Evolve questions weeks 1-7 Flashcards Preview

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Flashcards in Evolve questions weeks 1-7 Deck (189):
1

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code?
A. Improves self-health care
B. Protects the patient's confidentiality
C. Ensures identical care to all patients
D. Defines the principles of right and wrong to provide patient care

D. Defines the priciples of right and wront to provide patient care

2

An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?
A. Diagnosis
B. Evaluation
C. Assessment
D. Implementation

C. assessment

3

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed?
A. Planning
B. Evaluation
C. Assessment
D. Implementation

D. implementation

4

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient’s wishes with them. The nurse is acting as the patient’s:
A. Educator
B. Advocate
C. Caregiver
D. Case manager

B. advocate

5

The nurse spends time with the patient and family reviewing the dressing change procedure for the patient’s wound. The patient’s spouse demonstrates how to change the dressing. The nurse is acting in which professional role?
A. Educator
B. Advocate
C. Caregiver
D. Case manager

A. educator

6

The examination for registered nurse (RN) licensure is exactly the same in every state in the United States. This examination:
A. Guarantees safe nursing care for all patients
B. Ensures standard nursing care for all patients
C. Ensures that honest and ethical care is provided
D. Provides a minimal standard of knowledge for an RN in practice

D. provides a minimal standard of knowledge for an RN in practice.

7

Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform?
A. Moving from an acute illness to a health promotion, illness prevention model
B. Moving from illness prevention to a health promotion model
C. Moving from an acute illness to a disease management model
D. Moving from a chronic care to an illness prevention model

A. moving from an acute illness to a health promotion, illness prevention model

8

A nurse meets with the registered dietician and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
A. Patient-centered care
B. Safety
C. Teamwork and collaboration
D. Informatics

C. teamwork and collaboration

9

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
A. Patient-centered care
B. Safety
C. Teamwork and collaboration
D. Informatics

D. informatics

10

The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career?
A. Clinical nurse specialist
B. Nurse administrator
C. Nurse educator
D. Nurse researcher

D. nurse researcher

11

Nurses in an acute care hospital are attending a unit based education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education?
A. Continuing education
B. Graduate education
C. In-service education
D. Professional Registered Nurse Education

C. in-service education

12

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.)
A. Caregiver
B. Autonomy and accountability
C. Patient advocate
D. Health promotion
E. Lobbyist

A. caregiver
B. autonomy and accountability
C. patient advocate
D. Health promotion

13

Which of the following Internet resources available can assist consumers when comparing quality care measures? (Select all that apply.)
A. WebMD
B. Hospital Compare
C. Magnet Recognition Program
D. Hospital Consumer Assessment of Healthcare
E. The American Hospital Association’s webpage

B. hospital compare
D. Hospital consumer assessment of healthcare

14

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of:
A. Logical reasoning.
B. Egocentrism.
C. Concrete thinking.
D. Animism.

D. animism

15

An 18-month-old child is noted by the parents to be “angry” about any change in routine. This child’s temperament is most likely to be described as:
A. Slow to warm up.
B. Difficult.
C. Hyperactive.
D. Easy.

B. difficult

16

Nine-year-old Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson’s theory, failure at this stage of development results in:
A. A sense of guilt.
B. A poor sense of self.
C. Feelings of inferiority.
D. Mistrust.

C. feelings of inferiority

17

The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson’s stages of development?
A. Trust versus mistrust
B. Initiative versus guilt
C. Industry versus inferiority
D. Autonomy versus sense of shame and doubt

B. initiative versus mistrust

18

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of:
A.Object permanence.
B. Sensorimotor play.
C. Schemata.
D. Magical thinking.

A. object permanence

19

When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use?
A. Allowing the child to watch another child undergoing the same procedure
B. Showing the child pictures of what he or she will experience
C. Talking to the child in simple terms about what will happen
D. Preparing the child through play with a doll and toy medical equipment

D. preparing the child through play with a doll and toy medical equipment

20

You are caring for a recently retired man who appears withdrawn and says he is “bored with life.” Applying the work of Havinghurst, you would help this individual find meaning in life by:
A. Encouraging him to explore new roles.
B. Encouraging relocation to a new city.
C. Explaining the need to simplify life.
D. Encouraging him to adopt a new pet.

A. encouragin him to explore new roles

21

According to Piaget’s cognitive theory, a 12-year-old child is most likely to engage in which of the following activities?
A. Using building blocks to determine how houses are constructed
B. Writing a story about a clown who wants to leave the circus
C. Drawing pictures of a family using stick figures
D. Writing an essay about patriotism

B. writing a story about a clown who wants to leave the circus

22

Allison, age 15 years, calls her best friend Laura and is crying. She has a date with John, someone she has been hoping to date for months, but now she has a pimple on her forehead. Laura firmly believes that John and everyone else will notice the blemish right away. This is an example of the:
A. Imaginary audience.
B. False-belief syndrome.
C. Personal fable. Incorrect
D. Personal absorption syndrome.

A. Imaginary audience

23

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, “Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!” This is an example of adolescent:
A. Imaginary audience.
B. False-belief syndrome.
C. Personal fable.
D. Sense of invulnerability.

D. sense of invulnerability

24

Dave reports being happy and satisfied with his life. What do we know about him?
A. He is in one of the later developmental periods, concerned with reviewing his life.
B. He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives.
C. He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships.
D. It is difficult to determine Dave’s developmental stage since most people report overall satisfaction with their lives in all stages.

D. it is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages

25

Which of the following are examples of the conventional reasoning form of cognitive development? (Select all that apply.)
A. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her.
B. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son.
C. A teenage girl is encouraged by her peers to engage in shoplifting. She decides not to join her peers in this activity because she is afraid of getting caught in the act.
D. A single mother of two children is unhappy with her employer. She has been unable to secure alternate employment but decides to quit her current job.

A. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her.
B. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son.

26

Which of the following activities are examples of the use of activity theory in older adults? (Select all that apply.)
A. Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state
B. Introducing golf as a new hobby
C. Leading a group walk of older adults each morning
D. Engaging an older adult in a community project with a short-term goal
E. Directing a community play at the local theater

A. Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state
B. Introducing golf as a new hobby
D. Engaging an older adult in a community project with a short-term goal

27

A parent calls the pediatrician’s office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent?
A. Only infants and toddlers need to ride in the back seat.
B. All toddlers can move to a forward facing car seat when they reach age 2.
C. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing.
D. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

D. Toddlers must reach age 2 or weight requirement before they ride foward facing

28

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?
A. Activity Intolerance
B. Impaired Bed Mobility
C. Acute Pain
D. Risk for Falls

D. risk for falls

29

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:
A. Place a bed alarm device on the bed.
B. Place the patient in a belt restraint.
C. Provide one-on-one observation of the patient.
D. Apply wrist restraints.

A. place a bed alarm device on the bed

30

At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first?
A. Prepare for an influx of patients
B. Contact the American Red Cross
C. Determine how to resume normal operations
D. Evacuate patients per the disaster plan

A. prepare for an influx of patients

31

A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply.)
A. People who are homeless.
B. People with respiratory conditions.
C. People with cardiovascular conditions.
D. The very old.
E. People with kidney disorders.

