In the assessment phase of the teaching process what are you assessing? Learning needs of patient

What happens when we admit a patient to the hospital what’s going on in the admission process?

Provide better care Characteristics of critical thinking, when you are critically thinking you want to

Know what’s important in that given situation Patient has had surgery that their pain is a 9/10 and isn’t time to give them meds?

Diversion activities or explore other options With professional standards what influences a nurse’s critical thinking making?

Critical thinking for the highest quality of care Pt. with fractured hip. His discharge was delayed because he developed pneumonia. He had a fever with respiratory distress. They diagnosed his pneumonia through chest x-ray. What type of infection did he have?

Health care associated infection What happens if you have a child and as a parent they swallowed a hard candy for example?

Aspirate it into the lung What test might you do to confirm if the kid has the candy into the lungs?

X-ray When you are checking respiratory rate on a patient how would you do that?

Discretely count while doing their heart rate and continue to act like taking pulse. Watching the rise and fall of the chest

What type of exposure are you using a n95 mask for?

Airborne Symptoms of systemic infections? SELECT ALL THAT APPLY

Fever, fatigue, lack of appetite You have a patient and their HR is racing to 160. What might you instruct the patient to do?

Vagal response will stimulate the nervous system so you bear down.

Why do we do good foot care on a diabetic patient? Diabetic neuropathy, poor circulation, loss of sensation

When you give a cleansing enema before a surgery, what would be the maximum amount of fluid given to a 55 yr old patient.

750-1000 If you have a patient that is having a seizure what might you do?

Clear the area if you need to, safe environment You have a patient and they wonder around at night what might you do?

Accommodate by checking patient frequently What do we do when a patient is falling?

Slide them down your body When assessing a patient with CHF what might you hear?

Crackles, edema +2, weight gain+5lbs in three days, blood pressure increase When patients get patients get up out of bad and their blood pressure drops?

Orthostatic hypotension Patient with left sided weakness and they’re unable to do ADLS

Self care deficit Patient has nutriotional deficit, what might you instruct your patient to eat?

Complete protein, like eggs If you have a pressure ulcer and it has necrotic tissue can it be staged?

Unsteagable Patient needs to learn to use a walker, what type of domain?

Psychomotor domain Urinary catherization and the person is having trouble being in position what might you do?

Lay them on their side Doctor writes order for force clear liquids to prevent fluid electrolyte imbalance what might you give?

Give bullon broth Patients with SOB and suffer from anxiety, What might you do? Select all that apply?

Instruct patient with purse lip breathing, and elevate bed to semi fowler position

Condom catheter how much space do you need from the penis and catheter?

1-2 inch space If you have a patient that their wound is getting worse what you would do is call who?

Call wound care nurse Wounds that heal by primary intention leave what type of scaring?

Minimal scaring When going to a procedure what might you do?

Find experienced nurse, go through policy and procedure, and ask questions Evidence-based practice is a problem-solving approach to clinical practice that involves the conscientious use of current best evidence, along with clinical expertise and patient preferences and values, in making decisions about patient care.

The difference between hand washing and surgical scrub is when you do surgical scrub you have to hold the hands up

When you do a sterile dressing change you have to be sure that the packets are not damaged, the expiration date, and the packets have no discolor

When an elderly patient is going to take a tub bath make sure to check the temperature of the water first

Assessment: HR 88, RR 29, BP 150/86, T 99.2, O2 Priority nursing diagnoses when the patient is hemolized- ineffective airway

clearance Bed bound which patient is more affected? 72 year old with hip fracture Patient with glaucoma, when the have bowel movement have to be cautious

because of the increasing of the ayes pressure. Vasauvar maneuver When you administer an enema for bowel movement the tube must be

lubricated and inserted 3-4 inches Check dorsalis pedis pulse before and during TED(thrombo embolitic device) When you do the first dress changing after a patient had surgery what do you

need to report immediately? Bleeding coming out Patient taking off bed pan if you see something coming out ask for history of

hemorrhoids To ensure safety in artificial denture care, use paper towel and wash clothes

14.The nurse is caring for a client newly diagnosed with type 2 diabetes mellitus. Which of

the following nursing interventions best reflects Orem’s nursing theory? 1. Arranging for a consult with a certified diabetic nurse educator 2. Demonstrating proper documentation of glucose testing results 3. Explaining the role of A1C values in the management of glucose levels 4. Preparing discharge teaching to reinforce proper finger-stick technique

ANS: 4 If a nurse uses Orem’s theory in practice, the nurse assesses and interprets the data to determine the client’s self-care needs, self-care deficits, and self-care abilities in the management of a disease. The theory then guides the design of individualized nursing interventions. While the other interventions are appropriate and will ultimately affect effective client self-care/management of the diabetes, they are not the correct option because they are not directly involved in determining client self-care needs.

