Nursing Fundamentals Exam 1 Practice Test

A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe healthcare? (Select all that apply). [23]
1. Information provided by the head nurse
2. Policies and procedures of the employing hospital
3. State Nurse Practice Act
4. Regulations identified in the Joint Commission’s manual.
5. The American Nurses Association standards of practice.
2, 3, 4, 5
A nurse is sued for failure to monitor a patient appropriately after a procedure,. Which of the following statements are correct about this lawsuit? (Select all that apply) [23]
1. The nurse represents the plaintiff.
2. The defendant must prove injury, damage, or loss.
3. The person filing the lawsuit has the burden of proof.
4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.
3, 4
A nurse stops to help in an emergency at at the scene of an accident. The injured party files a suit and the nurse’s employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? [23]
1. The nurse’s auto insurance
2. The nurse’s homeowner’s insurance
3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence.
4. The Patient Care Partnership, which may grant immunity from suit if the injured party contends.
A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with the possible risks, complications, and benefits? [23]
1. Family member
2. Surgeon
3. Nurse
4. Nurse Manager
A woman who is a Jehovah’s Witness has severe, life-threatening injuries and is hemorrhaging following a car accident. The healthcare provider ordered 2 units of packed red blood cells to treat the woman’s anemia. The woman’s husband refuses to allow the nurse to give his wife the blood. What is the nurse’s responsibility? [23]
1. Obtain a court order to give the blood
2. Coerce the husband into giving the blood
3. Call security and have the husband removed from the hospital
4. Abide by the husband’s wishes and inform the healthcare provider
The nurse notes that an advance directive is on a patient’s medical record. Which statement represents the best description of an advance directive guideline the nurse will follow? [23]
1. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state.
2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
3. The patient can not make changes in the advance directive once admitted to the hospital.
4. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
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A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violoation of which act? [23]
1. Mental Health Parity Act
2. Patient Self-Determination Act (PSDA)
3. Health Insurance Portability and Accountability Act (HIPPA)
4. Emergency Medical Treatment and Active Labor Act
Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) [23]
1. Taking and selling controlled substances
2. Refusing to provide health care information to a patient’s child
3. Reporting suspected abuse and neglect of children
4. Applying physical restraints without a written physician’s order.
1, 4
The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient’s message board in the patient rooms. The nurse also lists the patient’s medical diagnoses on the message board. Later in the day, the nurse discusses the plan of care for a patient who is dying with the patient’s family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPPA)? [23]
1. Discussing the patient conditions in the nursing report room at the change of shift
2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned
3. Posting medical information about the patient on a message board in the patient’s room
4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared
The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient’s toes have become pale and cold but forgets to document this because one of the nurse’s other patient’s experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply). [23]
1. Failure to document a change in assessment data
2. Failure to provide discharge instructions
3. Failure to follow the six rights of medication administration
4. Failure to use proper medical equipment ordered for patient monitoring
5. Failure to notify a health care provider about a change in the patient’s condition
1, 5
A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? [23]
1. Health Insurance Portability and Accountability Act (HIPPA)
2. Americans with Disabilities Act (ADA)
3. Patient Self-Determination Act (PSDA)
4. Emergency Medical Treatment and Active Labor Act (EMTALA)
You are the night shift nurse and are caring for a newly admitted patient who appears confused. The family asks to see the patient’s medical record. What is the first nursing action to take? [23]
1. Give the family the record
2. Give the patient the record
3. Discuss the issues that concern the family with them
4. Call the nursing supervisor
A home health nurse notices significant bruising on the 2-year-old patient’s head, arms, abdomen, and legs. The patient’s mother describes the patient’s frequent falls. What is the best nursing action for the home health nurse to take? [23]
1. Document her findings and treat the patient
2. Instruct the mother on safe handling of a 2-year-old child
3. Contact a child abuse hotline
4. Discuss this story with a colleague
A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply) [23]
1. “I am thinking about joining the health committee at my church.”
2. “I need to read newspapers, watch news broadcasts, and search the Internet for information related to health.”