A. people who are homeless
C. people with cardiovascular conditions
D. The very old

32

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.)
A. Inadequate lighting
B. Throw rugs
C. Multiple medications
D. Doorway thresholds
E. Cords covered by carpets
F. Staircases with handrails

A. Inadequate lighting
B. Throw rugs
C. Multiple medications
D. Doorway thresholds
E. Cords covered by carpets

33

The family of a patient who is confused and ambulatory insists 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.)
A. Contact the nursing supervisor.
B. Restrict the family’s visiting privileges.
C. Ask the family to stay with the patient if possible.
D. Inform the family of the risks associated with side-rail use.
E. Thank the family for being conscientious and put the four rails up.
F. Discuss alternatives that are appropriate for this patient with the family.

C. Ask the family to stay with the patient if possible.
D. Inform the family of the risks associated with side-rail use.
F. Discuss alternatives that are appropriate for this patient with the family.

34

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.)
A. Drive shorter distances
B. Drive only during daylight hours
C. Use the side and rearview mirrors carefully
D. Keep a window rolled down while driving if has trouble hearing
E. Look behind toward the blind spot
F. Stop driving at age 75

A. Drive shorter distances
B. Drive only during daylight hours
C. Use the side and rearview mirrors carefully
D. Keep a window rolled down while driving if has trouble hearing
E. Look behind toward the blind spot

35

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.)
A. Check the patient's peripheral pulse in the restrained extremity
B. Evaluate the patient's need for toileting
C. Offer the patient fluids if appropriate
D. Release both limbs at the same time to perform range of motion (ROM)
E. Inspect the skin under each restraint

A. Check the patient's peripheral pulse in the restrained extremity
B. Evaluate the patient's need for toileting
C. Offer the patient fluids if appropriate
E. Inspect the skin under each restraint

36

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His 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 intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.)
A.Smokes a pack a day
B. Used a cane to walk at home
C.Takes antihypertensive and diuretics
D. History of recent fall
E. Neglect, spatial and perceptual abilities, impulsive
F. Requires assistance with activity, unsteady gait
G. IV line, urinary catheter

C.Takes antihypertensive and diuretics
D. History of recent fall
E. Neglect, spatial and perceptual abilities, impulsive
F. Requires assistance with activity, unsteady gait
G. IV line, urinary catheter

37

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.)
A. If patient is standing, attempt to get him or her back in bed.
B. With patient on floor, clear surrounding area of furniture or equipment.
C. If possible, keep patient lying supine.
D. Do not restrain patient; hold limbs loosely if they are flailing.
E. Never force apart a patient’s clenched teeth.

B. With patient on floor, clear surrounding area of furniture or equipment.
D. Do not restrain patient; hold limbs loosely if they are flailing.
E. Never force apart a patient’s clenched teeth.

38

What is your role as a nurse during a fire? (Select all that apply.)
A. Help to evacuate patients
B. Shut off medical gases
C. Use a fire extinguisher
D. Single carry patients out
E. Direct ambulatory patients

A. Help to evacuate patients
B. Shut off medical gases
C. Use a fire extinguisher
E. Direct ambulatory patients

39

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? (Select all that apply.)
A. Blood spots on clothing
B. Long-sleeved shirts in warm weather
C. Changes in relationships
D. Wearing dark glasses indoors
E. Increased computer use

A. Blood spots on clothing
B. Long-sleeved shirts in warm weather
C. Changes in relationships
D. Wearing dark glasses indoors

40

A manager is reviewing the nursing documentation entered by a staff nurse in a patient’s electronic medical record and finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?
A. “Avoid rushing when documenting an entry in the medical record.”
B. “Use correction fluid to remove the entry.”
C. “Draw a single line through the statement and initial it.”
D. Enter only objective and factual information about a patient in the medical record.

D. Enter only objective and factual information about a patient in the medical record.

41

A preceptor observes a new graduate nurse discussing changes in a patient’s condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse:
A. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone.
B. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record.
C. Gives a newly ordered medication before entering the order in the patient’s medical record.
D. Asks the preceptor to listen in on the phone conversation.

C. Gives a newly ordered medication before entering the order in the patient’s medical record.

42

As the nurse enters a patient’s room, the nurse notices that the patient is anxious. The patient quickly states, “I don’t know what’s going on; I can’t get an explanation from my doctor about my test results. I want something done about this.” Which of the following is the most appropriate way for the nurse to document this observation of the patient?
A. “The patient has a defiant attitude and is demanding test results.”
B. “The patient appears to be upset with the nurse because he wants his test results immediately.”
C. “The patient is demanding and is complaining about the doctor.”
D. “The patient stated feelings of frustration from the lack of information received regarding test results.”

D. “The patient stated feelings of frustration from the lack of information received regarding test results.”

43

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, “I’m not familiar with these HIPAA regulations. How will they affect my care?” Which of the following is the best response?
A. HIPAA allows all hospital staff access to your medical record.
B. HIPAA limits the information that is documented in your medical record.
C. HIPAA provides you with greater protection of your personal health information.
D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C. HIPAA provides you with greater protection of your personal health information.

44

A patient states, “I would like to see what is written in my medical record.” What is the nurse’s best response?
A. “Only your family can read your medical record.”
B. “You have the right to read your record.”
C. “Patients are not allowed to read their records.”
D. “Only health care workers have access to patient records.”

B. “You have the right to read your record.”

45

Which of the following documentation entries is most accurate?
A. “Patient walked up and down hallway with assistance, tolerated well.”
B. “Patient up, out of bed, walked down hallway and back to room, tolerated well.”
C. “Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.”
D. “Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise.”

D. “Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise.”

46

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
A. "CPOE reduces transcription errors."
B. "CPOE reduces the time needed for health care providers to write orders."
C. "CPOE eliminates verbal and telephone orders from health care providers."
D. "CPOE reduces the time nurses use to communicate with health care providers."

A. "CPOE reduces transcription errors."

47

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task with the time that it was completed?
A. 15 45, 17 34, 20 00
B. 3 45, 17 34, 20 00
C. 15 45, 5 34, 8 00
D. 3 45, 5 34, 8 00

A. 15 45, 17 34, 20 00

48

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient’s bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system?
A. Electronic health record
B. Clinical documentation
C. Clinical decision support system
D. Computerized physician order entry

C. Clinical decision support system

49

While reviewing the pulmonary assessment entered by a nurse in a patient’s electronic medical record (EMR), a physician notices that the only information documented in that section is “WDL” (within defined limits). The physician also is not able to find a narrative description of the patient’s respiratory status in the nurse’s progress notes. What is the most likely reason for this?
A. The nurse caring for the patient forgot to document on the pulmonary system.
B. The EMR uses a charting-by-exception format.
C. The computer shut down unexpectedly when the nurse was documenting the assessment.
D. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

B. The EMR uses a charting-by-exception format.

50

What is the appropriate way for a nurse to dispose of information printed out from a patient’s electronic health record?
A. Rip the papers up into small pieces and place the pieces into a standard trash can
B.Place all papers in the flip-top binder designated for that patient that is located in the nurse’s station on the patient care unit
C. Place papers with patient information in a secure canister marked for shredding
D. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

C. Place papers with patient information in a secure canister marked for shredding

51

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.)
A. The patient’s name, age, and admitting diagnoses
B. The discussion of any allergies to food and medications that the patient has
C. That the nurse receiving the report was advised that the patient is “needy” and “on the call light all the time”
D. That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Correct
E. Description of any unresolved problems and current interventions in place

A. The patient’s name, age, and admitting diagnoses
B. The discussion of any allergies to food and medications that the patient has
D. That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Correct
E. Description of any unresolved problems and current interventions in place

52

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.)
A. Documents a medication given by another nursing student.
B. Includes the date and time of the entry into the medical record.
C. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient’s room.
D. Leaves a slip of paper with her user name and password in the patient’s room.
E. Starts to enter “Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, “I had several loose stools yesterday, and I’m afraid if I take this dose the problem will get worse,” as a narrative comment.

