Term
1. The first practicing nurse epidemiologist was
a. Florence Nightingale.
b. Mildred Montag.
c. Clara Barton.
d. Mary Agnes Snively. |
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Definition
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Term
2. The American Red Cross was founded by
a. Florence Nightingale.
b. Harriet Tubman.
c. Clara Barton.
d. Mary Mahoney. |
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Definition
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Term
3. Nurses working in the Henry Street Settlement in 1893 were among the first nurses to demonstrate autonomy in practice. This was
because those nurses
a. Had no ability to work in the hospital setting.
b. Were required to use critical thinking skills.
c. Focused solely on healing the very ill.
d. Planned their care around research findings. |
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Definition
| Were required to use critical thinking skills. |
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Term
4. In 1923, the Goldmark Report was an important study that
a. Formed formal nurse midwifery programs.
b. Established the Center for Ethics and Human Rights.
c. Revised the ANA code of ethics.
d. Led to the development of the Yale School of Nursing. |
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Definition
| d. Led to the development of the Yale School of Nursing. |
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Term
The major difference between a baccalaureate degree nursing program and an associate’s degree nursing program is that the
baccalaureate program includes studies in
a. Basic sciences and theoretical courses.
b. Social sciences and humanities.
c. Theoretical and clinical courses.
d. Basic sciences and clinical courses. |
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Definition
| b. Social sciences and humanities. |
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Term
6. The nurse has been working in the clinical setting for several years as an advanced practice nurse and has earned her master’s
degree as a family nurse practitioner. However, she seems unfulfilled and has a strong desire to do research. To fulfill her desire, the
nurse most likely would apply to attend a program that would lead to a
a. Doctor of Nursing Science degree (DNSc).
b. Doctor of Philosophy degree (PhD).
c. Doctor of Nursing Practice degree (DNP).
d. Doctor in the Science of Nursing degree (DSN). |
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Definition
| b. Doctor of Philosophy degree (PhD). |
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Term
The nurse is caring for her patients and is focused on managing their care as opposed to managing and performing skills. This nurse
demonstrates which level of proficiency according to Benner?
a. Novice
b. Competent
c. Proficient
d. Expert |
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Definition
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Term
8. Which of the following resources guides faculty on structure and evaluation of the nursing curriculum?
a. ANA’s Standards of Nursing Practice
b. Essentials of Baccalaureate Education
c. NLNAC Interpretive Guidelines
d. Standards of Professional Performance |
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Definition
| . Essentials of Baccalaureate Education |
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Term
9. The nurse is caring for the patient who has had major abdominal surgery and also has a large sacral pressure sore. The nurse
implements coughing and deep breathing exercises and consults the wound care specialist to evaluate and prescribe care for the
pressure sore, even though no physician order has provided instructions to do so. In doing this, the nurse is implementing the
element of
a. Autonomy.
b. Accountability.
c. Advanced practice.
d. Nurse practitioner. |
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Definition
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Term
10. The physician is planning to take the patient to surgery in the morning and leaves an order for the nurse to get the patient to sign the
surgical permit. The physician’s note indicates that the patient has been educated on the procedure. However, the patient tells the
nurse, “I have no idea what he’s going to do. He rushed in and rushed out so fast, I couldn’t ask any questions.” The nurse does not
allow the patient to sign the permit and calls the physician to inform him of the patient’s statement. This is an example of the nurse
acting as
a. Patient advocate.
b. Patient educator.
c. Manager.
d. Clinical nurse specialist. |
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Definition
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Term
11. The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse midwife, she asks for a
referral to a pediatrician for the newborn. The nurse midwife should
a. Provide the referral as requested.
b. Offer to provide the newborn care.
c. Refer the patient to the supervising physician.
d. Tell the patient that she cannot make referrals. |
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Definition
| Offer to provide the newborn care. |
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Term
12. The student nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). It is important for the student to
understand that the CRNA
a. Works under the guidance of an anesthesiologist.
b. Manages acute medical conditions.
c. Manages gynecological services such as PAP smears.
d. Must have a PhD degree in anesthesiology. |
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Definition
| Works under the guidance of an anesthesiologist. |
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Term
The nurse is speaking in front of a group of ninth grade students about nursing as a profession. One student states that she does not
want to be a nurse because all nurses do is take care of sick people and play politics. The most appropriate response that the nurse
could give and expand on is that
a. Nursing is ideal for the person who hates politics.
b. Nursing focuses on curing the person’s disease.
c. Nursing is not political because it has its own knowledge base.
d. An area of nursing exists for every interest. |
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Definition
| An area of nursing exists for every interest. |
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Term
A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the
patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. The nurse realizes that
a. Legislation is politics beyond the nurse’s control.
b. National programs have no bearing on state politics.
c. The individual nurse can influence legislative decisions.
d. Focusing on nursing care provides the best patient benefit. |
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Definition
| The individual nurse can influence legislative decisions. |
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Term
During the American Civil War, which of the following women was active in the Underground Railroad movement and assisted in
leading more than 300 slaves to freedom?
a. Harriet Tubman
b. Clara Barton
c. Dorothea Dix
d. Mary Ann Ball (Mother Bickerdyke) |
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Definition
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Term
Graduates of baccalaureate degree or associate’s degree nursing programs are eligible to take which of the following to become
registered nurses in the state in which they will practice?
a. Continuing education credits
b. In-service education programs
c. National Council Licensure Examination
d. Graduate education |
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Definition
| National Council Licensure Examination |
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Term
Which concept means that the nurse is responsible, professionally and legally, for the type and quality of nursing care provided?
a. Autonomy
b. Accountability
c. Patient advocacy
d. Patient education |
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Definition
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Term
The nurse in the twenty-first century is facing an extremely complex profession with multiple external forces affecting the nursing
profession. Factors influencing the nursing profession include which of the following? (Select all that apply.)
a. Demography
b. Women’s health care
c. Human rights
d. The threat of bioterrorism
e. The medically underserved |
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Definition
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Term
After licensure, the practicing nurse is required to update his or her knowledge about the latest research and practice developments.
The most common way nurses do this is through _____ programs. (Select all that apply.)
a. Continuing education
b. Master’s degree
c. In-service education
d. DNP |
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Definition
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Term
Which of the following is (are) an example of an advanced practice nurse? (Select all that apply.)
a. Nurse practitioner
b. Clinical nurse specialist
c. Patient advocate
d. Certified registered nurse anesthetist
e. Nurse midwife |
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Definition
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Term
The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will
have to cancel one or two of its nurses. The orthopedic unit has agreed to “float” two of its nurses to the oncology unit if oncology
can “float” a nursing assistant to the orthopedic unit to help with obtaining vital signs. This is an example of (Select all that apply.)
a. Autonomy.
b. Accountability.
c. Political activism.
d. Politics. |
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Definition
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Term
The nurse is caring for a patient who is on Medicare. Because the patient is on Medicare, the nurse is aware that
a. The hospital will be paid for the full cost of the patient’s hospitalization.
b. Capitation provides the hospital with a means of recovering variable charges.
c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.
d. Medicare will pay the national average for the patient’s condition. |
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Definition
| Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. |
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Term
The advent of diagnosis-related groups (DRGs) and capitation has brought about many changes in how health care is provided and
paid for. Because of these changes, the nurse is aware that today’s managed care system has
a. Insured full coverage of health care costs.
b. Assumed all of the financial risk involved.
c. Allowed providers to focus on illness care.
d. Caused providers to focus on illness prevention. |
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Definition
| Caused providers to focus on illness prevention. |
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Term
A major outcome of managed care is that managed care organizations such as hospitals
a. Assume financial risk, as well as provide care.
b. Focus more on individual illness.
c. Decrease discharge planning activities.
d. Have increased lengths of stay. |
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Definition
| Assume financial risk, as well as provide care. |
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Term
Care designed to prevent further progression of a disease is termed
a. Primary prevention.
b. Secondary prevention.
c. Tertiary prevention.
d. Health promotion. |
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Definition
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Term
The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In doing so, the nurse is
applying for a position in _____care.
a. Secondary acute
b. Tertiary
c. Continuing
d. Restorative |
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Definition
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Term
The patient is to be discharged home from a tertiary care center later in the week; therefore, the nurse
a. Coordinates referral of patients to services provided by other disciplines.
b. Monitors the patient’s progress through discharge.
c. Cares for patients after discharge.
d. Anticipates and identifies patient needs. |
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Definition
| Anticipates and identifies patient needs. |
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Term
The nurse is serving on the hospital’s Quality Improvement Committee. As the nursing representative, the nurse focuses quality
improvement measures on
a. Outcomes unrelated to patient satisfaction.
b. Desired health outcomes.
c. Factors solely affecting inpatients.
d. Increasing patient-to-nurse ratios. |
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Definition
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Term
The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of information,
the nurse utilizes the
a. Healthcare Effectiveness Data and Information Set (HEDIS).
b. Centers for Medicaid and Medicare Services (CMS) standards.
c. Pew Health Professions Commission Report.
d. American Nurses Credentialing Center (ANCC) Magnet Recognition Program. |
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Definition
| a. Healthcare Effectiveness Data and Information Set (HEDIS). |
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Term
The student nurse is reporting to her group in post-conference about her observational rotation in the intensive care unit. The
student states that “it seems so much easier than floor nursing because everything is automated. There are machines that take vital
signs and regulate IVs.” The instructor’s best response is to
a. Agree with the student’s evaluation of ICU nursing.
b. Agree that IV pumps have made IV therapy totally safe.
c. Disagree, stressing the importance of taking vital signs themselves.
d. Disagree, stressing the importance of the nurse’s judgment. |
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Definition
| Disagree, stressing the importance of the nurse’s judgment. |
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Term
When the nurse first meets the patient, it is important to establish a dialogue if possible; patient-centered care stresses that it is
important for the nurse to recognize that
a. Patients usually want to rely on the nurse for patient care.
b. Patients usually want to keep their fears and concerns to themselves.
c. It is important to identify patient expectations.
d. Patients usually have insurance and do not worry about finances. |
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Definition
| It is important to identify patient expectations. |
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Term
In today’s society, the nurse is facing more and different challenges. Central to some of these challenges is the concept of
globalization, because it has led to
a. A more homogeneous mix of nursing staff.
b. Decreased poverty and increased diseases of affluence.
c. Decreased urbanization as populations shift to the suburbs.
d. Increased spread of communicable diseases. |
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Definition
| Increased spread of communicable diseases. |
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Term
The nurse is feeling overwhelmed by the constant changes that are part of nursing and the health care system in general.
