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Test Bank Fundamentals Nursing Human Health Function 7th Edition, Craven
Chapter 1- The Profession of Nursing
1. What is the major difference between nursing students today and nursing students 50 years ago?
A) Todays students are less caring.
B) Todays students are more intelligent.
C) Todays students reflect a more diverse population.
D) Todays students are less likely to be competent nurses.
2. The nurse is caring for a diabetic patient who expresses the desire to learn more about a diabetic diet in an attempt to gain better control of his blood sugar. The nurses actions will be based on which non-nursing theory?
A) Change theory
B) Maslows hierarchy of human needs
C) Neumans systems model
D) Watsons theory of caring
3. The Quality and Safety Education for Nurses Initiative (QSEN) has identified which key competencies for nurses? Select all that apply.
A) Patient-centered care
B) Teamwork and collaboration
C) Evidence-based practice
D) Quality improvement
E) Correct documentation
4. The nurse is caring for a patient who is on a ventilator. The nurse is bathing the patient and talking to them as she is carrying out care, as well as telling the patient what is going to happen next. The nurse speaks to the patient in a soothing manner. The nurse is acting in which role? (Select all that apply)
E) Patient advocate
5. The nurse offers a patient two possible times to ambulate as the physician has ordered. The nurse is acting in which nursing role?
B) Patient advocate
C) Manager and coordinator
6. The nurse is performing an extensive dressing change on a burn patient. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
B) Patient advocate
7. What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in nursing, take the NCLEX examination, and transition into a masters in nursing program?
A) Baccalaureate program
B) Graduate entry program
C) Advanced degree program
D) Continuing education program
8. A prospective nursing student desires a career that will allow him to provide patient care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
A) Associate of science registered nursing program
B) Baccalaureate of science registered nursing program
C) Licensed or vocational nursing program
D) Diploma nursing program
9. Nurses that enlist their services to the military are able to do so thanks to the work of which organizer of healthcare?
A) Linda Richards
B) Florence Nightingale
C) Theodor Fliedner
D) Dorthea Dix
10. Due to the rising cost of healthcare services, many procedures and treatments are being delivered in what type of setting?
B) medical centers
C) outpatient facility
D) community healthcare center
Chapter 2- Health, Wellness, and Complementary Medicine
1. A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Medical prevention
2. A patient inquires about the use of herbal therapy. Which statement by the nurse is most accurate?
A) All herbs are equal in purity, so purchase the cheapest brand.
B) Herbs can have side effects and can interact with prescription medications.
C) Be sure to pay attention to the packagings therapeutic and prevention information.
D) It is best if you select a licensed herbalist as a practitioner.
3. The nurse is caring for a terminally ill patient and asks the patients permission to incorporate therapeutic touch into the care provided. The nurses goal for this patient is to:
A) Prolong life
B) Control the dying process
C) Bring strength
D) Produce relaxation
4. The practitioner of therapeutic touch is listening with his/her
5. When practicing therapeutic touch, the practitioner begins by performing which intervention?
A) Calling to rebalance the soul
B) Bringing the practitioners attention to an inward peaceful consciousness
C) Embracing the patient for energy
D) Moving her hands 2 to 6 inches away from the patients skin surface
6. What nurse theorist developed therapeutic touch?
A) Dorothea Orem
B) Martha Rogers
C) Jean Watson
D) Dolores Krieger
7. A patient is asking for the nurse to explain acupuncture. What would you tell the patient?
A) Acupuncture is only done in Eastern countries
B) Acupuncture is a dangerous option for the treatment of disease
C) Acupuncture is beneficial to creating a mood of distraction
D) Acupuncture is used to correct disharmony
8. A patient is in the last stage of labor. During each contraction, she is focusing on her husbands voice and a picture brought from home. She is demonstrating which type of meditation?
9. A patient is very anxious before an invasive procedure. What CAM therapy would be most helpful to assist in decreasing anxiety?
B) Chinese medicine
10. Which of the following questions or statements to a patient convey acceptance?
A) You know supplements can be harmful. Do you take any supplements?
B) Have you ever discussed taking vitamins and supplements with your doctor?
C) Will you please share with me the prescription medicines and vitamins you take?
D) What helpful herbal supplements are you taking?
Chapter 3- Healthcare in the Community and Home
1. In the provision of nursing care, it is most important to perform which of the following actions?
A) Administration of prescribed medications
B) Implementation of physicians orders
C) Evaluation of patients responses
D) Coordination of care with the healthcare team
2. A nurse is caring for a 17-year-old pregnant woman. The woman needs to buy a baby bed and obtain baby items. The nurse should encourage the patient to go to
A) The visiting nurse association
B) A resale shop
C) A rental equipment store
D) The welfare office
3. A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately?
A) Infestation with roaches
B) The smell of natural gas
C) Unclean environment
D) Diminished food sources
4. A patient is diagnosed with mild dementia while in the hospital. In preparing for discharge, the nurse should discuss with the family the:
A) Possible need for home care
B) Legal responsibility for the future
C) Need for transfer to a long-term care facility
D) Lack of free resources of care
5. The home care nurse asks the patient and family about their socioeconomic status, culture, and beliefs. This occurs during which phase of care?
B) Nursing diagnosis
C) Outcome criteria
6. When the nurse is involved in the in-home phase, the nurse should
A) Use therapeutic communication
B) Record findings
C) Plan the next visit
D) Summarize accomplishments
7. A home care nurse has just completed a dressing change on her patient. Which statement best describes the termination phase?
