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Nursing Principles and Practices, Exams of Advanced Education

A wide range of nursing principles and practices, including topics such as lateral violence and intrapersonal conflict, burnout and secondary traumatic stress, nursing codes of ethics, contemporary influences on nursing, nursing care delivery models, community health nursing, cultural assessment, family-centered care, nursing diagnoses, patient assessment, and various nursing interventions. A comprehensive overview of key nursing concepts and skills, making it a valuable resource for nursing students and professionals. The depth and breadth of the content suggest this document could be used for study notes, lecture notes, summaries, assignments, or even as a reference for university essays or theses related to nursing education and practice.

Typology: Exams

2023/2024

Available from 08/16/2024

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NUR 150 Final Exam Study Guide with

Complete Solution 2023

Which nurse most likely kept records on sanitation techniques and the effects on health? a. Florence Nightingale b. Mary Nutting c. Clara Barton d. Lillian Wald - Correct Answer-a A nurse has compassion fatigue. What is the nurse experiencing? a. Lateral violence and intrapersonal conflict b. Burnout and secondary traumatic stress c. Short-term grief and single stressor d. Physical and mental exhaustion - Correct Answer-b A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts? a. Protects the nurse b. Protects the public c. Protects the provider d. Protects the hospital - Correct Answer-b A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using? a. Code of ethics b. Standards of practice c. Standards of professional performance d. Quality and safety education for nurses - Correct Answer-a A nurse is preparing a teaching session about contemporary influences on nursing. Which examples should the nurse include? (Select all that apply.) a. Human rights b. Affordable Care Act c. Demographic changes d. Medically underserved e. Decreasing health care costs - Correct Answer-a,b,c,d

The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? a. Assessment b. Diagnosis c. Planning d. Implementation - Correct Answer-c An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? a. Novice b. Proficient c. Competent d. Advanced beginner - Correct Answer-a A nurse is teaching the staff about Benner's levels of proficiency. In which order should the nurse place the levels from beginning level to ending level?

  1. Expert
  2. Novice
  3. Proficient
  4. Competent
  5. Advanced beginner a. 2, 4, 5, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 2, 5, 3, 1 d. 4, 5, 2, 1, 3 - Correct Answer-b The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize? a. Pew Health Professions Commission b. Healthcare Effectiveness Data and Information Set (HEDIS) c. American Nurses Credentialing Center (ANCC) Magnet Recognition Program d. Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) - Correct Answer-b A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse's best response? a. "Technology use has to be combined with nursing judgment." b. "The focus of effective nursing care is technology."

c. "If it's so easy, why don't you do it?" d. "That is true in the 20th century." - Correct Answer-a A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) a. Use informatics. b. Use transparency. c. Apply globalization. d. Apply quality improvement. e. Use evidence-based practice. - Correct Answer-a,d,e A nurse is working as a community health nurse. Which action is a priority for this nurse? a. Provide direct care to subpopulations. b. Focus on the needs of the ill individual. c. Provide first level of contact to health care systems. d. Focus on providing care in various community settings. - Correct Answer-a A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing? a. Public health b. Community health c. Community-based d. Community assessment - Correct Answer-c The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse's action? a. To prevent individual illness b. To prevent community outbreak of illness c. To prevent outbreak of illness in the family d. To prevent needs of the local population groups - Correct Answer-b While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment? a. Structure b. Population c. Social system d. Welfare system - Correct Answer-a

A nurse is assessing a community. Match each community element the nurse will assess with the correct example. a. Education Level b. Housing c .Government

  1. Structure
  2. Population
  3. Social system - Correct Answer-1. b
  4. a
  5. c The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention - Correct Answer-a The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion - Correct Answer-a A patient is admitted to a rehabilitation facility following a stroke. The patient has right- sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion - Correct Answer-c The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? a. Shock b. Withdrawal

c. Acceptance d. Rehabilitation - Correct Answer-b The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures. - Correct Answer-b The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion - Correct Answer-d A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic African-Americans - Correct Answer-b A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate. - Correct Answer-b A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma - Correct Answer-b

