Nursing Fundamentals ATC Farmer Exam 1 Davis Plus Questions – Flashcards
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Which of the following are responsibilities of each state's board of nursing? Select All That Apply 1) Determining the salaries of nurses working in the state 2) Approving nursing education programs 3) Establishing criteria that allow a person to be licensed as a registered nurse 4) Hiring instructors for schools of nursing in the state 5) Developing rules and regulations for guidance to nurses 6) Enforcing the rules that govern nursing
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2) Approving nursing education programs 3) Establishing criteria that allow a person to be licensed as a registered nurse 5) Developing rules and regulations for guidance to nurses 6) Enforcing the rules that govern nursing
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A friend recently graduated from high school and is planning to start a program to become a registered nurse, which will include 2 years of nursing classes plus many liberal arts and science classes. Whoch of the following educational routes is your friend taking to become a nurse? 1) Diploma program 2) Associate degree program 3) Baccalaureate degree program 4) Master's entry program
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2) Associate degree program
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Which of the following trends in the United States is most likely to increase the demand for nurses and other healthcare professionals? 1) Increased access to health and medical information among healthcare consumers 2) Growing proportion of older adults 3) Collective bargaining 4) The women's movement
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2) Growing proportion of older adults
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You work as a labor and delivery nurse in the birthing center of a large hospital. Your hospital follows a model of care in which during a single shift, you are assigned to provide all aspects of care for just one patient. This is an example of which model for nursing care? 1) Case method 2) Functional nursing 3) Team nursing 4) Primary nursing
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1) Case method
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You are currently a registered nurse but would like to become an advanced practical nurse. In particular, you would like to work with patients with cardiovascular disease in the coronary care unit of a hospital. Which advanced practice nursing certification should you pursue? 1) Nurse practitioner 2) Certified registered nurse anesthetist 3) Clinical nurse specialist 4) Certified nurse midwife
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3) Clinical nurse specialist
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In your career as a nurse, you have provided primary, secondary, and tertiary care to a wide variety of patients. Which of the following is an example of primary care? 1) Administering pneumonia immunizations to older adults in a community clinic 2) Administering an antibiotic to a child with strep throat in an ambulatory care center 3) Caring for a patient who is learning to walk again after a traumatic injury in a rehabilitation center 4) Providing in-home hospice care for a patient who is dying of brain cancer
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1) Administering pneumonia immunizations to older adults in a community clinic
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You have received unexpected blood test results for a patient and would like to confirm that there were no errors in the processing of the specimen. Which of the following healthcare professionals should you contact to address this concern? 1) Nursing assistant 2) Physical therapist 3) Physician's assistant 4) Laboratory technologist
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4) Laboratory technologist
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Which of the following is a recommendation for healthcare reform that the American Nurses Association (ANA) published in 2008? 1) Provide universal access to essential healthcare services for all citizens and residents 2) Privatize the entire healthcare system 3) Shift the priority from health promotion to illness care 4) Established a three-payer system for financing healthcare
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1) Provide universal access to essential healthcare services for all citizens and residents
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You are providing care for a 20-year-old who is currently unemployed, has no health insurance, and is struggling financially. Which of the following would it be most appropriate to provide information on? 1) Medicare 2) Medicaid 3) CHIP 4) Individual private insurance
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2) Medicaid
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The following each describes one of five of the stages in Benner's model of the process by which a nurse acquires clinical skills and judgement: novice, advanced beginner, competence, proficient, expert. Put the descriptions in the correct order according to the their corresponding stages. - Can handle patient load and prioritize situations - Can recognize problems in the absence of classic signs and symptoms - Has a more sophisticated use of rules; recognition of abnormal findings but not of significance - Is task oriented and focuses on "learning the rules" - Can see the "big picture," coordinate services, and forecast needs
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1) Has a more sophisticated use of rules; recognition of abnormal findings but not the significance 2) Can recognize problems in the absence of classic signs and symptoms 3) Can handle patient load and prioritize situations 4) Is task oriented and focuses on "learning the rules" 5) Can see the "big picture," coordinate services, and forecast needs
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In the hospital where you work as a registered nurse, nursing tasks are specialized. You are responsible for performing ordered treatments, such as giving injections, taking blood draws, and taking vital signs. A licensed practical nurse distributes medications to patients. A nursing assistant gives bed baths and makes the beds. This is an example of which model of nursing care? 1) Case method 2) Functional nursing 3) Team nursing 4) Primary nursing
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2) Functional nursing
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Which of the following were acknowledged by the American Nurses Association (ANA) in 2010 as key characteristics of registered nursing? Select All That Apply 1) Nursing practice is the same for every nurse 2) Nurses coordinate care by establishing partnerships 3) Care is central to the practice of the registered nurse 4) Registered nurses use a corporate process to plan and provide care to their healthcare consumers 5) A strong link exists between the work environment and the nurse's ability to achieve optimal outcomes 6) The profitability of the healthcare facility is central to the practice of the registered nurse
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2) Nurses coordinate care by establishing partnerships 3) Care is central to the practice of the registered nurse 5) A strong link exists between the work environment and the nurse's ability to achieve optimal outcomes
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Your uncle, who is 56, recently has a heart attack and was in the hospital for emergency coronary bypass surgery. After his stay in the hospital, he was moved to a facility for inpatient, multidisciplinary care for 6 weeks to help him recover and regain function. In which type of care facility was your uncle most likely treated? 1) Ambulatory care center 2) Nursing home 3) Rehabilitation center 4) Assisted living facility
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3) Rehabilitation center
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You are interested in joining a nursing organization that has as one of its primary goals the improvement of working conditions for nurses throughout the world. Which of the following organizations would be best for you to join? 1) American Nurses Association 2) National League for Nursing 3) International Council of Nursing 4) Sigma Theta Tau International
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3) International Council of Nursing
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Which of the following are factors that has a strong influence on the evolution of professional nursing? Select All That Apply 1) Buddhism 2) Societal beliefs 3) Architecture 4) Christianity 5) The marketplace 6) The military
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2) Social beliefs 4) Christianity 6) The military
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You perform a blood draw on a patient and afterward the patient says, "Nobody has ever done such a good job finding my vein and taking a blood sample. You really now what you're doing." What type of knowledge is the patient referring to in this situation? 1) Theoretical knowledge 2) Practical knowledge 3) Self-knowledge 4) Ethical knowledge
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2) Practical knowledge
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What are the two components of "doing" in the full-spectrum nursing concepts? 1) Critical thinking and theoretical knowledge 2) Practical knowledge and the nursing process 3) Self-knowledge and ethical knowledge 4) Patient data and patient preferences and context
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2) Practical knowledge and the nursing process
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Which of the following are examples of critical-thinking attitudes? Select All That Apply 1) Independent thinking 2) Intellectual curiosity 3) Intellectual empathy 4) Intellectual pride 5) Intellectual safety 6) Intellectual perseverance
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1) Independent thinking 2) Intellectual curiosity 3) Intellectual empathy 6) Intellectual perseverance
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While caring for a 6-year-old boy who is adjusting to being in the hospital for the first time, you suggest to his father that he bring in the boy's special blanket and favorite stuffed animal to help ease the transition. Which component of caring are you demonstrating by this action? 1) Knowing 2) Being with 3) Doing for 4) Enabling
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4) Enabling
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You are working with a patient who is in severe pain following a traumatic accident. The patient's religious beliefs prevent her from taking any kind of medication for pain. After experimenting with several different nonpharmacological methods of pain management, you discover that a combination of distractions works: the patient views a television program while receiving a shoulder massage, which is reasonably effective in providing her with relief from pain. Which of the following types of complex thinking is this best an example of? 1) Clinical reasoning 2) Diagnostic reasoning 3) Decision making 4) Problem-solving
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4) Problem-solving
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What are the two components of "caring" in the full-spectrum nursing concepts? 1) Critical thinking and theoretical knowledge 2) Practical knowledge and the nursing process 3) Self-knowledge and ethical knowledge 4) Patient data and patient preferences and context
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3) Self-knowledge and ethical knowledge
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Which of the following are examples of critical-thinking skills? Select All That Apply 1) Subjectively gathering information about a problem or issue 2) Recognizing the need for more information 3) Assuming the credibility and usefulness of sources of information 4) Recognizing gaps in one's knowledge 5) Speaking carefully 6) Separating relevant from irrelevant data
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2) Recognizing the need for more information 4) Recognizing gaps in one's knowledge 6) Separating relevant from irrelevant data
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A hospital administrator calls and asks you to prioritize treatment of a patient who is related to the administrator. This request bothers you, and you decide to report it to your supervisor. Which type of nursing knowledge are you acting on in this situation? 1) Theoretical knowledge 2) Practical knowledge 3) Self-knowledge 4) Ethical knowledge
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4) Ethical knowledge
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After assessing a client, you determine that the client has the following problem: imbalanced nutrition: less that body requirements. At which phase in the nursing process are you? 1) Assessment 2) Diagnosis 3) Planning 4) Implementation
