Yoost Fundamentals of nursing review questions with 100% correct answers/24-25, Exams of Nursing

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Yoost Fundamentals of nursing review questions with

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1. Which resource is most helpful when prioritizing identified nursing diag- noses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC): Answer: c Maslow's hierarchy of needs and the airway, breathing, circulation (ABCs) of life support are the most helpful tools in identifying priorities of care. Functional health patterns is one method of organizing assessment data. NOC and NIC are resources for identifying outcomes and interventions to include in a patient's care plan after priorities have been established. 2. A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient's chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy: b. Assessment 3. Which factors affect the nursing shortage? (Select all that apply.) a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses: a. Aging faculty b. Increasing elderly populationnumber of nurses d. Aging nursing workforce 4. Which statements describe a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration: a. Optimal functioning of the patient b. Interaction with components of the environment d. The illness and health concept 5. Which core competency of advanced practice nursing is the Master of Sci- ence in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques?

a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching: d. Expert coaching

6. Which are included in the ANA standards? (Select all that apply.) a. Standards of professional performance b. Code of ethics c. Standards of practice d. Legal scope of practice e. Licensure requirements: a. Standards for professional performance c. Standards of care 7. A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider (PCP). Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism: c. Accountability 8. Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Autocratic leadership: c. Cultural competence 9. What specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability: b. Body of knowledge 10. A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized process- es? (Select all that apply.) a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism: a. Code of ethics

b. Licensing c. Body of knowledge e. Altruism

11. In comparing the American Nurses Association (ANA) and the Internation- al Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illnes: c. Shaping health policy 12. Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient, and the patient says, "I've already heard all of that before, and I don't agree with any of it." How should the nurse proceed? a. Ask the patient to explain his values. b. Ask the patient to explain what he believes. c. Ask the patient about his prejudicial attitude. d. Confront the patient about the apparent values conflict.: b. Ask the patient to explain what he believes. 13. Which nursing theory of care describes how the nurse's presence in the nurse- patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient? a. Swanson's Theory of Caring Processes b. Madeline Leininger's Cultural Care Theory c. Watson's Theory of Human Caring d. Boykin and Schoenhofer's Theory of Nursing as Caring: c. Watson's Theory of Human Caring 14. Which statement best describes for new parents how and when children develop first- order beliefs? a. During infancy, and once developed, such beliefs seldom change b. From life experiences during the toddler and preschool years c. Throughout life from firsthand experiences and information provided by authority figures d. From teen and young-adult peer interaction and mentorship of professional role models: c. Throughout life from first-hand experiences and information provid- ed by authority figures 15. As the nurse explained the preoperative instructions to the patient, the patient's older brother suddenly stepped into the doorway and yelled, "People

who go under the knife always die. Don't do it! They're going to kill you." What type of higher- order belief is the patient's older brother displaying? a. Distress b. Stereotype c. Prejudice d. Denial: b. Stereotype

16. After admitting a homeless patient to the floor, the nurse tells a colleague that "homeless people are too dumb to understand instructions." What action should the colleague take first? a. Ignore the nurse's prejudicial comment without responding. b. Offer to trade assignments and care for the homeless patient. c. Ask the nurse about the patient's personal history assessment data. d. Challenge the nurse's thinking, pointing out the ability of all people.: c. Ask the nurse about the patient's personal history assessment data 17. The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child's mother, she smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been smoking, and the mother responds, "Yes, and I know they've told me before I can't smoke around him." What should the nurse do next? a. Ask the patient's mother what she values more, her child or her habit. b. Ask the patient's mother to explain what she believes about smoking and asthma. c. Ask the patient's mother about her prejudicial attitude toward smoking. d. Confront the patient's mother about the values conflict she's experiencing.- : b. Ask the patient's mother to explain what she believes about smoking and asthma. 18. A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which interventions would be most appropriate for the nurse to implement in this situation? (Select all that apply.) a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney. b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed deci- sion.

d. Ask for his permission to contact the kidney donation team to answer any questions he may have. e. Assure him that everything will be alright since he is helping his brother.: b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have.