3. “I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing.”
4. “Nurses do not have very much voice in legislation in Washington, D.C. because of the shortage of nurses.”
1, 2
You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first? [23]
1. Call the nursing supervisor to discuss the situation
2. Discuss the problem with a colleague
3. Leave the nursing unit and go home
4. Say nothing and begin your work
The nurse is having difficulty reading a physician’s order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? [31]
1. Call the pharmacist to interpret the order
2. Call the physician to have the order clarified
3. Consult the unit manager to help interpret the order
4. Ask the unit secretary to interpret the physician’s handwriting
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? [31]
1. 2 mL
2. 5 mL
3. 16 mL
4. 30 mL
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication? [31]
1. Outward
2. Back
3. Upward and back
4. Upward and outward
A patient is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? [31]
1. 1/2 tablet
2. 1 tablet
3. 1 1/2 tablets
4. 2 tablets
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action? [31]
1. Give the medication
2. Identify the patient using two identifiers
3. Withhold the medications and verify the medication orders
4. Provide medication education to the mother to help her better understand her child’s medications
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? [31]
1. Set up the follow-up appointments with the physician for the patient
2. Ensure that someone will provide housekeeping for the patient at home
3. Ensure that the home care agency is aware of medication and health teaching needs.
4. Make sure that the patient’s family knows how to safely bathe him or her and provide mouth care.
A nursing student takes a patient’s antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? [31]
1. Only the patient’s physician can give this information
2. The student provides the name of the medication and a description of its desired effect
3. Information about medications is confidential and cannot be shared
4. He has to speak with his assigned nurse about this
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s best course of action? [31]
1. Ask the prescriber to change the order
2. Crush the pill with a mortar and pestle
3. Hide the capsule in a piece of solid food
4. Open the capsule and sprinkle it over pudding
The nurse takes a medication to a patient, and the patient tells him or her to take it way because she is not going to take it. What is the nurse’s next action? [31]
1. Ask the patient’s reason for refusal
2. Explain that she must take the medication
3. Take the medication away and chart the patient’s refusal
4. Tell the patient that her physician knows what’s best for her
The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines that the appropriate route for administering the diuretic according to: [31]
1. Hospital policy
2. The prescriber’s orders
3. The type of medication ordered
4. The patient’s size and muscle mass
A patient is receiving an IV push medication. If the drug infiltrates into the outer tissues, the nurse: [31]
1. Continues to let the IV run
2. Applies a warm compress to the infiltrated site
3. Stops the administration of the medicine and follows agency policy
4. Should not worry about this because vesicant filtration is not a problem
If a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: [31]
1. Sepsis
2. Phlebitis
3. Infiltration
4. Fluid overload
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: [31]
1. Follow ISMP guidelines for safe medication abbreviations
2. Explain to the physician that the order needs to be given to a registered nurse
3. Write the order on the patient’s order sheet and read it back to the physician
4. Ensure that the six rights of medication administration are followed when giving the medication
A nurse accidentally gives a patient a medication at the wrong time. The nurse’s first priority is to: [31]
1. Complete an occurence report
2. Notify the healthcare provider
3. Inform the charge nurse of the error
4. Assess the patient for adverse effects
A patient is taking albuterol through a pressurized metered-dose inhaler that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the inhaler last? [31]
