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Test Bank Essentials Nursing Practice 8th Edition, Potter
Chapter 01: The Nursing Profession
1.A nurse uses effective strategies to communicate and handle conflict with nurses and other health care professionals. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating?
b. Quality improvement
c. Teamwork and collaboration
d. Evidence-based practice
2.A nurse is employed by a health care agency that provides an informal training session on how to properly use a new vital sign monitor. Which type of education did the nurse receive?
a. In-service education
b. Advanced education
c. Continuing education
d. Registered nurse education
3.A nurse listens to a patients lungs and determines that the patient needs to cough and deep breath. The nurse has the patient cough and deep breath. Which concept did the nurse demonstrate?
4.A registered nurse is required to participate in a simulation to learn how to triage patients who are arriving to the hospital after exposure to an unknown gas. This is an example of a response to what type of influence on nursing?
a. Workplace hazards
b. Nursing shortage
d. Emergency preparedness
5.A nurse is an advanced practice registered nurse (APRN) who cares for geriatrics. This nurse is which type of advanced practice nurse?
a. Clinical nurse specialist
b. Nurse practitioner
c. Certified nurse-midwife
d. Certified registered nurse anesthetist
6.A patient does not want the treatment that was prescribed. The nurse helps the patient talk to the primary health care provider and even talks to the primary health care provider when needed. The nurse is acting in which professional role?
d. Provider of care
7.A nurse must follow legal laws that protect public health, safety, and welfare. Which law is the nurse following?
a. Code of Ethics
b. Nurse Practice Act
c. Standards of practice
d. Quality and safety education for nurses
8.A nurse is directing the care and staffing of three cardiac units. The nurse is practicing in which nursing role?
a. Advanced practice registered nurse
b. Nurse researcher
c. Nurse educator
d. Nurse administrator
Chapter 02: Health and Wellness
1.A nurse is assessing a patients stage of behavioral change. Which statement by the patient will indicate to the nurse that the patient is in the preparation stage?
a. I started to exercise regularly, but it didnt last long. Ill probably try again in a few weeks.
b. I have a problem, and I really think I need to work on it.
c. I am really working hard to stop smoking.
d. There is nothing that I really need to change.
2.A patient is depressed after a divorce and is not eating. The nurse is using Maslow to prioritize care. Which patient need should the nurse address first?
b. Emotional safety
d. Love and belonging
3.A nurse is assessing a patients risk factors for heart disease and finds that the patient has several risk factors. How should the nurse interpret this finding?
a. The patient needs surgery for heart disease.
b. The patient has a genetic disease.
c. The patient will develop the disease.
d. The patient has an increased chance to develop the disease.
4.To determine a patients external variables for health beliefs and practices, which area should the nurse assess?
a. Emotional factors
b. Intellectual background
c. Developmental stage
d. Socioeconomic factors
5.Which nursing action best represents primary prevention?
a. Instructing a healthy individual to get a flu shot on a yearly basis
b. Instructing a patient to take blood pressure medication every day
c. Instructing a patient to live with a known disability
d. Instructing a patient to undergo physical therapy following a cerebrovascular accident
6.A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking. At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n):
a. acute illness.
b. tertiary prevention.
c. chronic illness.
d. internal variable.
7.Which information by a patient indicates teaching by the nurse was successful for the best definition of health?
a. State of complete well-being
b. Absence of disease
c. Vital signs within normal range
d. Maintenance of a normal weight
8.A patient with newly diagnosed diabetes is concerned about the risk for developing foot ulcers because the mother had a foot amputated as a result of the disease. This is an example of which of the following?
a. Health promotion
b. Health practices
c. Health beliefs
d. Holistic health
9.A patient with diabetes is diligent about testing blood sugar before meals. Which model is the nurse using when the nurse realizes the patient is taking preventative actions for health and represents the third component of this model?
a. Basic Human Needs
b. Health Belief
c. Holistic Health
d. Tertiary Prevention
10.Which will best assist a nurse in understanding a patients use of tying a silver dollar to the stomach of a newborn infant to heal an umbilical hernia?
a. Cultural background
b. Maslows Hierarchy of Needs
c. World Health Organizations definition of health
d. Primary prevention
Chapter 03: The Health Care Delivery System
1.A nurse is teaching the importance of breast self-examination to a group of 20-year-old women. The nurse is promoting which type of care?
2.A patient who needs nursing and rehabilitation after a stroke would benefit most by receiving care at which center?
a. Primary care center
b. Restorative care center
c. Assisted living center
d. Respite center
3.A patient states that he or she cannot afford health care insurance for the family because of a low income. What is the best form of insurance available for this patient?
c. Private insurance
d. A managed care organization
4.A nurse is teaching the staff about managed care. Which information should the nurse include?
a. Managed care focuses on long-term care services for skilled nursing.
b. Managed care focuses on hospital admissions and illnesses for a group of people.
c. Managed care focuses on control over primary health services for a defined population.
d. Managed care focuses on decreased access to care while increasing costs.
5.A nurse admits an older adult patient who states that he or she has no living relatives and only two close friends. Upon admission to the hospital, which action should the nurse initiate first?
a. Implement a process of payment.
b. Implement a discharge plan.
c. Implement a visit with the family.
d. Implement a resource utilization group.