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2) Diagnosis
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Which of the following are components of the definition of critical thinking? Select All That Apply 1) Reasoned thinking 2) Openness to alternatives 3) Adherence to established guidelines 4) Ability to reflect 5) Loyalty to traditional approaches 6) Desire to seek the truth
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1) Reasoned thinking 2) Openness to alternatives 4) Ability to reflect 6) Desire to seek the truth
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You are in the process of assessing a patient who is of another race and religion than yours. As you perform the assessment, you begin to wonder what factors—including the patient's race and religion—may be influencing your behavior in this situation. Which thinking process in the critical-thinking model are you demonstrating? 1) Contextual awareness 2) Inquiry 3) Considering alternatives 4) Reflecting skeptically and deciding what to do
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1) Contextual awareness
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In the course of a day, you encounter many different types of patients. Which of the following patients would most require you to use the most complex critical thinking skills in your care of him or her? 1) An 18-year-old football player who has broken his leg 2) A 60-year-old school teacher who has strep throat 3) A 45-year-old attorney who has developed high blood pressure 4) An 80-year-old woman with diabetes who has broken her hip
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4) An 80-year-old woman with diabetes who has broken her hip
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You have just finished a physical examination of an 8-year-old girl and discovered bruises on her body in places that make you suspect that she has been physically abused. Before you investigate that line of reasoning, however, you stop and think about all the other likely ways that a child her age could obtain bruises in those locations. Which thinking process in the critical-thinking model are you demonstrating? 1) Contextual awareness 2) Inquiry 3) Considering alternatives 4) Reflecting skeptically and deciding what to do
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3) Considering alternatives
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Place the following six phases of the nursing process in correct order. - Evaluation - Planning outcomes - Implementation - Assessment - Planning Interventions - Diagnosis
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1) Assessment 2) Diagnosis 3) Planning Outcomes 4) Planning Interventions 5) Implementation 6) Evaluation
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Which of the following is an example of a nurse who is using critical thinking? 1) Following the hospital's new policy to require a photo ID for all visitors to the birthing center 2) Questioning a medication order from a physician that doubles the patient's dosage when the patient exhibited no changes in a recent office visit 3) Recording the patient's vital signs once an hour, per the physician's request 4) Calculating the proper dosage of a child's oral medication based on established height/weight charts
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2) Questioning a medication order from a physician that doubles the patient's dosage when the patient exhibited no changed in a recent office visit
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You are conducting an initial assessment of a new client. The client does not have time today for a comprehensive assessment, so you will be doing that at the client's next visit. Which of the following types of data should you collect as part of this assessment? Select All That Apply 1) Status of a healing laceration 2) Emotional status 3) Phone number 4) Blood pressure 5) Marital status 6) Occupation
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3) Phone number 5) Marital status 6) Occupation
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A patient is in the examination room waiting to be assessed. You are the registered nurse assigned to assess the patient. You also have a nurse aide assisting you. Which aspects of the patient's assessment would be appropriate for you to delegate to the nurse aide? 1) Take the patient's temperature 2) Weigh the patient 3) Validate the data collected 4) Measure the patient's height 5) Conduct the patient interview 6) Complete the physical assessment
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1) Take the patient's temperature 2) Weigh the patient 4) Measure the patient's height
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As you perform a detailed assessment of a 10-year-old client, the client asks, "Why are you taking so long to check me out?" What is your most appropriate response to this patient? 1) "I have to figure out what's wrong with you." 2) "I have to get enough information so that I can help you." 3) "I have to decide what kind of treatment to give you." 4) "I have to help you feel better."
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2) I have to get enough information so that I can help you."
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During a physical examination, you gather much data on a client. Which of the following are data findings that you should validate? Select All That Apply. 1) A report of a height of 6 feet, 6 inches in a client who appears very tall 2) A blood pressure reading of 80/60 mm Hg in a client with hypertension who is not on medication 3) A heart rate of 40 beats/min in a moderately active 45-year-old 4) A denial of illicit drug use in conjunction with the observation of needle track marks on the client's arm 5) An oral temperature of 98.2*F 6) A total cholesterol score of 245
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2) A blood pressure reading of 8-/60 mm Hg in a client with hypertension who is not on medication 3) A heart rate of 40 beats/min in a moderately active 45-year-old 4) A denial of illicit drug use in conjunction with the observation of needle track marks on the client's arm
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As you perform an assessment of a client, which of the following actions are required by The Joint Commission? Select All That Apply 1) Record findings of the assessment in writing or on a computer tablet 2) Delegate taking the patient's biometric measures to a nurse aide 3) Include evaluation of the client's physical, psychological, and social status in the assessment 4) Follow agency policy regarding when the client is to be reassessed 5) Assess the client for possible physical abuse 6) Assess the client for pain
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1) Record findings of the assessment in writing or on a computer tablet 3) Include evaluation of the client's physical, psychological, and social status in the assessment 4) Follow agency policy regarding when the client is to be reassessed 6) Assess the client for pain
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Which phase of the nursing process uses the data gathered during assessment to identify the client's health problems and strengths? 1) Planning Interventions 2) Implementation 3) Diagnosis 4) Evaluation
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3) Diagnosis
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You are assessing a child with sickle cell disease who is experiencing an acute pain crisis. You are concerned that the child's spleen may be enlarged, which is a serious complication of this disease. You don't see any signs of enlargement in the patient's abdomen but you know that the condition may still be present. You decide to examine the patient's abdomen by feel. Which of the following physical assessment techniques are you using? 1) Inspection 2) Palpation 3) Percussion 4) Auscultation
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2) Palpation
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You are documenting the assessment data of a client. Which of the following is the most appropriate documentation? 1) Patient is angry over a long wait in the waiting room 2) Client is intoxicated 3) Child has bruises from being spanked 4) Patient has a cluster of three clear vesicles on the upper lip
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4) Patient has a cluster of three clear vesicles on the upper lip
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As a new nurse, you are interviewing a 15-year-old client as part of a comprehensive assessment and come to the portion of the health history that relates to her sexual health. You are embarrassed to ask someone her age about her sex life and you fear what her reaction will be. Which of the following actions should you take? 1) Skip this section and assume that the client will mention any problem she has in this area 2) Ask a more experienced nurse to complete the interview 3) Ask to speak to the client's mother about this topic 4) Explain that you will keep all information confidential and then ask the necessary questions
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4) Explain that you will keep all information confidential and then ask the necessary questions
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You are interviewing a client to obtain information about his health history. Because he appears nervous, you begin by using directive interviewing. Which of the following is an example of a question you might ask when using this type of interviewing? 1) "How has your weight loss program been going?" 2) "When was your last physical examination?" 3) "What signs or symptoms have you experienced related to your diabetes?" 4) "How would you describe your work environment?"
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2) "When was your last physical examination?"
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In your interview with a new client, you learn that she drinks six beers a day. In which section of the nursing health history would you record this information? 1) Biographical data 2) Chief complaint 3) Family health history 4) Social history
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4) Social history
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You are assessing the functional abilities of a client who is in hospice care and nearing the end of life. Which of the following special needs assessments would be most appropriate to use with this client? 1) Katz Index of Activities of Daily Living (ADL) scale 2) Lawton Instrumental Activities of Daily Living (IADL) scale 3) Karnofsky Performance scale 4) Wellness assessment
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3) Karnofsky Performance scale
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You have just completed a client assessment and need to record the data you have gathered. Which of the following guidelines should you observe as you complete this task? Select All That Apply. 1) Wait at least 24 hours before recording 2) If recording on paper, write only with pencils 3) Write the patient's own words, when possible, in quotation marks 4) Record only the most important patient words 5) Record inferences, not cues 6) Use concrete, specific information rather than vague generalities
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3) Write the patient's own words, when possible, in quotation marks 4) Record only the most important patient words 6) use concrete, specific information rather than vague generalities
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You are preparing for an interview with a client and deciding how to incorporate directive and nondirective interviewing techniques. Which of the following is a disadvantage of directive interviewing? 1) It may cause you to miss topics important to the patient 2) It is ineffective 3) It can produce much irrelevant data 4) It is not effective for clients who are anxious
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1) It may cause you to miss topics important to the patient
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A patient arrives at the clinic where you work complaining of pain in her temples. She describes the pain as throbbing and intense. This is an example of which type of data? 1) Primary subjective 2) Primary objective 3) Secondary subjective 4) Secondary objective
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1) Primary subjective
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As you are weighing a client and calculating her body mass index, you begin to think that a diagnosis of "Imbalanced nutrition: more than body requirements" would be appropriate for this client. Which of the following is true of this guess? 1) It illustrates that nursing diagnosis actually begins during assessment 2) It is an example of a nurse not properly following the nursing process 3) It is an example of the nurse making a medical diagnosis, which should not be done 4) It proves that the nursing process need not be followed
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1) It illustrates that nursing diagnosis actually begins during assessment.