19. A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu, because it is summer and the hospital is only offering chicken and fish, which in his culture are "hot" foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger's theory? a. Discourage the family from bringing in food, explaining that the idea of "hot" and "cold" foods is a superstition without scientific basis. b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options. d. Tell the family to bring in any foods they want, to help preserve the patient's cultural practices and dietary preferences.: b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. 20. In Swanson's Caring Theory, the nurse demonstrates caring using several techniques. Which intervention is appropriate and most important for the nurse to include in a patient's plan of care? a. Call patients by their first name to demonstrate a caring attitude. b. Sit at the bedside for at least 5 minutes each hour. c. Use touch based on the nurse's judgment of what is appropriate. d. Ask the patient to identify the most important thing to accomplish during the nurse's shift.: d. Ask the patient to identify the most important thing to accomplish during the nurse's shift 21. A new nurse is about to insert a nasogastric (NG) tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.)

a. Offer the patient pain medication to help her calm down. b. Hold the patient's hand while inserting the nasogastric tube. c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care. e. Delay inserting the nasogastric tube until the patient's husband comes to visit.: c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care.

22. A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient's call light is activated. What referent initiated communication between the patient and the nurse? a. Interaction between the patient and his wife b. Concern on the part of the patient's spouse c. Pain experienced by the patient d. Activation of the call light: c. Pain experienced by the patient 23. Which factors influence whether a message is effectively communicated? (Select all that apply.) a. Timing of the conversation b. Educational level of participants c. Mode of communication used d. Physical environment of discussion: a. Timing of the conversation b.Educational level of participants c. Mode of communication utilized d. Physical environment of discussion 24. If a patient is grimacing, what assessment statement or question would be most beneficial in identifying the underlying cause of the nonverbal commu- nication? a. "Did you lose something?" b. "You appear to be having pain." c. "I will turn off the lights and let you rest." d. "May I get you something to relieve your tension?": b. "You appear to be having pain." 25. What action by the nurse would most ensure accurate interpretation of patient communication? a. Providing feedback regarding the conveyed message b. Writing down the patient's conversational highlights c. Assuming significant cultural differences exist d. Verifying the patient's emotional state: a. Providing feedback regarding the conveyed message

26. If a patient's verbal and nonverbal communications are inconsistent, which form of communication is most likely to convey the true feelings of the patient? a. Written notes b. Facial expressions c. Implied inferences d. Spoken words: b. Facial expressions 27. What strategy would be most effective in communicating with a highly anxious adult immediately before surgery? a. Providing specific, concise instructions b. Detailing likely causes of their anxiety c. Focusing on postoperative details d. Using instructional multimedia DVDs: a. Providing specific, concise instruc- tions 28. What action should the nurse take if an alert and oriented patient asks the nurse for personal contact information? a. Ask the patient why the personal information is needed. b. Report the interaction to the nursing supervisor immediately. c. State that it would not be appropriate to share that information. d. Change the subject, and hope that the patient does not ask again.: c. State that it would not be appropriate to share that information. 29. What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments? a. "Can you tell me why you are undecided?" b. "It's always a good idea to have chemotherapy." c. "What are you thinking about the treatments at this point?" d. "You should follow whatever your health care provider recommends.": - "What are you thinking about the treatments at this point?" 30. Which statement is most accurate regarding symbolic expression? a. Skills confidence can be shared most effectively by nurses through wearing distinctive clothing. b. Clothing choices by a hospitalized patient rarely reflects his or her econom- ic resources. c. Make-up use by a patient is unnecessary for any reason during hospitaliza- tion. d. Nondramatic make-up use and minimal accessorizing by nurses demon- strates professionalism.: d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates professionalism.

31. Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care? a. Denial b. Regression c. Repression d. Displacement: b. Regression 32. The nurse receives change-of-shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. Problem solving b. Decision making c. Inference d. Reasoning: b. Decision making 33. In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. "What do I know about this situation?" b. "What additional details do I need to gather?" c. "Does the clinical presentation correlate with the diagnosis?" d. "Are the treatments appropriate for the diagnosis?": b. "What additional details do I need to gather?" 34. Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relationship of this information to other data?: c. What are the most significant factors in the problem? 35. The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint b. Request that another nurse be assigned to this patient c. Review information about the medical diagnosis and routine management d. Complete a physical assessment of the patient: c. Review data about the medical diagnosis and routine management 36. The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately em-

ploying the critical-thinking skill of analysis in the nursing process? (Select all that apply.) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient: a. As- sessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated

37. Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure to pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measure- ment: a. Using subjective and objective data to confirm a diagnosis 38. The nurse is completing an assessment on a patient with sudden on- set of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference: b. Interpretation 39. The nurse can facilitate critical thinking through the use of which interper- sonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning: a. Teamwork d. Conflict management e. Advocacy 40. In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indica- tion of bias? a. Collecting the patient's medical history

b. Initiating intravenous access c. Performing oral care d. Completing a bed bath: a. Collecting the patient's medical history

41. During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance: a. Clarity 42. What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the way nurses think about patient care d. Facilitating communication among members of the health care team: c. Organizing the ways nurses think about patient care 43. A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting: d. Severity and duration of the nausea and vomiting 44. An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient: d. Patient 45. What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice: b. Communicating patient needs 46. On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition

c. Clustered data d. Medical diagnoses: c. Clustered data

47. Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.: a. Patient will walk to the bathroom independently without falling within 2 days after surgery. 48. What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests: a. Patient needs 49. Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice and competency of the other team member. d. Call a meeting of the health care team to determine the needs of the patient.: c. Know the scope of practice for the other team member. 50. A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.: a. Identify reasons the patient is unable to sleep. 51. What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention

is needed.: c. Monitor patient urine output to evaluate the need for the current plan of care.

52. Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information: c. Greeting the nurse in the examina- tion room 53. Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers (PCPs) d. Physical condition of the patient e. Music preference of the patient: a. Distance between the chairs in which the nurse and patient are sitting b.Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient 54. Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning. b. Ask which name a patient prefers to be called during care to show respect and build trust. c. Quickly conduct a review of systems to determine the need for a complete or focused assessment. d. Begin with questions about intimacy and sexuality to address sensitive issues first.: b. Ask which name a patient prefers to be called during care to show respect and build trust. 55. Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed: b. Including selected family members in care planning

56. Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing: c. Comatose 57. Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breath- ing while exercising?": d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?" 58. Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet: a. Deeply sighing with fatigue 59. A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model: d. Functional health patterns model 60. When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluid: c. Assess the patient's vital signs 61. If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid

c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearance: d. Inspect the patient's left elbow to compare its appearance

62. What is the most important reason for nurses to use a standardized taxonomy, such as the ICNP, CCC, or NANDA-I? a. Insurance documentation b. Professional autonomy c. EMR data analysis d. Patient safety: .d. Patient safety 63. Which nursing diagnosis statements are appropriately written according to 2018- NANDA-I format? (Select all that apply.) a. Risk for Infection (ICNP) related to elevated temperature and white blood count b. Readiness for Effective Family Process (ICNP) as evidenced by an ex- pressed desire for improved communication and mutual respect verbalized by family members c. Impaired health maintenance (ICNP) related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time e. Chronic Pain (ICNP) related to osteoarthritis as manifested by verbalized postoperative discomfort: b. Readiness for Effective Family Process (ICNP) as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members c. Impaired health maintenance (ICNP) related to inability to access care as evi- denced by failure to keep appointments, homebound status d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time 64. Which phrase best represents a related factor in a problem-focused nurs- ing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness: c. Ineffective adaptation to recent loss 65. Which actions does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Review the patient's past and present medical history. b. Analyze the nursing assessment data to determine whether information is complete. c. Outline an individualized plan of care to address each concern. d. Consider potential complications to which the patient is susceptible.

e. Evaluate how the patient has responded to treatment.: a. Review the patient's past and present medical history. b. Analyze the nursing assessment data to determine whether information is com- plete. d. Consider potential complications to which the patient is susceptible.