6.A nurse is asked the most frequently cited reason for death in the world. How should the nurse reply?
a. Technological advances
b. Old age
7.A nurse is teaching the staff about the Prospective Payment System (PPS). Which information should the nurse include in the teaching session?
a. PPS establishes cost-based reimbursement for health care.
b. PPS provides reimbursement for every service the patient receives.
c. PPS establishes reimbursement rates based upon diagnosis-related groups (DRGs).
d. PPS provides money to the patient for health promotion use.
8.A 74-year-old patient was admitted to the hospital with diabetic ketoacidosis. How will the hospital be reimbursed by Medicare?
a. Based upon the diagnostic-related group
b. Based upon the cost of care
c. Based upon the actual length of stay
d. Based upon the number of medications
9.A patient tells the nurse that he or she does not understand the purpose of capitation. What is the nurses best response?
a. To provide high-quality care at the highest cost to the hospital, not the patient
b. To provide the least expensive care for patients regardless of outcomes
c. To build a payment plan that includes the best standards of care at the lowest cost
d. To ensure that all patients receive the same care for the same cost in all hospitals
10.A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use?
a. Continuing care
b. Preventative care
c. Secondary acute care
d. Restorative care
Chapter 04: Community-Based Nursing Practice
1.A student nurse is beginning the community-based primary care rotation. The student nurse anticipates that the assignment in community-based health care will most likely be at which organization?
a. An acute care hospital
b. A rehabilitation hospital
c. A nursing home
d. A high school
2.A nurse is practicing as a community health nurse. What is the primary focus of care for this nurse?
a. Providing care to subpopulations
b. Practicing care in existing services
c. Being a specialist in public health science
d. Having a case management certification
3.A community health nurse is using the goals of the Healthy People 2020 to focus care. Which goal is the priority?
a. To increase the life expectancy of people in the United States
b. To increase the health status of people throughout the world
c. To eradicate the human immunodeficiency virus (HIV)
d. To reduce health care costs
4.The teen pregnancy rate in one community significantly increased; as a result, the school system was seeing an increase in the dropout rate of teenage mothers. A nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. Which technique did the nurse use?
a. Incorporating immunizations for the infants and mothers
b. Responding to changes within the community
c. Influencing chronic environmental factors
d. Managing disease
5.A nurse notices that a particular area of the community had food poisoning. The nurse collected data from the people who were affected, identified a local restaurant that served all the people, and determined it was the chicken dish that caused the poisoning. Which community health nurse competency did the nurse demonstrate?
a. Public health
d. Case manager
6.Upon assessment the nurse finds the following: a 46-year-old immigrant patient from the Czech Republic has diabetes and hypertension and just recently moved in to live with a family member who must travel frequently. The patient speaks English very well. The community health nurse knows that this patient may be vulnerable because of which assessment finding?
b. Immigration status
7.A nurse wants to use the most important competency in community nursing. Which competency should the nurse use?
b. Case manager
8.A community health nurse is assessing the structure of a community. Which component will the nurse assess?
a. Available health systems
b. Available colleges and schools
c. Geographical boundaries
d. Predominant religious groups
Chapter 05: Legal Principles in Nursing
1.Which information indicates the nurse has an accurate understanding of the State Nurse Practice Act?
a. It is a federal senate bill.
b. It is a law enacted by the federal government.
c. It is a statute enacted by state legislature.
d. It is a judicial decision.
2.A student nurse must pass the NCLEX before practicing as a registered nurse. NCLEXstands for __________ Examination.
a. Nursing Council of Licensing
b. Nightingale Code of Licensure
c. Nursing Code of Licensure
d. National Council Licensure
3.A registered nurse was accused of patient abandonment when the nurse became angry, quit the job, and left the hospital before the end of the shift. This is an example of violating legal standards/guidelines set by which organization?
a. The State Department of Health
b. The Joint Commission
c. The State Board of Nursing
d. The National League for Nursing
4.An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed. The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law?
5.The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he or she will tie the patient down if the patient does not hold still. Which action did the nurse commit?
b. Unintentional tort
6.Which chart entry by a nurse would require follow up?
a. 0815 Patient found on floor.
b. 0816 Patient assessed and helped back to bed.
c. 0818 Physician notified of incident.
d. 0820 Occurrence report completed.
7.To establish the elements of malpractice against a nurse, which must be proved by the patient?
a. The patient must have been harmed as a result of the injury.
b. The patient must have paid for the health care services.
c. The patient must show evidence of malicious intent.
d. The patient must demonstrate personal accountability.
8.Which behavior is the best way for a nurse to avoid being liable for malpractice?
a. Purchasing quality malpractice insurance coverage on a yearly basis
b. Practicing nursing that meets the generally accepted standard of care
c. Not sharing his or her last name with patients and families
d. Not delegating any tasks to unlicensed assistive personnel
9.A nurse wants to follow nursing standards of care. Which document should the nurse follow?
a. World Health Organization guidelines
b. National League for Nursing brochure
c. Health care facilitys written procedure manual
d. Department of Health and Human Services guidelines
10.What is the nurses best proof against malpractice?
a. The nurse supervisors memory of the event
b. Recorded documentation written carelessly
c. The nurses memory of the event
d. Recorded documentation of nursing care
Chapter 06: Ethics
1.A 73-year-old patient with hypertension is awaiting a triple cardiac bypass surgery. The patient is hard of hearing and did not understand what the surgeon said regarding the surgery. The daughter is concerned that the patient does not understand the risks of the surgery. If not clarified, this would be a violation of what principle?