A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities. - Correct Answer-d A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? a. Provides care that fits the patient's valued life patterns and set of meanings b. Provides care that is based on meanings generated by predetermined criteria c. Provides care that makes the nurse the leader in determining what is needed d. Provides care that is the same as the values of the professional health care system - Correct Answer-a A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions - Correct Answer-a A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? a. Use partnered rather than married. b. Use mother rather than father. c. Use parents rather than guardian. d. Use wife/husband rather than significant other. - Correct Answer-a A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely? a. Young bisexuals b. Young caucasians c. Asian Americans d. African-Americans - Correct Answer-a The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? a. Marginalized groups

b. Health care disparity c. Transcultural nursing d. Culturally congruent care - Correct Answer-d A nurse is using the RESPECT mnemonic to establish rapport, the "R" in RESPECT. Which actions should the nurse take? (Select all that apply.) a. Connect on a social level. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures. - Correct Answer-a,c A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the "H"? a. Health b. Healers c. History d. Homeland - Correct Answer-b The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking. - Correct Answer-b A nurse is assessing a patient's ethnohistory. Which question should the nurse ask? a. What language do you speak at home? b. How different is your life here from back home? c. Which caregivers do you seek when you are sick? d. How different is what we do from what your family does when you are sick? - Correct Answer-b A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have? - Correct Answer-b,c,e

A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, "None of her jobs are getting done, and I don't do those jobs, so the house and the kids are falling apart." How will the nurse interpret this finding? a. The family structure is resilient. b. The family structure is flexible. c. The family structure is hardy. d. The family structure is rigid. - Correct Answer-d The nurse is interviewing a patient who is being admitted to the hospital. The patient's family went home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" What is the rationale for the nurse's action? a. To assess the family form b. To assess the family function c. To assess the family structure d. To assess the family generalization - Correct Answer-c A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregivers - Correct Answer-c A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? a. Assess family patterns versus individual characteristics. b. Assess how much the family provides the patient's basic needs. c. Use "family as patient" and "family as context" approaches simultaneously. d. Plan care to meet not only the patient's needs but those of the family as well. - Correct Answer-b The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregiver - Correct Answer-c

The nurse is caring for an older adult patient who has no apparent family. When questioned about family and the definition of family, the patient states, "I have no family. They're all gone." When asked, "Who prepares your meals?" the patient states, "I do, or I go out." Which approach should the nurse use for this patient? a. Family as context b. Family as patient c. Family as system d. Family as caregiver - Correct Answer-a A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family. Which action should the nurse take to help relieve stress? a. Encourage caregiver to do as much as possible. b. Focus primarily on the patient. c. Point out weaknesses. d. Provide education. - Correct Answer-d The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family? a. "You're doing that all wrong. Let me show you how to do it." b. "I don't know who showed you how to change a dressing, but you're not doing it right. Let me show you c. "You're hesitant about changing the dressing like I was before I was shown an easier way; would you like d. "I used to change the dressing the same way you are doing it: the wrong way. I'll show you the right way - Correct Answer-c The nurse is providing discharge teaching for an older-adult patient who will need tube feedings at home. The spouse is the only source of care and states "I will not be able to perform the feedings due to arthritis." Which action should the nurse take? a. Obtain extra feeding supplies. b. Arrange for home care. c. Cancel the discharge. d. Teach the spouse. - Correct Answer-b A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.) a. Developmental

b. Interactive c. Integrity d. Coping e. Life - Correct Answer-a,b,c,d A nurse is focusing on the interactive processes of family life and is asking the patient questions. Match the questions the nurse will ask to the interactive process. a.Intimacy expression b.Social support c.Roles d.Family nurturing 1.Who is the "peacekeeper" of the family?

  1. How are house rules established?
  2. How often does the family hug each other? 4.Who at your workplace is close to the family? - Correct Answer-1. c
  3. d
  4. a
  5. b A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a. Examine the meaning of data. b. Support findings and conclusions. c. Review the effectiveness of nursing actions. d. Search for links between the data and the nurse's assumptions. - Correct Answer-c The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation - Correct Answer-c A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered.

d. Offer to notify the health care provider after morning rounds are completed. - Correct Answer-a The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved - Correct Answer-a A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling - Correct Answer-c A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation - Correct Answer-a A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient's presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview. - Correct Answer-b Which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications - Correct Answer-c

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview. - Correct Answer-c The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon's Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment - Correct Answer-d A nurse is completing an assessment using the PQRST to obtain data about the patient's chest pain. Match the questions to the components of the PQRST that the nurse will be using. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10?

