Fundamentals of Nursing Exam 1 Flashcards
1
Q
You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A non-nursing colleague asks about this code. 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.
A
D. defines the principles of right and wrong to provide patient care.
2
Q
An 18 year old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collect blood and sputum samples for analysis. Which standard of practice is performed?
a. diagnosis
b. evaluation
c. assessment
d. implementation
A
C. assessment
3
Q
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
A
D. implementation
4
Q
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 the family. The nurse is acting as the patient’s
a. educator
b. advocate
c. caregiver
d. case manager
A
B. advocate
5
Q
Evidence-based practice is defined as:
a. nursing care based on tradition
b. scholarly inquiry of nursing and biochemical research literature
c. a problem-solving approach that integrates best current evidence with clinical experience
d. quality nursing care provided in an efficient and economically sound manner
A
C. a problem solving approach that integrates best current evidence with clinical experience
6
Q
The examination for registered nurse 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 a registered nurse in practice
A
D. provides a minimal standard of knowledge for a registered nurse in practice
7
Q
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
A. caregiver
B. autonomy and accountability
C. Patient advocate
D. Health promotion
8
Q
Advanced practice registered nurses generally:
a. function independently
b. function as unit directors
c. work in acute care settings
d. work in the university setting
A
A. function independently
9
Q
Health care reform will bring changes in the emphasis on 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
A. moving from an acute illness to a health promotion illness prevention model
10
Q
Which of the following nursing roles may have prescriptive authority in their practice
A
B. nurse practitioner
C. certified clinical nurse specialist
11
Q
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 competency?
a. patient-centered care
b. safety
c. teamwork and collaboration
d. informatics
A
D. informatics
12
Q
A nurse is caring for an older-adult couple in a community-based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which QSEN competency?
a. patient-centered care
b. safety
c. teamwork and collaboration
d. informatics
A
B. safety
13
Q
A nurse is working with a young childbearing family who has one child with a congenital heart disease. The parents are trying to determine the risks of a second child being born with congenital heart disease. Describe why genomics information is important in assisting the parents in this decision.
A
Genomics describes the study of all genes in a person and the interactions of these genes with one another and with that person’s environment. Genomic information allows health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions.
14
Q
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
Nurse researcher
15
Q
Nurses at a community hospital are in an 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
in-service education
16
Q
A nurse researcher interviews parents of children who have diabetes and asks them to describe how they deal with their child’s illness. The analysis of the interviews yields common themes and stories describing the parents’ coping strategies. This is an example of what type of study?
A
The data in this study were collected during interviews; information from the interviews was used to describe common themes and experiences of the parents. These are characteristics of qualitative research.
17
Q
A nurse who works in a newborn nursery asks, “I wonder if the moms who breastfeed their babies would be able to breastfeed more successfully if we played peaceful music while they were breastfeeding.” In this example of a PICOT question, the I is?
A
the Intervention in this PICOT question is playing peaceful music
18
Q
A nurse researcher conducts a study that randomly assigns 100 patient who smoke and attend a wellness clinic into two groups. One group receives the standard smoking cessation handouts; the other group takes part in a new educational program that includes a smoking cessation support group. The nurse plans to compare the effectiveness of the standard treatment with the educational program. What type of a research study is this?
A
this is a randomized controlled trial because patients are randomly assigned into the control or treatment group
19
Q
A group of nurses have implemented an evidence-based practice (EBP) change and have evaluated the effectiveness of the change. Their next step is to:
a. conduct a literature review
b. share the findings with others
c. conduct a statistical analysis
d. create a well-defined PICOT question
A
B. After completing an EBP project and evaluating its effectiveness, it is important to communicate the results with others.