A) You need to eat more protein to assist you with wound healing.
B) On a scale of 0 to 10 with 0 being no pain and 10 being the worst, where would you rate your pain?
C) Your wound is healing nicely. It is draining less and it is smaller by a half centimeter.
D) Have you had any problems since our last visit? Is your wife doing well with your dressing changes?
8. What is the purpose of the Standards of Care and Standards of Professional Performance?
A) To list treatments in the home care setting
B) To assist with virtual scenarios in the home
C) To understand the role of the medical nurse in the home
D) To guide the home care nurse in a collaborative role
9. When initiating home healthcare services, during which phase is it appropriate for the nurse to implement the initial patient assessment?
A) Initiation phase
B) Previsit phase
C) In-home phase
D) Termination phase
10. An 82-year-old woman is being discharged from the hospital following a bowel resection. The woman lives alone and her family is out of town. Which factor will have the greatest effect on her home care management?
A) Support systems
B) Medication management
D) Psychosocial needs
Chapter 4- Culture and Diversity
1. A nurse has just been hired at a healthcare facility that performs abortions. Based on the nurses religious beliefs, she strongly feels that abortion is unacceptable. This situation will prevent the nurse from being able to practice:
A) transcultural nursing
B) safe and effective care
C) efficient care
D) holistic care
2. While studying about various cultures, the student nurse is aware that a subculture is based on which characteristic? Select all that apply.
E) Sexual preference
3. The nurse caring for several patients on a surgical unit notes that one of the patients she is caring for is Muslim. The nurse decides to remove all pork from the patients meal tray prior to delivering it to his room. What best describes the nurses action?
C) Honoring rituals
D) Transcultural nursing
4. The nurse working on a medical unit washes her hands between contact with each patient. In addition to being an infection control measure, what kind of action is this practice?
A) A custom
B) An obsession
C) A habit
D) A ritual
5. What are characteristics of the nurse that make them a subculture within the United States? Select all that apply.
A) Uniforms worn based on place of employment
B) Language or medical terminology used to communicate
C) Legal authorization to provide health care to others
D) View of work as a reward and shared work ethic
E) Sensitivity to the importance of time
6. An African American patient refuses to allow any healthcare worker of Asian descent to care for him. This patient is demonstrating what practice?
D) Ethnic identification
7. The nurse correctly differentiates race from ethnicity by noting that race is based on which characteristics?
8. The public health nurse is preparing a presentation about disparities in healthcare in his community. What key concepts will the nurse include? Select all that apply.
A) Information regarding minorities within the community
B) Identifying groups that are disadvantaged within the community
C) Pointing out groups within the community that possess less power
D) Differences in beliefs within a particular culture
E) Ethnic identities within subcultures in the community
9. The nurse is caring for two patients from an Hispanic background. The nurse notices some differences between the two in the religious practices and the slang used for communicating. What is most likely the etiology of these differences?
A) Cultural norms
B) Cultural relativity
10. A patient tells the nurse that the only thing that helps him sleep is a glass of warm milk. The nurse caring for the patient insists that this practice is a myth and tries to convince the patient that reading a book will help to make him sleepy. What is the nurse demonstrating?
A) Cultural pervasiveness
B) Cultural superiority
Chapter 5- Communication in the Nurse-Patient Relationship
1. The nurse completes the admission process of a patient to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?
A) You have been having a great deal of fatigue for the last 3 months.
B) You are hoping to figure out the cause of your extreme fatigue during this hospital stay.
C) You are frustrated because you are too tired to perform normal acitivities.
D) You are unsure of what helps or prevents your fatigue.
2. The nurse is communicating with a patient following a routine physical examination. Which statement best demonstrates summarization of the appointment?
A) I think all went well with your physical, dont you?
B) Do you have any questions about all that was discussed during the exam?
C) We reviewed your plans for your new diet and medications. Do you have any other questions?
D) Will we see you in 6 months to see how your diet has progressed?
3. The student nurse is practicing communication skills by talking with several different patients in the hospital. In which instances would silence be appropriate? (Select all that apply)
A) Allowing the patient time to reflect on his or her thoughts
B) Reflecting on the communication that has occurred
C) After asking the patient a question
D) When the patient is upset and needs time to compose himself
E) When the nurse doesnt know the answer to a question
4. The community health nurse is preparing a campaign to educate the public about heart health. Which forms of verbal communication will be effective? (Select all that apply)
D) Voice tone
5. The nurse is providing teaching to a patient who sometimes has difficulty remembering information. Which form of communication will be most helpful for this patient?
A) Verbal communication
C) Non-verbal communication
D) Written communication
6. The student nurse is studying the concepts of communication. Which description demonstrates the student understands the concept of feedback?
A) The sender sends a clear message that is understood by the receiver.
B) The receiver listens to the sender in an unassuming way.
C) Feedback occurs when the sender and the receiver use one anothers reactions to produce further messages.
D) The senders message is translated into a code, using verbal and nonverbal communication.
7. The patient is talking to the nurse about recent health problems of immediate family members and the strain she has been under trying to care for them. She begins to cry between sentences. What response by the nurse demonstrates the most empathy?
A) I know how you feel. I was the primary caregiver for my father when he was dying.
B) Its okay to cry. Sometimes that helps us to feel better.