Understanding that changes are necessary, the nurse needs to be aware that
a. The nurse has no control over the changes, but needs to accept them.
b. Quality improvement depends on active participation of nurses.
c. Belonging to nursing organizations will help bring the right changes.
d. Active participation in nursing organizations will have no effect on change. |
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Definition
| Quality improvement depends on active participation of nurses. |
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Term
Which of the following, established by Congress in 1983, eliminated cost-based reimbursement for patients who received Medicare
benefits?
a. Prospective payment system (PPS)
b. Professional standards review organizations (PSROs)
c. Utilization review (UR) committees
d. Capitation |
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Definition
| Prospective payment system (PPS) |
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Term
14. The setting of health care services that includes blood pressure and cancer screening is _____ care.
a. Secondary acute
b. Preventive
c. Tertiary
d. Restorative |
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Definition
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Term
Health promotion programs focus on
a. Reducing the cost of health care.
b. Controlling risk factors for disease.
c. Immunizations.
d. Occupational health programs. |
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Definition
| Reducing the cost of health care. |
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Term
The nurse is caring for a patient who has a diagnosis that she is not familiar with. The nurse uses reference materials and does a
literature search to better understand the diagnosis. The nurse then utilizes this knowledge, along with the nurse’s experience and
patient preferences, to develop a plan of care. This is an example of the nurse using _____ to provide care for her patient.
a. Evidence-based practice
b. Research-based practice
c. Applied quality improvement
d. Nursing informatics |
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Definition
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Term
Government-instituted programs designed to control health care costs include (Select all that apply.)
a. Professional standards review organizations (PSROs).
b. Prospective payment systems (PPSs).
c. Diagnosis-related groups (DRGs).
d. “Never events.”
e. Third-party payers. |
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Definition
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Term
Primary health care focus includes (Select all that apply.)
a. Individual health screenings.
b. Community health promotion programs.
c. Development of health policies.
d. Disease prevention in communities.
e. Discharge planning for individual patients. |
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Definition
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Term
The nurse is evaluating the Falls Program instituted on the medical unit to decrease the number of falls. The number of falls has
decreased in the last month. The nurse realizes that (Select all that apply.)
a. The program has been successful and can be terminated.
b. Policies for the program need to be developed or evaluated further.
c. The program evaluation is a nursing-sensitive outcome that can enhance safety.
d. The program results need to be reported to the QI Committee only. |
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Definition
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Term
Nurses who work in a skilled nursing facility need nursing expertise in which of the following areas? (Select all that apply.)
a. Gerontological nursing
b. IV fluid management
c. Ventilator management
d. Depression/violent behavior management
e. Wound care management |
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Definition
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Term
Public health nursing differs from community health nursing in that public health nursing
a. Focuses on individuals and families.
b. Understands the needs of a population.
c. Ignores political processes.
d. Considers the individual as one member of a group. |
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Definition
| Understands the needs of a population. |
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Term
A specialist in public health nursing requires
a. The same level of education as the community health nurse.
b. Preparation at the basic entry level.
c. An advanced degree regardless of public health experience.
d. A graduate level education with a focus in public health science. |
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Definition
| A graduate level education with a focus in public health science. |
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Term
The community health nurse differs from the community-based nurse in that the community health nurse
a. Understands the needs of the population.
b. Focuses on the needs of the individual.
c. Is the first level of contact in the health care system.
d. Involves the family in decision making. |
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Definition
| Understands the needs of the population. |
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Term
The type of nursing that focuses on acute and chronic care of individuals and families while enhancing patient autonomy is known
as _____ nursing.
a. Public health
b. Community health
c. Community-based
d. Community-focused |
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Definition
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Term
The community health nurse is administering flu shots to children at a local playground. In doing so, the nurse’s focus is on
a. Preventing individual illness.
b. Preventing community outbreak of illness.
c. Preventing outbreak of illness in the family.
d. The needs of the individual or family. |
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Definition
| Preventing community outbreak of illness. |
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Term
The community health nurse is providing counseling to a group of teenage girls related to birth control and disease prevention. The
nurse does this because
a. Focusing on subpopulations leads to community health.
b. Community health nursing focuses on individuals only.
c. Community health nursing excludes direct care to subpopulations.
d. The focus is on preventing illness and unwanted pregnancy. |
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Definition
| Focusing on subpopulations leads to community health. |
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Term
Community-based nursing care takes place in community settings such as the home or a clinic. Ideally, this is done to
a. Exert greater control over individual or family decisions.
b. Provide services close to where patients live.
c. Isolate patients and prevent the spread of disease.
d. Reduce the need for self-care. |
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Definition
| Provide services close to where patients live. |
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Term
The community-based nurse is caring for a patient who is home bound by arthritis and chronic lung problems. The patient, however,
receives many visitors from the neighborhood and from former coworkers, as well as frequent phone calls from extended family.
When concerned about how the large number of visitors may be fatiguing the patient, the nurse should
a. Restrict the number of visitors for the patient’s welfare.
b. Voice concerns to the patient and proceed according to the patient’s wishes.
c. Allow visitors to come and go freely as they have been.
d. Create visiting hours when the patient may see non–family members. |
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Definition
| Voice concerns to the patient and proceed according to the patient’s wishes. |
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Term
The student nurse is trying to determine what type of nurse she wants to be after graduation. In class, she states that community
health nursing is probably not for her because community nursing focuses only on community issues such as preventing epidemics.
The instructor’s most appropriate response would be that community health nursing
a. Focuses on the health care of individuals, families, and groups in a community.
b. Focuses only on the health of a specific subgroup in a community.
c. Requires an advanced nursing degree, so the student need not worry.
d. Focuses only on maintaining the health of the community. |
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Definition
| Focuses on the health care of individuals, families, and groups in a community. |
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Term
Vulnerable populations include those patients who are more likely to develop health problems as a result of
a. Pregnancy.
b. Nontraditional healing practices.
c. Excessive risk.
d. Unlimited access to health care. |
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Definition
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Term
The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, “Why
is it that not all poor people are considered members of vulnerable populations?” The instructor’s best answer would be
a. “All poor people are members of a vulnerable population.”
b. “Poor people are members of a vulnerable population only if they take drugs.”
c. “Poor people are members of a vulnerable population only if they are homeless.”
d. “Members of vulnerable groups frequently have a combination of risk factors.” |
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Definition
| “Members of vulnerable groups frequently have a combination of risk factors.” |
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Term
The nurse is making a home visit to a Korean family whose daughter gave birth 6 weeks earlier. She finds the daughter in bed with
a severe headache. The daughter’s father is holding her hand and is pressing different parts of the hand and lower arm. The mother
explains that the father is trying to cure the headache by using pressure points. The nurse’s best response would be to
a. Tell the father to stop and give the daughter Tylenol.
b. Ask the mother and/or father to explain the procedure.
c. Explain to the father that what he is doing will not work.
d. Let the father finish and then give the daughter Tylenol. |
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Definition
| Ask the mother and/or father to explain the procedure. |
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Term
The nurse is working in a community clinic when a man and woman bring a 12 year-old boy in, stating that the child fell down a
flight of stairs and hurt his arm. The nurse notices several other bruises on the child’s body at varying stages of healing. The boy is
placed on the stretcher. When asked how he hurt himself, he states that he does not remember. However, the nurse notices that the
boy continuously avoids looking at the man, while the man stares at him constantly. The nurse should
a. Ask the boy if the man hurt him.
b. Confront the man directly.
c. Ask the man and woman to step out.
d. Ask the woman if the man hurt the boy. |
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Definition
| Ask the man and woman to step out. |
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Term
The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse provides the
patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. The
competency of the counselor requires the nurse to
a. Insist that the patient speak with a “Right-to-Life” advocate.
b. Provide a referral to an abortion service.
c. Refuse to provide referral to an abortion service.