20
Q
Arrange the following steps of evidence-based practice in the appropriate order:
a. integrate the evidence
b. ask the burning clinical question
c. evaluate the practice decision or change
d. share the results with others
e. critically appraise the evidence you gather
f. collect the most relevant and best evidence
A
Implementing EBP follows the logical progression of steps:
ask the burning clinical question
collect the most relevant and best evidence
critically appraise the evidence you gather
integrate the evidence
evaluate the practice decision or change
share the results with others
21
Q
When recruiting subject to participate in a study about the effects of an exercise program on balance, the researcher provides full and complete information about the purpose of the study and gives the subject the choice to participate or not participate in the study. This is an example of
A
Informal consent- the process of informed consent includes providing research subjects full disclosure about the study and provides the subject the opportunity to participate or not to participate in the study.
22
Q
Nurses on a pediatric nursing unit are discussing ways to improve patient care. One nurse asks a colleague, “I wonder how best to measure pain in a child who has sickle cell disease?”. This question is an example of a/an
a. hypothesis
b. PICOT question
c. problem-focused trigger
d. knowledge-focused trigger
A
knowledge-focused triggers are questions about information available on a specific topic.
23
Q
The nurses on a medical unit have seen an increase in the number of pressure ulcers that develop in their patients. They decide to initiate a quality-improvement project using the PDSA model. Which would be the “do” from that model?
a. implement the new skin care protocol on all medicine units
b. review the data collected on patients cared for using the protocol
c. review the QI reports on the six patients who developed ulcers over the last three months
d. based on findings from patients who developed ulcers, implement an evidence-based skin care protocol
A
A. in the “do” step, the nurse selects an intervention and implements it
24
Q
A nurse researcher decides to complete a study to evaluate how Florence Nightingale improved patient outcomes in the Crimean War. This is an example of what type of research?
A
Historical studies establish facts concerning past events.
25
A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which of the following is a nursing-sensitive outcome that the nurses need to consider measuring?
a. incidence of asthma among children of smokers
b. frequency of low blood sugar episodes in children at a local school
c. number of patients who fall and experience subsequent injury on the evening shift
d. number of sexually active adolescent girls who attend the community-based clinic for birth control
C. number of patients who fall and experience subsequent injury on the evening shift
nursing-sensitive outcomes are outcomes that are sensitive to nursing care
26
A group of staff nurses notice an increased incidence of medication errors on their unit. After further investigation it is determined that the nurses are not consistently identifying the patient correctly. A change is needed quickly. What type of quality improvement method would be most appropriate?
Rapid improvement events are appropriate to use when a serious problem that affects patient outcomes exists and needs to be resolved quickly
27
A nurse is providing care to a patient who is experiencing major abdominal trauma following a car accident. The patient is losing blood quickly and needs a blood transfusion. The nurse finds out that the patient is a Jehovah's Witness and cannot have blood transfusions because of religious beliefs. He or she notifies the patient's healthcare provider and receives an order to give the patient an alternative to blood products. This is an example of?
considering the patient's preferences and values while providing care
Providing evidence-based practice requires that you take the patient's values and beliefs into consideration while providing care.
28
A group of staff educators are reading a research study together at a journal club meeting. While reviewing the study, one of the nurses states that it evaluates if newly graduated nurses progress through orientation more effectively when they participate in patient simulation exercises. Which part of the research process is reflected in this nurse's statement?
Purpose Statement
The purpose statement includes research questions or hypotheses- predictions made about the relationship or difference between study variables
29
A research study is investigating the following research question: What is the effect of the diagnosis of breast cancer on the roles of the family? In this study "the diagnosis of breast cancer" and "family roles" are examples of:
Variables- concepts, characteristics, or trait that vary within or among subjects.
30
A nurse researcher is developing a research proposal and is in the process of selecting an instrument to measure anxiety. In which part of the research process is this nurse?
Designing the study- during study design the researcher selects instruments to measure variables.
31
A nurse hears a colleague tell a nursing student that she never touches a patient unless she is preforming a procedure or doing an assessment. The nurse tells the student that from a caring perspective:
a. she does not touch the patient either
b. touch is a type of verbal communication
c. there is never a problem with using touch
d. touch forms a connection between patient and nurse
D. touch forms a connection between patient and nurse
Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves skin-to-skin contact, whereas noncontact touch refers to eye contact.