1.The nursing instructor is teaching a class on nursing theory. One of the students asks,

“Why do we need to know this stuff? It doesn’t really affect patients.” The instructor’s best response would be 1. “You are correct, but we have to learn it anyway.”

2. “Exposure to theories will help you later in graduate school.”

3. “Theories help keep the focus of nursing narrow.”

4. “Theories help explain why nurses do what they do.”

ANS: 4 Theories offer well-grounded rationales or reasons for how and why nurses perform specific interventions. Learning about theories is important because these theories help to describe, explain, predict, and/or prescribe nursing care measures. Although nursing theory will help the nurse in graduate school, it is also an important basis for the nurse’s approach to daily patient care, and it expands scientific knowledge of the profession.

3.The type of theory that is used to develop and test specific nursing interventions is known

as _____ theory. 1. Grand 2. Prescriptive 3. Descriptive 4. Middle-range

ANS: 2 Prescriptive theories are action oriented and test the validity and predictability of a nursing intervention. These theories guide nursing research to develop and test specific nursing interventions. Grand theories are broad in scope and complex, and require further specification through research. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. The phenomena within middle-range theories tend to cross different nursing fields and reflect a wide variety of nursing care situations.

5.The student nurse is learning nursing theories but fails to see how they relate to the

nursing process. The professional nurse realizes that nursing theory 1. Has a minor role in professional nursing. 2. Requires the nursing process to develop knowledge. 3. Can direct how a nurse uses the nursing process.

4. is specific to certain patients only.

ANS: 3 Nursing theory can direct how a nurse uses the nursing process. Integration of theory into practice serves as the basis for professional nursing. The nursing process provides a systematic process for the delivery of care, not the knowledge component of the discipline. Useful theories are adaptable to different patients and to all care settings.

9.Many aspects of nursing theory are based on developmental theories because human

growth and development is believed to be 1. Erratic and difficult to predict. 2. An orderly predictive process. 3. An orderly process until adulthood. 4. Unpredictable during childhood.

ANS: 2 Human growth and development is an orderly predictive process that begins with conception and continues through death. It is not erratic or difficult to predict. It does not stop at adulthood and is not unpredictable during childhood.

8.The patient is admitted to the ICU to rule out a myocardial infarction (MI). During the

admission process, the patient is noted to have a history of methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and the patient declared noninfectious. During the isolation process, the nurse encourages family visits, realizing that which level of Maslow’s hierarchy of needs is at risk? 1. First level 2. Second level 3. Third level

4. Fourth level 5. Fifth level

ANS: 3 The third level contains love and belonging needs, including friendship, social relationships, and sexual love. The first level includes physiological needs. The second level includes safety and security needs. The fourth level encompasses esteem and self-esteem needs. The fifth and final level is the need for self-actualization.

15.The patient is newly diagnosed with diabetes and will be discharged in the next day or

so. The nurse is teaching the patient how to draw up and self-administer his insulin. Which nursing theory is the nurse utilizing? 1. Watson’s philosophy of transpersonal caring

2. Orem’s self-care deficit theory

3. Rogers’ theory

4. Henderson’s theory

ANS: 2 The goal of Orem’s theory is to help the patient perform self-care. In Watson’s theory, the nurse is concerned with promoting and restoring health and preventing illness. Rogers’ theory considers the individual as an energy field coexisting within the universe. Henderson defines nursing as “assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge.”

1.To provide patient care of the highest quality, nurses utilize an evidence-based practice

approach because evidence-based practice is 1. A guide for nurses in making clinical decisions. 2. Based on the latest textbook information. 3. Easily attained at the bedside. 4. Always right for all situations.

ANS: 1 Evidence-based practice (EBP) is a guide for nurses to structure how to make accurate, timely, and appropriate clinical decisions. A textbook relies on the scientific literature, which is often outdated by the time the book is published and is not the most reliable source for EBP. Unfortunately, most of the best information in evidence never reaches the bedside. EBP is not to be blindly applied without using good judgment and critical thinking skills. It is not appropriate for all settings.