d. Delay referral to an abortion service. |
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Definition
| Provide a referral to an abortion service. |
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Term
The patient is in the hospital with the diagnosis of early-onset Alzheimer’s disease. Before the patient is discharged, the
community-based nurse is making a visit to the patient’s home, where he lives with his daughter and her family. A major focus of
this visit will be to
a. Demonstrate caregiver techniques for providing care.
b. Stress to the family how difficult it will be to provide care at home.
c. Encourage the family to send the patient to an extended care facility.
d. Teach the family how to have the patient declared incompetent. |
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Definition
| Demonstrate caregiver techniques for providing care. |
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Term
The community has three components: structure or locale, the people, and the social systems. While doing a community assessment,
the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is
evaluating which of the following?
a. Structure
b. Population
c. Welfare system
d. Social system |
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Definition
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Term
The patient is being readmitted to an inner city hospital for chest pain after being discharged 3 months earlier after having a heart
attack. The patient was referred to the hospital’s cardiac rehabilitation program after her previous admission. The patient states that
she began going to cardiac rehabilitation and liked it but stopped. When asked why, she states that, at the beginning, the classes
were at 9 AM, but then got switched to 7 PM, when it’s dark. The cardiac rehabilitation program was within walking distance of the
patient’s home. What is the most likely cause of the patient’s unwillingness to go to cardiac rehabilitation?
a. Lack of transportation
b. Fear of walking at night
c. Reimbursement issues
d. Noncompliance |
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Definition
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Term
Community-based nursing requires a strong knowledge base in which of the following? (Select all that apply.)
a. Family theory
b. Communication
c. Group dynamics
d. Focus on the individual
e. Cultural diversity |
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Definition
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Term
Community-based nursing centers function as the first level of contact between members of a community and the health care
delivery system. Ideally, health care services (Select all that apply.)
a. Are provided where patients live.
b. Reduce the cost of health care for the patient.
c. Provide direct access to nurses.
d. Exclude interference from family or friends. |
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Definition
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Term
Of the following list of patients, which would be considered at high risk to be members of a vulnerable population? (Select all that
apply.)
a. An immigrant who speaks only Chinese
b. An Hispanic truck driver who speaks limited English
c. A 22-year-old pregnant woman
d. A 15-year-old rape victim
e. A 40-year-old schizophrenic |
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Definition
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Term
An argument for passing “universal health care” legislation is that it would help fulfill the Healthy People 2020 goal of
a. Increasing quality of life in America.
b. Prolonging healthy life in America.
c. Eliminating health disparities in America.
d. Promoting healthy behaviors. |
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Definition
| Eliminating health disparities in America. |
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Term
To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is
a. Allowing people to continue current behaviors to reduce the stress of change.
b. Focusing only on individual health changes that will lead to better communities.
c. Creating social and physical environments that promote good health.
d. Focusing on illness treatment to provide fast recuperation. |
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Definition
| Creating social and physical environments that promote good health. |
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Term
According to the World Health Organization, what is the best definition for “health”?
a. Simply the absence of disease
b. Involving the total person and environment
c. Strictly personal in nature
d. Status of pathological state |
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Definition
| Involving the total person and environment |
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Term
The nurse is preparing a smoking cessation class and is amazed at how many people still smoke even with the information on lung
cancer so readily available. She believes that her class will convert many smokers to nonsmokers once they get all the latest
information. The nurse is a believer in which of the following health care models?
a. Health Belief Model
b. Health Promotion Model
c. Basic Human Needs Model
d. Holistic Health Model |
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Definition
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Term
The health care model that utilizes Maslow’s hierarchy as its base is the _____ Model.
a. Health Belief
b. Health Promotion
c. Basic Human Needs
d. Holistic Health |
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Definition
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Term
The patient is describing moderate incisional pain that was not relieved by the last dose of hydromorphone (Dilaudid) given 90
minutes earlier. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks
what type of music she likes, and puts on the music channel on the television, setting it to play that type of music. The nurse is
attempting to utilize which health care model?
a. Health Belief Model
b. Health Promotion Model
c. Basic Human Needs Model
d. Holistic Health Model |
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Definition
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Term
Many variables influence a patient’s health beliefs and practices. Internal and external variables influence how a person thinks and
acts. An example of an internal variable would be
a. Perception of functioning.
b. Family practices.
c. Socioeconomic factors.
d. Cultural background. |
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Definition
| Perception of functioning. |
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Term
The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6
months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a
nonjudgmental attitude. Why does the nurse do this?
a. Noncompliant patients thrive on the disapproval of authority figures.
b. External variables have little effect on compliance.
c. A person’s compliance is affected by economic status.
d. Employment status is an internal variable that impacts compliance. |
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Definition
| A person’s compliance is affected by economic status. |
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Term
The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the
community. In doing so, the nurse is fostering the concept of
a. Illness prevention.
b. Active health promotion.
c. Wellness education.
d. Passive health promotion. |
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Definition
| Passive health promotion. |
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Term
The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to
provide
a. Primary prevention.
b. Secondary prevention.
c. Tertiary prevention.
d. Diagnosis and prompt intervention. |
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Definition
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Term
The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness
of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments.
What level of preventive care is this patient receiving?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Health promotion |
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Definition
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Term
A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The
patient will be receiving physical therapy and speech therapy. What are these examples of?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Health promotion |
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Definition
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Term
Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and
lifestyle. The presence of any of these risk factors means that
a. A person with the risk factor will get the disease.
b. The chances of getting the disease are increased.
c. The disease is guaranteed not to develop if the risk factor is controlled.
d. Risk modification will have no effect on disease prevention. |
|
Definition
| The chances of getting the disease are increased. |
|
|
Term
The nurse is caring for a patient who has been trying to quit smoking. She has been smoke free for 2 weeks but had two cigarettes
last night and at least two this morning. What should the nurse anticipate?
a. The patient does not want to and never will quit smoking.
b. The patient will return to the contemplation or precontemplation phase.
c. The patient will need to adopt a new lifestyle for change to be effective.
d. The patient must pick up her attempt right where she left off. |
|
Definition
| The patient will return to the contemplation or precontemplation phase. |
|
|
Term
The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient who says that she wants to be
“detoxified.” It is important for the nurse to
a. Identify the patient’s stage of change.
b. Realize that the patient is ready to change.
c. Instruct the patient that she will have to change her lifestyle.
d. Instruct the patient that relapses are not tolerated. |
|
Definition
| Identify the patient’s stage of change. |
|
|
Term
The patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she
stopped dieting. She is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right
after the holidays, in 3 months. The nurse recognizes that the patient is in which stage of the change process?
a. Precontemplation
b. Contemplation
c. Preparation
d. Action |
|
Definition
|
|
Term
The patient has quit smoking and has been smoke free for the past 2 years. Of the following stages, which best fits her current stage
of change?
a. Contemplation
b. Preparation
c. Action
d. Maintenance |
|
Definition
|
|
Term
The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and his wife refuse to talk about it and
refuse to be taught about how to care for it. The nurse realizes that the patient and his wife are in which stage of adjustment?
a. Shock
b. Withdrawal
c. Acceptance
d. Rehabilitation |
|
Definition
|
|
Term
A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit
smoking. When approached by the nurse, he states that he would be “better off dead.” He states that he has always supported his
family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to
go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse
should
a. Develop a plan of care for the family.
b. Contact psychiatric services.
c. Assure the patient that things will work out.
d. Focus the plan of care on maximizing patient function. |
|
Definition
| Develop a plan of care for the family. |
|
|
Term
Just as health and health behavior are affected by internal and external variables, so are illness and illness behavior. Which external
variables can affect illness and behavior? (Select all that apply.)
a. Perception of the seriousness of the illness
b. Patient’s coping skills
c. Cultural background
d. Social support
e. Socioeconomic status |
|
Definition
|
|
Term
Models of health offer a perspective by which to understand the relationships between the concepts of health, wellness, and illness.
Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health because nurses (Select all
that apply.)
a. Understand the challenges of today’s health care system.
b. Identify actual and potential risk factors.
c. Have coined the term “illness behavior.”
d. Can minimize the effects of illness and assist to the return of optimal health |
|
Definition
|
|
Term
To promote parent-child attachment with a healthy newborn, what should the nurse do?
a. Encourage close physical contact as soon as possible after birth.
b. Do not allow the newborn to remain with parents until the second hour after
delivery.
c. Never leave the newborn alone with the mother during the first 8 hours after
delivery.
d. Isolate the newborn in the nursery during the first hour after delivery. |
|
Definition
| Encourage close physical contact as soon as possible after birth. |
|
|
Term
The nurse knows that the mother of a newborn understands associated health risks to her baby when she states
a. “I need to moisten the umbilical cord every hour during the day until the cord falls
off.”
b. “I need to remind anyone who wants to hold the baby to wash their hands.”
c. “I need to leave the blankets off the baby to prevent smothering.”
d. “I can throw away the bulb syringe now because my baby is breathing on her
own.” |
|
Definition
| “I need to remind anyone who wants to hold the baby to wash their hands.” |
|
|
Term
The priority assessment immediately after birth is to
a. Assess infant-parent interactions.
b. Promote parent-newborn physical contact.
c. Open the airway.
d. Assess gestational age. |
|
Definition
|
|
Term
Immediate intervention is needed when the newborn exhibits
a. A soft, protuberant abdomen.