  1. Provokes
  2. Quality
  3. Radiate
  4. Severity 5.Time - Correct Answer-1. b
  5. a
  6. d
  7. e
  8. c While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation. - Correct Answer-a

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. "Data interpretation occurs before data validation." b. "Validation involves looking for patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation involves discovering patterns in professional standards." - Correct Answer-c Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and twants something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg d. The nurse elevates a leg cast when the patient reports decreased mobility. - Correct Answer-a The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The waiting room while the occupational therapist is working on leg exercises - Correct Answer-a A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes - Correct Answer-d A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics

c. Diagnostic reasoning d. Diagnostic labeling - Correct Answer-c A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety - Correct Answer-c The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a. Etiology b. Nursing diagnosis c. Collaborative problem d. Defining characteristic - Correct Answer-a A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing - Correct Answer-b A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection - Correct Answer-c Patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a. Adult failure to thrive

b. Hypothermia c. Deficient fluid volume d. Nausea - Correct Answer-c Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?" - Correct Answer-b The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased tolerance to activity over the next month. c. The patient will understand needed dietary changes by discharge. d. The patient will demonstrate increased mobility in 2 days. - Correct Answer-a A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence - Correct Answer-d A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible. - Correct Answer-d A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will walk unassisted to bathroom by the end of shift. c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift. - Correct Answer-a

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent b. Independent c. Interdependent d. Physician-initiated - Correct Answer-c A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent - Correct Answer-d A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statementRisk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. b. Obtain an interpreter for the patient as soon as possible. c. Assist the patient in performing swallowing exercises each shift. d. Ask the family to provide a sitter to remain with the patient at all times. - Correct Answer-a A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention ismost appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. b. Encourage patient to remain in bed most of the shift. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 4 hours or as tolerated. - Correct Answer-d A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take?

  1. Identify the problem.
  2. Discuss the findings and recommendation.
  3. Provide the consultant with relevant information about the problem.
  4. Contact the right professional, with the appropriate knowledge and expertise.
  5. Avoid bias by not providing a lot of information based on opinion to the consultant. a. 1, 4, 3, 5, 2 b. 4, 1, 3, 2, 5 c. 1, 4, 5, 3, 2

d. 4, 3, 1, 5, 2 - Correct Answer-a A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next? a. Include dressing change instructions and frequency in the care plan. b. Assume that the wound nurse will perform all dressing changes. c. Request that the health care provider look at the wound. d. Encourage the patient to perform the dressing changes. - Correct Answer-a A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? a. "This system can help medical students determine the cost of the care they provide to patients." b. "If the nursing department uses this system, communication among nurses who work throughout the hospital be enhanced." c. "We could use this system to help organize orientation for new nursing employees because we can better the nursing interventions we use most frequently on our unit." d. "The NIC system provides one way to improve safe and effective documentation in the hospital's electro record." - Correct Answer-a After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. b. Direct the nursing assistive personnel to ask if the headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care. - Correct Answer-c Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors. - Correct Answer-b,d,e A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

a. Reassess the patient and situation. b. Revise the turning schedule to increase the frequency. c. Delegate turning to the nursing assistive personnel. d. Apply medication to the area of skin that is broken down. - Correct Answer-a A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a. Heart rate 78 beats/min on 12/ b. Heart rate 78 beats/min on 12/ c. Heart rate 80 beats/min on 12/ d. Heart rate 80 beats/min on 12/4 - Correct Answer-a A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a. "Evaluative measures are multiple-page documents used to evaluate nurse performance." "Evaluative measures include assessment data used to determine whether patients have met their expecte b. outcomes and goals." "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making fr c. novice to expert nurse." d. "Evaluative measures are objective views for completion of nursing interventions." - Correct Answer-b The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Whichpriority action will the nurse take? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as "better" in the chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments - Correct Answer-c A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States feels better after talking with family and friends b. Consumes high-carbohydrate foods when stressed c. Dislikes the support group meetings d. Spends most of the day in bed - Correct Answer-a

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient's prescriptions have been filled to take home. - Correct Answer-b The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 2 hours. d. Discontinue the plan of care for wound care. - Correct Answer-b A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a. Identify factors interfering with goal achievement. b. Counsel the nursing assistive personnel on duty when the patient fell. c. Remove the fall risk sign from the patient's door because the patient has suffered a fall. d. Request that the more experienced charge nurse complete the documentation about the fall. - Correct Answer-a A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?

  1. Revise nursing diagnosis.
  2. Reassess blood pressure reading.
  3. Retake blood pressure after medication.
  4. Administer new blood pressure medication.
  5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 b. 2, 1, 5, 4, 3 c. 4, 3, 1, 5, 2 d. 5, 4, 5, 1, 2 - Correct Answer-b When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is thebest rationale for this step?

a. So fact is separated from opinion b. So different perspectives are respected c. So judgmental attitudes can be provoked d. So the group identifies the one correct solution - Correct Answer-b A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? a. Unequal power b. Presence of conflicting values c. Judgmental perceptions of patients d. Poor communication with the patient - Correct Answer-b The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Advocacy b. Responsibility c. Confidentiality d. Accountability - Correct Answer-b A nurse is a member of the ethics committee. Which purposes will the nurse fulfill in this committee? (Select all that apply.) a. Education b. Case consultation c. Purchasing power d. Direct patient care e. Policy recommendation - Correct Answer-a,b,e A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus's outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence - Correct Answer-d The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care

regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order.