3.The first step in evidence-based practice is to ask a clinical question. In doing so, the nurse

needs to realize that in researching interventions, the question 1. Is more important than its format. 2. Will lead you to hundreds of articles that must be read. 3. May be easier if in PICO format. 4. May be more useful the more general it is.

ANS: 3 The PICO format allows the nurse to ask questions that are intervention focused. Inappropriately formed questions will likely lead to irrelevant sources of information. It is not beneficial to read hundreds of articles. It is more beneficial to read the best four to six articles that specifically address the question. The more focused the question asked, the easier it will become to search for evidence in the scientific literature.

1.Caring is central to nursing practice, but technological advances for rapid diagnosis and

treatment should lead the nurse to realize that 1. Technology has replaced caring as nurses’ primary focus. 2. Technology and caring cannot coexist when related to patient care. 3. Technology becomes a powerful tool when it works with caring. 4. Caring is the essence of nursing and is isolated from technology.

ANS: 3 Technological advances become dangerous without a context of skillful and compassionate care. It is time to value and embrace caring practices and expert knowledge (technology), which are the heart of competent nursing practice. Neither technology nor caring can stand alone. They must coexist to provide ultimate patient care.

3.With respect to the concept of caring, most nursing theories

1. Embrace the disease orientation to health care as Watson does. 2. Recognize Leininger’s theory and reject culture as a caring force. 3. Identify caring as highly relational involving patient and nurse. 4. Stress the universality of the expression of caring.

ANS: 3 Nursing caring theories have common themes. Caring is highly relational. Caregiving relationships open up possibilities or close them down. Watson’s transpersonal caring theory rejects the disease orientation to health care and places care before cure. Leininger stresses the importance of nurses’ understanding of cultural caring behaviors. Caring is very personal, thus expression of caring differs for each patient.

6.The nurse is admitting a patient who will be having elective surgery. The nurse spends

over an hour asking the patient questions as part of the admission process. What is the nurse’s primary reason for doing this? 1. It is hospital protocol and part of the admission process. 2. The nurse is trying to make the patient more comfortable. 3. This will help the nurse provide better care for the patient. 4. The nurse needs the time to give a detailed description of what to expect.

ANS: 3 Focusing on building a relationship that allows the nurse to learn what is important to the patient helps the nurse to identify a patient’s unique perceptions and expectations. Knowing who patients are helps the nurse select caring approaches that are most appropriate to patients’ needs. Learning what is important to patients may determine how much description is needed.

1.Critical thinking characteristics include

1. Considering what is important in a given situation. 2. Accepting one, established way to provide patient care. 3. Making decisions based on intuition. 4. Being able to read and follow physician’s orders.

ANS: 1 Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physician’s orders is not considered a critical thinking skill.

11.A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? 1. Explain to the patient that nothing else has been ordered. 2. Explore other options for pain relief. 3. Offer to notify the health care provider after morning rounds are completed. 4. Discuss the surgical procedure and reason for the pain.

ANS: 2 The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

16.A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse

displays the critical thinking attitudes of humility and responsibility by 1. Refusing the assignment. 2. Asking for an orientation to the unit. 3. Assuming that patient care will be the same as on the other units. 4. Admitting lack of knowledge and going home.

ANS: 2 Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

17.Professional standards influence a nurse’s clinical decisions by

1. Bypassing the patient’s feelings to promote ethical standards. 2. Establishing minimal passing standards for testing. 3. Requiring the nurse to use critical thinking for the highest level of

quality nursing care. 4. Utilizing evidence-based practice based on nurses’ needs.

ANS: 3 Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patient’s feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses’ needs.

2.A nurse using the problem-oriented approach to data collection will first

1. Complete an observational overview. 2. Disregard cues and complete the database questions in chronological order. 3. Focus on the patient’s presenting situation. 4. Make accurate interpretations of the data.

ANS: 3 A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

5.A patient expresses fear of going home and being alone. Her vital signs are stable and her

incision is nearly completely healed. The nurse can infer from the subjective data that 1. The patient can now perform the dressing changes herself. 2. The patient can begin retaking all her previous medications. 3. The patient is apprehensive about discharge. 4. Surgery was not successful.