C) Just take your time. I am listening.
D) It is difficult when family members are ill. It helps if you take some time for yourself.
8. The nurse caring for a patient with a recent head injury asks the patient to raise his left arm as high as possible. The patient repeatedly raises his right arm. What does this indicate?
A) Difficulty with providing feedback
B) Difficulty with decoding messages
C) Difficulty with compliance
D) Difficulty with following commands
9. The 32-year-old patient in a mental health unit discusses his personal thoughts and feelings with the nurse. The nurse is maintaining the circle of confidentiality by reporting this information to which individuals? Select all that apply.
A) The patients physician
B) The patients family
C) The nurse from the oncoming shift
D) The units mental health technicians
E) The patients closest friend
10. The nurse is talking with a patient who is thinking about obtaining a second opinion regarding the surgeons recommendation for surgery. Which response by the nurse is considered an advocacy response?
A) You have one of the best surgeons in the area. I think it would be a waste of time to seek another opinion.
B) Your surgeon has always given you the best care and is genuinely concerned with your health.
C) You can do what you want, but I would get the surgery done as soon as possible.
D) Let us know if we can answer any further questions after you obtain your second opinion.
Chapter 6- Values, Ethics, and Legal Issues
1. The nurse is preparing to administer a medication ordered by the surgeon in a dose much higher than is recommended. What action should the nurse take?
A) Call the surgeon to clarify the order.
B) Administer the medication as ordered and chart the high dose.
C) Administer the medication and stay with the patient to observe for adverse reactions.
D) Administer the medication in the usual dosage.
2. When the nurse inserts an ordered urinary catheter into the patients urethra after the patient has refused the procedure and the patient suffers an injury, the patient may sue the nurse for which type of tort?
C) Invasion of privacy
D) Dereliction of duty
3. A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is
A) Well educated and can perform these duties
B) Able to practice as a nurse practitioner
C) Educated to practice only with pediatric patients
D) Practicing beyond his scope according to licensure
4. A nurse fails to administer a medication that prevents seizures, and the patient has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of?
5. A post-anesthesia nurse is reporting about the patient to the intensive care unit nurse in the elevator. There are staff members and visitors in the elevator. The nurse is
A) Implementing therapeutic communication
B) Interacting to maintain coordination of care
C) Breaching the patients confidentiality
D) Maintaining the continuity of care
6. When the nurse informs a patients employer of his autoimmune deficiency disease, the nurse is committing the tort of
A) Breach of contract
C) Invasion of privacy
7. A nurse states to the patient that she will keep her free of pain. However, her family wishes to try a treatment to prolong her life that may necessitate withholding pain medication. This factor will cause an ethical dilemma for the nurse in relation to which ethical principle?
8. An oncology patient in an outpatient chemotherapy clinic asks several questions regarding his care and treatment. The nurse explains the clinics routine, typical side effects of the chemotherapy, and ways to decrease the number of side effects experienced. What characteristic is the nurse demonstrating?
9. The foundation for decisions about resource allocation throughout a society or group is based on the ethical principle of
10. The patient being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the patient that it would be in his best interest to obtain which document?
A) A will
B) A living will
C) Proof of healthcare power of attorney
D) A proxy directive
Chapter 7- Nursing Research and Evidence-Based Care
1. In the development of a literature review, the most effective source of information for nursing research is which of the following?
A) New England Journal of Medicine
B) Cumulative Index of Nursing and Allied Health Literature
C) Journal of Nursing Research
D) American Journal of Nursing
2. When did evidenced-based practice become an important component of the delivery of nursing care?
A) The early 1800s
B) The early 1900s
C) The late 1900s
D) The early 2000s
3. Why is it important for the findings of a research study to be disseminated? Select all that apply.
A) So that clinical application can occur
B) To allow the nurse researcher to receive notoriety for the findings
C) In order for research replication by other nurses to take place
D) Because graduate-level nurses must conduct a specific number of research studies to maintain nursing licensure
E) To strengthen and validate conclusions by similar findings in more than one research study
4. The nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable?
5. The director of nurses (DON) in a long-term care facility has noticed an increased number of urinary tract infections (UTIs) on the east wing of the facility, and would like the infection control nurse to investigate this problem. What is the best problem statement for this study?
A) Is there a relationship between the personnel caring for specific patients and whether or not these patients developed UTIs?
B) Is there an increase in the number of UTIs on the east wing of the facility?
C) Does the east wing have a greater number of UTIs than the west wing of the facility?
D) What is the patient census on the east wing as opposed to the other wings of the facility?
6. A nursing researcher presents the findings of his current study at a School of Nursings research conference. While there, he speaks with another nurse researcher interested in similar topics and the two decide to discuss forming a partnership for further research projects. What is this type of interaction an example of?
B) Identifying variables
C) Investigating foreground questions
7. What type of research study would a hospital conduct to determine additional services the community would like to see offered by the facility?
8. What are the four properties identified by Diers that comprise the holistic perspective of nursing research?
A) The focus of nursing research must be on a variance that makes a difference in improving patient care.
B) Nursing research has the potential for contributing to the development of theory and the body of scientific nursing knowledge.
C) A research problem is a nursing research problem when nurses have access to and control over the phenomena being studied.
D) A nurse interested in research must have an inquisitive, curious, and questioning mind.
E) A nurse interested in research must be a graduate-level nurse to be able to adequately perform nursing research.