32
Of the five caring processes described by Swanson, which describes "knowing the patient"
a. anticipating the patient's cultural preferences
b. determining the patient's physician preferences
c. establishing an understanding of a specific patient
d. gathering task-oriented information during an assessment
C. Establishing an understanding of a specific patient
knowing the context of a patient's illness helps you choose and individualize interventions that will actually help him or her.
33
A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient"?
a. sharing feelings about the importance of having regular woman's health examinations
b. gaining an understanding of what a woman's health examination means to the patient
c. recognizing that the patient is modest, obtaining gender congruent caregiver
d. explaining the risk factors for cervical cancer
B. gaining an understanding of what a woman's health examination means to the patient
You should strive to understand an event as it is has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care.
34
Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes?
a. knowing
b. enabling
c. doing for
d. being with
B. Enabling
The caring behavior of enabling facilitates the other's passage through life transitions and unfamiliar events. When a nurse practice enabling, the patient and nurse work together to identify alternatives and resources
35
A patient is fearful of upcoming surgery and a possible cancer. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies:
a. spiritual care should be left to a professional
b. You are correct, religion is a personal decision
c. Nurses should not force their religious beliefs on others
d. Spiritual, mind, and body connections can affect health
D. Spiritual, mind, and body connections can affect health
Spirituality offers a sense of connectedness, intrapersonally, interpersonally, and transpersonally. In a caring relationship the patient and nurse come to know one another so both move toward a healing relationship.
36
Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors?
a. increasing the work hours of the staff
b. increasing salary benefits of the staff
c. creating a setting that allows flexibility and autonomy for staff
d. encouraging increased input concerning nursing functions from physicians.
C. Creating a setting that allows flexibility These factors all affect nursing satisfaction.
When nurses' job satisfaction is high, they have a greater connectedness with their patients and believe that caring practices are part of the nursing culture.
37
When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of
a. instilling hope and faith
b. forming a human-altruistic value system
c. cultural caring
d. being with
A. instilling and faith helps to increase an individual's capacity to get through an event or transition and face the future with meaning
38
An example of a nurse caring behavior that families of acutely ill patients perceive as important to patient's well-being is
a. making health care decisions for patients
b. having family members provide a patient's total personal hygiene
c. injecting the nurse's perceptions about the level of care provided.
d. asking permission before performing a procedure on a patient.
D. Asking permission before performing a procedure on a patient.
Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members
39
Listening is not only "taking in" what a patient says; it also includes
a. incorporating the views of the physician
b. correcting any errors in the patient's understanding
c. injecting the nurse's personal views and statements
d. interpreting and understanding what the patient means
D. Listening is powerful. It conveys the nurse's full attention and interest. A true caring presence involves listening. Listen to what is important to another person and the meaning of a situation to that person.
40
A nurse demonstrates caring by helping family members:
a. become active participants in care
b. provide activities of daily living
c. remove themselves from personal care
d. make health care decisions for the patient
A. Become active participants in care
Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members.
41
A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring?
a. the nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room
b. the nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat.
c. the nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.
d. the nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.
C. the nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.
Attentive listening lets the nurse hear the patient's story and then correctly summarize it. It does not occur when the nurse is distracted by equipment or other personnel. The importance of listening is not to distract the patient or solve the problem, but rather to hear what the patient has to say and understand what the situation means to him.
42
Presence involves a person-to-person encounter that
a. enables patients to take care for self
b. provides personal care to a patient
c. conveys a closeness and a sense of caring
d. describes being in close contact with a patient
C. Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves "being there" and "being with". Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances.
43
A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to insert the Foley catheter. This is an example of what type of touch?
Task Oriented Touch
Nurses use task-oriented touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern.
44
A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of the disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient for care, she touches his shoulder and tells him that she is present. This is an example of what type of touch?
Caring touch
Caring touch is a form of nonverbal communication. You express this in the way you hold a patient's hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally.