_______ days.
The nurse’s first action after discovering an electrical fire in a patient’s room is to: [27]
1. Activate the fire alarm
2. Confine the fire by closing all doors and windows
3. Remove all patients in immediate danger
4. Extinguish the fire by using the nearest fire extinguisher
A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? [27]
1. Give the child milk
2. Give the child syrup of ipecac
3. Call the poison control center
4. Take the child to the emergency department
The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? [27]
1. Activity intolerance
2. Impaired bed mobility
3. Acute pain
4. Risk for falls
A couple is with their adolescent daughter for a school physical and state they are worries about all the saftey risks affecting this age. What is the greatest risk for injury to an adolescent? [27]
1. Home accidents
2. Physiological changes of aging
3. Poisoning and child abduction
4. Automobile accidents, suicide, and substance abuse
The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) [27]
1. Insert a urinary catheter
2. Leave a night light on in the bathroom
3. Ask the physician to order a restraint
4. Keep the bed in low position with upper and lower side rails up
5. Assign a staff member to stay with the patient
6. Provide scheduled toileting during the night shift
7. Keep the pathway from the bed to the bathroom clear
2, 6, 7
The family of a patient who is confused and ambulatory insist that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) [27]
1. Contact the nursing supervisor
2. Restrict the family member’s visiting privileges
3. Ask the family to stay with the patient if possible
4. Inform the family of the risks associated with side-rail use
5. Thank the family for being conscientious and put the four rails up
6. Discuss alternatives with the family that are appropriate for this patient
3, 4, 6
A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. [27]
1. Explain what you plan to do
2. Wrap a limb restraint around a wrist or ankle with soft part toward skin and secure
3. Determine that restraint alternatives fail to ensure the patient’s safety
4. Identify the patient using proper identifier
5. Pad the patient’s wrist
3, 4, 1, 5, 2
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? [27]
1. Begin cardiopulmonary resuscitation
2. Restrain the child to prevent injury
3. Place a tongue blade over the tongue to prevent aspiration
4. Clear the area around the child to protect the child from injury
A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: [27]
1. A safe environment promotes patient activity
2. Assessment focuses on environmental factors only
3. Teaching home safety is a difficult to do in the hospital setting
4. Most accidents in the older adult are caused by lifestyle factors
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: [27]
1. Place a bed alarm device on the bed
2. Place the patient in a belt restraint
3. Provide one-on-one observation of the patient
4. Apply wrist restraints
To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply) [27]
1. Smoking is prohibited around oxygen
2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms
3. Do not use electrical equipment around oxygen
4. Special precautions may be required when traveling with oxygen
1, 3, 4
How does the nurse support a culture of safety? (Select all that apply) [27]
1. Completing incident reports when appropriate
2. Completing incident reports for a near miss
3. Communicating product concerns to an immediate supervisor
4. Identifying the person responsible for an incident
1, 2, 3
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply) [27]
1. Smokes a pack a day
2. Used a cane to walk at home
3. Takes antihypertensives and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities, impulsive
6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter
3, 4, 5, 6, 7
At 3am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? [27]
1. Prepare for an influx of patients
2. Contact the American Red Cross
3. Determine how to restore essential services
4. Evacuate patients per the disaster plan
If an infectious disease can be transmitted directly from one person to another, it is a: [28]
1. Susceptible host
2. Communicable disease
3. Port of entry to a host
4. Port of exit from the reservior
Which is the most likely means of transmitting infection between patients? [28]
1. Exposure to another patient’s cough
2. Sharing equipment between patients
3. Disposing of soiled linen in a shared linen bag
4. Contact with a health care worker’s hands
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. [28]
1. Illness stage
2. Convalescence
3. Prodromal stage
4. Incubation period
Which of the following is the most effective way to break the chain of infection? [28]
1. Hand hygiene
2. Wearing gloves
3. Placing patients in isolation
4. Providing private rooms for patients
A family member is providing care to a loved care who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? [28]
1. Wear gloves before eating or handling food
2. Place any soiled materials into a bag and double bag it
3. Have the family member check with the doctor about need for immunization
4. Perform hand hygiene after care and/or handling contaminated equipment or material
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? [28]
1. Provide a dark, quiet room to calm the patient
2. Reduce the level of precautions to keep the patient from angry
3. Explain the reasons for isolation procedures and provide meaningful stimulation