9. When the nurse researcher informs the participant that his or her identity will not be linked with the information that is collected, the researcher is ensuring the participants
B) Protection from harm
C) Ability to withdraw
10. The role of the institutional review boards for research studies is to
A) Determine the worthiness of a research study
B) Document the costs of the study
C) Publish the research study
D) Protect the rights of human subjects
Chapter 8- Patient Education and Health Promotion
1. An elderly woman is receiving Medicare benefits only and her source of income is Social Security. She has limited literacy skills and no family support. What is the major issue that puts her at risk for an alteration in health maintenance?
A) Unpleasant past experience
B) Family values
C) Lack of motivation
D) Knowledge deficit
2. A woman is admitted to the medical division with pelvic inflammatory disease. Which of the following statements would indicate that she requires more education on health promotion and illness prevention?
A) My sexual partner is at risk for infection when I have an infection.
B) The number of sexual partners increases my risk for infection.
C) Unprotected sexual intercourse increases my risk for infection.
D) Sexual relationships have no effect on the infections I get.
3. An appropriate topic on secondary prevention and health maintenance for a group of middle-aged adults is
A) Medical checkups
B) Prenatal checkups
C) Pregnancy prevention
D) Medication safety
4. A primary health-maintenance concern for adolescents is
A) Adequate rest
B) Alcohol abstinence
C) Exercise regimen
D) Job safety
5. The local health department inspects restaurants and food manufacturing facilities. This is an example of
A) Health protection
B) Health promotion
C) Illness prevention
D) Pest surveillance
6. The nurse instructs new mothers about illness prevention when the nurse tells the patients to be certain that their newborns are
A) Given massages
B) Mentally stimulated
C) Positioned prone for sleep
D) Immunized on schedule
7. What health-promotion activity would be the most appropriate to suggest to a 20-year-old female?
A) Aerobic exercise three times per week
B) Yearly breast mammography
C) Weekly blood-pressure screening
D) Intake of a diet high in fat
8. The School of Health Sciences, campus health center, and acute care facility establish a wellness center for the uninsured. This is an example of
A) Cost containment
B) Illness care
C) Community partnership
D) Mobilized healthcare
9. Which of the following guidelines is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?
A) Allow ample time for psychomotor skills
B) Keep the session at 2 to 3 hours
C) Allow for long-term memory loss
D) Provide information in a structured format
10. What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?
A) Role play
D) Test taking
Chapter 9- Caring for the Older Adult
1. The nurse is caring for an elderly patient on the medical unit admitted for diagnostic testing. He is alert and oriented and lives independently in his own home. Which nursing intervention will be most effective in the prevention of falls for this patient?
A) Using a gait belt each time he ambulates
B) Ensuring his glasses are close by his bed
C) Placing a bed alarm on his bed
D) Moving him to a room close to the nurses station
2. The nurse in a community health clinic is aware of the significant problems with nutrition in the elderly population. What percentage of the eldery living on their own consume fewer than 1,000 calories per day?
3. The nurse performs an assessment on a newly admitted elderly patient. The patient receives a score of 12 on the Braden scale. What is the risk for impaired skin integrity for this patient?
A) No risk
B) Low risk
C) Moderate risk
D) High risk
4. The home care nurse is aware of the growing problem of the mistreatment of the elderly population. How many elderly in the United States are estimated to be mistreated every year?
A) 700,000 to 1.2 million
B) 1.2 to 1.7 million
C) 1.7 to 2.2 million
D) 2.2 to 2.7 million
5. Which group of individuals in the elderly population are most likely to be widowed?
A) Women under the age of 65
B) Men under the age of 70
C) Men over the age of 75
D) Women over the age of 75
6. The nurse is preparing a presentation on chronic pain management to a group of elderly members of a community senior citizens center. Which chronic disease should the nurse focus on in her presentation?
A) Rheumatoid arthritis
7. The student nurse is conducting an informal study on pain management in the elderly population in a local long-term care facility. Which elderly patient population will the student most likely find to receive the least effective pain management?
A) Residents 85 years or older
B) Residents that have unaffected cognition
C) White females
D) Residents with chronic illness
8. An elderly patient tells his home care nurse that he doesnt seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the elderly patient that cause a less restful sleep include:
A) A decrease in stage I of the sleep cycle
B) A decrease in the deep sleep stage of the sleep cycle
C) A change in the normal progression of the sleep cycle
D) An increase in stage II of the sleep cycle
9. The unit manager at a long-term care facility is concerned with the recent weight loss of several residents. The nurse plans a staff inservice to discuss weight loss in the elderly, including identifying what possible causes? Select all that apply.
A) Decreased thirst and smell
B) Alterations in taste
C) Early satiation (feeling full)
E) Decline in physical activity
10. A nursing student is looking at the demographics related to the older adult and finds that what percent of the elderly population that is institutionalized falls into the age range of 85+ years?
Chapter 10- Nursing Process- Foundation for Practice
1. A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as
A) Life-sized mannequins with a sophisticated computer interface
B) Small doll-like devices used for measuring vital signs
C) Healthcare equipment that has practice modes
D) Life-saving equipment that resuscitates patients in cardiac arrest
2. What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?
3. The nurse is caring for a newly admitted patient. How can a nurse arrive at a more complete database for this patient?