A. Documents a medication given by another nursing student.
D. Leaves a slip of paper with her user name and password in the patient’s room.

53

What is the most effective way to control transmission of infection?
A. Isolation precautions
B. Identifying the infectious agent
C.Hand hygiene practices
D. Vaccinations

C.Hand hygiene practices

54

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part?
A. Reinforce dressing with a clean, dry dressing and call the health care provider.
B. Remove wet dressing and apply new dressing using sterile procedure.
C. Put on gloves before removing the old dressing; then obtain a wound culture.
D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

55

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient?
A. Reverse isolation
B. Droplet precautions
C. Standard precautions
D. Contact precautions

B. Droplet precautions

56

A family member is providing care to a loved one 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?
A. Wear gloves before eating or handling food.
B. Place any soiled materials into a bag and double bag it.
C. Have the family member check with the health care provider about need for immunization.
D. Perform hand hygiene after care and/or handling contaminated equipment or material.

D. Perform hand hygiene after care and/or handling contaminated equipment or material

57

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?
A. Provide a dark, quiet room to calm the patient.
B. Reduce the level of precautions to keep the patient from becoming angry.
C. Explain the reasons for isolation procedures and provide meaningful stimulation.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection

C. Explain the reasons for isolation procedures and provide meaningful stimulation.

58

What is the correct order of steps for removal of protective barriers after leaving an isolation room?
1. Remove gloves.
2. Perform hand hygiene.
3. Remove eyewear or goggles.
4. Untie top and then bottom mask strings and remove from face.
5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.
A. 1, 3, 5, 4, 2
B. 1, 5, 3, 4, 2
C. 1, 3, 4, 5, 2
D. 3, 1, 5, 4, 2

A. 1, 3, 5, 4, 2

59

A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order?
1. Notify the health care provider of the patient's status.
2. Reassure the patient and recheck the wound later.
3. Support the patient's fluid and nutritional needs.
4. Use aseptic technique to change the dressing.
A. 4, 1, 2, 3
B. 4, 2, 1, 3
C. 4, 2, 3, 1
D. 2, 4, 1, 3

B. 4, 2, 1, 3

60

A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.)
A. The organism is usually transmitted through the fecal-oral route.
B. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
C. Everyone coming into the room must be wearing a gown and gloves.
D. While the patient is in contact precautions, he cannot leave the room.
E. C. difficile dies quickly once outside the body.

A. The organism is usually transmitted through the fecal-oral route.
B. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
C. Everyone coming into the room must be wearing a gown and gloves.

61

When should a nurse wear a mask? (Select all that apply).
A. The patient’s dental hygiene is poor.
B.The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
C. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough.
D. The patient is in droplet precautions.
E. The nurse is assisting a health care provider in the insertion of a central line catheter.

B.The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
D. The patient is in droplet precautions.
E. The nurse is assisting a health care provider in the insertion of a central line catheter.

62

Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chicken pox/herpes zoster? (Select all that apply.)
A. Disposable gown
B. N 95 respirator mask
C. Face shield or goggles
D. Surgical mask
E. Gloves

A. Disposable gown
B. N 95 respirator mask
E. Gloves

63

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.)
A. Teaching correct handwashing to assigned patients
B.Using correct procedures in starting and caring for an intravenous infusion
C. Providing perineal care to a patient with an indwelling urinary catheter
D. Isolating a patient who has just been diagnosed as having tuberculosis
E. Decreasing a patient's environmental stimuli to decrease nausea

A. Teaching correct handwashing to assigned patients
B.Using correct procedures in starting and caring for an intravenous infusion
C. Providing perineal care to a patient with an indwelling urinary catheter

64

Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.)
A. Set up sterile field before patient and other staff come to the operating suite.
B. Keep the sterile field in view at all times.
C. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
D. Only health care personnel within the sterile field must wear personal protective equipment.
E. The sterile gown must be put on before the surgical scrub is performed

B. Keep the sterile field in view at all times.
C. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

65

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.)
A. It allows migration of organisms into the bladder.
B. The insertion procedure is not done under sterile conditions.
C. It obstructs the normal flushing action of urine flow.
D. It keeps an incontinent patient's skin dry.
E. The outer surface of the catheter is not considered sterile

A. It allows migration of organisms into the bladder.
C. It obstructs the normal flushing action of urine flow

66

What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.)
A.There is more than one organism in the wound that is causing the infection.
B. The antibiotics the patient has received are not strong enough to kill the organism.
C. The patient will need more than one type of antibiotic to kill the organism.
D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.
E. There are no longer any antibiotic options available to treat the patient's infection

B. The antibiotics the patient has received are not strong enough to kill the organism.
D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

67

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.)
A. Proper cleaning requires mechanical removal of all soil from an object or area.
B. General environmental cleaning is an example of medical asepsis.
C. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound.
D. Cleaning in a direction from the least to the most contaminated area helps reduce infections.
E. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

A. Proper cleaning requires mechanical removal of all soil from an object or area.
B. General environmental cleaning is an example of medical asepsis.
D. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

68

A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been here, 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’ve been in following his plan?” The nurse’s assessment covers which of Gordon’s functional health patterns?
A. Value-belief pattern
B. Cognitive-perceptual pattern
C. Coping–stress-tolerance pattern
D. Health perception–health management pattern

D. Health perception–health management pattern

69

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
A. Cue.
B. Reflection.
C. Clinical inference.
D. Probing.

C. Clinical inference.

70

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient’s room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient’s heart rate and blood pressure and asks him, “Tell me where your pain is.” Which of the following assessment approaches does this scenario describe?
A. Review of systems approach
B. Use of a structured database format
C. Back channeling
D. A problem-oriented approach

D. A problem-oriented approach

71

The nurse asks a patient, “Describe for me a typical night’s sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?
A. Orientation
B Working phase
C. Data validation
D. Termination

B Working phase

72

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse’s cultural competence in assessing the patient’s health care problems?
A. “I can tell that your eating habits have led to your diabetes. Is that right?”
B. “It’s been difficult for people to find jobs. Is that why you work part time?”
C. “You have four children; do you have any concerns about going home and caring for them?”
D. “I wish patients understood how overeating affects their health.”

C. “You have four children; do you have any concerns about going home and caring for them?”

73

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
A. Probing
B. Open-ended
C. Problem-oriented
D. Confirmation

B. Open-ended

74

A nurse is checking a patient’s intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
A. Patient’s level of function.
B. Patient’s willingness to perform self-care.
C. Patient’s level of consciousness.
D. Patient’s health management values.

A. Patient’s level of function.

75

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, “How do you see yourself now?” On the basis of Gordon’s functional health patterns, which pattern does the nurse assess?
A. Health perception–health management pattern
B. Value-belief pattern
C. Cognitive-perceptual pattern
D. Self-perception–self-concept pattern

D. Self-perception–self-concept pattern

76

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.
1. "You say you've lost weight. Tell me how much weight you've lost in the last 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. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"
A. 4, 2, 1, 3, 5
B. 2, 4, 3, 1, 5
C. 4, 2, 5, 1, 3
D. 2, 4, 1, 5, 3

D. 2, 4, 1, 5, 3

77

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?
A. So you’ve had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct?
B. Have you taken anything for your headaches?
C. Tell me what makes your headaches begin.
D. Uh huh, tell me more.