4. Limit family and other caregiver visits to reduce the risk of spreading infection
The nurse wears a gown when: [28]
1. The patient’s hygiene is poor
2. The nurse is assisting with medication administration
3. The patient has AIDS or hepatitis
4. Blood or body fluids may get onto the nurse’s clothing from a task that he or she plans to perform
The nurse has redressed a patient’s wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? [28]
1. Leave the gloves on to administer the medication
2. Remove gloves and administer the medication
3. Remove gloves and perform hand hygiene before administering the medication
4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient’s room
When a nurse is performing surgical hand asepsis, the nurse must keep hands: [28]
1. Below elbows
2. Above elbows
3. At a 45-degree angle
4. In a comfortable position
What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? [28]
1. Use an autoclave
2. Use boiling water
3. Use ethylene oxide gas
4. Use chemicals for disinfection
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? [28]
1. It keeps an incontinent patient’s skin dry
2. It can get caught in the linens or equipment
3. It obstructs the normal flushing action of urine flow
4. It allows the patient to remain hydrated without having to urinate
Put the following steps for removal of protective barriers after leaving an isolation room in order: [28]
1. Untie top, then bottom mask strings and remove from face
2. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side
3. Remove gloves
4. Remove eyewear or goggles
5. Perform hand hygiene
3, 4, 2, 1, 5
Your ungloved hands come in contact with the drainage from your patient’s wound. What is the correct method to clean your hands? [28]
1. Wash them with soap and water
2. Use an alcohol-based hand cleaner
3. Rinse them and use the alcohol-based cleaner
4. Wipe them with a paper towel
A patient’s surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? [28]
1. Notify the health care provider and use surgical technique to change the dressing
2. Reassure the patient and check the wound later
3. Notify the health care provider and support the patient’s fluid and nutritional needs
4. Alert the patient and caregivers to the presence of an infection to ensure care after discharge
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has been violated? [28]
1. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action
2. Fluid flows in the direction of gravity
3. A sterile field becomes contaminated by prolonged exposure to air
4. None of the principles were violated
A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?” The nurse’s assessment covers which of Gordon’s functional health patterns? [16]
1. Value-belief pattern
2. Cognitive-perceptual pattern
3. Coping-stress-tolerance pattern
4. Health perception-health management pattern
The nurse asks a patient, “Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a patient-centered interview? [16]
1. Setting the stage
2. Gather information about a patient’s chief concerns
3. Collecting the assessment
4. Termination
What type of interview techiniques does the nurse use when asking these questions, “Do you have pain or cramping?” “Does the pain get worse when you walk?” (Select all that apply) [16]
1. Active listening
2. Open-ended questioning
3. Closed-ended questioning
4. Problem-oriented listening
3, 4
What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16]
1. Active listening
2. Back channeling
3. Validating
4. Use of open-ended questions
5. Use of closed-ended questions
1, 2, 4
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16]
1. The skin around the wound is tender to touch
2. Fluid intake for 8 hours is 800 mL
3. Patient has a heart rate of 78 and regular
4. Patient has drainage from surgical wound
5. Body temperature is 101F (38.3 C)
6. Patient asks, “I’m worried that I won’t return to work when I planned.”
1, 4, 5
The nurse makes the following statement during a change of shift report to another nurse. “I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don’t think it’s that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?” What does the nurse’s conclusion suggest? [16]
1. The nurse is making an accurate clinical inference
2. The nurse has gathered cues to identify a potential problem area
3. The nurse has allowed stereotyping to influence her assessment
4. The nurse wants to validate her information with the other nurse
A nurse check a patient’s IV line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? [16]
1. Agenda setting
2. Problem-focused
3. Objective
4. Use of structured database format
A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses his inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon’s functional health patterns, which pattern does the nurse assess? [16]
1. Health perception- health management pattern
2. Value-belief pattern
3. Cognitive-perceptual pattern
4. Coping-stress tolerance pattern
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16]
1. “You say you’ve lost weight. Tell me how much weight you have lost in the past month.”
2. “My name is Todd. I’ll be the nurse taking care of you today. I’m going to ask you a series of questions to gather your health history.”
3. “I have no further questions. That you for your patience.”
4. “Tell me what brought you to the hospital.”
5. “So, to summarize, you’ve lost about 6 pounds in the last month, and your appetite has been poor – correct?”