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You have written your diagnostic statements for a client. Which of the following criteria should you use to judge their quality? Select All That Apply 1) In choosing a NANDA-I label, do not rely on the label definition alone 2) Include both problem and etiology, with cause and effect stated correctly 3) Be sure that the etiology restates the problem 4) Use medical diagnosis and treatments as etiological factors 5) Write the statement concisely 6) Be sure the statement is descriptive and specific
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1) In choosing a NANDA-I label, do not rely on the label definition alone. 2) Include both problem and etiology, with cause and effect stated correctly. 5) Write the statement concisely. 6) Be sure the statement is descriptive and specific.
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You are in the process of selecting a diagnostic label for a health problem of a client. Which of the following is the first step you should take in this process? 1) Narrow your search to the class or most likely labels 2) Identify the domain that seems to fit the cue cluster 3) Consult a nursing diagnosis handbook 4) Compare definitions and defining characteristics of the diagnostic labels to your cue cluster
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2) Identify the domain that seems to fit the cue cluster.
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You are caring for a client who complains of having hard stool and of not having had a bowel movement in 3 or 4 days. You suspect that the client has constipation. Moreover, after seeing his intake and output measures, you believe that the constipation is caused by inadequate intake of fluids and fiber-rich foods. Which of the following would be an appropriate nursing diagnosis based on these findings? 1) Hard stool and bowel movement every 3 or 4 days r/t constipation AMB inadequate intake of fluids and fiber-rich foods 2) Inadequate intake of fluids and fiber-rich foods r/t constipation AMB painful, hard tool and bowel movement every 3 or 4 days 3) Constipation r/t inadequate intake of fluids and fiber-rich foods AMB painful, hard tool and bowel movement every 3 or 4 days 4) Hard stool and bowel movement every 3 or 4 days r/t inadequate intake of fluids and fiber-rich foods AMB constipation
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3) Constipation r/t inadequate intake of fluids and fiber-rich foods AMB painful, hard tool and bowel movement every 3 or 4 days
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Which of the following is an example of an actual nursing diagnosis? 1) Risk for infection related to surgery 2) Impaired walking related to a diabetic ulcer 3) Possible risk for imbalanced nutrition: less than body requirements 4) Readiness for enhanced nutrition
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2) Impaired walking related to a diabetic ulcer
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While caring for a patient in the hospital, you note ulcers on the patient's feet. You recall that the patient's laboratory test results indicated a high blood glucose level. Which of the following is an appropriate nursing diagnosis that you could make in this situation? 1) Advanced type 2 diabetes mellitus 2) Staphylococcus infection of the feet 3) Impaired tissue integrity 4) Potential complication of type 2 diabetes mellitus: hyperglycemia
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3) Impaired tissue integrity
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You are reflecting critically on your diagnostic reasoning after formulating a nursing diagnosis. Which of the following questions should you ask yourself to evaluate your self-knowledge? Select All That Apply. 1) Is this diagnosis based on sound knowledge? 2) What biases and stereotypes may have influenced my interpretation of the data? 3) Did I rely too much on past experiences? 4) Do I feel reasonably sure I have interpreted the data correctly? 5) Did I rely too much on the client's medical diagnosis, the setting, or what others say about the client instead of on the data? 6) Am I qualified to make this diagnosis, or should I consult with a more experienced nurse or other member of the collaborative healthcare team?
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2) What biases and stereotypes may have influenced my interpretation of the data?3) Did I rely too much on past experiences? 6) Am I qualified to make this diagnosis, or should I consult with a more experienced nurse or other member of the collaborative healthcare team?
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Which of the following is the first step in the process of analyzing and interpreting data? 1) Cluster cues 2) Identify data gaps 3) Identify significant data 4) Identify data inconsistencies
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3) Identify significant data
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Which of the following is the best definition of health problem? 1) Any condition that requires intervention to promote wellness or to prevent or treat disease or illness 2) A statement of client health status that nurses can identify, prevent, or treat independently 3) A description of a disease, illness, or injury developed so that appropriate medical treatment can be given 4) A complication related to a disease that a nurse monitors to detect a change in status
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1) Any condition that requires intervention to promote wellness or to prevent or treat disease or illness
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You are preparing to write a collaborative problem diagnosis. Which of the following elements is typically left out of a collaborative problem? 1) Complication 2) Disease 3) Etiology 4) The word potential
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3) Etiology
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Which of the following is an example of a wellness nursing diagnosis? 1) Risk for infection related to surgery 2) Impaired walking related to a diabetic ulcer 3) Possible risk for imbalanced nutrition: less than body requirements 4) Readiness for enhanced nutrition
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4) Readiness for enhanced nutrition
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You are working with a client in the hospital who has lost 5 pounds since being admitted. You recognize that this client is probably experiencing imbalanced nutrition: less than body requirements. Which of the following are likely etiologies related to this diagnosis? Select All That Apply. 1) Excessive fear of weight gain 2) Self-induced vomiting related to self-starvation 3) Diet high in fat 4) Inability to ingest food 5) Lack of physical activity 6) Depression
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1) Excessive fear of weight gain 2) Self-induced vomiting related to self-starvation 4) Inability to ingest food 6) Depression
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Put the following steps of the diagnostic reasoning process in the correct order. - Verify problems with the patient. - Analyze and interpret data. - Record the diagnostic statements. - Draw conclusions about the patient's health status. - Prioritize the problems.
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1) Analyze and interpret data 2) Verify problems with the patient 3) Draw conclusions about the patient's health status 4) Record the diagnostic statements 5) Prioritize the problems
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Which of the following is an accurate statement regarding the relationship of the nursing diagnosis to outcomes and interventions? 1) The problem suggests the goals. 2) The etiology suggests the problem. 3) The goals suggest the etiology. 4) The interventions suggest the etiology.
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1) The problem suggests the goals.
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You are preparing to prioritize the health problems that you have identified for a patient. You have decided to prioritize them based on the problems that relate to the client's most basic human needs. Which theoretical framework are you using? 1) Problem urgency 2) Future consequences 3) Patient preference 4) Maslow's hierarchy
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4) Maslow's hierarchy
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You are creating a comprehensive care plan for a patient. Which of the following are examples of appropriate information to include in this plan? Select All That Apply. 1) Assistance the patient will require with bathing 2) Prescriptions for an antibiotic and an analgesic 3) A detailed family health history 4) A nursing diagnosis of "Impaired mobility related to fractured toe" 5) Information on the patient's insurance plan 6) Special teaching on care of an ostomy pouch
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1) Assistance the patient will require with bathing 2) Prescriptions for an antibiotic and an analgesic 4) A nursing diagnosis of "Impaired mobility related to fractured toe" 6) Special teaching on care of an ostomy pouch
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You are caring for a patient who is experiencing significant pain following surgery. You have been administering acetaminophen by mouth for the past 24 hours but can clearly see that the patient's pain level is high. You add a note to the patient's care plan and notify the patient's provider about the pain, recommending a change in medication. Which type of planning is this? 1) Initial, formal 2) Initial, informal 3) Ongoing, formal 4) Ongoing, informal
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3) Ongoing, formal
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Your hospital has recently implemented a new electronic health record system that includes computer-generated care plans. Which of the following are advantages of computerized planning? Select All That Apply. 1) Increases the use of intuition 2) Ensures consideration of a variety of actions 3) Prevents overlooking common and important interventions4) Increases the use of insight 5) Reduces time spent on paperwork 6) Enhances nursing expertise
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2) Ensures consideration of a variety of actions 3) Prevents overlooking common and important interventions 5) Reduces time spent on paperwork
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You are using the standardized Nursing Outcomes Classification (NOC) vocabulary to develop patient outcomes. In NOC vocabulary, the observable behaviors and states you can use to evaluate patient status are which of the following? 1) Indicators 2) Outcomes 3) Measurement scales 4) Outcome labels
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1) Indicators
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You are formulating a goal for a patient who is experiencing a disturbed sleep pattern related to anxiety about finances. Which of the following would be specific and concrete performance criteria for such a goal? Select All That Apply. 1) Will return to a normal sleep pattern 2) Will sleep at least 8 hours each night 3) Will fall asleep within 1 hour of going to bed 4) Will get enough sleep at night 5) Will report feeling rested in the morning 6) Will sleep more
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2) Will sleep at least 8 hours each night 3) Will fall asleep within 1 hour of going to bed 5) Will report feeling rested in the morning
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You are preparing to discharge a client and are deciding whether you need to create a comprehensive, formal discharge plan. Which of the following client characteristics or situations would tend to necessitate a formal discharge plan? Select All That Apply. 1) Mental illness 2) Medication continued at home 3) Complicated major surgery 4) Inadequate financial resources 5) A significant other to help provide care 6) Malnutrition
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1) Mental illness 3) Complicated major surgery 4) Inadequate financial resources 6) Malnutrition
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You have given a client the following nursing diagnosis: Ineffective Airway Clearance related to ineffective cough secondary to incisional pain. Which of the following is an example of an essential patient goal related to this diagnosis? 1) Coughs forcefully/effectively 2) Rates pain as < 3 on a scale of 1 to 10 scale 3) Splints incision while coughing 4) Lungs clear to auscultation
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4) Lungs clear to auscultation
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Below are the steps in the process for writing an individualized patient care plan. Put them in the correct order. - Transcribe medical orders to appropriate documents - Write activities of daily living and basic care needs in special sections of the Kardex, care plan, or computer - Make a working problem list - Develop individualized care plans for problems not addressed by standardized documents - Decide which problems can be managed with standardized care plans or critical pathways - Individualize the standardized plan as needed
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1) Individualize the standardized plan as needed 2) Write activities of daily living and basic care needs in special sections of the Kardex, care plan, or computer 3) Make a working problem list 4) Transcribe medical orders to appropriate documents 5) Decide which problems can be managed with standardized care plans or critical pathways 6) Develop individualized care plans for problems not addressed by standardized documents
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You have diagnosed a patient with the following nursing diagnosis: Possible Constipation related to suspected inadequate intake of fiber and fluids. Which of the following is the appropriate patient goal to address this diagnosis? 1) Will have normal, formed bowel movement within 24 hours after receiving stool softener 2) Will have bowel function within normal limits for patient 3) There is no patient goal. 4) Reports increased intake of dietary fiber and fluids
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3) There is no patient goal.