ANS: 3 Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

15.A new graduate nurse is not sure what the heart sound is that she is listening to on a

patient. To avoid diagnostic error, what should the nurse do? 1. Assign the nursing diagnosis of Decreased cardiac output. 2. Ask the patient if he has a history of cardiac problems before assigning the

diagnosis of Decisional conflict. 3. Check the previous shift’s assessment and document what was noted on the

last shift. 4. Ask a more experienced nurse to listen also.

ANS: 4 The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient’s status can change very rapidly. A nurse who copies the previous shift’s assessment is not practicing according to standards of practice and is violating the code of ethics.

6.The nurse is concerned that atelectasis may develop as a postoperative complication.

Which of the following is an appropriate diagnostic label for this problem, should it occur? 1. Impaired gas exchange 2. Decreased cardiac output 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

ANS: 1 A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis.

22.Which of the following would be the best example of a short-term safety goal for a client

who recently experienced abdominal surgery? 1. The client will show no systemic or local signs of infection by time of

discharge from hospital. 2. The client will demonstrate an understanding of the proper use of patient-

controlled analgesia (PCA). 3. The client will demonstrate effective coughing and deep-breathing techniques

within 2 hours of surgery. 4. The client will consistently use the call bell to notify the staff of a need

for assistance to the bathroom upon return to the nursing unit.

ANS: 4 Although all the options represent short-term goals, this option (consistently use the call bell to notify the staff) is directly related to client safety because it deals with fall prevention. Although this is short-term goal (by time of discharge), it is not as directly related to safety as some other options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as directly related to safety as some other options. Although this is short-term goal (2 hours), it is not as directly related to safety as some other options.

2.A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is

ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by 1. Asking physical therapy to assist the patient because of the new injuries. 2. Disregarding all previous diagnoses and establishing a new plan of care. 3. Reassessing the patient. 4. Setting new priorities for the patient.

ANS: 3

The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.

3.When planning patient care, a goal can be described as

1. A statement describing the patient’s accomplishments without a time restriction.

2. A realistic statement predicting any negative responses to treatments. 3. A broad statement describing a desired change in patient behavior. 4. An identified long-term nursing diagnosis.

ANS: 3 A goal is a broad statement that describes a desired change in a patient’s condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic.

4.Before implementing any intervention, the nurse uses critical thinking to

1. Determine whether an intervention is correct and appropriate for the given situation.

2. Evaluate the effectiveness of interventions. 3. Establish goals for a particular patient without the need for reassessment. 4. Read over the steps and perform a procedure despite lack of clinical

competency.

ANS: 1 Before implementing any intervention, the nurse uses critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment because patient conditions can change very rapidly. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse.

5.Which of the following is a nursing intervention?

1. The patient will ambulate in the hallway twice this shift using crutches correctly.

2. Impaired physical mobility related to inability to bear weight on right leg

3. Provide assistance while the patient walks in the hallway twice this shift with crutches.

4. The patient is unable to bear weight on right lower extremity.

ANS: 3

Providing assistance to a patient who is ambulating is a nursing intervention. The statement, “The patient will ambulate in the hallway twice this shift using crutches correctly” is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

8.What is the primary goal of outcomes management for professional nurses?

1. To promote purposeful actions focused on improving a patient’s health condition

2. To fine-tune nursing assessment skills

3. To support the delegation of more nursing tasks to nursing assistive personnel

4. To decrease the number of medication errors in nursing

ANS: 1 The primary goal of outcomes management is to improve a patient’s health status. Assessment skills probably will be improved if a nurse focuses on improving patient outcomes, but this is not the primary goal. Delegating to nursing assistive personnel is not the primary goal of outcomes management. Reducing medication errors is a possible result of outcomes management, but it is not the primary goal.

1.In which step of the nursing process does the nurse determine if the patient’s condition

has improved and whether the patient has met expected outcomes? 1. Assessment

2. Planning

3. Implementation

4. Evaluation

ANS: 4 In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes. Assessment, the first step of the process, includes data collection, validation, sorting, and documentation. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and prescribing nursing interventions. During implementation, nurses initiate nursing care, which is necessary to help patients achieve their goals.

4.Which statement indicates that the nurse has a good understanding of teaching/learning?

1. “Teaching and learning can be separated.”

2. “Learning is an interactive process that promotes teaching.”

3. “Learning consists of a conscious, deliberate set of actions designed to help the teacher.”