2, 4, 1, 5, 3
Which of the following are examples of data validation? (Select all that apply) [16]
1. The nurse assesses the patient’s heart rate and compares the value with the last value entered in the medical record
2. The nurse asks the patient if he is having pain and then asks the patient to rate the severity
3. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content
4. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement
5. The nurse asks the patient to describe a symptom by saying “Go on.”
1, 4
A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? [16]
1. So you’ve had an upset stomach and began vomiting – correct?
2. Have you taken anything for your stomach?
3. Is anything else bothering you?
4. Have you taken any medication for your vomiting?
The nurse is assessing the character of a patient’s migraine headache and asks, “Do you feel nauseated when you have a headache?” The patient’s response is “yes.” In this case, the finding of nausea is which of the following? [16]
1. An objective finding
2. A clinical inference
3. A validation
4. A concomitant symptom
During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply) [16]
1. Family report
2. Chest x-ray film
3. Physical examination with auscultation of the lungs
4. Medical record summary of x-ray film findings
3, 4
A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hosprial with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse’s knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply) [16]
1. A problem-focused approach
2. A structured comprehensive approach
3. Using multiple visits to gather a complete database
4. Focusing on the functional health pattern of the role-relationship
1, 3
A 58-year-old patient with nerve deafness has come to his doctor’s office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply) [16]
1. Maintain a neutral facial expression
2. Lean forward when interacting with the patient
3. Acknowledge the patient’s answers through head nodding
4. Limit direct eye contact
2, 3
The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format. [17]
Acute pain r/t incisional trauma evidenced by pain reported at 7, with guarding, and restricted turning and positioning.
Review the following nursing diagnoses and identify the diagnoses that are correctly stated. (Select all that apply) [17]
1. Anxiety related to fear of dying
2. Fatigue related to chronic emphysema
3. need for mouth care related to inflamed mucosa
4. Risk for infection
1, 4
A nurse reviews data gathered regarding a patient’s pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is example of the nurse avoiding an error in: [17]
1. data collection
2. data clustering
3. data interpretation
4. making a diagnostic statment
The nursing diagnosis readiness for enhanced communication is an example of a(n): [17]
1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Health promotion nursing diagnosis
4. Wellness nursing diagnosis
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply) [17]
1. The nurse who listens to lung sounds after a patient reports “difficulty breathing”
2. The nurse who considers conflicting cues in deciding which diagnostic label to choose
3. The nurse assessing the edema in a patient’s lower leg who is unsure how to assess the severity of edema
4. The nurse who identifies a diagnosis on the basis of a single defining characteristic
3, 4
A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is “diarrhea related to intestinal colitis.” This is an incorrectly stated diagnostic statement, best described as: [17]
1. Identifying the clinical sign instead of an etiology
2. Identifying a diagnosis based on prejudicial judgment
3. Identifying the diagnostic study rather than a problem caused by the diagnostic study
4. Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. [17]
1. Considers context of patient’s health problem and selects a related factor
2. Reviews assessment data, noting objective and subjective clinical criteria
3. Clusters clinical criteria that form a pattern
4. Chooses diagnostic label
2, 3, 4, 1
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply) [17]
1. Acute pain related to lumbar disk repair
2. Sleep deprivation related to difficulty falling asleep
3. Constipation related to inadequate intake of fluids
4. Potential nausea related to nasogastric tube insertion
1, 2, 4
The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2-3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37 C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply) [17]
1. Vital sign results
2. Abdominal distension
3. Age of patient
4. Change in bowel elimination pattern
5. Abdominal pain
6. No past history of hospitalization
2, 4, 5
The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is “always getting lost.” The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, “I just don’t know what to do because I worry she will fall or hurt herself.” The daughter states that, when she took her mother to the store, they became separated, and the mother couldn’t find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply) [17]
1. Daughter’s concern of mother’s risk for injury
2. Pacing
3. Patient getting lost easily
4. Daughter working part time
5. Getting up frequently
2, 3, 5
Which of the following are examples of collaborative problems? (Select all that apply) [17]
1. Nausea
2. Hemorrhage
3. Wound infection
4. Fear
2, 3
Two nurses are having a discussion at the nurses’ station. One nurse is a new graduate who added, “Patient needs improved bowel function related to constipation” to a patient’s care plan. The nurse’s colleague, the charge nurse says, “I think your diagnosis is possibly worded incorrectly. Let’s go over it together.” A correctly worded diagnostic statement is: [17]
1. Need for improved bowel function related to change in diet
2. Patient needs improved function related to alteration in elimination
3. Constipation related to inadequate fluid intake
4. Constipation related to hard infrequent stools
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? [17]
1. Risk for aspiration
2. Acute confusion
3. Readiness for enhanced coping
4. Sedentary lifestyle
A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient’s abdominal dressing, IV infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0-10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply) [18]