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You have given a client you are working with a nursing diagnosis of "Impaired Mobility related to atrophied muscles from confinement to bed." Which of the following states an appropriate long-term goal that addresses that problem? 1) Walk three steps using a walker 2) Walk down the hall and back unassisted 3) Perform exercises daily to strengthen legs 4) Client resists efforts at rehabilitating his legs
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2) Walk down the hall and back unassisted
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In preparing a care plan for a patient, you decide to use a preprinted plan. The plan you choose groups patients according to diagnosis, describes the minimal standard of care required to meet the recommended length of stay, and specifies patient outcomes and broad interventions for each day and each hour. Which type of plan have you chosen? 1) Unit standards of care 2) Critical pathway 3) Standardized patient care plan 4) Integrated plans of care
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2) Critical pathway
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A new nurse you are training asks why you have to write down the patient care plan. She tells you that at her last job, she didn't have to write anything down. Which of the following reasons would you tell her? Select All That Apply. 1) To ensure that care is complete 2) To help instill confidence in patients 3) To provide continuity of care 4) To promote efficient use of nursing efforts 5) To provide a guide for assessments and charting 6) To meet the requirements of accrediting agencies
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1) To ensure that care is complete 3) To provide continuity of care 4) To promote efficient use of nursing efforts 5) To provide a guide for assessments and charting 6) To meet the requirements of accrediting agencies
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During your physical examination of a new client, you observe that she appears underweight and you make a mental note that she may require counseling related to disordered eating. Which type of planning is this? 1) Initial, formal 2) Initial, informal 3) Ongoing, formal 4) Ongoing, informal
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2) Initial, informal
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You are formulating goals as part of creating an individualized care plan for a client. Which of the following is a goal or expected outcome, as opposed to just an outcome? 1) Constipation relieved 2) Pain level unchanged 3) Anxiety related to pending surgery 4) Allergic reaction to penicillin
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1) Constipation relieved
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A patient is becoming discouraged because she is struggling to relearn how to brush her teeth after a stroke. You decide to have her first attempt to grasp her modified toothbrush handle and hold it up for 10 seconds. This is an example of which of the following? 1) Short-term goal 2) Long-term goal 3) Short-term outcome 4) Long-term outcome
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1) Short-term goal
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Nursing interventions are actions based on clinical judgment and nursing knowledge that nurses perform to achieve client outcomes. Interventions are also referred to as which of the following? Select All That Apply. 1) Goals 2) Outcomes 3) Nursing actions 4) Measures 5) Strategies 6) Activities
answer
3) Nursing actions 4) Measures 5) Strategies 6) Activities
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Put the following steps in the evidence-based practice process in correct order. - Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions - Evaluating or grading the quality of the evidence obtained - "Translating" the evidence into guidelines for practice - Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristics - Compiling and analyzing the data to prepare a structured report of the review - Conducting a systematic review of published evidence (research) to find studies that shed light on the desired topic
answer
1) Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions 2) Evaluating or grading the quality of the evidence obtained 3) Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristics. 4) Compiling and analyzing the data to prepare a structured report of the review 5) "Translating" the evidence into guidelines for practice 6) Conducting a systematic review of published evidence (research) to find studies that shed light on the desired topic
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You are reflecting critically about a nursing order you have just composed for a client. You should make sure that the order is which of the following? Select All That Apply. 1) Complete, addressing all aspects of the problem 2) Generic, able to be used for a wide variety of clients 3) Clear, specific, and precise, avoiding vague language 4) Long and complex, including the details of all procedures 5) Technically complete, including all required components 6) Prioritized, indicating which orders must be implemented immediately
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1) Complete, addressing all aspects of the problem 3) Clear, specific, and precise, avoiding vague language 5) Technically complete, including all required components 6) Prioritized, indicating which orders must be implemented immediately
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In caring for a patient who is confined to bed in the hospital for many weeks, you are seeking interventions to help prevent decubitus ulcers, or pressure sores. You decide to conduct a systematic review of published research to find studies that shed light on this topic. This action is an example primarily of which of the following? 1) Theory 2) Critical pathway 3) Evidence-based practice 4) Protocol
answer
3) Evidence-based practice
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You are preparing to perform a blood draw on a client who is seated in a phlebotomy chair. The client appears pale and confesses that he "gets squeamish" at the sight of blood. Which of the following responses best illustrates the use of the critical-thinking skill of predicting to help generate an intervention in this situation? 1) With other clients who were squeamish, I have successfully distracted them by making small talk; maybe that will work for this client. 2) Because the client is squeamish, he may faint during the blood draw, so I should have him lie down. 3) I learned in a music therapy workshop that music can help calm anxious clients; perhaps I should play some soft music. 4) This client is experiencing a vasovagal response, in which the parasympathetic nervous system is triggered by a threat in the environment.
answer
2) Because the client is squeamish, he may faint during the blood draw, so I should have him lie down.
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Below are the steps for selecting the best nursing intervention for each patient. Put them in the correct order. - Identify several interventions or actions - Review the nursing diagnosis - Choose the best interventions for the patient - Review the desired patient outcomes - Individualize standardized interventions
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1) Review the desired patient outcomes 2) Individualize standardized interventions 3) Identify several interventions or actions 4) Review the nursing diagnosis 5) Choose the best interventions for the patient
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You are providing wellness teaching to a client who frequently experiences constipation. Which of the following interventions would be most appropriate in this situation? 1) Recommend an over-the-counter laxative 2) Administer a prescribed stool softener 3) Obtain more data to confirm or rule out constipation 4) Provide the patient with a daily fluid intake guide to promote optimal health
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4) Provide the patient with a daily fluid intake guide to promote optimal health
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You are researching standardized intervention classification systems to find spiritual care interventions to use with your clients. Which of the following are some spiritual care interventions you might consider? Select All That Apply 1) Spiritual growth facilitation 2) Religious ritual enhancement 3) Decision-making support 4) Health screening 5) Spiritual support 6) Bereavement support
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1) Spiritual growth facilitation 2) Religious ritual enhancement 5) Spiritual support 6) Bereavement support
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You are writing up a nursing order for a client. Which of the following components should you include in it? Select All That Apply. 1) Date 2) Subject 3) Prescribed medications 4) Action verbs 5) Times and limits 6) Signature
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1) Date 2) Subject 4) Action verbs 5) Times and limits 6) Signature
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Which of the following is an example of an interdependent intervention? 1) Assisting the client in performing leg exercises and reporting results to the physical therapist 2) Administering a prescribed antibiotic 3) Collecting a stool sample per orders 4) Encouraging the client to increase fluid intake to prevent dehydration
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1) Assisting the client in performing leg exercises and reporting results to the physical therapist
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While caring for a patient one day, you perform many interventions, both direct care and indirect care. Which of the following is an example of an indirect-care intervention? 1) Teaching a patient how to care for an incision site 2) Administering an injection 3) Listening to the patient explain fears related to death 4) Making a referral for the patient to see a speech pathologist
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4) Making a referral for the patient to see a speech pathologist
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You are a home health nurse and are planning interventions for a client who is recovering from a stroke. You would like to use an intervention classification system that is especially designed to meet the needs of home health nursing. Which of the following systems should you choose? 1) North American Nursing Diagnosis Association—International (NANDA-I) 2) Nursing Interventions Classification (NIC) 3) Clinical Care Classification (CCC) 4) Omaha System
answer
3) Clinical Care Classification (CCC)
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You are caring for a patient for whom you have given the actual nursing diagnosis of constipation. Based on the status of this problem, which of the following interventions should take priority? 1) Encourage the patient to drink more fluids 2) Administer a prescribed stool softener 3) Obtain more data to confirm or rule out the constipation 4) Provide the patient with a daily fluid intake guide to promote optimal health
answer
2) Administer a prescribed stool softener
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You are counseling a client on potential lifestyle changes to optimize her health. Which of the following is an appropriate wellness intervention for the client? 1) "The client will spend at least 15 minutes per day meditating for the next week." 2) "I will walk at least 1 mile every day at lunch time with a coworker for the next month." 3) "The client will take all prescribed medications at the right time for the next 3 months." 4) "I will perform hand exercises daily to regain strength lost following carpal tunnel surgery."