C. Tell me what makes your headaches begin.

78

Which of the following examples are steps of nursing assessment? (Select all that apply.)
A. Collection of information from patient’s family members Correct
B. Recognition that further observations are needed to clarify information Correct
C. Comparison of data with another source to determine data accuracy Correct
D. Complete documentation of observational information
E. Determining which medications to administer based on a patient’s assessment data

A. Collection of information from patient’s family members
B. Recognition that further observations are needed to clarify information
C. Comparison of data with another source to determine data accuracy

79

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
A. An observation of how a patient turns and moves in bed
B. The unit policy and procedure manual
C. The care recommendations of a physical therapist
D. The results of a diagnostic x-ray film
E. Your experiences in caring for other patients with similar problems

A. An observation of how a patient turns and moves in bed
C. The care recommendations of a physical therapist
D. The results of a diagnostic x-ray film

80

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.)
A. The skin around the wound is tender to touch.
B. Fluid intake for 8 hours is 800 mL.
C. Patient has a heart rate of 78 beats/min and regular.
D. Patient has drainage from surgical wound.
E. Body temperature is 38.3° C (101° F).
F. Patient states, "I'm worried that I won't be able to return to work when I planned."

A. The skin around the wound is tender to touch.
D. Patient has drainage from surgical wound.
E. Body temperature is 38.3° C (101° F).

81

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.)
A. Listen attentively to the patient's story.
B. Use gestures that reinforce your questions or comments.
C. Stand back away from the bedside.
D. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

A. Listen attentively to the patient's story.
B. Use gestures that reinforce your questions or comments.
D. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

82

The nursing diagnosis Impaired Parenting related to mother’s developmental delay is an example of a(n):
A. Risk nursing diagnosis.
B. Problem-focused nursing diagnosis.
C. Health promotion nursing diagnosis.
D. Wellness nursing diagnosis.

B. Problem-focused nursing diagnosis.

83

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:
A. Collaborative data set.
B. Diagnostic label.
C. Related factors.
D. Data cluster.

D. Data cluster.

84

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. For which of the following reasons is this an incorrectly stated diagnostic statement?
A. Identifying the clinical sign instead of an etiology
B. Identifying a diagnosis on the basis of prejudicial judgment
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study
D. Identifying the medical diagnosis instead of the patient’s response to the diagnosis.

D. Identifying the medical diagnosis instead of the patient’s response to the diagnosis.

85

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. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step?
1. Considers context of patient's health problem and selects a related factor
2. Reviews assessment data, noting objective and subjective clinical information
3. Clusters clinical cues that form a pattern
4. Chooses diagnostic label
A. 2, 3, 4, 1
B. 3, 2, 4, 1
C. 2, 3, 1, 4
D. 1, 4, 3, 2

A. 2, 3, 4, 1

86

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, “I believe this is a nursing diagnosis of Deficient Fluid Volume.” The lead charge nurse immediately goes to the patient’s room with the student to assess the patient’s orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error?
A. Insufficient cluster of cues
B. Disorganization
C. Insufficient number of cues
D. Evidence that another diagnosis is more likely

C. Insufficient number of cues

87

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse’s assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient’s nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best “related to” factor?
A. Infant crying at breast
B. Infant unable to latch on to breast correctly
C. Mother’s deficient knowledge
D. Lack of infant weight gain

C. Mother’s deficient knowledge

88

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient’s report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format?
A. Disturbed Sleep Pattern evidenced by frequent awakening
B. Disturbed Sleep Pattern related to family caregiving responsibilities
C. Disturbed Sleep Pattern related to need to improve sleep habits
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested.

D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

89

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?
A. Incorrect clustering
B. Wrong diagnostic label
C. Condition is a collaborative problem.
D. Premature closure of clusters

B. Wrong diagnostic label

90

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
A. Impaired Skin Integrity related to physical immobility
B. Fatigue related to heart disease
C. Nausea related to gastric distention
D. Need for improved Oral Mucosa Integrity related to inflamed mucosa
E. Risk for Infection related to surgery

A. Impaired Skin Integrity related to physical immobility
C. Nausea related to gastric distention

91

A nurse reviews data gathered regarding a patient’s ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.)
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
E. Goal setting.

A. Data collection.
C. Data interpretation.

92

In which of the following examples are nurses making diagnostic errors? (Select all that apply.)
A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data Correct
B. The nurse who measures joint range of motion after the patient reports pain in the left elbow
C. The nurse who considers conflicting cues in deciding which diagnostic label to choose
D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping Correct
E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. Correct

A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data
D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping
E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

93

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse’s cultural competence in making an accurate diagnosis? (Select all that apply.)
A. How is your diabetic diet affecting you and your family?
B. You seem to not want to follow health guidelines. Can you explain why?
C. What worries you the most about having diabetes?
D. What do you expect from us when you do not take your insulin as instructed?
E. What do you believe will help you control your blood sugar?

A. How is your diabetic diet affecting you and your family? Correct
C. What worries you the most about having diabetes? Correct
E. What do you believe will help you control your blood sugar? Correct

94

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.)
A. Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs Correct
B. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves
C. Helps nurses focus on the scope of nursing practice Correct
D. Creates practice guidelines for collaborative health care activities
E. Builds and expands nursing knowledge Correct

A. Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs
C. Helps nurses focus on the scope of nursing practice
E. Builds and expands nursing knowledge

95

Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
A. Fluid Volume Excess related to heart failure
B. Sleep Deprivation related to sustained noisy environment Correct
C. Impaired Bed Mobility related to postcardiac catheterization
D. Ineffective Protection related to inadequate nutrition Correct
E. Diarrhea related to frequent, small, watery stools.

B. Sleep Deprivation related to sustained noisy environment
D. Ineffective Protection related to inadequate nutrition

96

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient’s nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, “This is so unfair.” An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?
A. Giving the enema on time
B. Talking with the patient about her past experiences with illness
C. Talking with the patient about her concerns and acknowledging her sense of unfairness
D. Beginning instruction on postoperative procedures

C. Talking with the patient about her concerns and acknowledging her sense of unfairness

97

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) 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 outcomes is appropriate for the patient?
A. Patient will be turned every 2 hours within 24 hours.
B. Patient will have normal bowel function within 72 hours.
C. Patient’s skin integrity will remain intact through discharge.
D. Erythema of skin will be mild to none within 48 hours. Correct

D. Erythema of skin will be mild to none within 48 hours. Correct

98

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient?
A. Achieving wound healing of the foot ulcer
B. Enhancing patient knowledge about the effects of diabetes
C. Providing a dietitian consultation for diet retraining
D. Improving patient adherence to diabetic diet

B. Enhancing patient knowledge about the effects of diabetes

99

The nurse writes an expected outcome statement in measurable terms. An example is:
A. Patient will have normal stool evacuation.
B. Patient will have fewer bowel movements.
C. Patient will take stool softener every 4 hours.
D. Patient will report stool soft and formed with each defecation.