1. The family comes to visit the patient
2. The patient expresses concern about pain control
3. The patient’s vital signs change, showing a drop in blood pressure.
4. The charge nurse approaches the nurse and requests a report at end of shift.
2, 3
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient’s drainage tube disconnected, 100 mL of fluid in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first? [18]
1. Reconnect the drainage tube
2. Inspect the condition of the IV dressing
3. Improve the patient’s comfort and turn her onto her side
4. Obtain the next IV fluid bag from the medication room
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of “risk for impaired skin integrity.” Which of the following goals are appropriate for the patient? (Select all that apply) [18]
1. Patient will be turned every 2 hours within 24 hours
2. Patient will have normal bowel function within 72 hours
3. Patient’s skin will remain intact through discharge
4. Patient’s skin condition will improve by discharge
2, 3
Setting a time frame for outcomes of care serves which of the following purposes? [18]
1. Indicates which outcome has priority
2. Indicates the time it takes to complete an intervention
3. Indicates how long a nurse is schedules to care for a patient
4. Indicates when the patient is expected to respond in the desired manner
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as “deficient knowledge regarding insulin administration related to inexperience with disease management.” Which of the following patient care goals are long term? [18]
1. Patient will explain relationship of insulin to blood glucose control
2. Patient will self-administer insulin
3. Patient will achieve glucose control
4. Patient will describe steps for preparing insulin in a syringe
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as “deficient knowledge regarding insulin administration related to inexperience with disease management.” What does the nurse need to determine before setting the goal of “patient will self-administer insulin?” (Select all that apply) [18]
1. Goal within reach of the patient
2. The nurse’s own competency in teaching about insulin
3. The patient’s cognitive function
4. Availability of family members to assist
1, 3, 4
The nurse writes an expected-outcome statement in measurable terms. An example is: [18]
1. Patient will be pain free
2. Patient will have less pain
3. Patient will take pain medication every 4 hours
4. Patient will report pain acuity less than 4 on a scale of 0 to 10.
A patient has the nursing diagnosis of “nausea.” The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? [18]
1. Provide frequent mouth care
2. Maintain IV infusion at 100 mL/hr
3. administer prochlorperazine (Compazine) via rectal suppository
4. Consult with dietician on initial foods to offer patient
5. Control aversive odors or unpleasant visual stimulation that triggers nausea
A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? [18]
1. This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening
2. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient’s care
3. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient
4. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding
Which of the following outcome statements for the goal, “Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month” are worded incorrectly? (Select all that apply) [18]
1. Patient will eat at least three fourths of each meal by 1 week
2. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week
3. Patient will eat foods with high-calorie content by 1 week
4. Give patient liquid supplements 3 time a day
2, 4
A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital verses one for home care? [18]
1. The goals of care will always be more long term
2. The patient and family need to be able to independently provide most of the health care
3. The patient’s goals need to be mutually set with family members who will care for him or her
4. The expected outcomes need to address what can be influenced by interventions
Which outcome allows you to measure a patient’s response to care more precisely? [18]