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2) "I will walk at least 1 mile every day at lunch time with a coworker for the next month."
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Throughout your day as a nurse, you make many interventions, both independent and dependent. Which of the following is an example of an independent intervention? 1) Administering a prescribed analgesic 2) Delegating the bathing of a patient to a nurse aide 3) Drawing blood for an ordered complete blood count 4) Starting IV therapy
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2) Delegating the bathing of a patient to a nurse aide
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You are preparing to discharge a client and have concerns about his ability to adhere to the diabetic diet that you and the nutritionist have developed for him. Which of the following are effective ways to promote cooperation with the diet? Select That All Apply. 1) Assess the client's knowledge of diabetes. 2) Ask the client what concerns he has about going on the diet. 3) Provide teaching on what foods to avoid and what foods will help keep his blood glucose level steady. 4) Talk openly and regularly about adherence. 5) Be determined to change any of the client's attitudes that contribute to resistance to the diet. 6) Help the client set ambitious, challenging goals.
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1) Assess the client's knowledge of diabetes. 2) Ask the client what concerns he has about going on the diet. 3) Provide teaching on what foods to avoid and what foods will help keep his blood glucose level steady. 4) Talk openly and regularly about adherence.
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You are critically reflecting on variables that could have affected the results of an intervention. Which of the following should you consider? Select All The Apply. 1) Client's ability and motivation to follow directions for treatment 2) Effectiveness of the same treatment in clients in other regions 3) Availability and support from family and significant others 4) Client's family history 5) Client's lack of experience, knowledge, or ability 6) Staffing in the institution
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1) Client's ability and motivation to follow directions for treatment 3) Availability and support from family and significant others 5) Client's lack of experience, knowledge, or ability 6) Staffing in the institution
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Which of the following are key components of the implementation phase? Select All That Apply. 1) Diagnosing 2) Data gathering 3) Doing 4) Documenting 5) Decision making 6) Delegating
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3) Doing 4) Documenting 6) Delegating
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You are evaluating a client's collaborative problem of Potential Complication of myocardial infarction: congestive heart failure (CHF). Which of the following should be your primary goal in such evaluation? 1) Client reports no pain. 2) Client's reassessment data are within normal range. 3) Client achieves activities of daily living. 4) Client does not have another heart attack.
answer
2) Client's reassessment data are within normal range.
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As you are preparing to implement your nursing plan for applying dressings to a client who has sustained third-degree burns, you decide that it would be best to include times during each intervention that you will stop and check in with the client before continuing. This action is known as which of the following? 1) Checking your knowledge and abilities 2) Preparing supplies and equipment 3) Establishing feedback points 4) Preparing the patient
answer
3) Establishing feedback points
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A scale is reliable if it does which of the following? 1) Functions for many years 2) Yields consistent results time after time 3) Is accurately measuring a person's mass or weight 4) Is achieving expected or accepted levels of performance
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2) Yields consistent results time after time
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You are preparing to delegate several tasks to a licensed vocational nurse. Which of the following "rights" of delegation should you keep in mind as you do this? Select All That Apply. 1) Right task 2) Right circumstance 3) Right dosage 4) Right person 5) Right communication 6) Right supervision
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1) Right task 2) Right circumstance 4) Right person 5) Right communication 6) Right supervision
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You are now entering the implementation phase of the nursing process with a client. Which of the following are actions that would be appropriate to take in the implementation phase? Select All That Apply. 1) Write up a nursing order for the client. 2) Reposition a pregnant patient to her side to prevent compression of the inferior vena cava vein. 3) Develop expected outcomes related to a patient's progress with feeding himself. 4) Document a patient's anaphylactic response to a medication. 5) Delegate the application of cold compresses to the patient's forehead to a nurse aide. 6) Interview the patient to obtain a detailed health history.
answer
2) Reposition a pregnant patient to her side to prevent compression of the inferior vena cava vein. 4) Document a patient's anaphylactic response to a medication. 5) Delegate the application of cold compresses to the patient's forehead to a nurse aide.
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One of your patients needs to be transported via wheelchair to radiology for a chest x-ray. You have a nurse aide perform this task. This is an example of which of the following? 1) Assigning 2) Delegating 3) Collaborating 4) Coordinating
answer
2) Delegating
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Which of the following is a program designed to promote excellence in nursing? 1) Quality assurance 2) Reliability 3) Validity 4) Collaboration
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1) Quality assurance
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A client has been on cholesterol medication for 6 months now and recently had her cholesterol level checked. Although greatly improved, the cholesterol level is still above normal. The client will return in another 6 months to have her cholesterol checked again. Which type of evaluation is this? 1) Initial evaluation 2) Ongoing evaluation 3) Intermittent evaluation 4) Terminal evaluation
answer
3) Intermittent evaluation
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After evaluating a care plan, you determine that some goals have been met but others have not. Which of the following would be the most appropriate actions to take at this point? Select All That Apply. 1) Discontinue the care plan. 2) Examine the entire plan. 3) Revise the care plan only in the areas of the unmet goals. 4) Review all steps of the nursing process. 5) Revise the entire plan. 6) Continue with the same plan but allow more time for goal achievement.
answer
3) Revise the care plan only in the areas of the unmet goals. 6) Continue with the same plan but allow more time for goal achievement.
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You are performing an evaluation of the adequacy of your facility's radiography equipment to meet the imaging demands of patients. Which type of evaluation are you conducting? 1) Structure 2) Process 3) Outcomes 4) Reliability
answer
1) Structure
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You are training a new nurse on the evaluation phase of the nursing process. The nurse asks why evaluation is important. Which of the following are correct rationales for evaluation that you should tell the nurse? Select All That Apply. 1) To identify incompetent nurses so that they may be terminated 2) To ensure positive outcomes for patients 3) To conserve scarce resources 4) To validate established nursing practices 5) To satisfy professional standards of practice 6) To help ensure nursing's survival
answer
2) To ensure positive outcomes for patients 3) To conserve scarce resources 5) To satisfy professional standards of practice 6) To help ensure nursing's survival
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Below are the steps for evaluating patient progress. Put them in the correct order. - Record the evaluative statement - Judge goal achievement - Review outcomes - Collect reassessment data
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1) Record the evaluative statement 2) Judge goal achievement 3) Collect reassessment data 4) Review outcomes
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Which of the following are the four essential concepts of a nursing theory? 1) Nurse, context, patient, and health 2) Caring, person, theory, and nursing 3) Health, setting, patient, and treatment 4) Person, environment, health, and nursing
answer
4) Person, environment, health, and nursing
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You decide to conduct a qualitative study of asthma. Which of the following might be characteristics of such a study? Select All That Apply. 1) Goal of generalizing results to a similar population 2) Large numbers of subjects 3) Focus on the lived experience of a 12-year-old girl with asthma 4) Use of words and quotations from people interviewed 5) Controlled data collection 6) Purpose of sharing the experience of people in the study
answer
3) Focus on the lived experience of a 12-year-old girl with asthma 4) Use of words and quotations from people interviewed 6) Purpose of sharing the experience of people in the study
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You decide to develop your own theory of nursing. You begin by taking it for granted that all nurses have an impulse to serve those who are in need. This idea is an example of which of the following? 1) Phenomenon 2) Assumption 3) Concept 4) Definition
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2) Assumption
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Which of the following are true of theory? Select All That Apply. 1) A theory is a fact. 2) A theory is based on observations of facts. 3) A theory is a collection of random and unrelated ideas and concepts. 4) A theory helps us find meaning in our experiences. 5) A theory is a way of viewing reality. 6) A theory answers the question "Who am I?"
answer
2) A theory is based on observations of facts. 4) A theory helps us find meaning in our experiences. 5) A theory is a way of viewing reality.
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You have located a dozen research articles that directly address your research question and are preparing to read them. What questions should you ask yourself during reading so that you can best analyze the value of each article? Select All That Apply. 1) What is the book, journal, or article about as a whole? 2) What is being said in detail, and how? 3) How many pages does the article contain? 4) Is the book, journal, or article "true" in whole or part? 5) How long will it take to read the article? 6) Is it of any significance?