2.A 45-year-old mother of two children has cirrhosis of the liver and is on a waiting list for a liver transplant. She had to meet certain criteria to be eligible to receive a liver. She understands that she is next on the list for a donor liver that matches. This is an example of which ethical principle?
3.A registered nurse who works on an oncology unit discussed pain control options that the primary health care provider had ordered with a patient undergoing treatment for pancreatic cancer. The patient requested that the intravenous (IV) pain medication be given on a regular basis. The nurse agreed to provide the IV pain medication as requested and continued to reevaluate the pain levels. The nurse is following which ethical principle?
4.A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications and may not recover. The nurse ensures that the patient has been given information regarding the risks and potential benefits of the procedure. The nurse is following which ethical principle?
5.A registered nurse is working on a pediatric oncology unit and caring for four children undergoing chemotherapy. Today a new nursing assistive personnel (NAP) who has passed a competency examination is assigned to the team. The nurse will delegate a portion of the fundamental nursing tasks to the NAP during the shift, but realizes that he or she is still responsible for his or her own actions and is accountable for the care. The nurse is following which principle of behavior?
a. Ethical dilemma
b. Code of ethics
d. Feminist ethics
6.The mother of a 45-year-old patient is a retired physician and requests to discuss the patients plan of care with the nurse caring for the patient. What is the nurses best response to this request?
a. I will need to ask permission from my supervisor before I can share that information.
b. I will show you the chart, just follow me and we can discuss your questions and concerns.
c. I would suggest that you leave me out of your family problems. I am here to care for the patient.
d. I will have to get the patients permission before I can share that information.
7.A nurse bases ethical decisions on the effect, or consequences, an act will have and uses the following guidelines: the greatest good for the greatest number of people. Which ethical system is the nurse using?
d. Ethics of care
8.A registered nurse has recently been reassigned to the gynecology unit at the hospital. The nurse is strongly against abortion because of religious beliefs and contacts the nursing supervisor regarding the assignment because the unit cares for women who are undergoing abortions. The nurse is having a conflict in which area?
c. Social networking
9.A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride the wounds. The patient is crying and does not want to go to the physical therapy department for treatment. The registered nurse caring for the patient knows that, even though it is uncomfortable, the patient needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which ethical principle?
10.Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, the nurse recently transferred to a pediatric unit in the hospital. The nurse will be in orientation for several days to learn about the different systems and will need to demonstrate proficiency in various pediatric areas such as medication administration. Which behavior is the nurse demonstrating?
Chapter 07: Evidence-Based Practice
1.Which organization is preparing future nurses to have the knowledge, skills, and attitudes (KSAs) of evidence-based practices necessary to continuously improve the quality and safety of the health care systems within which they work?
a. The Joint Commission
b. Quality and Safety Education for Nurses (QSEN)
c. The National Database of Nursing Quality Improvement (NDNQI)
d. The Agency for Health care Research and Quality (AHRQ)
2.A registered nurse questioned the nurses on the neonatal intensive care unit about the practice of kangaroo care for neonates. The nurse had read literature supporting the practice, but the nurses that work on the neonatal unit stated that they had never done anything like that at their institution. The nurse continued to ask questions and began a literature review. Which behavior was the nurse demonstrating?
b. Peer review
c. Evidence-based practice
d. Process measurement
3.A registered nurse wants to review the latest information regarding prevention of a health care acquired infection. Where is the best place for the nurse to obtain this information?
a. Online information
b. Peer-reviewed nursing journal
c. Latest edition of a nursing textbook
d. Most recent edition of a popular magazine
4.A 15-year-old patient was admitted to the hospital with a bowel obstruction. The patient underwent surgery and was experiencing postoperative pain. The nurse caring for the patient had recently read a research article in which a study had been done with neonatal (infant) patients and the use of therapeutic touch to assist with pain control. Which factor is mostimportant for the nurse to consider in this case when applying research to clinical practice?
a. The patients gender
b. The patients preference
c. The patients allergies
d. The patients roommate
5.A nurse is using evidence-based practice (EBP) to provide care. Which action should the nurse take first?
a. Collect the most relevant and best evidence.
b. Integrate evidence with ones clinical expertise.
c. Critically appraise the evidence gathered.
d. Ask a clinical question.
6.The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. The nurse manager wants to address this situation using evidence-based practice. Which type of trigger did the nurse manager use?
a. Literature-focused trigger
b. Problem-focused trigger
c. Knowledge-focused trigger
d. Expectations-focused trigger
7.A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. The nurse would like to apply the research findings to the unit. How did the nurse formulate the clinical question?
a. Measurement-focused trigger
b. Problem-focused trigger
c. Knowledge-focused trigger
d. Expectations-focused trigger
8.A nurses manager has suggested that a nurse formulate a PICO question to clarify the topic before doing a literature review. When the nurse asks what the acronym PICO stands for, how should the nurse manager respond?
a. Policy, information, comparison, outcome
b. Patient, information, collection, outcome
c. Patient, intervention, comparison, outcome
d. Policy, intervention, communication, outcome
9.A nurse working on a PICO question has found a large amount of literature available on the topic with multiple studies that have been published. Which type of study should have the bestevidence?