45
The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing?
primary prevention
46
A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating?
tertiary prevention
47
Based on the trans-theoretical model of change, what is the most appropriate response to a patient who states:"Me, exercise? I haven't done that since Jr High and I hated it then!"
a. that's fine. exercise is bad for you anyway
b. OK, I want you to walk 3 miles 4 times a week, and I'll see you in a month
c. I understand. Can you think of one reason why being more active would be helpful for you?
d. I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables a day.
C. I understand. Can you think of one reason why being more active would be helpful for you?
48
A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise?
a. Walking is OK, I really think running is better.
b. Yes, walking is great exercise. Do you think you could go for a 5 minute walk next week?
c. Yes, I want you to begin walking every day. Walk for 30 minutes every day and start to eat more fruits and vegetables.
d. They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good.
B. Yes, walking is great exercise. Do you think you could go for a 5 minute walk next week.
49
A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practice?
Difficulty paying his bills
family practice of not routinely seeing a health care provider
stress from the divorce and the loss of a job
50
The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and stool and improving the lighting for the couple. The nurse is addressing which level of need according to Maslow?
Safety and security
51
When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model?
Holistic
52
When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness?
illness behavior
53
A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model?
perceived susceptibility to the disease
54
A nurse works in a special care unit for children with severe immunology problems and is caring for a 3 year od boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take?
search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community
55
A patient with a 20 year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image?
a. I just don't have any energy to get out of bed in the morning
b. I've been attending church regularly with my wife since I got out of the hospital
c. My wife has taken over paying the bills since I've been in the hospital
d. I don't go out very much because everyone stares at me.
D. I don't go out very much because everyone stares at me.
56
The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change?
Action
57
The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness?
a. I don't have time to exercise because I have to work after school every night.
b. I'm worried about becoming overweight and getting diabetes because my father has it
c. The statistics of how many teenagers are overweight is scary
d. I've decided to start a walking club at school for interested students.
B. I'm worried about becoming overweight and getting diabetes because my father has it
58
The nurse assesses the following risk factors for coronary artery disease in a male patient. Which factors are classified as genetic and physiological?
a. sedentary lifestyle
b. father died of CAD at age 50
c. history of hypertension
d. eats diet high in sodium
e. elevated cholesterol level
f. age is 44 years
B, C, E, F
59
Which activity represents secondary prevention?
a. a home health care nurse visits a patient's home to change a wound dressing
b. a 50 year old woman with no history of disease attends the local health fair and has her blood pressure checked
c. the school health nurse provides a program to the first year students on healthy eating
d. the patient attends cardiac rehabilitation sessions weekly.
A. a home health care nurse visits a patient's home to change a wound dressing
60
If an infectious disease can be transmitted directly from one person to another, it is a ....
communicable disease
61
Which is the most likely means of transmitting infection between patients?
a. exposure to another patient's cough
b. sharing equipment among patients
c. disposing of soiled linen in a shared linen bag
d. contact with a health care worker's hands.
D. contact with a health care worker's hands
62
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection.
prodromal stage
63
Which of the following is the most effective way to break the chain of infection?
a. hand hygiene
b. wearing gloves
c. placing patients in isolation
d. providing private rooms for patients
C. placing patients in isolation
64
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 of organic material?
Perform hand hygiene after care and/or handling contaminated equipment or material
65
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is 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 reason for isolation procedures and provide meaningful stimulation
66
The nurse wears a gown when:
a. the patient's hygiene is poor
b. the nurse is assisting with medication administration
c. the patient has AIDS or hepatitis
d. blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform
D. blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform
67
The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure?
a. leave the gloves on to administer the medication
b. remove gloves and administer the medication
c. remove gloves and perform hand hygiene before administering the medication
d. leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room
C. remove gloves and perform hand hygiene before administrating the medication
68
When a nurse is performing surgical hand asepsis, the nurse must keep hands:
a. below elbows
b. above elbows
c. at a 45 degree angle
d. in a comfortable position
B above elbows
69
What is the best method to sterilize a straight urinary catheter and suction tube in the home setting?
a. use an autoclave
b. use boiling water
c. use ethylene oxide gas
d. use chemicals for disinfection
B use boiling water
70
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection?