b. Molding.
c. Lack of reflexes.
d. Cyanotic hands and feet. |
|
Definition
|
|
Term
Normal physical findings in a healthy newborn include
a. Sporadic motor movements.
b. Cyanosis of the feet and hands for the first 48 hours.
c. Triangle-shaped anterior fontanel.
d. Weight of 4800 grams. |
|
Definition
| Sporadic motor movements. |
|
|
Term
The nursing instructor will need to provide further instruction to the student who states, “Development proceeds
a. In a proximal-distal pattern.”
b. In a cephalocaudal pattern.”
c. At a slower rate during the embryonic stage.”
d. At a predictive rate from the moment of conception.” |
|
Definition
| At a slower rate during the embryonic stage.” |
|
|
Term
When comparing physical growth patterns between school-aged children and adolescents, the nurse notes that
a. Physical growth usually slows during the adolescent period.
b. Boys usually exceed girls in height and weight by the end of the school years.
c. Secondary sex characteristics usually develop during the adolescent years.
d. The distribution of muscle and fat remains constant during the adolescent years. |
|
Definition
| Secondary sex characteristics usually develop during the adolescent years. |
|
|
Term
A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at
birth. What finding indicates that the child needs further assessment?
a. Height of 30 inches
b. Weight of 16 pounds
c. The infant is not yet potty-trained.
d. The infant is not yet walking up stairs. |
|
Definition
|
|
Term
Which of the following is characteristic of the cognitive changes in a preschooler?
a. The ability to think in a logical manner about the here and now
b. The ability to think abstractly and deal effectively with hypothetical problems
c. The inability to assume the view of another person and to use symbols to
represent others
d. The ability to classify objects by size or color |
|
Definition
| The ability to classify objects by size or color |
|
|
Term
The nursing instructor will need to provide further instruction to the student who uses which of these statements when describing
the differences between cognitive and psychosocial development in children?
a. “The preschooler develops the ability to play in small groups.”
b. “The toddler may participate in parallel play.”
c. “The school-aged child still requires total assistance in all activities for safety.”
d. “The toddler period is a time of potential frustration manifested by temper
tantrums.” |
|
Definition
| “The school-aged child still requires total assistance in all activities for safety.” |
|
|
Term
The nurse is observing his 2-year-old hospitalized patient in the playroom. The nurse is most likely to observe the child
a. Participating as the leader of a small group activity.
b. Sitting beside another child while playing with blocks.
c. Separating building blocks into groups by size and color.
d. Seeking out same sex children to play with. |
|
Definition
| Sitting beside another child while playing with blocks. |
|
|
Term
When communicating with a newly admitted teenaged patient, the nurse should
a. Avoid questioning the patient about cigarette use when she observes a cigarette
lighter lying on the bedside table.
b. Complete the admission database as quickly as possible by asking yes and no
questions.
c. Ignore the patient’s withdrawn behavior.
d. Observe for congruency between the patient’s facial expressions and verbal
responses. |
|
Definition
Observe for congruency between the patient’s facial expressions and verbal
responses. |
|
|
Term
During infant/child development, play is best recognized as
a. A means to interact with the environment and relate to others.
b. Independent of cognitive and social development.
c. Nonexploratory and simply play.
d. Too soon to achieve milestones. |
|
Definition
| A means to interact with the environment and relate to others. |
|
|
Term
Which statement by the nurse best explains the importance of play during the toddler stage of development?
a. “Exploration can suppress the toddler’s curiosity to promote safety.”
b. “Parental control during play will eliminate the frustration of learning
self-control.”
c. “Play can enhance cognitive and psychosocial development.”
d. “Play will enhance the toddler’s ability to explore the environment safely without
supervision.” |
|
Definition
| “Play can enhance cognitive and psychosocial development.” |
|
|
Term
After comparing appropriate play activities for infants and preschool children, the nurse should appropriately offer which of the
following activities to an infant?
a. Set of cards to organize and separate into groups
b. Set of plastic stacking rings
c. Paperback book
d. Set of sock puppets with movable eyes |
|
Definition
| Set of plastic stacking rings |
|
|
Term
A mother expresses concern because her 5-year-old child frequently talks about friends who don’t exist. What is the nurse’s best
response to this mother’s concern?
a. “Have you considered a child psychological evaluation?”
b. “It’s very normal for a 5-year-old child to have imaginary playmates.”
c. “You should stop your child from playing electronic games.”
d. “Pretend play is a sign your child watches too much television.” |
|
Definition
| t’s very normal for a 5-year-old child to have imaginary playmates.” |
|
|
Term
Encouraging children to play a game of kickball would be best suited for which age group?
a. Infant
b. Toddler
c. Preschool
d. School-aged |
|
Definition
|
|
Term
Which of these manifestations, if identified in a school-aged child during a routine assessment, should a nurse associate with a
possible developmental delay or problem?
a. Withdrawn demeanor and verbalizes that he has no friends
b. Absence of secondary sex characteristics
c. Lack of peer relationships
d. Curiosity about his or her sexuality |
|
Definition
| Withdrawn demeanor and verbalizes that he has no friends |
|
|
Term
The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of a
infant’s developmental needs when he states
a. “My child is too young to understand words.”
b. “My child will begin to speak in sentences by 1 year of age.”
c. “My child will probably enjoy playing peek-a-boo.”
d. “While my child is in the hospital, I should let the nurses provide most of the
care.” |
|
Definition
| “My child will probably enjoy playing peek-a-boo.” |
|
|
Term
During hospitalization, the nurse should encourage the parents of an 8-month-old infant to
a. Provide as much care as possible.
b. Not worry about attachments because the infant is too young to develop them.
c. Remember that infants cannot differentiate a stranger from a familiar person.
d. Relax and allow nursing staff to care for the child at all times. |
|
Definition
| Provide as much care as possible. |
|
|
Term
The nursing student correctly explains health promotion teaching points for parents of toddlers when she states
a. “Setting consistent, firm limits will help the child cope with the frustration of
learning self-control.”
b. “Slower development of motor skills prevents the child from participating in
self-care activities.”
c. “Toddlers have a natural sense of right and wrong and know when they do
something wrong.”
d. “Temper tantrums should never be tolerated, and toddlers need to do what they
are told.” |
|
Definition
“Setting consistent, firm limits will help the child cope with the frustration of
learning self-control.” |
|
|
Term
The nursing student is preparing a teaching project for parents of school-aged children. Which statement correctly identifies health
risks in this age group?
a. “School-aged children are more likely to suffer from unintentional injury.”
b. “The risk for infection is not a major concern of this age group as immunity
develops.”
c. “Mental retardation, learning disorders, and malnutrition are prevalent across all
socioeconomic categories.”
d. “Poor nutrition and lack of immunizations continue to be health concerns for
children of the poor.” |
|
Definition
Poor nutrition and lack of immunizations continue to be health concerns for
children of the poor.” |
|
|
Term
Which of these statements, if made by a parent, would require further instruction?
a. “I should not be surprised that my teenager has so many friends.”
b. “I get worried because my teenager thinks he’s indestructible. He takes a lot of
risks.”
c. “I should cover for my school-aged child when he makes a mistake until he learns
the ropes.”
d. “My 10-year-old child is always hungry right after school, so I usually fix him a
nutritious snack.” |
|
Definition
“I should cover for my school-aged child when he makes a mistake until he learns
the ropes.” |
|
|
Term
Which of these toys, if selected by the parent of a 10-month-old child, would indicate that the parent has a correct understanding of
infant growth and development?
a. A game requiring two to four players
b. Electronic games
c. Small, plastic alphabet letters and magnets
d. Plastic stacking rings |
|
Definition
|
|
Term
The nurse should instruct the parents of an adolescent about which of the following health concerns? (Select all that apply.)
a. Signs of substance abuse
b. Suicide prevention
c. Safe sex practices
d. Pregnancy
e. Gonadotropic hormone stimulation
f. Voice changes |
|
Definition
|
|
Term
Despite significant improvements in the overall health status of the U.S. population over the past few decades, disparities among
ethnic and racial minorities have
a. Decreased as education levels equal those of non-Hispanic whites.
b. Disappeared in relation to non-Hispanic white populations.
c. Remained a serious challenge locally and nationally.
d. Decreased faster than anticipated. |
|
Definition
| Remained a serious challenge locally and nationally. |
|
|
Term
Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has become one of the
two most important priorities of Healthy People 2020 because populations with health disparities have
a. Increased incidence of disease.
b. Lower levels of morbidity.
c. Lower mortality rates.
d. Decreased incidence of disease. |
|
Definition
| Increased incidence of disease. |
|
|
Term
According to the Office of Minority Health (OMH), the thoughts, communications, actions, customs, beliefs, values, and
institutions of racial, ethnic, religious, or social groups are known as
a. Culture.
b. Subculture.
c. Ethnicity.
d. Cultural backlash. |
|
Definition
|
|
Term
When asked to describe the differences between ethnicity and race, what should the student nurse explain?
a. Ethnicity refers to a shared identity, whereas race is limited to biological
attributes.
b. Ethnicity and race are actually the same and are based in cultural norms.
c. Ethnicity can be understood only through an ethic worldview.