4. “Teaching is most effective when it responds to the learner’s needs.”

ANS: 4

Teaching is most effective when it responds to the learner’s needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

8.While preparing a teaching plan, the nurse described what the learner will be able to

accomplish after the teaching session. Which action did the nurse complete? 1. Developed learning objectives

2. Provided positive reinforcement

3. Implemented interpersonal communication

4. Presented facts and knowledge

ANS: 1 Learning objectives describe what the learner will be able to do after successful instruction. Positive reinforcement follows feedback and involves the use of praise and acknowledgment of new attitudes, behaviors, or knowledge. Interpersonal communication is necessary for the teaching/learning process, but describing what the learner will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be presented in the teaching session.

9.A student nurse learns that a normal adult heartbeat is 60 to 100 beats/minute. In which

domain did learning take place? 1. Kinesthetic

2. Cognitive

3. Affective

4. Psychomotor

ANS: 2 Cognitive learning includes all intellectual behaviors and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. The student nurse acquired knowledge, which is cognitive. Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Psychomotor learning involves acquiring skills that require integration of mental and muscular activities, such as the ability to walk or to use an eating utensil.

16.A nurse is teaching the staff about nursing and teaching processes. Which information

should the nurse include regarding the teaching process? During the teaching process, what should the nurse do? 1. Assess all sources of data. 2. Identify that it is the same as the nursing process. 3. Perform nursing care therapies. 4. Focus on a patient’s learning needs.

ANS: 4

The teaching process focuses on the patient’s learning needs and willingness and capability to learn. Nursing and teaching processes are not the same. All the rest are components of the nursing process: Assess all sources of data and perform nursing care therapies.

15.The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the

nurse to consider the need for restraint? 1. The patient refuses to call for help to go to the bathroom. 2. The patient continues to remove the nasogastric tube. 3. The patient gets confused regarding the time at night. 4. The patient does not sleep and continues to ask for items.

ANS: 2 Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

16.The nurse is discussing with a patient’s physician the need for restraint. The nurse

indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? 1. The patient continues to get up from the chair at the nurses’ station. 2. The patient apologizes for being “such a bother.”

3. The patient folds three washcloths over and over. 4. The sitter leaves the patient alone to go to lunch.

ANS: 3 Offering diversionary activities such as something to hold is a way to keep the hands busy and provides an alternative to restraints. Assigning a room near the nurses’ station or a chair at the desk can be an alternative for continuous monitoring. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to keep him occupied can be an alternative to restraints, but the sitter needs to be continuous.

28.A confused patient is restless and continues to try to remove his oxygen and urinary

catheter. What is the priority nursing diagnosis and intervention to implement for this patient? 1. Risk for injury: Prevent harm to patient, use restraints if alternatives

fail. 2. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary

catheter. 3. Disturbed body image: Encourage patient to express concerns about body. 4. Caregiver role strain: Identify resources to assist with care.

ANS: 1

The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurses’ station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient’s caregiver is strained.

30.The nurse enters the patient’s room and notices a small fire in the headlight above the

patient’s bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? 1. Activate the alarm. 2. Extinguish the fire. 3. Remove the patient. 4. Confine the fire.

ANS: 3 Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation.

20.The nurse is preparing to assist with a sterile procedure in the surgical suite. An

appropriate technique that the nurse includes in the surgical scrub is to: 1. Keep the hands below the elbows throughout the scrub 2. Use a brush on the palms and dorsal surface of the hands 3. Maintain the scrub for at least 2 to 5 minutes 4. Wash well around all jewelry

ANS: 3 A surgical scrub should be maintained for at least 2 to 5 minutes. To avoid contamination during a surgical hand scrub, the nurse holds the hands above the elbows. Several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially when an alcohol-based product is used. For maximum elimination of bacteria, all jewelry should be removed.

1.The posterior hypothalamus helps control temperature by

1. Causing vasoconstriction. 2. Shunting blood to the skin and extremities. 3. Increasing sweat production.

4. Causing vasodilation.

ANS: 1 If the posterior hypothalamus senses that the body’s temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production.

3.The patient has a temperature of 105.2° F. The nurse is attempting to lower his

temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient’s temperature through the use of 1. Radiation. 2. Conduction. 3. Convection. 4. Evaporation.