It obstructs the normal flushing action of urine flow
71
Put the following steps for removal of protective barriers after leaving an isolation room in order:
a. untie top, then bottom mask strings and remove from face
b. untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side.
c. remove gloves
d. remove eyewear or goggles
e. perform hand hygiene
C, D, B, A, E
72
Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands?
wash them with soap and water
73
A patient's surgical wound has become swollen, red, and tender. You note that the patient has new fever and leukocytosis. What is the best immediate intervention?
notify the health care provider and support the patient's fluid and nutritional needs
74
While preparing to do a sterile dressing change, a nurse accidently sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated?
a. when a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action
b. fluid flows in the direction of gravity
c. a sterile field becomes contaminated by prolonged exposure to air
d. none of the principles were violated
C. a sterile field becomes contaminated by prolonged exposure to air
75
A 52 year old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoke for 35 years and recently lost over 10 pounds. Her vital signs on admission are HR 112,BP 138/82, RR22, tympanic temperature 36.8C (98.2F), and O2 sat is 94%. She is receiving oxygen at 2L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?
a. temp 98.6
b. radial pulse 112
c. respiratory rate 24
d. oxygen sat 96%
e. blood pressure 134/78
D oxygen saturation 96%
76
The licensed practical nurse provides you with the change-of-shift vital signs of four of your patients. Which patient do you need to assess first?
a. 84 year old man recently admitted with pneumonia, RR 28, SpO2 89%
b. 54 year old woman admitted after surgery for fractured arm BP 160/86 mm Hg, HR 72
c. 63 year old man with venous ulcers from diabetes, temp 99.HR 84
d. 77 year old woman with left mastectomy 2 days ago, RR 22, BP 148/62
A. 84 year old man recently admitted with pneumonia, RR 28, SpO2 89%
77
A 56 year old patient with diabetes admitted for community acquired pneumonia has a temp of 100.8F via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection?
a. heart rate
b. presence of diaphoresis
c. smoking history
d. respiratory rate
e. recent bowel movements
f. blood pressure in right arm
g. patient's normal temperature
h. blood pressure in distal extremity
A, B, D, G
78
A 55 year old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has laceration on her forehead. An intravenous line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature?
right popliteal and right axillae
79
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
baseline vital signs
80
During a patient's routine annual physical, she tells you that she has noted that her heart feels like it is racing, usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 bpm and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating patient's racing heart?
a. dietary habits
b. medication list
c. exercise regimen
d. age, weight, and height
A and B
81
You observe a nursing student taking a blood pressure on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?
a. 96/40 mm Hg
b. 110/66 mm Hg
c. 130/70 mm Hg
d. 156/82 mm Hg
D 156/82 mm Hg
82
As you are obtaining the oxygen saturation on a 19 year old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish has to be removed. Your best reply is?
nail polish interferes with sensor function
83
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temps of 101.6 F(04 00), 97.9F (0800), 98.4F(1200), 99.6F(1600), 100.9F (2000). How would you describe this pattern of measurements?
a. usual range of circadian rhythm measurements
b. sustained fever pattern
c. intermittent fever pattern
d. resolving fever pattern
C. intermittent fever pattern
84
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?
a. request that the nursing assistant repeat the pulse check
b. call for a stat electrocardiogram
c. assess the patient's apical pulse and evidence of a pulse deficit
d. prepare to administer cardiac-stimulating medications
C. assess the patient's apical pulse and evidence of a pulse deficit
85
Which of the following patients is most at risk for tachycardia?
a. a healthy professional tennis player
b. a patient admitted with hypothermia
c. a patient with a fever of 103F
d. a 90 year old male taking beta blockers
C. a patient with a fever of 103F
86
Which of the following patients is at most risk for tachypnea?
a. patient just admitted with four rib fractures
b. woman who is 9 months pregnant
c. adult who has consumed alcoholic beverages
d. adolescent awaking from sleep
A and B
87
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the health care provider for hypertension evaluation?