d. Race refers to a shared identity, whereas ethnicity is limited to biological
attributes. |
|
Definition
Ethnicity refers to a shared identity, whereas race is limited to biological
attributes. |
|
|
Term
Care that includes the nurse learning about cultural issues involved in the patient’s health care belief system and enable patients and
families to achieve meaningful and supportive care is known as
a. Ethnocentrism.
b. Culturally competent care.
c. Cultural imposition.
d. Culturally congruent care. |
|
Definition
| Culturally competent care. |
|
|
Term
The nurse is caring for a Native American who has had recent surgery. In the patient’s culture, it is a sign of weakness to complain
of pain. In the nurse’s culture, people who are having pain ask for pain medicine. The nurse has assumed that the patient has not
been having pain and does not need medication because he has not complained of pain. What is the nurse doing?
a. Utilizing cultural imposition by not asking the patient about his pain
b. Striving to provide culturally congruent care by allowing the patient to suffer
c. Operating from an emic worldview of the patient’s cultural beliefs
d. Practicing discrimination by not giving the patient pain medicine |
|
Definition
| Utilizing cultural imposition by not asking the patient about his pain |
|
|
Term
In performing a cultural assessment, knowledge of a patient’s country of origin and its history and ecological contexts is known as
a. Ethnohistory.
b. Biocultural history.
c. Social organization.
d. Religious and spiritual beliefs. |
|
Definition
|
|
Term
The nurse is caring for a patient of Asian descent who speaks very little English. The nurse is especially concerned and attempts to
develop a trusting relationship with the patient. She does this knowing that
a. Cultural assessment needs to be done quickly to provide the best care early.
b. Miscommunication cannot be tolerated in cultural assessment.
c. The goal is to get the patient to conform to American health care norms.
d. Cultural assessment is intrusive in contrast to other types of interviews. |
|
Definition
| Cultural assessment is intrusive in contrast to other types of interviews. |
|
|
Term
The nurse is caring for a patient who has emigrated from another country. The patient is in need of abdominal surgery but seems
reluctant to sign the surgical permits. What is one tactic that the nurse should use?
a. Determine the family social hierarchy.
b. Encourage the patient to sign the permits.
c. Call the physician so that surgery can be canceled.
d. Impress on the patient that her life is in jeopardy. |
|
Definition
| Determine the family social hierarchy. |
|
|
Term
The nurse is caring for a Chinese patient who is reluctant to answer questions about her health background. The nurse asks the
patient if she would like her husband present when health questions are asked. The nurse does this knowing that the Chinese culture
is a collectivistic and patrilineal culture. What does this mean?
a. Kinship extends to both the father’s side and the mother’s side of the family.
b. Kinship is limited to the side of the father.
c. Kinship is limited to the side of the mother.
d. The husband becomes part of the wife’s clan after marriage. |
|
Definition
| Kinship is limited to the side of the father. |
|
|
Term
The nurse is caring for a patient who does not speak English. She decides to use an interpreter to explain procedures and to answer
questions that the patient may have. In performing the interview, what should the nurse do?
a. Direct questions to the interpreter to ask the patient.
b. Disregard the age and gender of the interpreter.
c. Direct questions to the patient.
d. Ask the interpreter to ask the patient for clarification at the end. |
|
Definition
| Direct questions to the patient. |
|
|
Term
Which statement is true relative to caring for a Hindu patient who is dying?
a. The family will turn his head eastward or to the right.
b. A close kin will stay with the patient to hear his last wishes.
c. Anointing of the sick is a common right of the dying.
d. The family will place a drop of water on the patient’s lips. |
|
Definition
| The family will place a drop of water on the patient’s lips. |
|
|
Term
In comparing American culture with Asian cultures, which of the following statements is true?
a. American culture supports collectivism.
b. Asian communication can be ambiguous.
c. American communication patterns downplay autonomy.
d. Asian communication is direct to avoid conflict. |
|
Definition
| Asian communication can be ambiguous. |
|
|
Term
When caring for a patient of a different culture, it is important for the nurse to understand that
a. The nurse should protect the patient from family intrusion in her health care
decisions.
b. Working within the established family hierarchy produces better outcomes.
c. Women as primary caregivers make independent health decisions.
d. Gender is not a factor when it comes to role expectations. |
|
Definition
| Working within the established family hierarchy produces better outcomes. |
|
|
Term
The nurse is caring for a member of the Jewish faith who needs to undergo a critical procedure on Saturday. The patient is refusing
the procedure because it is scheduled to be done on the Sabbath. The nurse impresses on the patient the urgency of the procedure,
stating that delaying the procedure would put his life at risk. The patient continues to refuse. What should the nurse do?
a. Cancel the procedure.
b. Seek permission from the patient to contact the patient’s rabbi.
c. Have a family member sign the permit.
d. Have the procedure done against patient wishes. |
|
Definition
| Seek permission from the patient to contact the patient’s rabbi. |
|
|
Term
The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are
acceptable, the wife continues to interrupt with statements like, “Oh, he doesn’t eat that,” or, “All he eats is rice and beans.” What
should the nurse do?
a. Ask the wife to leave so he/she can focus on teaching the patient.
b. Explain how “rice and beans” are not acceptable foods on a diabetic diet.
c. Provide a diet plan with only food alternatives selected by the patient.
d. Refer the patient and his wife to a dietitian familiar with Spanish food choices. |
|
Definition
| Refer the patient and his wife to a dietitian familiar with Spanish food choices. |
|
|
Term
Providing culturally congruent care means providing care that
a. Fits the patient’s valued life patterns and set of meanings.
b. Is based on meanings generated by predetermined criteria.
c. Is the same as the values of the professional health care system.
d. Holds one’s own way of life as superior to those of others. |
|
Definition
| Fits the patient’s valued life patterns and set of meanings. |
|
|
Term
Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. These modes are “cultural
care preservation or maintenance,” “cultural care accommodation,” and “cultural care repatterning.” When assessing patients during
the admission process, the nurse utilizes
a. These action modes in a distinct order.
b. These action modes individually, one at a time.
c. Only one action mode per patient.
d. All these action modes simultaneously. |
|
Definition
| All these action modes simultaneously. |
|
|
Term
Compare the following statements. Which are considered predominant in non-Western cultures? (Select all that apply.)
a. Causes of illness are biomedical in nature.
b. Illness is an imbalance between humans and nature.
c. Caring patterns are based in self-care and self-determination.
d. Diagnoses are described as holistic.
e. Treatment of disease can be magico-religious based. |
|
Definition
|
|
Term
Foster (1976) identified two distinct categories of healers cross-culturally. Of the following characteristics, which are congruent
with the healing practices of naturalistic practitioners? (Select all that apply.)
a. Illness is impersonal and is due to biological forces.
b. Illness is caused by alterations in the body equilibrium.
c. Sorcerers can cause health and illness.
d. Human relationships should be emphasized.
e. Healing modalities include herbs, massage, and surgery. |
|
Definition
|
|
Term
When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient’s
behavior. From a growth and development perspective, what should the nurse recall?
a. Individuals have uniform patterns of growth and development.
b. Health is promoted based on how many developmental failures a patient
experiences.
c. Culture usually has no effect on predictable patterns of growth and development.
d. When individuals experience repeated developmental failures, inadequacies
sometimes result. |
|
Definition
When individuals experience repeated developmental failures, inadequacies
sometimes result. |
|
|
Term
The nursing instructor will need to provide further instruction to the student who states
a. “Intellectual development is affected by cognitive processes.”
b. “Socioemotional processes can influence an individual’s growth and
development.”
c. “Breast development is an example of a change resulting from biological
processes.”
d. “An individual’s biological processes determine physical characteristics and do
not affect growth and development.” |
|
Definition
An individual’s biological processes determine physical characteristics and do
not affect growth and development.” |
|
|
Term
Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and
developmental delays?
a. “How many times per week do you exercise?”
b. “Are you able to stand on one foot for 5 seconds?”
c. “Would you please describe your usual activities during the day?”
d. “How many hours a day do you spend watching television or sitting in front of a
computer?” |
|
Definition
| “Would you please describe your usual activities during the day?” |
|
|
Term
The nurse knows that a priority reason for being knowledgeable about biophysical developmental theories is to
a. Understand how the physical body grows.
b. Predict definite patterns of cognitive development.
c. Anticipate how patients’ social behaviors develop.
d. Describe the process of psychological development. |
|
Definition
| Understand how the physical body grows. |
|
|
Term
While assessing an 18-month-old toddler, the nurse distinguishes normal from abnormal findings by remembering that Gesell’s
theory of development states
a. “The developmental stage of the toddler is affected solely by environmental
influence.”
b. “Developmental patterns are not affected by gene activity.”
c. “Skill development should be identical to that of other toddlers in the playroom.”
d. “Environmental influence does not affect the sequence of development.” |
|
Definition
| “Environmental influence does not affect the sequence of development.” |
|
|
Term
When utilizing Freud’s psychoanalytical/psychosocial theory, the nurse recalls that
a. Adult personality is the result of resolved conflicts between sources of sexual
pleasure and the mandates of reality.
b. Development occurs throughout the life span and focuses on psychosocial stages.
c. The genital stage precedes the phallic stage of development.