66. What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis? a. Related factors are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.: a. Related factors are not part of a risk diagnosis. 67. What is the most important action for a nurse to take to have a new nursing diagnosis considered for inclusion in the ICNP or NANDA-I taxonomies? a. Share concerns with the nurse manager on the nursing unit. b. Offer alternative care for a patient and family members. c. Discuss how to address patient needs with physicians. d. Provide evidence-based research to support nursing care.: d. Provide evi- dence-based research to support nursing care. 68. What is the most significant problem that may result from improperly written NANDA-I nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs: a. Lack of direction for formulating patient plans of care 69. Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.: d. Medical diagnoses may be interrelated to nursing diagnoses 70. A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition.

c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.: b. Perform the steps of the nursing process related to the patient's current condition.

71. Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data: d. Rank patient concerns from assessment data 72. What signs and symptoms would the nurse appropriately cluster as sup- porting data for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 bpm c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone.: b. Elevated pulse rate auscultated at 140 bpm c. Continuous foot tapping throughout intake interview e. Patient states, "I feel nervous all the time, especially when I am alone." 73. If a patient is exhibiting signs and symptoms of each of these nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Lack of Knowledge d. Disturbed Body Image: b. Acute Pain 74. Which statement illustrates a characteristic of goals within the care plan- ning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.: d. Long-term goals are helpful in judging a patient's progress. 75. Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization.

c. Patient's visitors will be instructed in proper handwashing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.: b. Patient's white blood count will remain within normal range throughout hospitalization

76. If the nurse chooses the Nursing Outcome Classification (NOC), Appetite for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections: a. Expressed desire to eat b. Report that food smells good d. Preparation of home-cooked meals for self and family 77. Which action by the nurse would be most important in developing a patient- centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation: c. Listening to the patient's concerns and beliefs about proposed treatment 78. Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages: b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors 79. The nurse notices that a patient is becoming short of breath and anxious. Which intervention is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation

d. Evaluating the patient's peripheral circulation: b. Administering oxygen by nasal cannula

80. Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview: a. Hospice referral 81. What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change: a. Potential communication barriers b.Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient 82. Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient's spouse to assist with all bathing: c. Encourage the patient to rest between bathing activities 83. Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.: b. Dou- ble-check the patient's allergies before giving the drug. 84. Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy

d. Encouraging the patient to explore options for care: d. Encouraging the patient to explore options for care

85. What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Nurse's professional expertise d. Current evidence-based research e. Convenience to the nursing staff: a. Patient's treatment preferences b.Cultural and ethnic influences c. Nurse's professional expertise d. Current evidence-based research 86. Which task may the registered nurse safely delegate to unlicensed assis- tive personnel without prior intervention? a. Ambulating a patient with ataxia and new right-sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications: c. Transporting a patient to the hospital entrance for discharge 87. Which actions are part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input: a. Recognizing the need for modifications to the care plan d. Reviewing whether a patient met their short-term goal 88. Which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions: c. Doc- umenting patient assessment findings in the patient's chart 89. Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired.

b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.: d. Goal met; patient ambulated three times in the hallway without SOB.