a. 120/80, 118/77, 124/82
b. 128/84, 124/86, 128/88
c. 148/82, 148/78, 134/86
d. 154/78, 118/76, 126/84
C. 148/82, 148/78, 134/86
88
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess?
a. right arm BP 120/80
b. radial pulse rate 72 and irregular
c. temporal temp 99.3F
d. respiratory rate 28
e. oxygen saturation 99%
B D E
89
A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The LPN reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response?
a. assess the patient's apical pulse to obtain the heart rate
b. obtain the heart rate from right and left radial sites
c. obtain the heart rate using the oximeter probe
d. perform a complete assessment of all pulses
D perform a complete assessment of all pulses.
90
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?
a. appearance and behavior
b. measurement of vital signs
c. observing specific body systems
d. conducting a detailed health history
A. appearance and behavior
91
The nurse is teaching a young mother to palpate her 8 year old child to quickly evaluate if the child has a fever. Which information is more important for the nurse to include?
a. place the palm of the hand on the child's back
b. lightly touch the child's forehead with the fingertips
c. Place the back of your hand against the child's forehead and then on the back of the neck
d. use the pads of your fingers and press against the child's neck and over the thorax
C. place the back of your hand against the child's forehead and then on the back of the neck
92
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?
a. respiratory rate of 14
b. pain reported when palpating posterior lower thorax
c. thorax rising and falling symmetrically for right and left lungs
d. vesicular breath sounds heard with auscultation of peripheral lung fields
B. pain reported when palpating posterior lower thorax
93
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?
a. avoid sunbathing between 3pm and 7pm
b. oral contraceptives and anti-inflammatories make the skin more susceptible to the sun
c. call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown
d. wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor
B. oral contraceptives and anti-inflammatories make the skin more susceptible to the sun
94
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention?
a. applying adhesive tape to anchor a nasogastric tube
b. inserting a rubber Foley catheter into the patient's bladder
c. providing oral hygiene using a standard toothbrush and toothpaste
d. giving an injection using plastic syringes with rubber coated plungers
A, B, and D
95
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up?
a. palpation of a femoral pulse with a heart rate of 76
b. auscultation of a heart murmur over the left thorax
c. identification of mild bruising at the catheter insertion site
d. palpation of a right dorsalis pedis pulse with strength of +1
D. palpation of a right dorsalis pedis pulse with strength of +1
96
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection?
a. buccal mucosa is moist and dark pink
b. respiratory rate is 18, rhythm is even
c. retropharyngeal lymph nodes are enlarged and firm
d. inspection with a tongue depressor on the posterior tongue causes gagging
C retropharyngeal lymph nodes are enlarged and firm
97
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include?
a. a normal pulse on the top of the foot indicates adequate blood flow to the foot
b. to located the dorsalis pedis pulse, take the fingers and palpate behind the knee
c. when there is poor arterial blood flow, the leg is generally warm to the touch
d. loss of hair on the lower leg indicates a long term problem with arterial blood flow.
A and D
98
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?
supine with the right arm abducted and hand under the head and neck
99
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?
a. the aorta can be felt using deep palpation in the upper abdomen near the midline
b. the patient should be sitting to best determine the contour and shape of the abdomen
c. always wear gloves when palpating the skin on the patient's abdomen
d. avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness
A. the aorta can be felt using deep palpation in the upper abdomen near the midline
100
The nurse is teaching a patient how to perform a testicular self-examination Which statement by the nurse is correct?
a. the testes are normally round and feel smooth and rubbery
b. the best time to do a testicular self exam is before your bath or shower
c. perform a testicular self exam weekly to detect signs of testicular cancer
d. since you are over 40 years old, you are in the highest risk group for testicular cancer.
A. the testes are normally round and feel smooth and rubbery
101
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?
Patient's abduction of right arm was limited to 100 degrees.
102
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform?
a. tell me where you are
b. what can you tell me about your illness
c. repeat these number back to me 7...5...8
d. what does this mean? a stitch in time saves 9
D a stitch in time saves 9
103
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up to smile. What nerve does the nurse explain to the patient?