a. Meta-analysis of randomized control trials
b. Opinion of an expert committee
c. One well-designed randomized control trial
d. Systematic review of descriptive and qualitative studies
10.A registered nurse is concerned about the patients perceptions and feelings about the quality of life that they experience after a diagnosis of liver cancer. Which is the most appropriate type of research study the nurse should use to gather information about this situation?
a. Quantitative study
b. Randomized trial
c. Qualitative study
d. Case controlled study
Chapter 08: Critical Thinking
1.A registered nurse is caring for a patient in the trauma unit who had been involved in a motor vehicle accident. Although the patient denied pain, during the nurses assessment, the nurse observed that the patient groaned when moving and was protective of the right arm. The nurse believed the patient had pain and reported it to the primary health care provider, who ordered a radiograph (x-ray) of the right arm. The radiograph revealed a fractured arm. Which technique did the nurse use?
b. Critical thinking
2.A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during the shift. The nurse remembers that this was similar to a situation that happened in the past when a patient developed an internal bleed. Based upon the nurses thoughts, which skill did the nurse use?
b. Critical thinking
c. Nursing process
3.A nurse is admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patients daughter and son-in-law are present. The nurse notices that the patient does not make eye contact when answering questions and the nurse senses that something is not right about the situation. Which technique did the nurse use?
b. Critical thinking
c. Nursing process
4.A student nurse is administering an enema with an instructor in the room. The patient states that he or she can no longer hold the enema solution. The student nurse acknowledges the patients request and begins to tell the patient to go to the bathroom but asks the instructor if this is OK. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylors model?
a. Level 1: Basic
b. Level 2: Complex
c. Level 3: Commitment
d. Level 4: Expert
5.A nurse is describing risk taking, creativity, and integrity in nursing care. What is the nurse explaining?
a. Attitudes of critical thinking
b. Competencies of critical thinking
c. Standards for critical thinking
d. Nursing process for critical thinking
6.A nurse is using the scientific method to solve a patient situation. Which action should the nurse take first?
a. Collect data.
b. Identify a problem.
c. Formulate a question.
d. Evaluate the results.
7.A registered nurse is explaining a procedure to a patient who speaks another language. Which action by the nurse reflects critical thinking?
a. Teach with unfamiliar explanations.
b. Explain using medical jargon.
c. Use vague descriptions.
d. Obtain an interpreter.
8.A patient receiving blood after an abdominal surgery notified the nurse that the IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked. On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which behavior on the part of the nurse?
a. Effective problem solving
b. Diagnostic reasoning
c. Scientific method
d. Commitment level of critical thinking
9.A patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that the patient may have an infection and notifies the primary health care provider of the change in the patients condition. This concern is based on the nurses experience as a pediatric nurse. The nurses ability to make a tentative conclusion regarding this patients situation based on observed data is known as what?
a. Scientific method
b. Clinical inference
c. Effective problem solving
d. Data collection
10.A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patients white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection. The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation?
a. Medical diagnosis
b. Scientific method
c. Diagnostic reasoning
d. Data collection
Chapter 09: Nursing Process
1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?
2.The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process?
3.A postoperative patient is continuing to have incisional pain. As part of the nurses assessment, the nurse notes that the patient is grimacing when he or she changes position. The patients grimace can be useful in the assessment and can be described as which of the following?
d. Health pattern
4.A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as?
d. Health pattern
5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data?
a. Heart rate of 96
b. Incisional erythema
c. Emesis of 150 mL
d. Sharp, burning pain
6.The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective?
a. The patients toes of right foot are warm and pink.
b. The patient reports a dull ache in the right hip.
c. The patient says feels tired all the time.
d. The patient is concerned about insurance coverage.
7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior
b. Behavior is inappropriate, requests registered nurse do the assessment
c. States, I want a registered nurse to do my assessment
d. Is grumpy, registered nurse notified
8.A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patients spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurses behavior?
a. The patient is exhibiting confusion.
b. The spouse is being obnoxious.
c. The patient is the best source of information.
d. The spouse is too controlling.
9.A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed?
a. Patient chart
10.A nurse is interviewing a patient being admitted to the hospital for surgery. During the interview, the nurse introduces self and explains that will be gathering some information. The nurse is in which phase of the interview?
Chapter 10: Informatics and Documentation
1.A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality patient care?
a. Cost of care per patient day
b. Number of registered nurses
c. Absence of sentinel events
d. Documentation audits
2.A registered nurse is caring for an older adult patient with lung cancer. The daughter, who is also a nurse, asks to see the chart. What is the nurses best response?
a. Come with me and we will look at it together.
b. Im sorry; this information is confidential.
c. Let me ask my supervisor if it is okay.
d. You should know better than to ask me that.
3.A nursing student is working on a clinical assignment. Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?
a. Patient room number
b. Patient date of birth
c. Patient medical record number
d. Patient nursing diagnosis
4.A nurse is working in an agency with standards that require a nurses documentation to be within the context of the nursing process. The nurse is working for which agency?
a. Centers for Disease Control and Prevention accredited hospital
b. World Health Organization hospital
c. The Joint Commission accredited hospital
d. Agency for Healthcare Research and Quality hospital
5.Which information indicates the nurse has a correct understanding of the purpose of a patients medical record?
a. To invoice the nurse for reimbursement
b. To protect the patient in case of a malpractice suit
c. To ensure everyone is working toward a common goal of providing safe care
d. To contribute to a worldwide databank for trends in health care
6.A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patients chart. Which entry is the bestway that the nurse should document what happened?
a. Patient stated that fell while going to the bathroom. Physician notified.
b. Nobody available to answer call bell; patient got up on own and fell.
c. Patient fell because of unsafe staffing levels on unit.
d. Patient waited as long as possible but nobody there to help and fell.