d. Problems evident in adult life are due to early successes and resolution of earlier
developmental stages. |
|
Definition
Adult personality is the result of resolved conflicts between sources of sexual
pleasure and the mandates of reality. |
|
|
Term
The nurse is teaching a young adult couple about promoting the health of their 8-year-old child. The nurse knows that the parents
understand the developmental stage their child is in according to Erikson when they state, “We should
a. Provide proper support for learning new skills.”
b. Encourage devoted relationships with others.”
c. Limit choices and provide harsh punishment for mistakes.”
d. Not leave our child at school for longer than 3 hours at a time.” |
|
Definition
| Provide proper support for learning new skills.” |
|
|
Term
Jean Piaget’s cognitive developmental theory focuses on four stages of development, including
a. Formal operations.
b. Intimacy versus isolation.
c. Latency.
d. The postconventional level. |
|
Definition
|
|
Term
According to Piaget’s formal operations level, a 13-year-old adolescent will likely
a. Hit other students to deal with environmental change.
b. Use play to understand her surroundings.
c. Question her parents about an upcoming presidential election.
d. Question where the ice is hiding when ice has melted in her drink. |
|
Definition
| Question her parents about an upcoming presidential election. |
|
|
Term
According to Piaget’s theory of cognitive development, the nurse should allow a hospitalized 4-year-old patient to safely play with
a. The pump administering intravenous fluids.
b. The blood pressure cuff.
c. A baseball bat.
d. A book to read alone in a quiet place. |
|
Definition
|
|
Term
Which of these manifestations, if identified in a 6-year-old patient, should the nurse associate with a possible developmental delay
based on Piaget’s theory?
a. The child speaks in complete sentences but often talks only about himself.
b. The child still plays with a favorite doll that he has had since he was a toddler.
c. The child continues to suck his thumb.
d. The child describes an event from his own perspective, even though the entire
family was present. |
|
Definition
| The child continues to suck his thumb. |
|
|
Term
An 18-month-old patient is brought into the clinic for evaluation because the mother is concerned. The 18-month-old child hits her
siblings and says only “No” when communicating verbally. According to Piaget’s theory, what recommendation should the nurse
make a priority?
a. Consult the social worker because the child is hitting other children.
b. Reassure the mother that the child is developmentally within specified norms.
c. Encourage the mother to seek psychological counseling for the child.
d. Remove all toys from the child’s room until this behavior ceases. |
|
Definition
| Encourage the mother to seek psychological counseling for the child. |
|
|
Term
A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home. When approaching
this patient, which intervention should the nurse plan first?
a. Offer a reward for participation in all events.
b. Encourage the patient to attend all social events scheduled for the patients.
c. Allow the patient to incorporate personal belongings into her room.
d. Advise the patient of the importance of attending mandatory activities. |
|
Definition
| Allow the patient to incorporate personal belongings into her room. |
|
|
Term
The parents of a 14-year-old boy express concern over their child’s rebellious behavior. The nurse should plan to respond to the
parents’ concern by informing them that their
a. Child should be referred to a juvenile correctional facility.
b. Child’s behavior is normal because the adolescent is trying to adjust to his
emerging identity.
c. Child’s behavior is a matter of concern because he is likely conflicted about
establishing companionship with a partner.
d. Child’s behavior is expected because he is expressing his need to support future
generations. |
|
Definition
Child’s behavior is normal because the adolescent is trying to adjust to his
emerging identity. |
|
|
Term
The teaching plan for a 3-year-old child who is at risk for developmental delay should include which of these instructions for the
parents?
a. Encourage play as your child is exploring his or her surroundings.
b. Insist that your child discuss various points of view, not just his or her own.
c. Discuss world events with your child to foster language development.
d. Actively encourage your child to read lengthy books to expedite reading and
writing abilities. |
|
Definition
| Encourage play as your child is exploring his or her surroundings. |
|
|
Term
A nurse should instruct the parents of a 10-year-old child to keep which of the following theoretical principles in mind when
dealing with a behavioral problem at home?
a. Strategies that worked well with the first child will be equally as effective for the
second child.
b. Encourage the child to volunteer some time at a local hospital to instill a sense of
fulfillment.
c. Bargaining about chores in exchange for privileges may be an effective method of
encouraging helpful activities.
d. Do not offer praise for accomplishments and punishment for behavioral issues. |
|
Definition
Bargaining about chores in exchange for privileges may be an effective method of
encouraging helpful activities. |
|
|
Term
The parents of a 15-month-old child express concern to the nurse about their child’s thumb-sucking habit. Which of these
explanations related to the child’s age and developmental level would be most appropriate for the nurse to give the parents?
a. Thumb sucking at this age indicates a developmental delay and should be further
assessed.
b. Sucking achieves a pleasing result for infants, and generalizing that action by
thumb sucking is normal.
c. Thumb sucking at this age demonstrates a transition away from egocentric
thinking.
d. At this age, thumb sucking will enhance language development. |
|
Definition
Sucking achieves a pleasing result for infants, and generalizing that action by
thumb sucking is normal. |
|
|
Term
Which of these approaches would be most appropriate for the nurse to use when teaching a 4-year-old patient about a scheduled
surgery?
a. Give the parents a book to read about the procedure and do not discuss the
procedure with the child to decrease anxiety.
b. Set boundaries before teaching by telling the child that she can ask only three
questions because time is limited.
c. Insist that the parents wait outside the room to ensure privacy of the child.
d. Allow the child to touch and hold medical equipment such as thermometers and
syringes. |
|
Definition
Allow the child to touch and hold medical equipment such as thermometers and
syringes. |
|
|
Term
When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do?
(Select all that apply.)
a. Stick with one developmental theory for consistency.
b. Apply developmental theories when making observations of the individual’s
patterns of growth and development.
c. Compare the individual’s assessment findings versus established normal findings.
d. Recognize his/her own moral developmental level.
e. Apply a unidimensional life span perspective. |
|
Definition
|
|
Term
The nurse is planning playroom activities for a hospitalized 6-year-old patient. Which of the following age appropriate items that
the nurse should ensure are available? (Select all that apply.)
a. Crayons and paper
b. Children’s books
c. 500-piece puzzle
d. Building blocks
e. Magazines and newspapers |
|
Definition
|
|
Term
As the aging population in the United States increases, the nurse knows that the
a. Baby boomer generation accounts for a very small percentage of this group.
b. Extension of the average life span has also increased.
c. Population segment over age 85 is decreasing.
d. Diversity of this age group will certainly decrease. |
|
Definition
| Extension of the average life span has also increased. |
|
|
Term
As a patient ages, the nursing plan of care
a. Should be standardized because all geriatric patients have the same needs.
b. Needs to be individualized to the patient’s unique needs.
c. Should be based on chronological age alone.
d. Focuses on the disabilities that all aging persons face. |
|
Definition
| Needs to be individualized to the patient’s unique needs. |
|
|
Term
Which of these findings, if identified in a patient on a gerontological unit, would be most surprising to a culturally sensitive nurse?
a. The older person not being functionally independent
b. Preferences in food, music, and religion
c. Use of conventions of the handshake, silence, and eye contact
d. Personal health practices and spiritual resources |
|
Definition
| The older person not being functionally independent |
|
|
Term
Which of the following statements by a new graduate nurse should be corrected by an experienced nurse?
a. “Most older patients are ill and disabled. That’s why we care for so many of them
in the hospital.”
b. “Older adults are many times still interested in sexual relations.”
c. “Patients over age 65 are still lifelong learners.”
d. “Many older adult patients remain independent enough to live alone.” |
|
Definition
“Most older patients are ill and disabled. That’s why we care for so many of them
in the hospital.” |
|
|
Term
Which teaching strategy is best to utilize with older adult patients?
a. Provide several topics of discussion at once to promote independence and making
choices.
b. Avoid uncomfortable silences after questions by helping patients complete their
statements.
c. Ask patients to recall past experiences that correspond with their interests.
d. Speak in a high pitch to help patients hear better. |
|
Definition
| Ask patients to recall past experiences that correspond with their interests. |
|
|
Term
An older patient has fallen and broken his hip. As a consequence, the patient’s family is concerned about his ability to care for
himself, especially during his convalescence. What should the nurse do?
a. Stress that older patients usually ask for help when needed.
b. Inform the family that placement in a nursing center is a permanent solution.
c. Tell the family to enroll the patient in a ceramics class to maintain his quality of
life.
d. Provide information and answer questions as family members make choices
among care options. |
|
Definition
Provide information and answer questions as family members make choices
among care options. |
|
|
Term
What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center?
a. Suggest choosing a nursing center that is as sanitary as possible. The closer the
center is to hospital standards, the better.
b. Have family members evaluate nursing home staff according to their ability to get
tasks done efficiently.
c. Make sure that nursing home staff members get patients out of bed every day for
the entire day.
d. Explain that it is probably best for the family to visit the center and inspect it
personally. |
|
Definition
Explain that it is probably best for the family to visit the center and inspect it
personally. |
|
|
Term
A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. When discussing health care services
and possible long-term living arrangements with the patient’s only son, what should the nurse suggest?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
d. That placement is irrelevant because the patient is retreating to a place of
inactivity |
|
Definition
| A nursing center because home care is no longer safe |
|
|
Term
Several theories on aging have been put forth, and the nurse should use these theories to
a. Guide nursing care.
b. Explain the stochastic view of genetically programmed physiological changes.
c. Select one theory to guide nursing care for all geriatric patients.
d. Understand the nonstochastic views of aging as the result of cellular damage. |
|
Definition
|
|
Term
The nurse correctly describes psychosocial theories on aging as theories that
a. Describe role changes in behaviors in older adults.
b. Emphasize that all adults age in similar ways.
c. Stress the need for the aging to discontinue activities as they age.
d. Describe behavior patterns for all aging adults as unpredictable. |
|
Definition
| Describe role changes in behaviors in older adults. |
|
|
Term
When comparing developmental tasks of middle-aged persons versus older adults, what should the nurse infer?
a. Learning to cope with loss is most common during the middle adult years.
b. After age 65, most older adults age both biologically and psychologically the same
way.
c. All older adults will need nursing assistance to deal with loss.
d. Older adults fear and resent retirement as a disruption of their lifestyle. |
|
Definition
| All older adults will need nursing assistance to deal with loss. |
|
|
Term
An 80-year-old male is brought to the emergency department with an exacerbation of chronic obstructive pulmonary disease
(COPD). He states that he quit smoking 30 years ago, so it can’t be COPD. He argues, “It’s just these colds I’ve been getting.