VII facial nerve
104
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation?
a. inspect the lips and mucous membranes to determine if they are moist
b. pinch the skin on the back of the hand to see if the skin tents
c. check the patient's pulse and blood pressure
d. weight the patient daily
A,B and D
105
The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response.
Help the patient return to bed
106
A patient who is cognitively impaired and has dementia requires hygienic care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient?
a. allow the patient to perform as much of the care as possible
b. start by washing the face
c. try an alternative to traditional bathing such as the bag bath
d. use restraints to prevent the patient from injuring self or the nurse
A. allow the patient to perform as much of the care as possible
107
What is the priority concern when providing oral hygiene for a patient who is unconscious?
preventing aspiration
108
A male nurse is caring for a 32 year old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is/are appropriate actions?
a. finding a female nurse to help the patient
b. convincing the patient that he will work quickly and provide as much privacy as possible
c. skipping hygiene care for the day except for the parts that the patient can complete independently
d. asking the patient if she prefers a family member to assist with care.
A and D
109
You are helping a female patient bathe. As you are about perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action should you take initially.
a. explain to the patient that, because of her symptoms, you need to observe the perineal area
b. insist that you are supposed to complete the care
c. honor the patient's request to complete her own care to avoid any embarrassment
d. ask the patient if a family member can complete the care instead
A. explain to the patient that, because of her symptoms, you need to observe the perineal area
110
Your patient wears full dentures. His usual denture care includes taking them out once a day to brush. He wears the dentures over night. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in your teaching plan for denture care?
a. remove dentures overnight once a week while they soak in a cleansing bath
b. do not wear damaged or poorly fitting dentures
c. observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth
d. see dentist regularly
e. rinse dentures after meals
f. clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime
B, C, D, E
111
A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate?
a. decreasing frequency of oral hygiene
b. applying water-soluble moisturizing gel on the oral mucosa
c. encouraging intake of soft foods
d. using commercial mouth wash
B and C
112
While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first?
a. a patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10
b. a patient who prefers a bath in the evening when his wife visits and can help him
c. a patient who is experiencing frequent incontinent diarrhea stools
d. a patient who just returned from diagnostic testing and complains of being very fatigued
C. a patient who is experiencing frequent incontinent diarrhea stools
113
During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to:
Fowler's
114
A nurse caring for a male patient observes the nursing assistive personnel performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP?
a. used clean gloves
b. did not retract the foreskin before cleansing
c. used the clean portion of washcloth for each cleansing wipe
d. used a circular motion to cleanse from urinary meatus outward.
B. did not retract the foreskin before cleansing
115
A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used for?
stimulate venous return
116
Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy?
a. checking frequently for soiling
b. washing the perineal area with strong soap and water
c. placing the call light within easy reach
d. keeping a pad under the patient
A. checking frequently for soiling
117
The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do?
a. avoid cleaning the feet until an order fro the health care provider is received.
b. wash the feet with lukewarm water and then dry well
c. apply moisturizing lotion to the feet, especially between the toes
d. file the toenails straight across
B and D
118
The nurse recognizes that her older adult patient needs additional teaching about skin care when the older adult says, " I should
a. bathe twice a week
b. rinse well after using soap
c. use hot water for bathing
d. drink plenty of fluids.
C. use hot water for bathing
119
You ask the nursing assistive personnel to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient's gown and linen. Which of the following requires your immediate attention?
a. room temp is overly warm
b. room door is open to the hallway
c. television volume is too loud
d. strong odor of urine is detected
B room door is open to the hallway!