7.A registered nurse is documenting patient assessments. Which documentation written by the nurse is most clear?
a. Seems comfortable at this time.
b. Is asleep, appears not to be experiencing pain.
c. Apparently is not in pain because patient didnt rate it high on the scale.
d. States pain is a 2 on a 0 to 10 scale.
8.A patient states that he or she is experiencing pain in the lower back. What is the best way for the nurse to document this subjective information?
a. Seems back is hurting.
b. States My lower back hurts.
c. Grimaces when moving; I believe patient has lower back pain.
d. Appears to be uncomfortable with lower back pain.
9.Which documentation by the nurse best describes patient data?
a. Moderate amount of clear yellow urine voided.
b. Voided 220 mL clear yellow urine.
c. A small amount of urine voided into absorbent pad.
d. Patient incontinent of urine.
10.Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?
a. Sm. amt. of emesis.
b. 150 mL of cloudy dark yellow urine.
c. Had a good day.
d. Looks bad.
Chapter 11: Communication
1.A nurse who works for an oncology unit is preparing to bathe a patient who recently underwent surgery to remove an abdominal tumor. Before beginning the bath, the nurse explains the procedure. Which of the following best describes the nurses communication role?
2.A patient is being cared for by a nurse. The patient has questions regarding what time the surgery is scheduled. When the nurse responds to the question, the nurse is assuming which communication role?
3.A registered nurse is a new nurse manager who needs to council an employee regarding attendance. Because the nurse manager is new to the position, the nurse is rehearsing what is planning to say to the employee before the meeting. The nurse is using which form of communication?
4.A nurse is working in a busy emergency department of an urban hospital. The family of a patient brought in by ambulance asks the nurse what the doctor meant when he or she said that the patient was coding. In this situation, the word coding is an example of which of the following?
a. Denotative meaning
b. Connotative meaning
5.A patient asked a nurse when the primary health care provider would make rounds. The nurse was taking another patient for a stat test and replied very quickly, I have no idea. The patient most likely interpreted the nurse as uncaring because of which factor?
d. Personal appearance
6.A 9-year-old patient who is hospitalized for bowel surgery appears very frightened. To appear less threatening to the child, which action should the nurse take?
a. Stand over the bed when talking to the patient.
b. Sit in a chair next to the bed when talking to the patient.
c. Maintain constant eye contact with the patient at all times.
d. Stay within 12 inches of the patient when talking to the patient.
7.A nurse went into a patients room at 0900, shortly after the patient was told that he or she had liver cancer. The patient asked the nurse to stay because he or she did not want to be alone. The nurse stood very close to the patient, held the patients hand, and told the patient that he or she had plenty of time. A few minutes later, the nurse thought to check the time on the wristwatch because the nurse was supposed to take another patient for a test at 0945. The patient saw the nurse look at the wrist watch and told the nurse it was now okay to be alone. What was the most likely reason the patient said it was okay for the nurse to leave?
a. Invasion of personal space
b. Verbal communication
c. Nurses gesture
8.A registered nurse is caring for a postoperative patient who is experiencing respiratory distress after the administration of pain medication. The nurse called the patients primary health care provider immediately. The information regarding the patient was conveyed using the SBAR format. Which information did the nurse convey to the primary health care provider?
a. Situation, background, assessment, recommendation
b. STAT, background, assessment, requirement
c. Status, background, analysis, recommendation
d. Setting, belief, assessment, requirement
9.Which behavior by the nurse would be considered most professional?
a. Addressing a patient by dear
b. Wearing small earrings
c. Being task oriented
d. Avoiding troublesome patients
10.When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient?
a. Using a cultural joke to break the ice
b. Stereotyping the patient within his or her culture
c. Considering the context of the patients background
d. Assuming the patient or the family member speaks English
Chapter 12: Patient Education
1.A nurse has been asked to prepare patient education for Spanish-speaking patients regarding diabetes. This information will be available to patients in the diabetes clinic. What is the primarygoal for this patient education?
a. To reduce the legal liability of the clinic
b. To teach Spanish-speaking patients some English
c. To assist Spanish-speaking patients to reach optimal health
d. To provide information so they can make a decision between oral and injectable medications
2.A patient with newly diagnosed diabetes is being discharged from the hospital. The patient will be going to an outpatient diabetic center to learn more about diet, exercise, disease management, and insulin administration. Which statement made by the patient indicates that effective teaching can take place?
a. I dont want to get sick again so I will do what is needed.
b. I am so happy to be going home so I dont have to eat hospital food anymore.
c. I will be glad when they find a cure for diabetes.
d. I dont think I will need to take insulin for very long because I already feel better.
3.The parents of a 3-month-old infant are preparing to take their child home from the hospital. Before being discharged, the parents must be educated on infant CPR. What is the mostappropriate learning objective for this situation?
a. The parents will be able to understand CPR skills.
b. The parents will demonstrate infant CPR skills.
c. The infant will not require further hospitalization.
d. The parents will call the hospital for help.