  1. The nurse identifies possible solutions or actions to resolve the dilemma.
  2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation.
  3. Health care providers use negotiation to redefine the patient's plan of care.
  4. The nurse evaluates the plan and revises it with input from other health care providers as necessary.
  5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. a. 6, 1, 2, 5, 4, 3 b. 5, 6, 2, 3, 4, 1 c. 1, 2, 5, 4, 3, 6 d. 2, 5, 6, 1, 3, 4 - Correct Answer-d An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance? a. The nurse acted appropriately and saved the patient's life. b. The nurse stayed within the guidelines of the Good Samaritan Law. c. The nurse took actions beyond those that are standard and appropriate. d. The nurse should have just stayed with the patient and waited for help. - Correct Answer-c A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? a. Ask a family member to translate what the nurse is saying. b. Request an official interpreter to explain the terms of consent. c. Notify the nursing manager that the patient doesn't speak English. d. Use hand gestures and medical equipment while explaining in English. - Correct Answer-b A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. Which action is most appropriate for the nurse to take? a. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability an Accountability Act (HIPAA).

b. Use the book as needed while keeping it away from individuals not involved in patient care. c. Move the book to the upper ledge of the nursing station for easier access. d. Ask the nurse manager to move the book to a more secluded area. - Correct Answer- b While recovering from a severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. Which response by the nurse is most appropriate? a. "Check with your admitting health care provider whether a copy is on your chart." b. "Let me check with someone here in the hospital who can assist you." c. "You are not allowed to ever change a living will after signing it." d. "Your living will can be changed only once each calendar year." - Correct Answer-b A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. Which is the best action by the nurse at this time? a. Apply restraints loosely on the patient's dominant wrist. b. Notify the health care provider that restraints are needed immediately. c. Try other approaches to prevent the patient from touching these care items. d. Allow the patient to pull out lines to prove that the patient needs to be restrained. - Correct Answer-c Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. Which initial action should the nurse take? a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. b. Tell the cameraman where the hospital's public relations department is located. c. Have the cameraman wait for permission from the health care provider. d. Ask the cameraman how the pictures are to be used in the newspaper. - Correct Answer-b A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend - Correct Answer-c

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Nonjudgmental b. Socializing c. Narrative d. SBAR - Correct Answer-c A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Socio-consultative b. Personal c. Intimate d. Public - Correct Answer-b Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination - Correct Answer-a A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are." - Correct Answer-b Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately b. Uses automatic responses fluently c. Demonstrates passive remarks accurately d. Self-examines personal communication skills - Correct Answer-d An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum.

b. Turn off the television. c. Speak clearly and loudly. d. Use at least 14-point print. - Correct Answer-b Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond. - Correct Answer-a The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations. - Correct Answer-b A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Teaching is most effective when it responds to the learner's needs." d. "Learning consists of a conscious, deliberate set of actions designed to help the teacher." - Correct Answer-c A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a. A nurse presents information about diabetes. b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient. - Correct Answer-b A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? a. If you still do not understand, ask again. b. Ask a nurse to be your advocate or supporter. c. The nurse is the center of the health care team. d. Inappropriate medical tests are the most common mistakes. - Correct Answer-a

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a. "Patient education is an essential component of safe, patient-centered care." b. "Patient education is a standard for professional nursing practice." c. "Patient teaching falls within the scope of nursing practice." d. "Patient teaching is documented and part of the chart." e. "Patient education is not effective with children." f. "Patient teaching can increase health care costs." - Correct Answer-a,b,c,d A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? a. The nurse b. The patient c. The nurse teaching about healthy food choices d. The patient stating that eating yogurt is better than eating cake - Correct Answer-a While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. Which action is the nurse completing? a. Developing learning objectives b. Providing positive reinforcement c. Presenting facts and knowledge d. Implementing interpersonal communication - Correct Answer-a A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? a. Sociocultural background and motivation b. Stage of grieving and overall physical health c. Developmental capabilities and physical capabilities d. Psychosocial adaptation to illness and active participation - Correct Answer-c Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. A patient has the ability to grasp and apply the elastic bandage. b. A patient has sufficient upper body strength to move from a bed to a wheelchair. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe. - Correct Answer-c