A) Through clustering of data
B) Analysis of lab values
C) Review of the chart
D) Consult with several sources
4. A patient complains of weakness following his administration of insulin. The nurse decides to assess the patients blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?
A) Clinical reasoning
5. A nursing student is caring for a patient who has diabetes mellitus. The patient takes insulin two times per day. Based on the students knowledge of insulins onset of action, he makes sure the patients meals arrive in coordination with the insulins effect. The knowledge used by the student is
6. For the nursing student to implement the most effective care for her patients, she must
A) Have rudimentary critical-thinking skills
B) Apply preexisting knowledge
C) Apply clinical knowledge to theoretic knowledge
D) Establish a clinical log for evaluation
7. What type of learning best takes place in the nursing laboratory?
A) Kinesthetic learning
B) Auditory learning
C) Concrete learning
D) Collaborative learning
8. Which of the following learners enjoy learning that takes place in the clinical setting?
A) Sequential thinkers
B) Grade-oriented students
C) Learning-oriented students
D) Active experimenters
9. A nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the patients ability to learn?
C) Previous knowledge
10. A patient who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this patient, she must first
A) Implement critical-thinking skills
B) Develop a relationship with the patient
C) Engage the services of a social worker
D) Determine what care has been provided
Chapter 11- Nursing Assessment
1. During data collection the nurse may validate data by which method? (Select all that apply)
A) Comparing cues to normal function
B) Referring to textbooks, journals, and research reports
C) Checking consistency of cues
D) Clarifying the patients statements
E) Seeking consensus with colleagues about inferences
These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses.
2. When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?
A) Validate inferences with the patient
B) Do not share inferences with the patient
C) Document all inferences
D) Avoid making any inferences
3. While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history?
4. The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate?
A) When I perform the nursing history I will need to ask your family to leave the room.
B) I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes.
C) I will perform a physical assessment while I am obtaining the nursing history.
D) I will leave a form with you to complete the nursing history information I need.
5. The RN is admitting a patient to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process, the patient complains of a severe headache so the nurse reassesses the vital signs to find the patients blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?
A) The company that made the blood pressure equipment
B) The nurse
C) The UAP
D) The charge nurse
6. A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?
A) Size of the liver
B) Presence of peristalsis
C) Pupil reaction
D) Skin temperature
7. Which of the following are examples of objective data?
A) Patient describing his pain
B) Laboratory results
C) Breath sounds
D) Mother describing her childs asthma attack
E) a patients temperature
8. Which of the following would be considered examples of subjective data? Select all that apply.
A) Comments made by the patients family.
B) Description of a symptom by a patient.
C) A mother telling a nurse what the baby looked like when he was very ill.
D) A nursing assessment of the patients vital signs.
E) The physical exam notes made by the physician.
9. The nurse has identified a priority problem on her unit. Which of the following statements is true regarding addressing a priority problem?
A) Setting priorities involves skipping interventions.
B) Priorities are set at predetermined intervals throughout the shift.
C) A priority problem requires a nursing intervention before another problem is addressed.
D) Priority of problems is established and continued according to the nursing plan of care.
E) The physician is responsible for determining priority of patient needs.
10. During the interview component of the health assessment, the nurse conveys to the patient that the information is important by
A) Nodding frequently during the interview
B) Sitting at eye level with the patient
C) Standing next to the patient while interviewing
D) Limiting questions to those with yes or no answers
Chapter 12- Nursing Diagnosis
1. Which of the following assessment findings would support the nursing diagnosis of acute pain? Select all that apply.
A) Patient had an abdominal hysterectomy 1 day ago.
B) Patient is crying in pain about 20 minutes before her pain medicine is due.
C) Patient has a history of osteoarthritis.
D) Patient had back surgery 2 years ago and expresses the need for ibuprofen on most days.
E) Patient is a heavy cigarette smoker.
2. What is the process of gathering and clustering data to draw inferences and propose a diagnosis?
A) Critical thinking
B) Analytical reasoning
C) Diagnostic reasoning
3. The purpose of establishing a nursing diagnosis is to
A) Describe a functional health problem
B) Collaborate with the physician
C) Identify medical problems
D) Meet accreditation criteria
4. Why is coding important when writing a nursing diagnosis?
A) Enhances the professionalism of the nursing process
B) Allows for direct reimbursement for nurses
C) Evaluates the diagnostic statement for accuracy
D) Provides legal characteristics for licensure
5. Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?
A) Ineffective airway clearance related to bed rest
B) Immobility related confinement to bed
C) Potential for pneumonia related to inactivity
D) Risk for impaired skin integrity related to bed rest
6. A nurse sees the patient grimace and documents that the patient is in pain, without interviewing the patient to obtain further cues. The nurse has
A) Impaired cluster interpretation
B) A lack of cues or premature closure
C) Ineffective database
D) Inaccurate evaluation
7. The act of analyzing and synthesizing cues requires
A) critical thinking
C) advanced practice
D) attendance at NANDA
8. A patient is experiencing shortness of breath, lethargy, and cyanosis. These three cues provides organization or
9. One major requirement of a nursing diagnosis is that it focuses on a problem that is
A) Established by the physician
B) Based on the patients pathophysiology
C) Legally treatable by registered nurses
D) Included within the diagnosis-related group
10. What information provides the nurse with accuracy when developing a nursing diagnosis?
A) A set of lab values
B) Abnormal diagnostic tests
C) A set of clinical cues
D) Specific nursing interventions
Chapter 13- Outcome Identification and Planning
1. One of the primary factors that the nurse considers when setting priorities for the patient in the acute care setting after cardiac surgery is the patients
A) Support system
B) Medical orders
C) Past medical history
2. The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students in that the clinical nursing care plan usually
A) does not contain documented scientific rationales
B) Does not contain abbreviated nursing diagnoses
C) Separates goal statements from the plan of care
D) Separates outcome criteria from the plan of care
3. When a nurse assists a postoperative patient to the chair, which type of nursing intervention does this represent?
4. A nurse is demonstrating foley catheter care to a patient. Which type of nursing intervention does this best represent?