4.Which finding will best indicate to the nurse that the teaching about a dressing change was successful?
a. The patient understands how to change an abdominal dressing.
b. The patient acknowledges the principles of an abdominal dressing change.
c. The patient correctly demonstrates an abdominal dressing change as taught.
d. The patient states, Yes, I know how to change the dressing.
5.A patient recently had a stroke and suffered right-sided weakness. The patient is being discharged from a rehabilitation hospital after learning to use a walker. Which learning domain was primarily used to teach the patient to be independent with the walker?
6.Which patient is the most likely to be motivated to learn?
a. A 23-year-old smoker being taught about weight control
b. A 45-year-old man being taught about importance of prostate cancer screening
c. A 63-year-old knee replacement patient being taught postsurgical knee rehabilitation
d. A 15-year-old girl being taught about safe sex
7.A postsurgical patient is being taught about wound care before being discharged from the hospital and is in a semiprivate room with another patient. The other patient is upset with a family member and is crying. The television is on to try to provide some distraction from the roommate. Which action should the nurse take to best facilitate patient education for wound care?
a. Explain to the patient that everything is in the handout.
b. Take the patient to a quiet area to do the patient teaching.
c. Ask the roommate to please be considerate of the patient because patient education is occurring.
d. Request that a home health nurse follow up with the patient at home to teach about wound care.
8.A nurse will be teaching a prepared childbirth class for the first time at a neighborhood church. The nurse has gone to the church to determine which room would be best suited to teach a group of six couples. Which room configurations would be most appropriate for teaching this group?
a. A small carpeted room with no furniture
b. A large auditorium with a stage and theater-style seating
c. A lunchroom with stationary tables and chairs
d. A Sunday-school classroom with tables and chairs
9.A patient who is a migrant farm worker did not graduate from high school and speaks English as a second language. The nurse will be providing discharge teaching after a hysterectomy. The nurse is concerned about the patients ability to understand the discharge instructions. Which of the following should be of most concern in this situation?
b. Developmental stage
c. Health literacy
d. Psychomotor learning
10.A patient was recently diagnosed with heart failure. The health care provider has ordered a low-sodium diet. A nurse is planning patient education for diet instruction. Which information should the nurse present first?
a. How much daily intake of sodium is recommended
b. How to read food labels at the grocery store
c. How to understand the metric system of measurement
d. How to cook different meals with low-sodium foods
Chapter 13: Managing Patient Care
1.A registered nurse works as a case manager in the local hospital. What primary role will the nurse be fulfilling?
a. Coordinating care for patients with a specific condition
b. Only working with primary health care providers
c. Directing care of all patients in the hospital setting
d. Providing direct care to specific patients
2.A nurse manager is interested in supporting more involvement of the staff nurses on the unit. What is one approach the nurse manager can take to facilitate this involvement?
a. Inform the staff of decisions made.
b. Use decentralized management.
c. Avoid unit goals.
d. Discourage input from other personnel.
3.A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patients diet. As the staff delivers the plan of care the primary nurse evaluates whether the plan is working. Which attribute is the primary nurse displaying?
b. Interprofessional collaboration
d. Staff involvement
4.A registered nurse delegates vital signs on a patient to the unlicensed assistive personnel (UAP). The nurse reviews the documented vital signs from the UAP to determine if they are within normal parameters for the patient. The nurse in this example is demonstrating which attribute when following up on the vital signs?
a. Interprofessional collaboration
b. Staff education
5.A nurse is using SBAR. Which information will the nurse report for the B?
a. The patient had a broken right leg with a cast applied 2 days ago.
b. The toes are cool and pale.
c. The patient is reporting severe pain10 out of 10even after pain medication was given.
d. The nurse requests that the primary health care provider examine the patient.
6.A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia (VAP). To achieve this outcome, the nurse delegates the following to the unlicensed assistive personnel: Please perform oral care on the patient every 2 hours. In this situation oral care would include using the special swabs we have for our patients on VAP precautions so we can prevent pneumonia. Which of the five rights of delegation did the nurse use?
a. Right route
b. Right direction/communication
c. Right dose
d. Right supervision
7.A patient is admitted to the hospital for hip replacement surgery after falling at home and breaking a hip. The patient has developed pneumonia while in the hospital and has required frequent suctioning from the tracheostomy. The nurse decides to delegate I&O to the unlicensed assistive personnel but does not delegate suctioning. This is an example of which of the five rights of delegation?
a. Right task
b. Right direction/communication
c. Right intervention
d. Right supervision
8.A nurse is in the acute care unit caring for a 67-year-old patient with a varicose ulcer in the right lower leg. The wound has been healing well but will require a dressing change during the shift. What priority level should the nurse classify this problem?
a. High priority
b. Low priority
c. Mid priority
d. Intermediate priority
9.A new nurse would like to work where clinical performance is valued and in an environment that uses evidence-based practice. Given the new nurses goals, which organization would be the best for this nurse?
a. Private hospitals
b. Community hospitals
c. Not-for-profit hospitals
d. Magnet-designated hospitals
10.A nurse has worked in a variety of nursing areas and would like to find a unit within the hospital that mirrors the nurses own professional values. The best way for the nurse to find a unit that would be a good fit is for the nurse to examine which document?
a. Hospital mission statement
b. Unit policies and procedures
c. Unit philosophy of care
d. Hospital vision statement
Chapter 14: Infection Prevention and Control
1.The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not been ill from the bacteria, the nurses nasal cavity can best be described as a:
a. susceptible host.
c. portal of entry.
d. mode of transmission.