ANS: 2 Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

16.While the nurse is assessing the patient’s respirations, it is important for the patient to

1. Be aware of the procedure being done. 2. Not know that respirations are being assessed. 3. Understand that respirations are estimated to save time. 4. Not be touched until the entire process is finished.

ANS: 2 Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

4.The charge nurse is reviewing a patient’s plan of care, which includes the nursing

diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? 1. Nursing diagnosis

2. Etiology

3. Patient chief complaint

4. Defining characteristic

1.The structure that is responsible for returning oxygenated blood to the heart is the 1. Pulmonary artery. 2. Pulmonary vein. 3. Superior vena cava. 4. Inferior vena cava.

3.The nurse knows that the primary function of the alveoli is to 1. Carry out gas exchange. 2. Store oxygen. 3. Regulate tidal volume. 4. Produce hemoglobin.

9.While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate? 1. Left-sided heart failure

2. Right-sided heart failure

3. Atrial fibrillation

4. Myocardial ischemia

24.What assessment finding is the earliest sign of hypoxia? 1. Restlessness

2. Decreased blood pressure

3. Cardiac dysrhythmias

4. Cyanosis

2.The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.

The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is 1. Pressure. 2. Resistance. 3. Stress. 4. Weight.

4.The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? 1. Stage I pressure ulcer

2. Healing stage II pressure ulcer

3. Healing stage III pressure ulcer

4. Stage III pressure ulcer

2.Chemical receptors that stimulate inspiration are located in the

1. Brain. 2. Lungs. 3. Aorta.

4. Heart.

7.The nurse would expect to see increased ventilations if a patient exhibits 1. Increased oxygen saturation. 2. Decreased carbon dioxide levels. 3. Decreased pH. 4. Increased hemoglobin levels.

14.A patient’s heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n) 1. Increase in diastolic filling time. 2. Decrease in cardiac output. 3. Increase in stroke volume. 4. Increase in contractility.

31.The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? 1. Encourage the patient to stay up to date on all vaccinations. 2. Inform the patient of the importance of finishing the entire dose of antibiotics. 3. Schedule patient to get annual tuberculosis skin testing. 4. Create an exercise routine to run 30 minutes every day.

6.A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include? 1. The nurse is the center of the health care team. 2. If you still do not understand, ask again. 3. Ask a nurse to be your advocate or supporter. 4. Inappropriate medical tests are the most common mistakes.

2.What is the involuntary motion of retracting the body from painful stimuli? 1. Sensation

2. Reception

3. Perception

4. Reaction

8.Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? 1. Self-care deficit

2. Risk for falls

3. Social isolation

4. Impaired physical mobility

9.A patient informs the nurse that she often becomes nauseated when riding in motor

vehicles. The nurse knows that this is related to which sensory deficit? 1. Neurological deficit

2. Visual deficit

3. Hearing deficit

4. Balance deficit

1.What is the most appropriate way to assess the pain of a patient who is oriented and has

recently had surgery? 1. Assess the patient’s body language. 2. Observe cardiac monitor for increased heart rate. 3. Ask the patient to rate the level of pain. 4. Ask the patient to describe the effect of pain on the ability to cope.

17.The nurse recognizes that which of the following is a modifiable contributor to a patient’s

perception of pain? 1. Age and gender

2. Anxiety and fear

3. Culture

4. Previous pain experience

22.The nurse knows that which technique is best for assessing pain in a child who is 4 years

of age? 1. Ask the parents if they think their child is in pain. 2. Use the FACES scale. 3. Ask the child to rate the level of pain on a 0 to 10 pain scale. 4. Check to see what previous nurses have charted.

8.A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? 1. Relaxation and guided imagery

2. Transcutaneous electrical nerve stimulation (TENS)

3. Herbal supplements with analgesic effects

4. Pudendal block

1.If obstructed, which component of the urination system would cause peristaltic waves?

1. Kidney

2. Ureters

3. Bladder

4. Urethra

3.A patient is experiencing oliguria. Which action should the nurse perform first? 1. Increase the patient’s intravenous fluid rate. 2. Encourage the patient to drink caffeinated beverages. 3. Assess for bladder distention. 4. Request an order for diuretics.

16.Which assessment question should the nurse ask if stress incontinence is suspected? 1. “Does your bladder feel distended?”

2. “Do you empty your bladder completely when you void?”

3. “Do you experience urine leakage when you cough or sneeze?”