5. A treatment based on a nurses clinical judgment and knowledge to enhance patient outcomes is a nursing:
6. The most basic level of nursing interventions is
7. What are specific measurable and realistic statements of goal attainment?
A) Nursing diagnoses
B) Nursing interventions
D) Outcome criteria
8. When establishing patient outcomes with the patient, what is the qualifier in the outcome?
A) The short-term goal
B) The long-term goal
C) The problem statement
D) The outcome parameter
9. What is the purpose of the patient outcome?
A) To address the problem in the nursing diagnosis
B) To evaluate the plan of care developed
C) To provide a basis for the scientific rationale
D) To coordinate the nursing intervention
10. For the postoperative patient, which of the following nursing diagnoses will require outcome identification that could contribute to a maladaptive postoperative recovery?
B) Ineffective breathing patterns
C) Alteration in bowel elimination
Chapter 14- Implementation and Evaluation
1. A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every two to three hours by age 1 week. The mother presents to the follow-up center at 1 week and reports the she discontinued breastfeeding. The nurse evaluates the original goal as:
B) Partially met
C) Completely unmet
D) Inappropriately chosen for this patient
2. A patient with a recently fractured left femur has been reluctant to comply with his physical therapy for fear of the pain associated with movement. A goal for this patient is to attend therapy treatments three times each day. The nurse is evaluating the goal for this patient. The patient states, I dont like therapy, it hurts, but I have been going twice a day. The patient chart has an entry from the last shift nurse stating the patient went to therapy two times with encouragement. The nurse evaluates the goal as:
A) Goal met
B) Goal partially met
C) Goal completely unmet
D) New diagnoses have developed
E) Goal revision needed
3. The nurse is assessing the patients behavioral response to a nursing intervention. This type of evaluation is known as:
A) Structural evaluation
B) Behavior modification
C) Outcome evaluation
D) Process evaluation
E) Goal evaluation
4. The nursing supervisor is presenting the staff nurse with her yearly performance evaluation. This type of evaluation would be called:
A) outcome evaluation
B) technical evaluation
C) structural evaluation
D) process evaluation
E) goal evaluation
5. The nursing supervisor is evaluating how many patients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:
6. Which of the following describe the purpose of evaluation? Select all that apply.
A) To examine the patients behavioral responses to nursing interventions
B) To appraise the extent to which patient goals were attained or problems resolved
C) To appraise involvement and collaboration of the patient, family members, nurses, and healthcare team members in healthcare decisions
D) To ensure the plan of care was followed as it was originally prepared
E) To collect subjective and objective data to make judgments about nursing care delivered
7. After the nursing plan of care has been developed, the nurse knows:
A) each encounter with the patient is an opportunity to reassess and revise the plan of care if necessary.
B) the plan will be followed by other healthcare providers and filed with the patients chart upon discharge.
C) the responsibility for the assessment of the patient has ended.
D) care plans are rigid and do not change.
E) the plan of care can only be changed by the nurse who developed it.
8. Which of the following are the two priority nursing diagnoses?
A) Risk for infection
C) Acute Pain
D) Ineffective Airway Clearance
E) Feeding Self-Care Deficit
9. The primary purpose for evaluating data about a patients care according to a functional health approach is to
A) Meet accreditation standards
B) Determine implementation of medical orders
C) Evaluate the need for healthcare consultations
D) Revise or modify the nursing care plan
10. When a nursing supervisor evaluates the staff nurses performance with a group of patients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation?
A) Outcome evaluation
B) Summary evaluation
C) Structure evaluation
D) Process evaluation
Chapter 15- Documentation and Communication in the Healthcare Team
1. Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?
A) If I make an error, I can draw a red circle around it.
B) If I make an error, I have to rewrite the entire entry.
C) If I make an error, I draw a single line through it and put my initials by it.
D) If I make an error, I place an X through it.
E) If I make an error, I use white-out on it.
2. The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, I dont want to live anymore. I am a burden on everyone. I dont feel like doing anything at all. I dont even want to get up today. Which of the following should the nurse record in his charting? Select all that apply.
A) Patient is crying.
B) Patient states, I dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today.
C) Patient seems depressed.
D) Patient is suicidal.
E) Patient is in a bad mood.
3. The patient states, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurses charting? Select all that apply.
A) Seems angry today
B) Unhappy with his care
C) Arms are folded across his chest and brow is furrowed
D) States, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today.
E) Refuses to allow morning vital sign measurements
4. Which of the following describe best practices for charting? Select all that apply.
A) Use long narratives to be sure your documentation is understood
B) Always use complete sentences
C) Use only approved abbreviations
D) Always use the patients name and words referring to the patient in each entry
E) Use partial sentences and phrases
5. Which of the following should the nurse include in his/her charting? Select all that apply.
A) The nursing assistant reports the patients breath smelled of alcohol.
