify the health care provider and use surgical technique to change the dressing
  6. Reassure the patient and check the wound later
  7. Notify the health care provider and support the patient's fluid and nutritional needs
  8. Alert the patient and caregivers to the presence of an infection to ensure care after discharge - correct answers 3 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]
  9. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action
  10. Fluid flows in the direction of gravity
  11. A sterile field becomes contaminated by prolonged exposure to air

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

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  1. None of the principles were violated - correct answers 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 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]
  2. Value-belief pattern
  3. Cognitive-perceptual pattern
  4. Coping-stress-tolerance pattern
  5. Health perception-health management pattern - correct answers 4 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]
  6. Setting the stage
  7. Gather information about a patient's chief concerns
  8. Collecting the assessment
  9. Termination - correct answers 3 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]
  10. Active listening
  11. Open-ended questioning

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  1. Closed-ended questioning
  2. Problem-oriented listening - correct answers 3, 4 What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16]
  3. Active listening
  4. Back channeling
  5. Validating
  6. Use of open-ended questions
  7. Use of closed-ended questions - correct answers 1, 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]
  8. The skin around the wound is tender to touch
  9. Fluid intake for 8 hours is 800 mL
  10. Patient has a heart rate of 78 and regular
  11. Patient has drainage from surgical wound
  12. Body temperature is 101F (38.3 C)
  13. Patient asks, "I'm worried that I won't return to work when I planned." - correct answers 1, 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.

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He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? [16]

  1. The nurse is making an accurate clinical inference
  2. The nurse has gathered cues to identify a potential problem area
  3. The nurse has allowed stereotyping to influence her assessment
  4. The nurse wants to validate her information with the other nurse - correct answers 3 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]
  5. Agenda setting
  6. Problem-focused
  7. Objective
  8. Use of structured database format - correct answers 2 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]
  9. Health perception- health management pattern
  10. Value-belief pattern
  11. Cognitive-perceptual pattern
  12. Coping-stress tolerance pattern - correct answers 1

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

LATEST UPDATE 2023/2024 BEST EXAM FOR NURSING

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16]

  1. "You say you've lost weight. Tell me how much weight you have lost in the past month."
  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?" - correct answers 2, 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." - correct answers 1, 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]

GUIDE WITH 386QUESTIONS AND ANSWERS BEST EXAM SOLUTION

LATEST UPDATE 2023/2024 BEST EXAM FOR NURSING

  1. So you've had an upset stomach and began vomiting - correct?
  2. Have you taken anything for your stomach?
  3. Is anything else bothering you?
  4. Have you taken any medication for your vomiting? - correct answers 3 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]
  5. An objective finding
  6. A clinical inference
  7. A validation
  8. A concomitant symptom - correct answers 4 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]
  9. Family report
  10. Chest x-ray film
  11. Physical examination with auscultation of the lungs
  12. Medical record summary of x-ray film findings - correct answers 3, 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 knowledge about this patient results