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1) What is the book, journal, or article about as a whole? 2) What is being said in detail, and how? 4) Is the book, journal, or article "true" in whole or part? 6) Is it of any significance?
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Which of the following accurately describe nursing research? Select All That Apply. 1) Requires a master's degree in nursing for one to participate in it 2) Is systematic 3) Is subjective 4) Involves analysis of phenomena 5) Encompasses all clinical practice areas 6) Provides evidence on which to base nursing care
answer
2) Is systematic 4) Involves analysis of phenomena 5) Encompasses all clinical practice areas 6) Provides evidence on which to base nursing care
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You are interested in researching the unique role or function that nurses perform and the basic needs of patients that they address. You should investigate the theory of which of the following nursing theorists? 1) Florence Nightingale 2) Virginia Henderson 3) Hildegard Peplau 4) Nola Pender
answer
2) Virginia Henderson
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You are formulating a searchable research question that considers the effectiveness of nonpharmacological methods of pain management with the use of analgesics. You are at the point now at which you are deciding which nonpharmacological methods to research. At which point in the acronym PICO is this question addressed? 1) P 2) I 3) C 4) O
answer
2) I
question
Below are six basic human needs that make up Maslow's Hierarchy of Needs. Put them in the correct order, from the most basic need to the least basic need. - Self-esteem needs - Self-actualization needs - Physiological needs - Safety and security needs - Transcendence of self - Love and belonging needs
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1) Safety and security needs 2) Transcendence of self 3) Self-esteem needs 4) Self-actualization needs 5) Love and belonging needs 6) Physiological needs
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After consulting with many nursing colleagues, you are surprised at how many do not use research as the basis for their practice. Which of the following are common barriers to using research? Select All That Apply. 1) Negative attitudes toward research 2) Lack of research conducted in areas relevant to the field of nursing 3) Lack of knowledge of nursing research 4) Inadequate forums for disseminating research 5) Lack of support from the employing institution 6) Study findings that are not ready for the clinical environment
answer
1) Negative attitudes toward research 3) Lack of knowledge of nursing research 4) Inadequate forums for disseminating research 5) Lack of support from the employing institution 6) Study findings that are not ready for the clinical environment
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After working in a new job at a hospital for several months, you observe that the method in place for administering patient medications seems inefficient. With the permission of your charge nurse, you implement a new approach to administration of medications, using it for 1 week and then reverting to the established method the following week. You follow this plan for a month and record the time it takes each shift to administer the regular medications. You find in the end that the hospital's approach was actually faster. What method of gaining knowledge did you employ in this case? 1) Authority and tradition 2) Scientific method 3) Logical reasoning 4) Trial and error plus common sense
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2) Scientific method
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You are looking for a narrowly focused nursing construct that will specifically guide how you approach teaching patients self-care just before discharge from the hospital. Which of the following should you consider? 1) Grand theories 2) Clinical practice theories 3) Conceptual frameworks 4) Conceptual models
answer
2) Clinical practice theories
question
You are assisting a nurse researcher in conducting a research study on the sleep quality of inpatients in a large metropolitan hospital. Halfway through the study, one of your subjects informs you that he no longer wants to participate in the study. You recognize his right to leave the study and thank him for participating. Which right has this subject exercised? 1) Right to full disclosure 2) Right to self-determination 3) Right not to be harmed 4) Right to privacy
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2) Right to self-determination
question
Below are the phases of the research process. Put them in the correct order. - Select a research design - Analyze data - Collect data - Use the research findings - Select and define the problem
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1) Use the research findings 2) Collect data 3) Select a research design 4) Analyze data 5) Select and define the problem
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During a late shift in the emergency room, you see a patient arrive limping and supported on either side by a friend. When you examine the patient's leg, you see that the ankle is swollen and red. The patient describes the pain as severe, especially when he puts any weight on the leg. You determine from these findings that the ankle is likely fractured. Which of the following processes did you use to arrive at this conclusion? 1) Deductive reasoning 2) Conceptual framework 3) Inductive reasoning 4) Conceptual model
answer
3) Inductive reasoning
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You are teaching a group of older adults in a senior center on factors that increase their susceptibility to infection. Which of the following should you mention? Select All That Apply. 1) Living alone 2) Smoking cigarettes 3) Obesity 4) Immune-suppressing agents 5) Retirement 6) Urinary catheterization
answer
2) Smoking cigarettes 4) Immune-suppressing agents 6) Urinary catheterization
question
You are providing teaching to a client who frequently develops upper respiratory infections. Which of the following lifestyle practices should you encourage her to adopt to support her immune defenses? Select All That Apply. 1) Drink more water than usual when you have a fever. 2) Maintain a healthy intake of protein during illness. 3) Sleep at least 5 hours per day. 4) Wash your hands frequently. 5) Exercise moderately. 6) Laugh often.
answer
1) Drink more water than usual when you have a fever. 2) Maintain a healthy intake of protein during illness. 4) Wash your hands frequently. 5) Exercise moderately. 6) Laugh often.
question
You are caring for a client with tuberculosis. The pathogen associated with this disease is very small and remains infectious over long distances when suspended in the air. It is easily transmitted through ventilating systems. Which type of precautions should be used with a client with this disease? 1) Standard 2) Contact 3) Droplet 4) Airborne
answer
4) Airborne
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You are providing training on infection control to healthcare workers at your hospital. Which of the following should you mention as primary defenses of the body against infectious disease? Select All That Apply. 1) Phagocytic white blood cells 2) Fever 3) The skin 4) B lymphocytes 5) Mucous membranes of the trachea 6) Acid in the stomach
answer
3) The skin 5) Mucous membranes of the trachea 6) Acid in the stomach
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You are donning your personal protective equipment using sterile technique. Put the following steps in correct order. - Perform the surgical scrub. - Put on shoe covers, hair covers, and a mask. - Don gloves using the closed method. - Secure the waist tie on your gown. - Keep your hands within your field of vision at all times. - Don the gown, with assistance from a coworker.
answer
1) Put on shoe covers, hair covers, and a mask 2) Perform the surgical scrub 3) Don the gown, with assistance from a coworker. 4) Don gloves using the closed method 5)Secure the waist tie on your gown 6) Keep your hands within your field of vision at all times.
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You are preparing to perform a physical examination of a healthy, young student athlete. Which type of precautions should be used with this client? 1) No precautions required 2) Standard 3) Contact 4) Droplet
answer
2) Standard
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You are caring for a client who has developed methicillin-resistant Staphylococcus aureus (MRSA). Which of the following risk factors related to this infection should you most suspect in this client? 1) Employment in a preschool 2) Multiple sexual partners 3) Multiple stays in the intensive care unit 4) Smoking
answer
3) Multiple stays in the intensive care unit
question
Below are steps to take in the event of a biological epidemic. Put them in the correct order. - Institute the appropriate level of standard precautions. - Recognize an outbreak. - Prepare clients for a pandemic. - Notify the safety officer.
answer
1) Recognize an outbreak 2) Notify the safety officer 3) Institute the appropriate level of standard precautions 4) Prepare clients for a pandemic
question
As a nurse in the intensive care unit, you realize that you are at high risk of transmitting multidrug-resistant organisms (MDROs) to patients. Given what you know about how these organisms are usually transmitted, which of the following infection prevention measures is most important for you to implement? 1) Wearing a mask 2) Wearing a gown 3) Performing hand hygiene 4) Following airborne precautions
answer
3) Performing hand hygiene
question
Which of the following are examples of emerging infectious diseases? Select All That Apply. 1) Microorganisms in humans that extend their host range to begin infecting animals 2) Newly identified diseases caused by an unrecognized microorganism 3) Diseases occurring in new geographical areas 4) Microbes that evolve to become more virulent 5) Known diseases that dramatically decrease in incidence 6) Organisms that are deliberately altered for bioterrorism
answer
2) Newly identified diseases caused by an unrecognized microorganism 3) Diseases occurring in new geographical areas 4) Microbes that evolve to become more virulent 6) Organisms that are deliberately altered for bioterrorism
question
You are responsible for sterilizing all critical items used in a recent surgery. Which of the following methods would be appropriate for this purpose? 1) Autoclave with moist heat 2) Chemical germicides 3) Water and detergents 4) Ultraviolet light
answer
1) Autoclave with moist heat
question
Below are the five stages of infection. Put them in the correct order. - Decline - Illness - Incubation - Convalescence - Prodromal stage
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1) Incubation 2) Prodromal stage 3) Illness 4) Decline 5) Convalescence
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You are washing your hands in preparation for performing a standard physical examination on a client. Which of the following actions should you take? Apply All That Apply. 1) Wash the hands vigorously for 2 to 6 minutes. 2) Use hot water. 3) Use agency-approved soap. 4) Rub the backs of the hands and between the fingers. 5) Remove jewelry and clean areas underneath. 6) Clean underneath the fingernails using an orangewood stick.