2.The nursing assistive personnel (NAP) is working on a busy pediatric unit in a hospital. She has a cut on her hand that has not been kept covered. It hurts her to wash her hands or sanitize them, so she has been providing patient care without performing hand hygiene. Several of the patients on the pediatric unit have suffered hospital-associated infections of rotavirus. This was thought to be a result of the NAPs lack of hand hygiene. This type of disease transmission can best be described as:
b. natural active immunity.
d. natural passive immunity.
3.The nurse is working for a postsurgical unit. He is caring for four postsurgical patients, all of whom have been in the hospital for 3 days or more. Which of the following patients should he be most concerned about regarding a health careassociated infection?
a. An asymptomatic elderly patient with bacteria in his urine
b. A middle-aged woman with a white blood cell count of 10,000/mm3
c. A young adult woman who is 1 day postoperative with redness at incision site
d. A middle-aged man with temperature of 101.3 F and complaints of malaise
4.A patient with a history of poor nutrition and chronic illness is admitted to the medical unit. The nurse caring for this patient is preparing to provide the patient with a bed bath and recalls that normal body flora:
a. are only found on the skin surface.
b. are beneficially aided by the use of antibiotics.
c. are primary sources of infection when balanced.
d. help to maintain health.
5.An emergency department nurse is caring for a patient with a laceration on the lower leg that has become infected. On assessment the nurse realizes that a sign of an inflammatory response consists of:
a. wound blanching.
b. coolness at the site of injury.
c. a vascular reaction that delivers fluid, blood, and nutrients to the area.
d. decreased pain sensation.
6.There was an outbreak of Salmonella poisoning at a nursing home. Several residents were hospitalized as a result of their infections. What is the best term to describe this infection?
a. Exogenous infection
b. Endogenous infection
c. Community-acquired infection
7.A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:
a. insert indwelling catheters to prevent incontinence.
b. use aseptic technique when performing procedures.
c. use barriers sparingly to reduce the patients sense of isolation.
d. keep mucus membranes dry to prevent maceration.
8.The infection control nurse is presenting an in-service presentation on infection prevention and control. A participating nurse identifies what patient as most susceptible to acquiring an infection?
a. An 81-year-old patient with a fractured hip
b. A 10-month-old patient with a first-degree burned hand
c. A 40-year-old patient with a recent uncomplicated laparoscopic cholecystectomy
d. A 16-year-old athlete with a repair of the medial collateral ligament
9.A senior nursing student is working on a community health project for the local homeless shelter. There are several indigent men who come to the shelter in cold weather to sleep for the night. The student nurse knows that these men do not bathe on a regular basis. One of the men has been sick several times recently with skin infections. Which of the following is the best way for the student nurse to explain the importance of personal hygiene to this individual?
a. You dont have to shower every day. You only need to take a shower when you feel like youre going to be sick.
b. Take a shower. If you dont take a shower, you will continue to get sick.
c. Showering regularly will remove germs that cause skin infections. What do you think we should do about these skin infections of yours?
d. Showering with warm water is enough to wash away bacteria. Soap is not needed if you dont like it.
10.The student nurse who is developing a plan of care for a postoperative patient who underwent abdominal surgery to remove a tumor. The student has chosen Risk for Infection as a nursing diagnosis. Which of the following is the most appropriate goal for this diagnosis?
a. The patients wound drainage will decrease in 2 days.
b. The patient will report decrease in incisional pain by discharge.
c. The progression of infection will be controlled or decreased.
d. The patient will describe signs/symptoms of wound infection.
Chapter 15: Vital Signs
1.The nursing student is obtaining the patients vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?
a. Temperature, pulse, respirations
b. Temperature, pulse, respirations, oxygen saturation
c. Temperature, pulse, respirations, blood pressure, oxygen saturation
d. Temperature, pulse, respirations, blood pressure, oxygen saturation, pain
2.Upon a patients admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurses responsibility regarding delegating this task?
a. This is inappropriate delegation; the nurse should always take the vital signs.
b. Have the NAP repeat the measurement if vital signs appear abnormal.
c. The nurse should review and interpret the vital sign measurements.
d. This task has been delegated so the nurse is not responsible.
3.A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?
a. Call the health care provider because the patients values differ from the standard range.
b. Immediately call the health care provider and request antihypertensive medication.
c. Ask the patient what his blood pressure normally measures for comparison.
d. Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.
4.A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.6 F. Which of the following is the best reason why the patient should not receive an antipyretic at this time?
a. A temperature of 100.3 F is within the normal range.
b. Shivering is a more effective way to dissipate heat energy.
c. Corticosteroids are safer to use than antipyretics.
d. Mild fevers are an important defense mechanism of the body.
5.A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through which of the following?
6.A 6-year-old was taken to the hospital after having a seizure at home. The patients mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patients mother believes that the seizure was caused by a fever of 99.5 F, which the patient had during the course of her illness. What is the nurses best response?
a. With a temperature that high, we can only hope that there is no permanent damage.
b. Fevers in this range are part of the bodys natural defense system
c. Febrile seizures are common in children Nancys age.
d. The child will need antibiotics. Does she have any allergies?