D. Patient will report stool soft and formed with each defecation.

100

A nursing student is reporting during hand-off to the RN assuming her patient’s care. She explains, “I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention?
A. Reporting hand-off at change of shift
B Ambulating patient down hallway
C. Sleep hygiene
D. IV fluid administration

D. IV fluid administration

101

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort?
A. Engage the patient in setting mutual outcomes for distance he is able to walk
B. Confirm with the patient's health care provider about ambulation goals
C. Have physical therapy assist with ambulation
D. Refer to medical record regarding nature of patient's physical problem

A. Engage the patient in setting mutual outcomes for distance he is able to walk

102

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 remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first?
A. Reconnect the drainage tubing
B. Inspect the condition of the IV dressing
C. Obtain the next IV fluid bag from the medication room
D. Explain when the health care provider is likely to visit

A. Reconnect the drainage tubing

103

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient’s colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.)
A. Assess condition of skin before making the call Correct
B. Rely on the nurse specialist to know the type of surgery the patient likely had
C. Explain the patient’s response emotionally to the repeated leaking of stool
D. Describe the type of bag being used and how long it lasts before leaking
E. Order extra colostomy bags currently being used

A. Assess condition of skin before making the call
C. Explain the patient’s response emotionally to the repeated leaking of stool
D. Describe the type of bag being used and how long it lasts before leaking

104

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient’s plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.)
A. Using a standardized checklist for essential information
B. Asking the wife to briefly leave the room
C. Completing the hand-off without inviting questions
D. Doing prework such as checking laboratory results before giving a report
E. Including the wife in the hand-off discussion

A. Using a standardized checklist for essential information
D. Doing prework such as checking laboratory results before giving a report
E. Including the wife in the hand-off discussion

105

Which of the following factors does a nurse consider in setting priorities for a patient’s nursing diagnoses? (Select all that apply.)
A. Numbered order of diagnosis on the basis of severity
B Notion of urgency for nursing action
C. Symptom pattern recognition suggesting a problem
D. Mutually agreed on priorities set with patient
E. Time when a specific diagnosis was identified

B Notion of urgency for nursing action
C. Symptom pattern recognition suggesting a problem
D. Mutually agreed on priorities set with patient

106

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.)
A. Providing mouth care every 4 hours
B. Maintaining intravenous (IV) infusion at 100 mL/hr =
C. Administering prochlorperazine (Compazine) via rectal suppository
D. Consulting with dietitian on initial foods to offer patient
E. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

B. Maintaining intravenous (IV) infusion at 100 mL/hr
D. Consulting with dietitian on initial foods to offer patient

107

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient’s sleep? (Select all that apply.)
A. The intervention should be directed at reducing noise.
B. The intervention should be one shown to be effective in promoting sleep on the basis of research.
C. The intervention should be one commonly used by the patient’s sleep partner.
D. The intervention should be one acceptable to the patient.
E. The intervention should be one you used with other patients in the past.

A. The intervention should be directed at reducing noise.
B. The intervention should be one shown to be effective in promoting sleep on the basis of research.
D. The intervention should be one acceptable to the patient.

108

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient’s room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse’s unit environment will affect her ability to set priorities? (Select all that apply.)
A. Policy for conducting hourly rounds
B. Staffing level
C. Interruption by staff nurse colleague
D. RN’s years of experience
E. Competency of patient care technician

A. Policy for conducting hourly rounds
B. Staffing level
C. Interruption by staff nurse colleague

109

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient’s care. The student states, “Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse’s goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.)
A. IV site not tender
B. Uses cane to walk
C. Walked to end of hall
D. No shortness of breath
E, Slept better during night

C. Walked to end of hall Correct
D. No shortness of breath Correct

110

The nurse administers a tube feeding via a patient’s nasogastric tube. This is an example of which of the following?
A. Physical care technique
B Activity of daily living
C. Indirect care measure
D. Lifesaving measure

A. Physical care technique

111

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?
A. Knowing the source of the guideline
B. Reviewing the evidence used to develop the guideline
C. Individualizing how to apply the clinical guideline for a patient
D. Explaining to a patient the purpose of the guideline

C. Individualizing how to apply the clinical guideline for a patient

112

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this?
1. Modify care plan as needed.
2. Decide if the nursing interventions remain appropriate.
3. Reassess the patient.
4. Compare assessment findings to validate existing nursing diagnoses.
A. 2, 1, 3, 4
B. 3, 4, 2, 1
C. 4, 3, 2, 1
D. 3, 4, 1, 2

B. 3, 4, 2, 1

113

Before consulting with a physician about a female 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 exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?
A. Cognitive
B Interpersonal
C. Psychomotor
D. Consultative

A. Cognitive

114

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?
A. Measures a nurse’s competency in interdisciplinary care
B Measures the number of adverse events in a hospital
C. Measures quality of care within hospitals
D. Measures referrals to a health care agency

C. Measures quality of care within hospitals

115

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient’s ability to stand, remain balanced, or walk. Which of the following is an example of a nurse’s review of this situation?
A. Critical thinking
B. Managing an adverse event
C. Exercising self-discipline
D. Time management

A. Critical thinking

116

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient’s bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?
A. Environment
B Personnel
C Equipment
D Patient

D Patient

117

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse’s understanding and ability to safely delegate to the patient care tech? (Select all that apply.)
A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test.
B. Determining what is the patient care technician’s current workload.
C. The nurse chooses to delegate the measurement of a stable patient’s vital signs and not the assessment of the patient arriving from a diagnostic test.
D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.
E. The nurse confers with another registered nurse about organizing priorities.

A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test.
C. The nurse chooses to delegate the measurement of a stable patient’s vital signs and not the assessment of the patient arriving from a diagnostic test.
D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.

118

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient’s plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.)
A. Is willing to challenge other members’ ideas because the nurse disagrees with their rationale
B. Shows competence in how to monitor patients’ clinical status and inform the physician of critical changes
C. Asks a more experienced nurse to attend the conference
D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly
E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

B. Shows competence in how to monitor patients’ clinical status and inform the physician of critical changes
D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly

119

A nurse is visiting a patient in the home and is assessing the patient’s adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)
A. Reviewing the family caregiver’s availability during medication administration times
B. Making a judgment of the value of improved adherence for the patient
C. Reviewing the number of medications and time each is to be taken
D. Determining all consequences associated with the patient missing specific medicines
E. Reviewing the therapeutic actions of the medications

B. Making a judgment of the value of improved adherence for the patient
D. Determining all consequences associated with the patient missing specific medicines

120

The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions? (Select all that apply.)
A. The application of the skin barrier is a dependent care measure.
B. The call to the ostomy and wound care specialist is an indirect care measure.
C. The cleansing of the skin is a direct care measure.
D. The application of the skin barrier is an instrumental activity of daily living.
E. Inspecting the skin in a direct care activity.

B. The call to the ostomy and wound care specialist is an indirect care measure.
C. The cleansing of the skin is a direct care measure.

121

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.)
A. Checks scientific literature or policy and procedure
B. Reassesses the patient’s condition
C. Collects all necessary equipment
D. Delegates the procedure to a more experienced nurse
E. Considers all possible consequences of the procedure

A. Checks scientific literature or policy and procedure
B. Reassesses the patient’s condition
C. Collects all necessary equipment
E. Considers all possible consequences of the procedure

122

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.)
A. Makes it quicker and easier for nurses to intervene
B. Sets a level of clinical excellence for practice
C Eliminates need to create an individualized care plan for the patient
D. Delivers evidence-based interventions for stage II pressure ulcer
E. Summarizes the various approaches used for the practice concern or problem

A. Makes it quicker and easier for nurses to intervene
B. Sets a level of clinical excellence for practice
D. Delivers evidence-based interventions for stage II pressure ulcer

123

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication?
A. Include communication while performing tasks such as changing dressings and checking vital signs.
B. Ask the patient if you can talk during the last few minutes of visiting hours.
C. Ask Pastoral care to come back a little later in the day.
D. Remind the nurse to complete all her tasks and then set up remaining time for communication.