120
While assessing a patient, the nurse observes that the patient's IV line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
problem solving
121
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:
diagnostic reasoning
122
A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff responds, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency treatment together. The staff discusses what occurred over the 30 minute time-frame, what actions took place, and whether other steps should have been taken. The nurses in this situation are:
conducting reflective practice
123
A nurse has worked on an oncology unit for 3 years. One patient has become weaker and comments that they feel funny. The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient is shivering. The nurse goes to the phone, calls the physician, and begins the conversation with "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking does the nurse show?
a. experience
b. ethical
c. analyticity
d. self-confidence
e. risk taking
E. risk taking
124
A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their IV lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent use of clinical decision making for groups of patients?
a. consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction
b. think about past experience with patients who develop postoperative complications
c. decide which activities can be combined for patients B and C
d. carefully gather any assessment information and identify patient problems.
A and C
125
The surgical unit has initiated the use of pain-rating scale to assess patients' pain severity during their postoperative recovery. The RN looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
consistent
126
During a home health care visit the nurse prepares to instruct a patient in how to perform range-of-motion exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose of the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "this hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in the following..
I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax.
127
A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is
a. commitment
b. scientific method
c. basic critical thinking
d. complex critical thinking
C. basic critical thinking
128
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40mL of drainage in the surgical drainage collection device for an 8 hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:
a. planning
b. evaluation
c. intervention
d. diagnosis
B evaluation
129
A 67 year old patient will be discharged from the hospital in the morning. The health care provider has ordered three new modifications for her. Place the following steps of the nursing process in the correct order.
a. the nurse returns to the patient's room and asks her to describe the medicines she will be taking at home
b. the nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit
c. the nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medicines
d. the nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her
e. the nurse considers what she learns from the patient and identifies the patient's nursing diagnosis
```
the correct order is...
C. assessment
E. nursing diagnosis
B. planning
D. intervention
A. evaluation
```
130
The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is
a. experience
b. problem solving
c. knowledge application
d. clinical decision making
C. knowledge application
131
A nurse is working with a nursing assistive personnel on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine sample from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation?
a. A nurse explain to the NAP the approach to use in getting the patient up and why the patient has activity limitations
b. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead
c. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early.
d. The nurse is in patient B's rom to check an IV line and collects the urine specimen while in the room.
e. the nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight
A. C. D.
132
Which of the following is unique to the commitment level of critical thinking?
a. weighs benefits and risks when making a decision
b. analyzes and examine choices more independently
c. concrete thinking
d. anticipates when to make choices without others' assistance
D. anticipates when to make choice without others' assistance
133
In which of the following examples is the nurse not applying critical thinking skills in practice?
a. the nurse considers personnel experience in performing IV line insertion and ways to improve performance.
b. the nurse uses a fall risk inventory scale to determine a patient's fall risk
c. the nurse observes a change in a patient's behavior and considers which problem is likely developing
d. the nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.
D. the nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.
134
A nurse assesses a patient who comes to the pulmonary clinic. "I see that its been over 6 months since you've been in , but your appointment was for every 2 months. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?
a. value-belief pattern
b. cognitive-perceptual pattern
c. coping-stress-tolerance pattern
d. health perception- health maintenance pattern
D. health perception- health maintenance pattern
135
The nurse asks a patient, "Describe for me you typical diet over a 24 hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?
a. setting the stage
b. gathering information about the patient's chief concerns
c. collecting the assessment
d. termination
C. collecting the assessment
136
What type of interview techniques does the nurse use when asking these questions, "do you have pain or cramping?" "does the pain get worse when you walk?"
a. active listening
b. open-ended questioning
c. closed-ended questioning
d. problem-oriented questioning
C and D
137
What technique(s) best encourage(s) a patient to tell his or her full story?
a. active listening
b. back channeling
c. validating
d. use of open-ended questions
e. use of closed-ended questions
A B and D
138
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem?
a. the skin around the wound is tender to touch
b. fluid intake for 8 hours is 800mL
c. patient has a heart rate of 78 and regular
d. patient has drainage from surgical wound
e. body temperature is 101F
f. patient asks, "I'm worried that I won't return to work when I planned."
A D and E
139
The nurse makes the following statement during a change of shift report to another nurse, "I assessed Mr. Diaz, my 61 year old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says the he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it is that severe. You know that back patients have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest?
the nurse has allowed stereotyping to influence her assessment.