They’re just getting worse and worse.” The nurse understands that
a. These symptoms are more associated with normal aging than with disease.
b. Older adults do not have to alter physical activity because of physical changes.
c. The patient’s age will require adjustment of lifestyle to one of inactivity.
d. Older adults usually are aware and accepting of the aging process. |
|
Definition
| Older adults do not have to alter physical activity because of physical changes. |
|
|
Term
During assessment of an older adult’s skin integrity, expected findings include which of the following?
a. Decreased elasticity
b. Oily skin
c. Increased facial hair in men
d. Faster nail growth |
|
Definition
|
|
Term
An older adult patient in no acute distress reports being less able to taste and smell. What is the nurse’s best response to this
information?
a. Notify the physician immediately to rule out cranial nerve damage.
b. Perform testing on the vestibulocochlear nerve and a hearing test.
c. Schedule the patient for an appointment at a smell and taste disorders clinic.
d. Explain to the patient that diminished senses are normal findings. |
|
Definition
| Explain to the patient that diminished senses are normal findings. |
|
|
Term
Which symptom is an expected cognitive change in the older adult patient?
a. Disorientation
b. Slower reaction time
c. Poor judgment
d. Loss of language skills |
|
Definition
|
|
Term
A patient with gradual, progressive cognitive impairment (dementia) is admitted to the nursing unit after hip replacement surgery.
Which of the following is a nursing care principle for care of cognitively impaired older adults?
a. Maintain physical health.
b. Evaluate the patient’s manifestations of standard symptoms.
c. Assist patient with all ADLs.
d. Isolate patients to protect others. |
|
Definition
| Maintain physical health. |
|
|
Term
To promote physical well-being and socialization in an older adult, what should the nurse realize?
a. Social isolationism is always a chosen behavior.
b. Body image plays no role in decision making by the older adult.
c. No community resources are focused on the older adult.
d. Older adults may have a functional purpose in social arenas. |
|
Definition
| Older adults may have a functional purpose in social arenas. |
|
|
Term
A male older adult patient expresses his concern and anxiety about decreased penile firmness during erection. What is the nurse’s
best response?
a. Explain that over time, his libido will decrease, as will the frequency of sexual
activity.
b. Tell the patient to double his antidepressant medication to increase his libido.
c. Tell the patient that this change is expected in aging adults.
d. Tell the patient that touching should be avoided unless intercourse is planned. |
|
Definition
| Tell the patient that this change is expected in aging adults. |
|
|
Term
A patient asks the nurse what the term polypharmacy means. The nurse defines this term as
a. Multiple side effects experienced when taking a medication.
b. The concurrent use of many medications.
c. The many adverse drug effects reported to the pharmacy.
d. The risks of medication effects due to aging. |
|
Definition
| The concurrent use of many medications. |
|
|
Term
An outcome for an older adult patient living alone is to be free from falls. Which of these statements by a patient indicates that
teaching on safety concerns has been effective?
a. “I’ll leave my throw rugs in place so that my feet won’t touch the cold tile.”
b. “I’ll take my time getting up from the bed or chair.”
c. “I should wear my favorite smooth bottom socks to protect my feet when walking
around.”
d. “I will have my son dim the lighting outside to decrease the glare in my eyes.” |
|
Definition
| “I’ll take my time getting up from the bed or chair.” |
|
|
Term
One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks
associated with medication usage is to
a. Periodically review the patient’s list of medications.
b. Inform the patient that polypharmacy is to be avoided at all cost.
c. Be aware that medication is absorbed the same way regardless of patient age.
d. Focus only on prescribed medications. |
|
Definition
| Periodically review the patient’s list of medications. |
|
|
Term
An older adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient’s vital
signs are normal. What should the nurse do?
a. Take into account age-related changes in body systems that affect
pharmacokinetic activity.
b. Increase the dose of tranquilizer if the cause of the confusion is an infection.
c. Note when the confusion occurs and medicate before that time.
d. Restrict telephone usage to prevent further confusion. |
|
Definition
Take into account age-related changes in body systems that affect
pharmacokinetic activity. |
|
|
Term
Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention?
a. Presbycusis
b. Confusion
c. Death of a spouse 3 months ago
d. Temperature of 97.6° F |
|
Definition
|
|
Term
Which of these patient statements is the most reliable indicator that an older adult has the correct understanding of health promotion
activities?
a. “I need to increase my fat intake and limit protein.”
b. “I should discontinue my fitness club membership for safety reasons.”
c. “I’m up to date on my immunizations, but at my age, I don’t need the tetanus
vaccine.”
d. “I still keep my dentist appointments even though I have partials now.” |
|
Definition
| “I still keep my dentist appointments even though I have partials now.” |
|
|
Term
A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years.
She never learned how to drive. She lives in a rural area that does not have public transportation. Which of the following
psychosocial changes does the nurse focus on as a priority?
a. Sexuality
b. Housing and environment
c. Retirement
d. Social isolation |
|
Definition
|
|
Term
A recently widowed 80-year-old male is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the
evening shift, the patient becomes acutely confused. The nurse’s best action is to assess the patient for which of the following
reversible causes? (Select all that apply.)
a. Electrolyte imbalance
b. Hypoglycemia
c. Drug effects
d. Dementia
e. Cerebral anoxia |
|
Definition
|
|
Term
The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse
a. Completes a comprehensive database.
b. Identifies pertinent nursing diagnoses.
c. Intervenes based on patient goals and priorities of care.
d. Determines whether outcomes have been achieved. |
|
Definition
| Completes a comprehensive database. |
|
|
Term
A nurse using the problem-oriented approach to data collection will first
a. Complete an observational overview.
b. Disregard cues and complete the database questions in chronological order.
c. Focus on the patient’s presenting situation.
d. Make accurate interpretations of the data. |
|
Definition
| Focus on the patient’s presenting situation. |
|
|
Term
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistant. With
this in mind, what clinical decision should the nurse make?
a. Administer scheduled medications assuming she would have been informed if the
vital signs were abnormal.
b. Have the patient transported to the radiology department for a scheduled x-ray,
and review vital signs upon return.
c. Ask the nursing assistant to record the patient’s vital signs before administering
medications.
d. Omit the vital signs because the patient is presently in no distress. |
|
Definition
Ask the nursing assistant to record the patient’s vital signs before administering
medications. |
|
|
Term
Subjective data include
a. A patient’s feelings, perceptions, and reported symptoms.
b. A description of the patient’s behavior.
c. Observations of a patient’s health status.
d. Measurements of a patient’s health status. |
|
Definition
| A patient’s feelings, perceptions, and reported symptoms. |
|
|
Term
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
a. The patient can now perform the dressing changes herself.
b. The patient can begin retaking all her previous medications.
c. The patient is apprehensive about discharge.
d. Surgery was not successful. |
|
Definition
| The patient is apprehensive about discharge. |
|
|
Term
Which of the following methods of data collection is utilized to establish a patient’s nursing database?
a. Reviewing the current literature to determine evidence-based nursing actions
b. Orders for diagnostic and laboratory tests
c. Physical examination
d. Anticipated medications to be ordered |
|
Definition
|
|
Term
To gather information about a patient’s home and work surroundings, the nurse will need to utilize which method of data
collection?
a. Carefully review lab results.
b. Conduct the physical assessment before collecting subjective information.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview. |
|
Definition
| Perform a thorough nursing health history. |
|
|
Term
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering
questions. This nurse should
a. Notify the physician to recommend a psychological evaluation.
b. Consider cultural differences during this assessment.
c. Ask the patient to make eye contact to determine her affect.
d. Continue with the interview and document that the patient is depressed. |
|
Definition
| Consider cultural differences during this assessment. |
|
|
Term
After setting the agenda during a patient-centered interview, what will the nurse do?
a. Begin by introducing himself.
b. Conduct a nursing health history.
c. Explain that the interview will be over in a few more minutes.
d. Tell the patient that he’ll be back to administer medications in 1 hour. |
|
Definition
| Conduct a nursing health history. |
|
|
Term
The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse
ask?
a. “Is there anything that you are stressed about right now?”
b. “What reasons do you think are contributing to your fatigue?”
c. “What are your normal work hours?”
d. “Are you sleeping 8 hours a night?” |
|
Definition
| “What reasons do you think are contributing to your fatigue?” |
|
|
Term
Components of a nursing health history include
a. Current treatment orders.
b. Nurse’s concerns.
c. Nurse’s goals for the patient.
d. Patient expectations. |
|
Definition
|
|
Term
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The
nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep.