1. The patient’s wound will appear normal within 3 days
2. The patient’s wound will have less drainage within 72 hours
3. The patient’s wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4.
4. The patient’s wound will heal without redness or drainage by day 4.
A nurse identifies several interventions to resolve a patient’s nursing diagnosis of “impaired skin integrity.” Which of the following are written in error? (Select all that apply) [18]
1. Turn the patient regularly from side to back to side.
2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence
3. Apply a pressure-relief device to bed
4. Apply transparent dressing to sacral pressure ulcer
1, 3
The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse’s actions? (Select all that apply) [19]
1. The application of the skin barrier is a dependent measure
2. The call to the ostomy and wound care specialist is an indirect care measure
3. The cleansing of the skin is a direct care measure
4. The application of the skin barrier is a direct care measure
2, 3, 4
During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in correct order: [19]
1. Review the care plan
2. Decide if the nursing interventions remain appropriate
3. Reassess the patient
4. Compare assessment findings to validate existing nursing diagnoses
3, 1, 4, 2
A nurse checks a physician’s order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse’s best action before giving the medication is to: [19]
1. Have the nurse colleague check the dose with her before giving the medication
2. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, an the potential side effects
3. Ask the nurse colleague to administer the medication to her patient
4. Administer the medication as prescribed and on time
When does implementation begin as the fourth step of the nursing process? [19]
1. During the assessment phase
2. Immediately in some critical situations
3. After the care plan has been developed
4. After there is mutual goal setting between a nurse and patient
Before consulting with a physician about a patient’s need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exist, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? [19]
1. Cognitive
2. Interpersonal
3. Psychomotor
4. Consultative
The nurse enters a patient’s room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? [19]
1. Meeting the patient’s expressed wishes
2. Indirect care measure
3. Protecting a patient from injury
4. Staying organized when implementing a procedure
In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an IV catheter? (Select all that apply) [19]
1. Following the procedural guideline for IV insertion
2. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse
3. Showing confidence in performing the correct IV insertion technique
4. Being sure that the IV dressing covers the IV site completely
2, 3
Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply) [19]
1. Seeks necessary knowledge
2. Reassesses the patient’s condition
3. Collects all necessary equipment
4. Delegates the procedure to a more experienced nurse
5. Considers all possible consequences of the procedure
1, 3, 5
A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse check the patient’s medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventative intervention? [19]
1. Tertiary
2. Direct care
3. Primary
4. Secondary
A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, “Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient’s situation unique?” What is the nurse’s best answer? [19]
1. Standing orders are used to meet our physician’s preferences.
2. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias
3. Standing orders allow us to respond quickly and safely to a rapidly changing situation
4. Standing orders minimize the documentation we have to provide
A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the steps in their proper order: [19]
1. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea
2. The nurse enters data in the assessment column showing new information about the patient’s nausea
3. The nurse adds the current date to show that the diagnosis of nausea is still relevant
4. The nurse decides to use the patient’s self-report of appetite and fluid intake as evaluation measures
2, 3, 1, 4
When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient’s tolerance, this is an example of what type of implementation skill? [19]
1. Interpersonal
2. Cognitive
3. Collaborative
4. Psychomotor
The nurse reviews a patient’s medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietician and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? [19]
1. Preventative
2. Controlling for adverse reaction
3. Consulting
4. Counseling
A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of “impaired skin integrity related to pressure and moisture on skin.” The patient is 72-years-old and had a stroke. The weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply) [19]
1. Review the set of all possible nursing interventions for the patient’s problem
2. Review all possible consequences associated with each possible nursing action
3. Consider own level of competency
4. Determine the probability of all possible consequences
1, 2, 4
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient’s lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? [20]
1. Suctioning the airway
2. Sitting the patient up in bed
3. Auscultating lungs sounds
4. Patient describing type of discomfort
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient’s lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply) [20]