B) I feel something is going on she is not telling me.
C) The patient was overheard telling his family about more bleeding than he has reported to his physician.
D) The incision is oozing a small amount of red blood.
E) The patients pupils are dilated.
6. The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.
A) Access to records outside of the patients home facility
B) Increased accuracy of treatment for the patient outside their home facility
C) Easier access to data for research
D) Increased incidence of identity theft
E) Greater accuracy and improved patient care
A benefit of computer-based records would not be to increase the incidence of identity theft.
7. The patient record is utilized for many purposes. Which of following might be uses for the patient record?
A) Education of student nurses
B) Reimbursement for services
D) Giving information over the phone when unidentified callers call the hospital unit
E) Education for medical students
8. The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurses shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?
A) Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition.
B) No, but it will relieve the nurse of any wrongdoing.
C) No, if the blood pressure measurement was not documented, it did not happen.
D) Yes, the nurse was not on duty when the stroke occurred.
9. Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?
A) Vital sign sheet
B) Intake and output sheet
C) Critical care flow sheet
D) Health assessment flow sheet
10. Charting in which the nurse writes a progress note that relates to one health problem is a
A) PIE note
B) Flow sheet
C) Narrative note
D) SOAP note
Chapter 16- Health Assessment
1. A parent of a school age child is told her child has normal vision. The school nurse explains the childs vision is
2. Peripheral cyanosis and clubbing of the nails are symptoms of
A) Normal aging
B) Increased cholesterol
D) Chronic hypoxia
3. A nurse auscultates the right carotid artery in an elderly client and identifies a bruit. What does this assessment finding mean?
A) It is normal
B) It is distended
C) It is dissecting
D) It is inflamed
4. To assess an adult clients hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the
A) Front of the ear
B) Mastoid process
C) Top of the head
D) Affected ear
5. A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called
6. When performing a cranial nerve assessment on an adult client, the nurse assesses the trigeminal nerve by
A) Asking the client to smile
B) Eliciting the clients gag reflex
C) Having the client turn his head
D) Eliciting the clients blink reflex
7. To assess a clients visual accommodation, the nurse has the client
A) Stand 20 feet from the Snellen chart
B) Sit still while a penlight is shined at the pupil
C) Look straight ahead with one eye covered
D) Look at a close object, then at a distant object
8. While assessing a 48-year-old clients near vision, you can anticipate the client will state that her vision is
9. When percussing the liver, the sound should be
10. During a health assessment, the nurse uses deep palpation to assess a clients
A) Skin turgor
B) Finger nodules
Chapter 17- Vital Signs
1. The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the babys pulse is 140 beats per minute. The parent is concerned, stating, That seems kind of high! The nurse responds:
A) Yes, this is termed tachycardia. I will let the doctor know right away.
B) Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow.
C) I know it seems fast, but normal infant heart rates are 100-160 beats per minute.
D) Yes, this is termed tachypenia. I will let the doctor know right away.
2. A patient has had a left-side mastectomy. How does this affect the blood pressure assessment?
A) Assess the blood pressure in the wrist
B) There is no effect on the blood pressure
C) Assessment of blood pressure is impeded
D) The blood pressure stays within normal range
3. A patient has smoked most of his life and has labored respirations. He is experiencing
4. Patients demonstrating apnea have
A) Usually have a temporary cessation of breathing
B) Decreased rate and depth of respirations
C) Increased rate and depth of respirations
D) Normal respiratory rate of 20
5. A pulse deficit is the difference between
A) The systolic and diastolic blood pressure readings
B) Palpated and auscultated blood pressure readings
C) The radial pulse and the ulnar pulse rates
D) The apical pulse and the radial pulse rate
6. An adult pulse greater than 100 beats per minute is
7. An ultrasonic Doppler is used for
A) Auscultating a pulse that is difficult to palpate
B) Auscultating diastolic blood pressure
C) Aiding palpation of pulse and rhythm
D) Aiding palpation of diastolic blood pressure
8. A nurse can most accurately assess a patients heart rate and rhythm by which of the following methods?
A) Listen with the stethoscope at the fifth intercostals space left mid-clavicular line
B) Listen with the stethoscope at the fifth intercostals space at the sternum
C) Listen with a stethoscope at the neck to the right of the cricoid process
D) Listen with a stethoscope at the second intercostal space left sternum
9. A nurse is assessing an apical pulse on a cardiac patient. The patient is taking digoxin. The nurse can anticipate that the digoxin will
A) Decrease the blood glucose
B) Decrease the blood volume
C) Decrease the apical pulse
D) Decrease the respiratory rate
10. Infants and childrens pulses vary most with
Chapter 18- Asepsis and Infection Control
1. The nurse explains to the patient the first line of defense against infection is:
A) frequent hand washing with soap and water.
B) early intervention with antibiotics.
C) staying home when sick.
D) intact skin and mucous membranes.
E) low levels of normal flora.
2. A patient has an inguinal hernia repair and later develops a methicillin-resistantStaphylococcus aureus infection. What is the most important factor to prevent this infection?