4. “Do your symptoms increase with consumption of alcohol or caffeine?”

19.When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? 1. Bacteria

2. Casts

3. Crystals

4. Protein

1.The nurse knows that most nutrients are absorbed in which portion of the digestive tract?

1. Stomach

2. Duodenum

3. Ileum

4. Cecum

3.Which of the following is not a function of the large intestine? 1. Absorbing nutrients

2. Absorbing water

3. Secreting bicarbonate

4. Eliminating waste

20.The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be 1. Cloudy. 2. Discolored. 3. Sweet smelling. 4. Painful.

7.A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? 1. Administering laxatives to the patient

2. Raising the head of the bed

3. Preparing to administer a barium enema

4. Withholding narcotic pain medication

9.A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? 1. “This is probably a false negative; we should rerun the test.”

2. “Do you take iron supplements?”

3. “You should schedule a colonoscopy as soon as possible.”

4. “Sometimes severe stress can alter stool color.”

12.The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? 1. A 40-year-old patient with an ileostomy

2. A 25-year-old patient with Crohn’s disease

3. A 30-year-old patient with C. difficile

4. A 70-year-old patient with stool incontinence

1.A number of factors influence a patient’s personal preferences for hygiene. Because of this,

it is important for the nurse to realize that.. 1. No two individuals perform hygiene in the same manner. 2. It is important to standardize a patient’s hygienic practices. 3. Hygiene care is always routine and expected. 4. Hygiene is not the time to learn about patient needs.

6.When providing hygiene for an elderly patient, it is important for the nurse to closely assess the skin. This is because as the patient ages 1. Skin becomes more resilient. 2. Sweat glands become more active. 3. Skin becomes less subject to bruising. 4.

Less frequent bathing may be required.

10.Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is: 1. Client states side effects of a medication 2. Client responds appropriately to eye contact 3. Client independently plans an exercise program 4. Client demonstrates the proper use of a walking cane

ANS: 4 Determining whether the client is able to demonstrate a newly learned skill is an example of an evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity, such as walking with a cane. Having the client state side effects of a medication is an example of an evaluation of cognitive learning. Determining whether a client responds appropriately to eye contact is an example of evaluation of affective learning. The client who planned an exercise program is demonstrating cognitive learning.

8.When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean the area with mild soap, dry, and add a protective moisturizer. 2. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to

the area. 3. Soak the area in normal saline solution. 4. Wash the area with an astringent and paint it with povidone-iodine

(Betadine).

ANS: 1 The skin should be cleansed and completely dried and a protective moisturizer applied to keep the epidermis well lubricated. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the client’s risk for an accidental burn. The area should not be soaked because this may lead to maceration of the skin. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.

44.Wounds that heal by primary intention will most likely: 1. Have minimal scarring 2. Contain infected tissue 3. Present with ragged edges 4. Have portions of missing tissue

ANS: 1 Healing occurs by epithelialization; these wounds heal quickly with minimal scar formation.

49.A client presents with a pressure ulcer that the nurse is documenting in the medical

record. The nurse notes necrotic tissue on the pressure ulcer, which indicates that: 1. The pressure ulcer is automatically a stage IV 2. The pressure ulcer cannot be staged 3. The client has been abused 4. The pressure ulcer is healing

ANS: 2 Staging systems for pressure ulcers are based on describing the depth of tissue destroyed. Accurate staging requires knowledge of the skin layers, and a major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or removed to expose the wound base to allow for assessment. The necrotic tissue present on the pressure ulcer doesn’t necessarily indicate that the client has been abused, nor does it indicate that the wound is healing.

9.A client is getting up for the first time after a period of bed rest. The nurse should first:

1. Assess respiratory function 2. Obtain a baseline blood pressure 3. Assist the client with sitting at the edge of the bed 4. Ask the client if he or she feels light-headed

ANS: 2

When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure. Assessing the client’s respiratory function is not the nurse’s first intervention when getting a client up for the first time after prolonged bed rest. After the nurse assesses the client’s blood pressure, the nurse can assist the client to a sitting position at the side of the bed. After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels light-headed.

30.Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? 1. Lubricating the nares with water-soluble lubricant

2. Applying a small ice bag to the nose for 5 minutes every 4 hours

3. Instilling Xylocaine into the nares once a shift

4. Changing the tape holding the tube in place once a shift

ANS: 1 The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.