90. What situations would necessitate modification of a patient's plan of care? (Select all that apply.) a. Decrease in patient's level of orientation b. Discharge of patient to rehabilitation facility c. Patient adherence to established plan of care d. Sudden onset of shortness of breath in patient receiving oxygen: a. De- crease in patient's level of orientation b. Discharge of patient to rehabilitation facility d. Sudden onset of shortness of breath in patient receiving oxygen 91. A hospital has just implemented the use of electronic health records (EHRs). While learning to use this new system, the nurse realizes that EHRs may do which of the following? a. Limit access to the patient record to one person at a time b. Improve access to patient information at the point of care c. Negate the use of nursing documentation d. Increase the potential for medication errors: b. Improve access to client information at the point of care 92. Which statement best contributes to the nurse's documentation of assess- ment of patient status in the patient's medical chart? a. "Patient had a good day with minimal complaints. Patient was pleasant and cooperative during morning care." b. "Patient complained that the nurse didn't come quickly enough when she pressed the call button." c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m. reporting pain 3/10 at 8:30 a.m." d. "Patient was grumpy today, even after administration of pain medication, a back massage, and a nap.": c. "Patient complained of pain 7 of 10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3 of 10 at 8:30 a.m." 93. A patient requests a copy of his medical record. What is the correct response by the nurse? a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff. b. Tell him that the Code for Nurses does not allow you to give him access to his records. c. Acknowledge that he has the right to have a copy of his records, and make

arrangements per facility policy. d. Refer his request to the hospital administrator because all such requests need to go through proper channels.: c. Acknowledge that he has the right to have a copy his records, and make arrangements per facility policy.

94. A patient's sister comes to visit and asks to read the patient's medical records. What is the best response by the nurse? a. Settle her in a chair at the nurses' station and give her access. b. Respond that the contents of a patient's medical records are private and confidential. c. Tell her she can read the medical records only if the patient sits with her. d. Distract the sister by changing the subject and then walking away.: b. Respond that the contents of a patient's chart are private and confidential. 95. Which are reasons that accurate documentation in the medical record is important? (Select all that apply.) a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers d. Nonlegal documentation of a nurse's actions e. Promotion of continuity of care: a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers e. Promotion of continuity of care 96. Which note is an example of the S in SBAR? a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic. b. Patient was admitted on evening shift with a fractured right femur after a fall at home. c. Patient's pain was rated 8/10 before administration of narcotic pain medica- tion. d. Assess pain every 2 hours, continue pain medication as prescribed, and provide backrub.: b. Patient was admitted on evening shift with a fractured right femur after a fall at home. 97. Which attributes are important in nursing documentation? (Select all that apply.) a. Inconsequentiality b. Timeliness c. Relevancy d. Accuracy e. Factual basis: b. Timeliness c. Relevancy

d.Accuracy e. Factual basis

98. When should administered medications be documented? a. At the end of a shift when all medications have been given b. As given to avoid the possibility of double dosing c. After every meal to document at least three times daily d. When the nurse has time before going on break: b. As given to avoid the possibility of double dosing 99. What is an advantage of the use of paper medical records? a. Charts with paper records are always available to all health care team members. b. Paper records do not need much storage space in the health care facility. c. Writing implements are always available on nursing units and patient rooms. d. Recording on paper does not require any special computer knowledge.: c. Recording on paper does not require any special computer knowledge. 100. What is a purpose of a hand-off report? a. Ensures continuity of care and patient safety b. Keeps the doctor informed c. Completed when a patient is discharged to home d. Determines patient assignments: a. Ensures continuity of care and patient safety 101. On which ethical theory do nurses implement their care when they act on the basis of the needs of one specific patient rather than the potential consequences to other patients? a. Deontology b. Autonomy c. Utilitarianism d. Nonmaleficence: a. Deontology 102. Which nursing intervention is the best example of patient advocacy? a. Collecting blood samples according to the physician's order each morning b. Assessing the vital signs of a patient who is receiving a blood transfusion c. Seeking an additional analgesic medication order for a patient who is experiencing severe pain d. Accompanying an ambulating patient who is walking for the first time after undergoing surgery: c. Seeking an additional analgesic medication order for a patient who is experiencing severe pain 103. What action should nurses who demonstrate accountability take if they forget to administer a patient's medication at the ordered time? a. Document the medication as refused by the patient.

b. Administer the medication as soon as the error is discovered. c. Record the medication as given after making sure the patient is okay. d. Follow the administration and documentation procedures for medication errors.: d. Follow the administration and documentation procedures for medication errors.