A) Surgical asepsis
B) Increased T cells
C) Decreased antibiotics
D) Increased vitamin C
3. A patient has a draining wound that is contaminated with Staphylococcus aureus. The nurse should observe
A) Droplet precautions
B) Universal precautions
C) Reverse precautions
D) Body-substance isolation
4. When the patient who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is
A) Droplet precautions
B) Universal precautions
C) Reverse precautions
D) Body-substance isolation
5. Disinfectants are used
A) To prepare instruments for surgery
B) To sterilize surgical drapes
C) To clean rooms between patients
D) For preoperative bowel preparations
6. Surgical asepsis is defined as
A) Absence of all virulent microorganisms
B) Absence of all microorganisms
C) Slowed growth of microorganisms
D) Use of handwashing, gowning, and gloving
7. To eliminate needlesticks as potential hazards to nurses, the nurse should
A) Place the uncapped needle on a tray, carry it to the medicine room for disposal
B) Immediately deposit uncapped needles into puncture-proof plastic container
C) Stick the uncapped needle into a Styrofoam block and deposit in a plastic container
D) Slide the needle into the cap and deposit it in a puncture-proof plastic container
8. To protect the school-age children from communicable disease, the school nurse maintains records on the childrens
9. What is the most common patient site for development of nosocomial infections?
A) Surgical wound
B) Respiratory tract
D) Urinary tract
10. When a nurse picks up a patients contaminated tissue without gloves and fails to wash his hands sufficiently, the nurse provides for the patients organisms to be spread by which type of transmission?
Chapter 19- Medication Administration
1. When administering heparin subcutaneously, the nurse should
A) Aspirate after injection
B) Aspirate before the injection
C) Vigorously massage the site
D) Never aspirate
2. When the nurse administers the morning dose of a medication during the evening, which of the rights of medication administration has she failed to follow?
3. Childrens medication dosages are most often calculated using the childs body surface area and
4. Drugs known to cause birth defects are called
A) Pregnancy sensitivity
B) Umbilical cross
5. A severe allergic reaction from a medication requires
6. Following an allergic reaction to a medication, the nurse should
A) Instruct the patient to wear an identification addressing the allergy
B) Instruct the patient to be sure the allergy is on his medical record
C) Inform the patient that an allergic reaction can be transient
D) Inform the patient that the medication may cause an allergy only one time
7. When the patient demonstrates a rash 30 minutes after she has taken a dose of penicillin, the nurse recognizes that the patient is likely demonstrating which type of drug reaction?
8. Which of the following patients is likely to have altered metabolism of medications?
A) School-age children
C) Middle adults
9. What is involved in the absorption, distribution, metabolism, and excretion of medication?
10. The physiologic and biochemical effects of a drug on the body defines
Chapter 20- Intravenous Therapy
1. The nursing instructor is discussing IV fluid overload with the nursing students. Which of the following will the nurse include in her discussion? Select all that apply.
A) The use of packed cells instead of whole blood will decrease the fluid volume delivered to the patient.
B) A symptom of fluid overload is distended neck veins.
C) The patient will likely develop a fever in the presence of fluid overload
D) Fluid overload is more likely in very young children
E) The infusion rate must be carefully monitored during the administration of blood.
2. The nurse is administering blood to the patient. During the infusion, the patient reports a headache and feeling very tired. Which of the following will the nurse do first?
A) Notify the physician
B) Notify the blood bank
C) Check the patients vital signs
D) Check the patients temperature
E) Stop the infusion
3. The chemotherapy patient has been admitted for thrombocytopenia. Which of the following blood products will the nurse anticipate administering?
B) Fresh frozen plasma
C) Whole blood
D) Packed cells
E) White blood cells
4. A patient with chronic anemia is admitted for the administration of blood. Which of the following would the nurse expect the physician to order?
A) Whole blood
B) Packed cells
C) White blood cells
E) D5W 1000 mL
5. A 2-year-old child has been injured in a motor vehicle accident and is in immediate need of a blood transfusion for profuse bleeding. Which of the following access sites might the nurse expect to use for the infusion?
B) Dorsalis pedis
C) Great saphenous vein
D) Scalp vein
E) Intraosseous access
6. The nurse is discussing epidural analgesia with the nursing student. Which of the following statements by the nursing student indicate a need for additional education?
A) Epidural analgesia is always administered in a continuous infusion to prevent or treat the patients pain.
B) The patient may be able to control the epidural analgesia infusion.
C) The epidural analgesia may be used in the laboring patient.
D) The epidural is always discontinued after delivery of the newborn.
7. The charge nurse on the medical/surgical unit is reviewing physician orders for a patient with a diagnosis of congestive heart failure. Which of the following infusion orders would the nurse question?
A) 50 mL D5W to run in 60 minutes
B) 250 mL 0.9 NaCl to run in 60 minutes
C) 1000 D5W to run in 30 minutes
D) 20 mL 0.9 NaCl to run in 20 minutes
8. Which of the following are required to manually regulate an IV drip? Select all that apply.
A) A clock
B) A minimum of 1000 cc of fluid
C) Tubing with a roller clamp
D) An antecubital access site
9. The nurse is preparing to insert an intravenous needle in a 1-year-old child for a one-time administration of fluids due to dehydration. Which of the following needles would the nurse likely select?
A) A 22-gauge intravenous catheter
B) A 19-gauge winged infusion set
C) A 23-gauge winged infusion set
D) An 18-gauge intravenous catheter
10. A patient suffers from a genetic bleeding deficiency. What blood product will be administered?
A) Whole blood
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