23.A condom catheter is to be used for an adult male client in the extended care facility. In

the application of the condom catheter, the nurse employs appropriate technique when: 1. Using sterile gloves 2. Wrapping the adhesive tape securely around the base of the penis 3. Leaving a 1- to 2-inch space between the tip of the penis and the end of

the catheter 4. Taping the tubing tightly to the thigh and attaching the drainage bag to the

bed frame

ANS: 3 A 1- to 2-inch space should be left between the tip of the penis and the end of the catheter. Nonsterile gloves are worn to apply a condom catheter. Standard adhesive tape should never be used to secure a condom catheter because it does not expand with change in penis size and is painful to remove. The tubing of a condom catheter is not taped tightly to the thigh. The drainage bag is attached to the lower bed frame.

15.The nurse is working with a client who has a urinary diversion. Included in the plan of care for this client is instruction that: 1. Special clothing will need to be ordered in order to fit around the diversion 2. A stomal bag will only need to be worn at night 3. A reduction in physical activity will be planned 4. Special skin care is a priority

ANS: 4 Special skin care is a priority in caring for a client with a urinary diversion. Local irritation and skin breakdown occur when urine comes in contact with the skin for long period. Special clothing is not necessary for the client with a urinary diversion, but the client must wear a stomal pouch continuously because there is no sphincter control for regulation of urine flow. There is no need to plan for a reduction in activity.

11.A client is seen in the outpatient clinic for follow-up of a nutritional deficiency. In planning for the client’s dietary intake, the nurse includes a complete protein, such as: 1. Eggs 2. Oats 3. Lentils 4. Peanuts

ANS: 1 A complete protein contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Eggs and meats are examples of complete proteins. Incomplete proteins lack one or more of the nine essential amino acids and include oats (cereals) and legumes (lentils and peanuts).

13.The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the following interventions does the nurse plan to include in the client’s care? 1. Assess nares for skin breakdown every 6 hours. 2. Check patency of the cannula every 2 hours. 3. Inspect the mouth every 6 hours. 4. Check oxygen flow every 24 hours.

ANS: 1 The nurse caring for the client with a nasal cannula should plan to assess the client’s nares and superior surface of both ears for skin breakdown every 6 hours. The nurse should check patency of the cannula every 8 hours. The nurse does not need to check the client’s mouth in relation to the client’s use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures. Oxygen flow should be checked every 8 hours, not every 24 hours.

49.A 47-year-old female client tells the nurse that her heart feels as though it is racing. The client’s pulse is 160 beats per minute. The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to: 1. Bear down as though she is having a bowel movement 2. Take a hot shower 3. Take a cold bath

4. Hold her breath

ANS: 1 Paroxysmal supraventricular tachycardia is a sudden rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. When needed, treatment includes vagal stimulation such as carotid sinus massage or Valsalva maneuver to decrease the ventricular response. A hot shower would cause the heart to beat faster in order to cool down the body. A cold bath could cause additional stress and would not be appropriate. Holding the breath will increase the heart rate as it compensates for the lack of oxygen intake and buildup of carbon dioxide.

30.The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change? 1. Decreased lung defense mechanisms may cause ineffective airway

clearance. 2. Thickening of the heart muscle wall decreases cardiac output. 3. Decreased lung capacity makes proper anesthesia induction more difficult. 4. Alterations in mental status prevent patients’ awareness of ineffective

breathing.

ANS: 1 The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction.

42.The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? 1. Suctioning respiratory secretions several times every hour

2. Administering humidified oxygen through a tracheostomy collar

3. Instilling normal saline into the tracheostomy to thin secretions before suctioning

4. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

ANS: 2 Humidification of air will help keep the mucous membranes moist and will make secretions easier to expel. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should never be instilled into a tracheostomy because this could lead to infection. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the physician.

12.A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: 1. Powerlessness 2. Self-care deficit 3. Tissue integrity impairment 4. Knowledge deficit of hygiene practices

ANS: 2 The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.

39.A nurse finds that an electrical cord has shorted out in a client’s room, causing a fire. The

nurse should do which of the following actions first? 1. Activate the alarm. 2. Confine the fire by closing the client’s door. 3. Remove the client from the room. 4. Extinguish the fire.

ANS: 3 The mnemonic RACE should be used to help remember to rescue or remove all clients in immediate danger, activate the alarm, confine the fire, and extinguish the fire