104. Nursing students are held to which standards by the Code of Ethics for Nurses? (Select all that apply.) a. Clinical skills performance equal to that of an experienced nurse b. Demonstration of respect for all individuals with whom the student interacts c. Avoidance of behavior that shows disregard for the effect of those actions on others d. Accepting responsibility for resolving conflicts in a professional manner e. Incorporating families in patient care regardless of patient preference: b. Demonstration of respect for all individuals with whom the student interactsc. Avoid- ance of behavior that shows disregard for the effect of those actions on othersd. Accepting responsibility for resolving conflicts in a professional manner 105. If a student nurse overhears a peer speaking disrespectfully about a patient, nurse, faculty member, or classmate, what is the most ethical first action for the student nurse to take? a. Discuss the peer's actions during group clinical conference b. Ignore the initial occurrence and observe if it happens again c. Report the actions of the classmate to the clinical instructor d. Speak to the peer privately to prevent further occurrences: d. Speak to the peer privately to prevent further occurrences 106. What nursing intervention is best when a patient is struggling with the decision to abort an abnormally developing fetus discovered during genetic testing in the first trimester of pregnancy? a. Recommend additional testing b. Refer the patient to an abortion clinic c. Listen to the patient's concerns d. Discuss regional adoption agencies: c. Listen to the patient's concerns 107. Making prejudicial, untrue statements about another person during con- versation may expose a nurse to being charged with what offense? a. Libel b. Assault c. Slander d. Malpractice: c. Slander 108. What legal consequences may a nurse experience if the nurse is convict- ed of a crime? (Select all that apply.)

a. Loss of nursing licensure b. Employment affirmation c. Monetary penalty d. Unit transfer e. Imprisonment: a. Loss of nursing licensure c. Monetary penalty e. Imprisonment

109. What is the best way for a nurse to avoid crossing professional practice boundaries with patients? a. Spend extensive time with a patient without visitors b. Focus on the needs of patients and their families c. Intervene in problematic patient relationships d. Relay personal stories when unsolicited: b. Focus on the needs of patients and their families 110. What action should a nurse take if a patient who needs to sign an informed- consent form for nonemergency surgery appears to be under the influence of drugs or alcohol? a. Contact the physician to see what should be done. b. Ask the patient's spouse to sign the informed-consent form. c. Request permission to bypass the need for a signed consent form. d. Wait to have the informed-consent form signed when the patient is alert and oriented.: d. Wait to have the informed-consent form signed when the patient is alert and oriented. 111. The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.: B. Consider the possibility of health literacy limitations and assess further. 112. A 58-year-old man is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. Which action(s) should the nurse do before placing the NG tube? a. Take two additional staff members into the room when placing the tube so

the patient can be restrained if needed. b. Request an interpreter per facility protocol. c. Do not place the NG tube because the physician would not want to frighten the patient. d. Document the inability to place the NG tube due to lack of ability to communicate.: A. Assess the presence of any family members who may speak English and the patient's native language.

113. Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Moral Distress b. Ready to Learn c. Difficulty Coping d. Literacy Problem e. Anxiety: b. Ready to Learn d. Literacy Problem 114. Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Ready to Learn b. Lack of Knowledge c. Effective Information Processing d. Health-Seeking Behaviors: a. Ready to Learn 115. A 61-year-old man is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork. b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—these just don't work." c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms. d. Setting the clipboard aside and staring tearfully out the window. e. Returning the forms only partially filled out, with missing or inaccurate information.: b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—these just don't work." c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms. e. Returning the forms only partially filled out, with missing or inaccurate information. 116. Teaching a patient to use an incentive spirometer by demonstration, with a return demonstration by the patient is an example of teaching based on