7.A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5 F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, the patients mother was asked to help reduce the fever by limiting the number of blankets covering the patient. After interventions, the childs temperature is 100.5 F. The nurse recognized that the mother has an understanding of the patients condition when she states which of the following?
a. The high temperature is useful in fighting bacteria and viruses as long as its not too high.
b. You need to get her temperature down quickly. Shes so uncomfortable.
c. Her fever is dropping because she is shivering. She must be cold.
d. She probably picked up a bacteria. Thats what kids do. Thats why they get infected.
8.The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girls temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?
a. Children usually run lower rather than higher temperatures when ill.
b. Because of her age, it is probably a bacterial infection.
c. Rectal temperatures are higher than temperatures obtained orally.
d. When taking multiple temperatures, the sites should be rotated.
9.A 6-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following?
b. An allergic response to the prescribed medication
c. Febrile seizures
d. Fever of unknown origin (FUO)
10.A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2 F after caring for her 5-year-old granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first?
a. Administer antibiotic.
b. Administer antipyretic.
c. Draw blood cultures.
d. Apply water cooled blankets.
Chapter 16: Health Assessment and Physical Examination
1.While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. These sounds can best be described as which of the following?
d. A friction rub
2.The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate the patients abdomen?
a. Palpate tender areas last.
b. Palpate tender areas first to get it over.
c. Palpate tender areas before inspection.
d. Palpate before auscultation.
3.The registered nurse is precepting a first-year nursing student. She is demonstrating how to appropriately auscultate. Auscultation is defined as which of the following?
a. Listening with a stethoscope to sounds produced by the body
b. Tapping the body with the fingertips to produce a vibration
c. Becoming familiar with the nature and source of body odors
d. Using the hands to touch body parts to make a sensitive assessment
4.A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment. After using light palpation to examine the patient, the nurse uses deep palpation. With deep palpation the nurse does which of the following?
a. Performs a completely safe method of examination
b. Should use two hands only
c. Uses the upper hand to exert an upward pressure
d. Can examine the condition of organs
5.A nurse is preparing to perform a physical examination on a patient who has mobility issues. In preparing for the examination, the nurse should do which of the following?
a. Be sure that a well-equipped examination room is available.
b. Tune the radio to the nurses favorite station to relax the patient.
c. Perform thorough hand hygiene before preparing equipment.
d. Instruct the patient on the safest way to transfer onto the examination table.
6.A registered nurse is preparing to perform a physical examination on a 5-year-old child. To make the child feel safer during the examination the nurse should do which of the following?
a. Examine the childs fingernails before listening to his breath sounds.
b. Question only the child so as to avoid unwanted parental influence.
c. Perform palpation before visual inspection.
d. Calls the parents by their first names to establish a more trusting bond.
7.A nurse is preparing to perform a physical exam on a patient. She has found that it is best to perform the physical with a head-to-toe approach. Why is this important?
a. The head-to-toe format excludes unnecessary body systems.
b. It is a methodical way to include all body systems.
c. It reduces time by allowing examination of only one side.
d. It requires that painful procedures be done first.
8.A nurse is admitting a 79-year-old woman with a fractured hip to the orthopedic unit. Her husband states that she broke her hip when she tripped in her garden. Upon examination, the nurse notes purple, green, and yellow bruises on the back and arms. The patient states that those were received when she fell. The nurse should do which of the following?
a. Ask the husband to wait in the waiting room.
b. Ignore the bruises because the patient has provided an explanation.
c. Realize that the patient may be abused, but that is a family issue.
d. Prepare to discharge the patient home once treatment is complete.
9.The student nurse has been assigned to the pediatric unit for her clinical training this semester. She is assisting with the admission of a 5-month-old infant admitted with pneumonia. The student nurse is responsible for taking the childs vital signs and weighing and measuring the child. The infants mother is very concerned when the student nurse tells her that the baby weighs 14 pounds. The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home. What is the student nurses best response to the mothers concern?
a. To get an accurate weight, babies are weighed at different times of the day.
b. Variations occur because we place our hand firmly on the child.
c. Even if we use the same scale, the variation can be 1 to 2 pounds.
d. Weight measurements can vary with different scales.
10.An older adult African-American woman has gone to the clinic where a RN volunteers twice a week. She is a diabetic and has some skin breakdown on the calf of her right leg. Her skin is very darkly pigmented. To best examine the patients skin, the nurse should use which of the following?
a. Halogen lighting
b. Artificial warming to increase room temperature
c. Natural sunlight
d. Air conditioning to lower room temperature
Chapter 17: Administering Medications
1.A registered nurse for more than 15 years was concerned when she learned that her hospital was going to let unlicensed nursing assistants start IVs on patients. The nurse knew this was in violation of the scope of nursing practice in her state. Which of the following organizations defines the scope of nursings professional functions and responsibilities?
a. The US Food and Drug Administration (FDA)
b. The MedWatch program
c. Employee assistance programs (EAP)
d. State Nurse Practice Acts
2.A 34 year old has been on morphine for 6 months after back surgery and has gone to multiple health care providers to obtain prescriptions. Which term best describes this situation?
a. Medication dependence
b. Medication abuse
c. Medication misuse
d. Medication underuse
3.A patient calls to say that he is unable to pay for the medication from a specific manufacturer that was prescribed. The health care provider gives another name for the medication and
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