answer
3) Use agency-approved soap. 4) Rub the backs of the hands and between the fingers. 5) Remove jewelry and clean areas underneath. 6) Clean underneath the fingernails using an orangewood stick.
question
Below are the six links in the chain of infection. Put them in the correct order, beginning with the source of infection. - Mode of transmission - Susceptible host - Reservoir - Portal of entry - Infectious agent - Portal of exit
answer
1) Infectious agent 2) Reservoir 3) Portal of exit 4) Mode of transmission 5) Portal of entry 6) Susceptible host
question
You are caring for a 32-year-old client who is recovering from surgery and general anesthesia. You recognize that this client is at risk for pneumonia. Which of the following nursing activities would be most effective in preventing infection? 1) Encourage the client to cough and breathe deeply on a regular basis. 2) Provide special oral care to the client. 3) Encourage the client to be immunized. 4) Follow medical asepsis guidelines.
answer
1) Encourage the client to cough and breathe deeply on a regular basis.
question
A child has just been brought into the emergency room for suspected poisoning. Which of the following interventions should you most expect to be ordered? 1) Administering ipecac syrup to induce vomiting 2) Administering activated charcoal 3) Mechanically inducing vomiting by triggering the child's gag reflex 4) Performing the Heimlich maneuver
answer
2) Administering activated charcoal
question
One of your clients has recently taken a job in road construction. Which of the following are adverse health effects associated with substantial exposure to loud noises that you should warn the client about, to encourage him to use hearing protection? Select All That Apply. 1) Respiratory disease 2) Hearing loss 3) Stress 4) Cancer 5) Elevated blood pressure 6) Loss of sleep
answer
2) Hearing loss 3) Stress 5) Elevated blood pressure 6) Loss of sleep
question
Following allergy testing with a child, you find that she is allergic to cockroaches. This finding means that the child is at greater risk for which of the following? 1) Severe asthma 2) Rabies 3) Lung cancer 4) Fungal infection
answer
1) Severe asthma
question
You are in a restaurant when you see a diner having difficulty breathing. Which of the following is the first thing you should do? 1) Perform the Heimlich maneuver. 2) Perform the choking rescue maneuver. 3) Ask the person, "Are you choking?" 4) Have someone call 911.
answer
3) Ask the person, "Are you choking?"
question
You are providing safety promotion counseling to the mother of a 2-year-old. Which of the following should you warn her is the leading cause of death in children her child's age? 1) Motor vehicle accidents 2) Drowning 3) Poisoning 4) Homicide
answer
2) Drowning
question
You are caring for an older client with Alzheimer's disease. You are concerned about this client getting out of bed unassisted and falling. Which of the following would be the best intervention to prevent this from occurring? 1) Install full-length siderails on the client's bed and raise them all the way up. 2) Apply a cloth vest restraint to the client. 3) Use a bed alarm with the client and conduct hourly rounds to observe her. 4) Explain the risk of falling to the client and ask her to call for assistance when she needs to get up.
answer
3) Use a bed alarm with the client and conduct hourly rounds to observe her.
question
You provide home nursing care to an older client who lives alone in a cluttered apartment and who has macular degeneration. You are concerned that the client may fall while at home alone. Which of the following nursing diagnoses would be most appropriate? 1) Risk for Falls related to poor vision and a cluttered home environment 2) Risk for falls related to environmental and physical factors 3) Risk for Falls related to a sensory problem and environment 4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
answer
4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
question
After giving a client the nursing diagnosis of Risk for Falls related to Alzheimer's disease, you write an individualized goal to address this diagnosis. Which of the following would be the most appropriate goal for this client? 1) Client will not experience a fall while in the hospital. 2) Client will explain several strategies for preventing falls while in the hospital. 3) Client will demonstrate clear and focused thinking and thus will avoid falling while in the hospital. 4) Client will be able to move independently around her room without falling.
answer
1) Client will not experience a fall while in the hospital.
question
You have decided that as a last resort you must apply physical restraints to a client who is at risk of injuring himself and healthcare team members. Which of the following actions must you take? Select All That Apply. 1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 3) Check restraints every 2 hours. 4) Remind prescriber to reassess and reorder the restraints every week, as needed. 5) Ensure that the restraints do not impair circulation or tissue integrity. 6) Release restraints and assess every 8 hours.
answer
1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 5) Ensure that the restraints do not impair circulation or tissue integrity.
question
You are teaching a group of older adults in a senior center about the hazards of carbon monoxide poisoning and methods to prevent it. Which of the following interventions should you mention related to this hazard? 1) Avoid smoking in the home. 2) Avoid exposing oxygen administration equipment to an open flame. 3) Avoid contact with clothing contaminated by toxins from industrial workplaces. 4) Avoid using your gas range to heat your home.
answer
4) Avoid using your gas range to heat your home.
question
Below are the top six causes of accidental death. Put them in the correct order, from the most prevalent cause to the least prevalent cause of the six. - Fires - Falls - Motor vehicle accidents - Drowning - Firearms - Poisoning
answer
1) Poisoning 2) Motor vehicle accidents 3) Firearms 4) Falls 5) Drowning 6) Fires
question
Which of the following are "never" events—events that can cause serious injury or death to a patient and should never happen in a hospital? Select All That Apply. 1) Myocardial infarction resulting from atherosclerosis 2) A surgical sponge left in a patient after surgery 3) Anaphylactic response to latex gloves 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
answer
2) A surgical sponge left in a patient after surgery 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
question
You are preparing to use the Morse fall scale to assess a client's risk for falls. Which of the following factors does this scale assess for in the client? Select All That Apply. 1) History of falling 2) Age 3) Gender 4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
answer
1) History of falling 4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
question
You are caring for an older patient in the hospital who is at risk for falling. The client is cognitively normal but lacks coordination. Which of the following are interventions you should take to help prevent the client from falling? Select All That Apply. 1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 4) Keep water, urinal, bedpan, and tissues out of reach so that the patient must have assistance to get them. 5) Encourage the patient to move to and from the bathroom independently, to build confidence. 6) Provide a night light.
answer
1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 6) Provide a night light.
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You are conversing with a 13-year-old client while reviewing his health history before a physical examination. The client mentions to you that he went shooting with his father last weekend. After listening to his story, you ask him whether he knows the rules for safe gun handling. He stammers a minute and then tells you he can't remember them. Which of the following rules should you tell him? Select All That Apply. 1) Keep your finger on the trigger until you are ready to shoot. 2) Always keep the gun pointed in a safe direction. 3) Assume that a gun is unloaded until you have checked the chamber. 4) Always keep the gun unloaded until ready to use it. 5) Before cleaning a gun make sure that it is loaded. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
answer
2) Always keep the gun pointed in a safe direction. 4) Always keep the gun unloaded until ready to use it. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
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You are providing hygiene care for an older client who requires assistance with activities of daily living. When you ask her how often she typically bathes, she replies, "A couple of times per week." How should you respond to the client? 1) Agree to bathe her twice per week. 2) Insist on bathing her daily for health reasons. 3) Agree to bathe her twice a week, but insist on using a substantial amount of deodorant soap. 4) Encourage her to bathe only once a week and to use a skin moisturizer instead.
answer
1) Agree to bathe her twice per week.
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Below are the steps for making an occupied bed. Put them in the correct order. - Position the patient laterally near the far siderail. - Move to the other side of the bed. - Pull the soiled and clean linens through, and complete the linen change. - Place clean linens on the side nearest you. - Roll the soiled linens under the patient. - Assess the patient's ability to move and need for assistive equipment. - Tuck the clean linens under the soiled linens. - Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail.
answer
1) Assess the patient's ability to move and need for assistive equipment and patient-handling devices. 2) Position the patient laterally near the far siderail. 3) Roll soiled linens under him. 4) Place clean linens on the side nearest you. 5) Tuck the clean linens under the soiled linens. 6) Roll the patient over the "hump," and position him on his other side, near you. Raise the near siderail. 7) Move to the other side of the bed. 8) Pull the soiled and clean linens through, and complete the linen change.
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You are teaching a client with diabetes how to care for her feet. Which of the following guidelines should you give her? Select All That Apply. 1) Inspect the feet daily using a mirror to view all surfaces. 2) Soak the feet daily. 3) File down callused areas. 4) Check between the toes for cracks or redness. 5) Wear open-toed shoes when possible to expose the feet to air. 6) Apply over-the-counter corn medicines to the feet.
answer
1) Inspect the feet daily using a mirror to view all surfaces. 4) Check between the toes for cracks or redness.