A. Include communication while performing tasks such as changing dressings and checking vital signs.

124

A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, “I want to be clear. Can you tell me in your words the purpose of this medicine?” This exchange is an example of which element of the transactional communication process?
A. Message
B. Obtaining feedback
C. Channel
D. Referent

B. Obtaining feedback

125

A patient who is Spanish-speaking does not appear to understand the nurse’s information on wound care. Which action should the nurse take?
A. Arrange for a Spanish-speaking social worker to explain the procedure
B. Ask a fellow Spanish-speaking patient to help explain the procedure
C. Use a professional interpreter to provide wound care education in Spanish
D. Ask the patient to write down questions that he or she has for the nurse

C. Use a professional interpreter to provide wound care education in Spanish

126

A nurse prepares to contact a patient’s physician about a change in the patient’s condition. Using SBAR (Situation, Background, Assessment, and Recommendation) communication, which of the following is the correct order?
1.“She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 pm yesterday. She complains of a poor appetite.”
2. “The patient reported feeling very nauseated after her dose of Levaquin an hour ago.”
3. “Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?”
4. “The patient started complaining of nausea yesterday evening and has vomited several times during the night.”
A. 1, 3, 4, 2
B. 4, 1, 2, 3
C. 2, 1, 3, 4
D. 4, 2, 1, 3

B. 4, 1, 2, 3

127

A nurse is assigned to care for a patient for the first time and states, “I don’t know a lot about your culture and want to learn how to better meet your health care needs.” Which therapeutic communication technique did the nurse use in this situation?
A. Validation
B. Empathy
C. Sarcasm
D. Humility

D. Humility

128

A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem?
A. Challenge the nurses in a public forum to embarrass them and change their behavior
B. Talk with the department secretary and ask if this has been a problem for other nurses
C. Talk with the preceptor or manager and ask for assistance in handling this issue
D. Say nothing and hope things get better

C. Talk with the preceptor or manager and ask for assistance in handling this issue

129

A nurse has been gathering physical assessment data on a patient and is now listening to the patient’s concerns. The nurse sets a goal of care that incorporates the patient’s desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship?
A. Working phase
B. Preinteraction phase
C. Termination phase
D. Orientation phase

A. Working phase

130

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic?
A. “Why did you drive after you had been drinking?”
B. “We have multiple patients to see tonight as a result of this accident.”
C. “Tell me what happened before, during, and after the automobile accident tonight.”
D. “It will be okay. No one was seriously hurt in the accident.”

C. “Tell me what happened before, during, and after the automobile accident tonight.”

131

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to “tell his story.” This is an example of which step of the nursing process?
A. Planning
B. Assessment
C. Intervention
D. Evaluation

D. Evaluation

132

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.)
A.Check for needed adaptive equipment.
B. Exaggerate lip movements to help the patient lip read.
C. Give the patient time to respond to questions.
D. Keep communication short and to the point.
E. Communicate only through written information

A.Check for needed adaptive equipment.
C. Give the patient time to respond to questions.
D. Keep communication short and to the point.

133

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.)
A. Improve the nurse’s status with the health team members
B. Reduce the risk of errors to the patient
C. Provide optimum level of patient care
D. Improve patient outcomes
E. Prevent issues that need to be reported to outside agencies

B. Reduce the risk of errors to the patient
C. Provide optimum level of patient care
D. Improve patient outcomes

134

Motivational interviewing (MI) is a technique that applies understanding a patient’s values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.)
A. Gaining an understanding of patient’s motivations
B. Focusing on opportunities to avoid poor health choices
C. Recognizing patient’s strengths and supporting their efforts
D. Providing assessment data that can be shared with families to promote change
E. Identifying differences in patient’s health goals and current behaviors

A. Gaining an understanding of patient’s motivations
C. Recognizing patient’s strengths and supporting their efforts
E. Identifying differences in patient’s health goals and current behaviors

135

Which strategies should a nurse use to facilitate a safe transition of care during a patient’s transfer from the hospital to a skilled nursing facility? (Select all that apply.)
A. Collaboration between staff members from sending and receiving departments
B. Requiring that the patient visit the facility before a transfer is arranged
C. Using a standardized transfer policy and transfer tool
D.Arranging all patient transfers during the same time each day
E. Relying on family members to share information with the new facility

A. Collaboration between staff members from sending and receiving departments
C. Using a standardized transfer policy and transfer tool

136

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse’s silence? (Select all that apply.)
A. Prevent the nurse from saying the wrong thing
B. Prompt the patient to talk when he or she is ready
C. Allow the patient time to think and gain insight
D. Allow time for the patient to drift off to sleep
E. Determine if the patient would prefer to talk with another staff member

B. Prompt the patient to talk when he or she is ready
C. Allow the patient time to think and gain insight

137

Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress?
A. Keep a journal
B. Participate in a unit meeting to discuss feelings about the patient deaths
C. Ask the nurse manager to assign you to less difficult patients
D. Review the policy and procedure manual on proper care of patients after death

B. Participate in a unit meeting to discuss feelings about the patient deaths

138

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:
A. Creativity.
B. Fairness.
C. Clinical reasoning.
D. Applying ethical criteria

D. Applying ethical criteria

139

A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of:
A. Accuracy.
B. Reflection.
C. Risk taking.
D. Basic critical thinking

D. Basic critical thinking

140

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor’s order. At the bedside the nurse checks the patient’s name against the medication order as well. The nurse is following which critical thinking attitude:
A. Responsible
B. Complete
C. Accurate
D. Broad

A. Responsible

141

By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
A. Curiosity
B. Adequacy
C. Discipline
D. Thinking independently

C. Discipline

142

A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother’s obesity and inexperience. The nurse’s review of the situation is called:
A. Reflection.
B. Perseverance.
C. Intuition.
D. Problem solving.

A. Reflection.

143

Place the steps of the scientific method in their correct order with number 1 being the first step of the process.
1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis.
A. 4, 3, 1, 5, 2
B. 3, 4, 1, 2, 5
C. 4, 3, 2, 1, 5
D. 3, 4, 1, 5, 2

A. 4, 3, 1, 5, 2

144

An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient?
A. Working in multiple health care settings
B. Learning good communication skills
C. Spending time establishing relationships with patients
D. Relying on evidence in practice

C. Spending time establishing relationships with patients

145

A nurse enters a 72-year-old patient’s home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient’s leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of:
A. Inference.
B. Basic critical thinking.
C. Evaluation.
D. Diagnostic reasoning

D. Diagnostic reasoning

146

A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.)
A. Consider availability of assistive personnel to obtain the specimen
B. Combine activities to resolve more than one patient problem
C. Analyze the diagnoses/problems and decide which are most urgent based on patients’ needs
D. Plan a family conference for tomorrow to make decisions about resources the patient will need to go home
E. Identify the nursing diagnoses for the patient going home

A. Consider availability of assistive personnel to obtain the specimen
B. Combine activities to resolve more than one patient problem
C. Analyze the diagnoses/problems and decide which are most urgent based on patients’ needs

147

A nurse changed a patient’s surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse’s approach to the dressing change? (Select all that apply.)
A. Clinical inference
B. Basic critical thinking
C. Complex critical thinking
D. Experience
E. Reflection

C. Complex critical thinking
D. Experience

148

Which of the following describes a nurse’s application of a specific knowledge base during critical thinking? (Select all that apply.)
A. Initiative in reading current evidence from the literature
B. Application of nursing theory
C. Reviewing policy and procedure manual
D. Considering holistic view of patient needs
E. Previous time caring for a specific group of patients

A. Initiative in reading current evidence from the literature
B. Application of nursing theory
D. Considering holistic view of patient needs

149

n which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.)
A. The nurse thinks back about a personal experience before administering a medication subcutaneously.
B. The nurse uses a pain-rating scale to measure a patient’s pain.
C. The nurse explains a procedure step by step for giving an enema to a patient care technician.
D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis.
E. A nurse offers support to a colleague who has witnessed a stressful event.