1. Patient drinks contents of water glass
2. Patient’s lungs are clear to auscultation in bases
3. Patient reports abdominal pain on a scale of 0 to 10
4. Patient’s rate and depth of breathing are normal with head of bed elevated
2, 4
The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? [20]
1. Evaluating the patient’s response to selected nursing interventions
2. Selecting an observable or measurable state or behavior that reflects goal achievement
3. Reviewing the patient’s nursing diagnoses and establishing goals and outcome statements
4. Matching the results of evaluative measures with expected outcomes to determine patient’s status
A goal specifies the expected behavior or response that indicates: [20]
1. The specific nursing action was completed
2. The validation of the nurse’s physical assessment
3. The nurse has made the correct nursing diagnoses
4. Resolution of a nursing diagnosis or maintenance of a healthy state
A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of “risk for infection.” Which of the following is an appropriate goal statement for the diagnosis? [20]
1. Patient will remain afebrile to discharge
2. Patient’s wound will remain free of infection by discharge
3. Patient will receive ordered antibiotic on time over next 3 days
4. Patient’s abdominal incision will be covered with a sterile dressing for 2 days
Unmet and partially met goals require the nurse to do which of the following? (Select all that apply) [20]
1. Redefine priorities
2. Continue intervention
3. Discontinue care plan
4. Gather assessment data on a different nursing diagnosis
5. Compare the patient’s response with that of another patient
1, 2
A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient’s obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of “imbalanced nutrition: more than body requirements,” the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply) [20]
1. The patient eats 2000 calories a day
2. The patient is weighed during each clinic visit
3. The patient discusses factors that increase the risk of an asthma attack
4. The patient’s food diary that tracks intake of daily meals is reviewed
2, 4
The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. [20]
1. The nurse judges the extent to which the condition of the skin matches the outcome criteria
2. The nurse tries to determine why the outcome criteria and actual condition of the skin do not agree
3. The nurse inspects the condition of the skin
4. The nurse reviews the outcome criteria to identify the desired skin condition
5. The nurse compares the degree of agreement between desired and actual condition of the skin
4, 3, 5, 1, 2
The nurse check the IV solution that is infusing into the patient’s left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses’ notes from the previous shift to determine if the dressing over the site what changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply) [20]
1. Checked the IV infusion location in left arm
2. Checked the type of IV solution
3. Confirmed from nurses’ notes the time of dressing change and checked label
4. Inspected the condition of the IV dressing
3, 4
Which of the following statements correctly describe the evaluation process? (Select all that apply) [20]
1. Evaluation is an ongoing process
2. Evaluation usually reveals obvious changes in patients
3. Evaluation involves making clinical decisions
4. Evaluation requires the use of assessment skills
1, 3, 4
A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of “imbalanced nutrition: less than body requirements related to reduced intake of food.” For the goal of “Patient will return to baseline weight in 3 months,” which of the following outcomes would be appropriate? (Select all that apply) [20]
1. Patient will discuss source of depression by next clinic visit.
2. Patient will acheive a calorie intake of 2400 daily in 2 weeks.
3. Patient will report improvement in appetite in 1 week.
4. Patient will identify food protein sources
2, 3
A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs or redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the would and applying dressings correctly to the nurse. These behaviors are an example of: [20]
1. Evaluative measure
2. Expected outcome
3. Reassessment
4. Standard of care
A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. the nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? [20]
1. Uses walker during ambulation
2. Presence of altered balance
3. Limited mobility in lower extremities
4. Observation of distance patient is able to walk
A patient is being discharged today. In preparation the nurse removes the IV line from the right arm and documents that the site was “clean and dry with no signs of redness or tenderness.” On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? [20]
1. Patient expresses acceptance of health status by day of discharge
2. Patient’s surgical would will remain free of infection
3. Patient’s IV site will remain free of phlebitis
4. Patient understands when to call physician to report possible complications
A nursing student is talking with one of the staff nurses who works on a surgical unit. The student’s care plan is to include nursing-sensitive outcomes for the nursing diagnosis of “acute pain.” A nursing-sensitive outcome suitable for this diagnosis would be: [20]
1. Patient will achieve pain relief by discharge
2. Patient will be free of a surgical wound infection by discharge
3. Patient will report reduced pain severity in 2 days
4. Patient will describe purpose of pain medicine by discharge