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You are delegating the bathing of a client to a nursing assistive personnel (NAP). About which of the following should you give instructions to the NAP? Select All That Apply. 1) Patient's family history of multiple sclerosis 2) Mobility limitations 3) Use of a walker 4) Medication allergy 5) Presence of intravenous (IV) tubing 6) Skin condition
answer
2) Mobility limitations 3) Use of a walker 5) Presence of intravenous (IV) tubing 6) Skin condition
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You are caring for a client who can participate in dressing herself but requires assistance because of a severe tremor in her hands resulting from Parkinson's disease. She does not use any assistive devices. Which of the following would be the most accurate diagnosis for this client? 1) Dressing Self-Care Deficit (2) related to hand tremors secondary to Parkinson's disease 2) Self-Care Deficit (dressing) related to Parkinson's disease secondary to hand tremors 3) Parkinson's disease related to hand tremors as evidenced by Dressing Self-care Deficit (3) 4) Dressing Self-Care Deficit (1) related to Parkinson's disease as evidenced by hand tremors
answer
1) Dressing Self-Care Deficit (2) related to hand tremors secondary to Parkinson's disease
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You work with patients with a variety of conditions, many of whom you must assist with activities of daily living (ADLs) during their stay in the hospital. You should be prepared to provide hygiene assistance to patients with which of the following conditions? Select All That Apply. 1) Severe pain resulting from third-degree burns 2) Stage I hypertension 3) Diabetes mellitus 4) Rheumatoid arthritis and limited mobility 5) Macular degeneration 6) Schizophrenia
answer
1) Severe pain resulting from third-degree burns 4) Rheumatoid arthritis and limited mobility 5) Macular degeneration 6) Schizophrenia
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You moisten 10 washcloths with sterile water and a pH-balanced, no-rinse soap, warm them up, and then cleanse each part of a client's body using a fresh cloth. Which type of bath are you giving the client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath
answer
1) Bag bath
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You are preparing to bathe an older adult who is incontinent and who is unable to bathe himself. As you remove his diaper, you see that his perineal area is covered with feces. Which type of bath would be most appropriate to give this client? 1) Bag bath 2) Towel bath 3) Bed bath 4) Basin and water bath
answer
4) Basin and water bath
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As you are bathing a client, you notice some breaks in the skin on the back. When you ask the client about it, he says, "Something has been making me itch back there. I've probably just scratched it too hard." Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne
answer
1) Pruritus
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As you are bathing an older client who has urinary incontinence, you notice that the skin of her perineal area is soft, fragile, and white. Which of the following conditions has the client experienced? 1) Pruritus 2) Maceration 3) Pressure ulcer 4) Acne
answer
2) Maceration
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As you are bathing a client, you notice a yellow discoloration of the sclerae of the eyes. Which of the following conditions should you suspect in this client? 1) Lack of peripheral perfusion 2) Vasodilation and inflammation 3) Decreased oxygenation of the blood 4) Impaired liver function
answer
4) Impaired liver function
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Which of the following are effects of a client performing personal hygiene and activities of daily living (ADLs) for herself? Select All That Apply. 1) Promotes comfort 2) Promotes dependence 3) Improves self-image 4) Decreases infection and disease 5) Decreases activity 6) Increases risk of anxiety
answer
1) Promotes comfort 3) Improves self-image 4) Decreases infection and disease
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You are providing eye care to a patient who is in a coma. Which of the following should you do? 1) Lubricate the eyes with saline every 2 to 4 hours. 2) Use a protective eye shield to keep the eyes open. 3) Instill eye ointment in the upper lids. 4) Occasionally stimulate the client's blink reflex to help lubricate the eye.
answer
1) Lubricate the eyes with saline every 2 to 4 hours.
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As you are providing oral hygiene for a client, you notice some white patches and ulcers on the oral mucosa. Which of the following actions should you take? 1) Explain to the client that he may have oral cancer. 2) Encourage the client to see a dentist immediately. 3) Recommend that the client increase his intake of vitamin B12. 4) Urge the client to brush his teeth and floss regularly.
answer
2) Encourage the client to see a dentist immediately.
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You are assessing a client's self-care abilities and begin by obtaining a health history. Which of the following is the correct rationale for this action? 1) To determine overall grooming and cleanliness 2) To identify underlying illness, injury, or disease that might contribute to a self-care deficit 3) To assess for tactile disturbances 4) To assess pain
answer
2) To identify underlying illness, injury, or disease that might contribute to a self-care deficit
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A client has mentioned that she would like to begin an exercise program that includes cycling and weight lifting. You mention that she should also include exercise that warms the muscles before activity, cools them afterward, limits post-exercise stiffness, and keeps joints mobile. Which type of exercise are you recommending for this client? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning
answer
1) Flexibility training
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You are caring for a client who has a dislocated shoulder. Which type of synovial joint is the shoulder? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
answer
1) Ball-and-socket
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You are caring for a client with emphysema who frequently experiences shortness of breath. Which of the following positions would be best to place the client in? 1) Semi-Fowler's 2) Orthopneic 3) Lateral 4) Sims'
answer
2) Orthopneic
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You are teaching a client about how to establish a healthy and effective exercise program. Which of the following should you do? Select All That Apply. 1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 3) Recommend that the client stick to one activity, to promote discipline. 4) Warn your client that exercise is difficult and that he might not be able to maintain his program. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
answer
1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
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You are counseling a client with osteoarthritis about possible exercise programs suited to her needs. Which of the following types of exercise would be best for her? 1) Resistance training with free weights 2) Jogging 3) Soccer 4) Swimming
answer
4) Swimming
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You are instructing a client to actively move his arm through its full range of motion. Which division of the client's nervous system is allowing him to move his arm in this way? 1) Autonomic 2) Sympathetic 3) Parasympathetic 4) Somatic
answer
4) Somatic
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You are helping a client who has been confined to bed for over a week prepare for walking again. Which of the following measures should you specifically take to help prevent orthostatic hypotension in the client? 1) Quadriceps and gluteal drills 2) Pull-ups using a trapeze bar 3) Dangling the feet 4) Brushing the hair
answer
3) Dangling the feet
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You are caring for a client who has been confined to bed for several weeks. Which of the following are effects of immobility that you should assess for and address in this client? Select All That Apply. 1) Contractures 2) Hypertrophy 3) Ankylosis 4) Tremor 5) Atrophy 6) Osteoporosis
answer
1) Contractures 3) Ankylosis 5) Atrophy 6) Osteoporosis
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You are teaching a client about the benefits of regular aerobic exercise. Which of the following should you mention? Select All That Apply. 1) Decreases risk of musculoskeletal injury 2) Improves the pumping action of the heart 3) Decreases heart rate 4) Decreases risk of dehydration 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
answer
2) Improves the pumping action of the heart 3) Decreases heart rate 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
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You are talking with a client who recently started lifting free weights three days a week to improve strength. Which of the following types of exercise is this? 1) Isometric anaerobic 2) Isotonic aerobic 3) Isotonic anaerobic 4) Isokinetic aerobic
answer
3) Isotonic anaerobic
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A client recently sustained a back injury from improper lifting while at work. You are instructing him on how to achieve proper balance when lifting to avoid injury in the future. Which of the following instructions should you give him? Select All That Apply. 1) Place your center of gravity farthest from your base of support. 2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight. 5) Roll your shoulders forward. 6) Keep your feet together.
answer
2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight.
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You are caring for a client who has developed a bone spur in her first vertebra (the atlas), which limits the movement in her atlantoaxial joint. Which type of joint is this? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
answer
4) Pivot
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Below are the steps for transferring a patient from a bed to a wheelchair. Put them in the correct order. - Instruct the patient to place her arms around you between your shoulders and waist. - Place the bed in the low position and lock the wheels. - Instruct the patient to pivot and turn with you toward the wheelchair. - Ask the patient to stand as you move to an upright position by straightening your legs and hips. - Ask the patient to flex her hips and knees as she lowers herself to the wheelchair. Guide her motion while maintaining a firm hold on her. - Assist the patient to dangle at the side of the bed. - Lock the wheels of the wheelchair. - Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt.
answer
1) Lock the wheels of the wheelchair. 2) Place the bed in the low position and lock the wheels. 3) Assist the patient to dangle at the side of the bed. 4) Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt. 5) Instruct the patient to place her arms around you between your shoulders and waist. 6) Ask the patient to stand as you move to an upright position by straightening your legs and hips. 7) Instruct the patient to pivot and turn with you toward the wheelchair. 8) Ask the patient to flex her hips and knees as she lowers herself to the wheelchair. Guide her motion while maintaining a firm hold on her.
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You are flexing and extending a client's forearm at the elbow as far as it will comfortably go without any assistance from the client. This activity is known as which of the following? 1) Body alignment 2) Line of gravity 3) Passive range of motion 4) Active range of motion
answer
3) Passive range of motion
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You are helping an obese client develop an exercise plan. Which of the following is a likely barrier to exercise that is associated with obesity? 1) Muscle wasting 2) Osteoarthritis 3) Negative nitrogen balance 4) Inadequate protein stores available to maintain or repair body tissue
answer
2) Osteoarthritis