A. The nurse thinks back about a personal experience before administering a medication subcutaneously.
B. The nurse uses a pain-rating scale to measure a patient’s pain.
D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis

150

A new nurse is caring for a hospitalized obese patient who is homeless. This is the first time the patient has been admitted to the hospital, and the patient is scheduled for surgery. Which of the following is a universal skill that will help the nurse work effectively with this patient?
A. The nurse shifts her focus to understanding the patient by asking her, “Describe for me the course of your illness.”
B. The nurse tells the patient, “Your choices of foods and unwillingness to exercise are adding to your health problems.”
C. The nurse asks the patient, “Tell me about the main problems you have had with your health from not having a home.”
D. The nurse explains, “Because you have obesity, it is important to know the effects it has on wound healing because of reduced tissue perfusion.”

C. The nurse asks the patient, “Tell me about the main problems you have had with your health from not having a home.”

151

Which statement made by a new graduate nurse about the teachback technique requires intervention and further instruction by the nurse’s preceptor?
A. “After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient’s understanding.”
B. “The Teach Back technique is an ongoing process of asking patients for feedback.”
C. “Using Teach Back will help me identify explanations and communication strategies that my patients will most commonly understand.”
D. “Using pictures, drawings, and models can enhance the effectiveness of the Teach Back technique.”

A. “After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient’s understanding.”

152

n the United States, there has never been a president of Asian or Hispanic culture. This is an example of:
A. Social inequality
B. Marginalization
C. Under inclusion
D. Social location

B. Marginalization

153

A nurse has worked in a home health agency for a number of years. She goes to visit a patient who has diabetes and who lives in a public housing facility. This is the first time the nurse has cared for the patient. The patient has four other family members who live with her in the one-bedroom apartment. Which of the following, based on Campinha-Bacote’s (2002) model of cultural competency, is an example of cultural awareness?
A. The nurse begins a discussion with the patient by asking, “Tell me about your family members who live with you?”
B. The nurse asks, “What do you believe is needed to make you feel better?”
C. The nurse silently reflects about how her biases regarding poverty can influence how she assesses the patient.
D. The nurse uses a therapeutic and caring approach to how she interacts with the patient

C. The nurse silently reflects about how her biases regarding poverty can influence how she assesses the patient.

154

A nurse is preparing to perform a cultural assessment of a patient. Which of the following questions is an example of a contrast question?
A. Tell me about your ethnic background.
B. Have you had this problem in the past?
C. Where do other members of your family live?
D. How different is this problem from the one you had previously?

D. How different is this problem from the one you had previously?

155

During an encounter with an elderly patient, the nurse recognizes that a thorough cultural assessment is necessary because the patient has recently come to the United States from Russia and has never been hospitalized before. The nurse wants to discuss cultural similarities between herself and the patient. Which step of the LEARN mnemonic is this?
A. Listen
B. Explain
C. Acknowledge
D. Recommend treatment
E. Negotiate agreement

C. Acknowledge

156

Which of the following are considered social determinants of health? (Select all that apply.)
A. Lack of primary health care providers in a zip code
B. Poor-quality public school education that prevents a person from developing adequate reading skills
C. Lack of affordable health insurance
D. Employment opportunities that do not provide paid vacation or sick leave
E. The number of times a person exercises during a week
F. Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home

A. Lack of primary health care providers in a zip code
B. Poor-quality public school education that prevents a person from developing adequate reading skills
C. Lack of affordable health insurance
D. Employment opportunities that do not provide paid vacation or sick leave
F. Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home

157

Which of the following changes can help create a more inclusive environment for lesbian, gay, bisexual, and transgender (LGBT) patients? (Select all that apply.)
A. Explicitly including sexual orientation and gender identity into nondiscrimination policies
B. Displaying art that reflects LGBT community
C. Modifying health care forms to provide opportunities for gender identity and sexual orientation disclosure
D. Not asking patients about their gender identity and sexual orientation to avoid making them uncomfortable
E. Ensuring access to unisex or single-stall bathrooms

A. Explicitly including sexual orientation and gender identity into nondiscrimination policies
B. Displaying art that reflects LGBT community
C. Modifying health care forms to provide opportunities for gender identity and sexual orientation disclosure
E. Ensuring access to unisex or single-stall bathrooms

158

Which of the following are examples of problems with the health care system that contribute to health disparities? (Select all that apply.)
A. A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for missed visits.
B. The discharge nurse at a hospital uses Teach Back with a patient to ensure that she has communicated the discharge instructions clearly.
C. A community hospital lacks an adequate staff of social workers who are able to ensure patients’ access to resources they need to take care of their health.
D. A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow-up appointment.
E. A nurse uses a family member as an interpreter to explain the patient’s medications.
F. The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities

A. A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for missed visits.
C. A community hospital lacks an adequate staff of social workers who are able to ensure patients’ access to resources they need to take care of their health.
D. A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow-up appointment.
E. A nurse uses a family member as an interpreter to explain the patient’s medications.
F. The hospital conducts quality improvement without stratifying data by race, ethnicity, language, socioeconomic status, sexual orientation, and other axes of social group identities

159

How can a nurse work on developing cultural awareness? (Select all that apply.)
A. Reflect on his or her past learning about health, illness, race, gender, and sexual orientation
B. Develop greater self-knowledge about personal biases
C. Recognize consciously the multiple factors that influence his or her own world view
D. Engage in an in-depth self-examination of his or her own background
E. Learn as many facts as possible about an ethnic group

A. Reflect on his or her past learning about health, illness, race, gender, and sexual orientation
B. Develop greater self-knowledge about personal biases
C. Recognize consciously the multiple factors that influence his or her own world view
D. Engage in an in-depth self-examination of his or her own background

160

A patient is admitted through the emergency department (ED) after a serious car accident. The nurse assesses the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which interventions would be appropriate at this time? (Select all that apply.)
A. The nurse requests a professional interpreter.
B. Since this is an emergent situation, the nurse will interpret and identify the patient’s priority needs.
C. The nurse determines the interpreter’s qualifications and makes sure that the interpreter can speak the patient’s dialect.
D. The nurse uses short sentences to explain the treatments provided in the ED.
E. The nurse directs questions to the patient by looking at the patient instead of at the interpreter

A. The nurse requests a professional interpreter
C. The nurse determines the interpreter’s qualifications and makes sure that the interpreter can speak the patient’s dialect.
D. The nurse uses short sentences to explain the treatments provided in the ED.
E. The nurse directs questions to the patient by looking at the patient instead of at the interpreter

161

When you care for a patient who does not speak English, it is necessary to call on a professional interpreter. Which of the following are proper principles for working with interpreters? (Select all that apply.)
A. Expect the interpreter to interpret your statements word-for-word so there is no misunderstanding by the patient.
B. If you feel an interpretation is not correct, stop and address the situation directly with the interpreter.
C. Pace a conversation so there is time for the patient’s response to be interpreted.
D. Direct your questions to the interpreter.
E. Ask the patient for feedback and clarification at regular intervals

B. If you feel an interpretation is not correct, stop and address the situation directly with the interpreter.
C. Pace a conversation so there is time for the patient’s response to be interpreted.
E. Ask the patient for feedback and clarification at regular intervals

162

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
A. Oxygen saturation of 95%
B. Difficulty arousing the patient
C. Respiratory rate of 10 breaths/min
D. Pain intensity rating of 5 on a scale of 0 to 10

B. Difficulty arousing the patient

163

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement: “Fentanyl patch 100 mcg, change every 3 days.” On the basis of this order, the nurse takes the following action:
A. Calls the health care provider and questions the order
B. Applies the patch the third postoperative day
C. Applies the patch as soon as the patient reports pain
D. Places the patch as close to the hip dressing as possible

A. Calls the health care provider and questions the order

164

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication?
A. Opioid antagonists
B. Antiemetics
C. Stool softeners
D. Muscle relaxants

C. Stool softeners

165

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question?
A. The drug
B. The time interval
C. The dose
D. The route

B. The time interval

166

The nurse reviews a patient’s medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most?
A. The patient’s level of pain
B. The potential for addiction
C. The amount of daily acetaminophen
D. The risk for gastrointestinal bleeding

C. The amount of daily acetaminophen

167

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:
A. Opioid toxicity.
B. Opioid tolerance.
C. Opioid addiction.
D. Opioid withdrawal.

D. Opioid withdrawal.

168

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider’s order reads as follows: “Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn.” Which action by the nurse is most appropriate?
A. No action is required by the nurse because the order is appropriate.
B. Request to have the order changed to around the clock (ATC) for the first 48 hours.
C. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn.
D. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

B. Request to have the order changed to around the clock (ATC) for the first 48 hours.

169

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient’s wife says that he can’t be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain?
A. Patient’s self-report
B. Behaviors
C. Surrogate (wife) report
D. Vital sign changes

A. Patient’s self-report

170

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include?
A. TENS works by causing distraction.
B. TENS therapy does not require a health care provider’s order.
C. TENS requires an electrical source for use.
D. TENS electrodes are applied near or directly on the site of pain.

D. TENS electrodes are applied near or directly on the site of pain.

171

A postoperative patient currently is asleep. Therefore the nurse knows that:
A. The sedative administered may have helped him sleep, but it is still necessary to assess pain.
B. The intravenous (IV) pain medication given in recovery is relieving his pain effectively.
C. Pain assessment is not necessary.
D. The patient can be switched to the same amount of medication by the oral route.

A. The sedative administered may have helped him sleep, but it is still necessary to assess pain.

172

A patient is prescribed morphine patient-controlled analgesia (PCA). What is the correct order for administering PCA?
1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval.
2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly.
3. Administer loading dose of analgesia as prescribed.
4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing.
5. Identify patient using two identifiers.
6. Insert and secure needleless adapter into injection port nearest patient.
A. 1, 2, 4, 1, 6, 3
B. 2, 5, 1, 4, 6, 3
C. 1, 2, 5, 4, 6, 3
D. 2, 5, 4, 1, 3, 6

B. 2, 5, 1, 4, 6, 3

173

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.)
A. Transcutaneous electrical nerve stimulation (TENS)
B. Administer naloxone (Narcan) 2 mg intravenously
C. Provide back massage
D. Reposition the patient
E. Withhold any pain medication and tell the patient that she is at risk for addiction

A. Transcutaneous electrical nerve stimulation (TENS)
C. Provide back massage
D. Reposition the patient

174

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.)
A. Only the patient should push the button.
B. Do not use the PCA until the pain is severe.
C. The PCA system can set limits to prevent overdoses from occurring.
D. Notify the nurse when the button is pushed.
E. Do not push the button to go to sleep.

A. Only the patient should push the button.
C. The PCA system can set limits to prevent overdoses from occurring.
E. Do not push the button to go to sleep.

175

When using ice massage for pain relief, which of the following is correct? (Select all that apply.)
A. Apply ice using firm pressure over skin.
B. Apply ice for 5 minutes or until numbness occurs.
C. Apply ice no more than 3 times a day.
D. Limit application of ice to no longer than 10 minutes.
E. Use a slow, circular steady massage.

A. Apply ice using firm pressure over skin.
B. Apply ice for 5 minutes or until numbness occurs.
E. Use a slow, circular steady massage.

176

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.)
A. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids.
B. Stopping acetaminophen when the pain becomes very severe.
C. Avoiding polypharmacy by limiting the use of medication to one agent at a time.
D. Avoiding total sedation, regardless of the severity of the pain.
E. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

A. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids.
E. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

177

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

178

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
A. Necrotic tissue
B. Wound drainage
C. Wound circumference
D. Cleansed wound

D. Cleansed wound

179

What is the correct sequence of steps when performing a wound irrigation?
1. Use slow continuous pressure to irrigate wound.
2. Attach angio catheter to syringe
3. Fill syringe with irrigation fluid
4. Place water proof bag near bed
5. Position angio catheter over wound
A. 4, 3, 2, 5, 1
B. 3, 4, 2, 1, 5
C. 4, 2, 3, 5, 1
D. 2, 3, 4, 5, 1

A. 4, 3, 2, 5, 1

180

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
A. Binder
B. Ice bag
C. Elastic bandage
D. Absorptive dressing

B. Ice bag

181

Which of the following describes a hydrocolloid dressing?
A. A seaweed derivative that is highly absorptive
B. Premoistened gauze placed over a granulating wound
C. A debriding enzyme that is used to remove necrotic tissue
D. A dressing that forms a gel that interacts with the wound surface

D. A dressing that forms a gel that interacts with the wound surface

182

What is the removal of devitalized tissue from a wound called?
A. Debridement
B. Pressure reduction
C. Negative pressure wound therapy
D. Sanitization

A. Debridement

183

What does the Braden Scale evaluate?
A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown
C. The amount of repositioning that the patient can tolerate
D.The factors that place the patient at risk for poor healing

B. Risk factors that place the patient at risk for skin breakdown

184

On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?
A. Category/Stage II
B. Category/Stage IV
C. Unstageable
D. Suspected deep tissue damage

C. Unstageable

185

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)
A. Notify the surgeon
B. Allow the area to be exposed to air until all drainage has stopped
C. Place several cold packs over the area, protecting the skin around the wound
D.Cover the area with sterile, saline-soaked towels and immediately.
E. Cover the area with sterile gauze and apply an abdominal binder

A. Notify the surgeon
D.Cover the area with sterile, saline-soaked towels and immediately.

186

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)
A. Frequent position changes.
B. Keeping the buttocks exposed to air at all times
C. Using a large absorbent diaper, changing when saturated
D. Using an incontinence cleaner
E. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
F.Applying a moisture barrier ointment

A. Frequent position changes.
D. Using an incontinence cleaner
F.Applying a moisture barrier ointment

187

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)
A. Collection of wound drainage
B. Provides support to abdominal tissues when coughing or walking
C. Reduction of abdominal swelling
D. Reduction of stress on the abdominal incision
E. Stimulation of peristalsis (return of bowel function) from direct pressure

B. Provides support to abdominal tissues when coughing or walking
D. Reduction of stress on the abdominal incision

188

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)
A. To relieve edema
B. To reduce shivering
C. To improve blood flow to an injured part
D. To protect bony prominences from pressure ulcers
E. To immobilize area

A. To relieve edema
C. To improve blood flow to an injured part

189

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)
A. Use a transfer device, e.g. transfer board
B. Have head of bed elevated when transferring patient
C. Have head of bed flat when re positioning patients
D. Raise head of bed 60 degrees when patient positioned supine
E. Raise head of bed 30 degrees when patient positioned supine

A. Use a transfer device, e.g. transfer board
C. Have head of bed flat when re positioning patients
E. Raise head of bed 30 degrees when patient positioned supine