A more theoretically sound approach would be to first
a. Document the sleep patterns and complaint in the patient’s chart.
b. Tell the patient you are just focused on the leg right now.
c. Explain that a more thorough assessment will be needed next shift.
d. Ask the patient about his usual sleep patterns and the onset of having difficulty
resting. |
|
Definition
Ask the patient about his usual sleep patterns and the onset of having difficulty
resting. |
|
|
Term
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient
who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this
situation?
a. Comprehensive assessment using Gordon’s Functional Health Patterns
b. General to specific assessment
c. Activity-exercise pattern assessment
d. Problem-oriented assessment |
|
Definition
| Problem-oriented assessment |
|
|
Term
A nurse comparing data validation and data interpretation correctly explains the difference with which statement?
a. “Validation involves looking for patterns in professional standards.”
b. “Data interpretation involves discovering patterns in professional standards.”
c. “Validation involves comparing data with other sources for accuracy.”
d. “Data interpretation occurs before data validation.” |
|
Definition
| “Validation involves comparing data with other sources for accuracy.” |
|
|
Term
Which scenario best illustrates the use of data validation when making an independent nursing clinical decision?
a. The nurse determines that she needs to remove a wound dressing when the patient
reveals the time of the last dressing change, and she notices that the present
dressing is saturated with fresh and old blood.
b. The nurse administers pain medicine due at 1700 at 1600 because the patient
complains of increased pain.
c. The nurse removes a leg cast when the patient complains of decreased mobility.
d. The nurse administers potassium when a patient complains of leg cramps. |
|
Definition
The nurse determines that she needs to remove a wound dressing when the patient
reveals the time of the last dressing change, and she notices that the present
dressing is saturated with fresh and old blood. |
|
|
Term
While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most
appropriate nursing action is to first
a. Leave the room and place the patient in isolation.
b. Ask the patient to describe the type of reaction.
c. Proceed to the termination phase of the interview.
d. Document the latex allergy on the medication administration record. |
|
Definition
| Ask the patient to describe the type of reaction. |
|
|
Term
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the
nurse’s best action in response to her observation?
a. Proceed to the next patient’s room while making rounds.
b. Offer a massage because the patient does not want any more pain medicine.
c. Administer the pain medication ordered for moderate to severe pain.
d. Ask the patient about the facial grimacing with movement. |
|
Definition
| Ask the patient about the facial grimacing with movement. |
|
|
Term
The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview?
a. The patient’s room with the door closed
b. The waiting area with the television turned off
c. The patient’s room before administration of pain medication
d. The patient’s room while the occupational therapist is working on leg exercises |
|
Definition
| The patient’s room with the door closed |
|
|
Term
A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present
in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene?
a. The nursing student is making eye contact with the patient.
b. The nursing student is speaking only to the patient’s daughter.
c. The nursing student nods periodically while the patient is speaking.
d. The nursing student leans forward while talking with the patient. |
|
Definition
| The nursing student is speaking only to the patient’s daughter. |
|
|
Term
Which of the following are examples of subjective data? (Select all that apply.)
a. Patient describing excitement about discharge
b. Patient’s wound appearance
c. Patient’s expression of fear regarding upcoming surgery
d. Patient pacing the floor while awaiting test results
e. Patient’s temperature |
|
Definition
|
|
Term
One purpose of using standard formal nursing diagnoses in practice is to
a. Form a language that can be encoded only by nurses.
b. Distinguish the nurse’s role from the physician’s role.
c. Allow for the communication of patient needs to assistive personnel.
d. Help nurses focus on the scope of medical practice. |
|
Definition
| Distinguish the nurse’s role from the physician’s role. |
|
|
Term
Which diagnosis below is NANDA-I approved?
a. Sleep disorder
b. Acute pain
c. Sore throat
d. High blood pressure |
|
Definition
|
|
Term
Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?
a. Risk for infection related to lower lobe infiltrate
b. Risk for deficient fluid volume related to dehydration
c. Impaired gas exchange related to alveolar-capillary membrane changes
d. Ineffective breathing pattern related to pneumonia |
|
Definition
| Impaired gas exchange related to alveolar-capillary membrane changes |
|
|
Term
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?
a. Nursing diagnosis
b. Etiology
c. Patient chief complaint
d. Defining characteristic |
|
Definition
|
|
Term
The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is
known as
a. Diagnostic reasoning.
b. Defining characteristics.
c. Assigning clinical criteria.
d. Diagnostic labeling. |
|
Definition
|
|
Term
A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is
stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate
discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?
a. Posttrauma syndrome
b. Constipation
c. Urinary retention
d. Acute pain |
|
Definition
|
|
Term
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The
patient’s kidney function labs are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which
step of the nursing process should the nurse proceed to after this review?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus
assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary
elimination is which type of diagnosis?
a. Actual
b. Risk
c. Health promotion
d. Wellness |
|
Definition
|
|
Term
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to
the nurse that the patient’s blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not
had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is
re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation |
|
Definition
|
|
Term
Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility
secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal
distention, and complaints of abdominal pain.
a. Decreased gastrointestinal motility
b. Pain medication
c. Abdominal distention
d. Constipation |
|
Definition
|
|
Term
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of
shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of
Activity intolerance?
a. Decreased oral intake and decreased oxygen saturation when ambulating
b. Decreased oxygen saturation when ambulating and complaints of shortness of
breath when getting out of bed
c. Complaints of shortness of breath when getting out of bed and a productive cough
d. Productive cough and decreased oral intake |
|
Definition
Decreased oxygen saturation when ambulating and complaints of shortness of
breath when getting out of bed |
|
|
Term
Which of these selections is an etiology for Acute pain versus a defining characteristic?
a. Complaint of pain as a 7 on a 0 to 10 scale
b. Disruption of tissue integrity
c. Dull headache
d. Discomfort while changing position |
|
Definition
| Disruption of tissue integrity |
|
|
Term
A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet
owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less
than body requirements related to
a. Religious preferences.
b. Decreased oral intake.
c. Weight loss.
d. Race and ethnicity. |
|
Definition
|
|
Term
After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing
process?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
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?
a. Assign the nursing diagnosis of Decreased cardiac output.
b. Ask the patient if he has a history of cardiac problems before assigning the
diagnosis of Decisional conflict.
c. Check the previous shift’s assessment and document what was noted on the last
shift.
d. Ask a more experienced nurse to listen also. |
|
Definition
| Ask a more experienced nurse to listen also. |
|
|
Term
Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of
diagnostic error?
a. Assigning diagnoses while completing the database
b. Assigning a documented nursing diagnosis of Risk for infection for a patient on
intravenous antibiotics
c. Completing the interview before performing the physical examination
d. Documenting cultural and religious preferences |
|
Definition
| Assigning diagnoses while completing the database |
|
|
Term
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body
temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses?
a. Adult failure to thrive
b. Hypothermia
c. Deficient fluid volume
d. Nausea |
|
Definition
|
|
Term
Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of
Diarrhea?
a. “What types of foods do you think caused your upset stomach?”
b. “How many bowel movements a day have you had?”
c. “Are you able to get to the bathroom in time?”
d. “What medications are you currently taking?” |
|
Definition
| “How many bowel movements a day have you had?” |
|
|
Term
A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing
diagnosis of Urinary retention?
a. “Do you feel like you need to use the bathroom?”
b. “Are you able to walk to the bathroom by yourself?”
c. “When was the last time you took your medicine?”
d. “Do you have a safety rail in your bathroom at home?” |
|
Definition
| “Do you feel like you need to use the bathroom?” |
|
|
Term
After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the
nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
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
a. Asking physical therapy to assist the patient because of the new injuries.
b. Disregarding all previous diagnoses and establishing a new plan of care.
c. Reassessing the patient.
d. Setting new priorities for the patient. |
|
Definition
|
|
Term
When planning patient care, a goal can be described as
a. A statement describing the patient’s accomplishments without a time restriction.
b. A realistic statement predicting any negative responses to treatments.
c. A broad statement describing a desired change in patient behavior.
d. An identified long-term nursing diagnosis. |
|
Definition
| A broad statement describing a desired change in patient behavior. |
|
|
Term
When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient
with a pelvic fracture on bed rest? The patient will increase mobility by
a. Ambulating in the hallway two times this shift.
b. Turning side to back to side with assistance every 2 hours.
c. Using the walker correctly to ambulate to the bathroom as needed.
d. Using a sliding board correctly to transfer to the bedside commode as needed. |
|
Definition
| Turning side to back to side with assistance every 2 hours. |
|
|
Term
The following statements are on a patient’s nursing care plan. Which of the following statements is written as an outcome?
a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by
the end of this shift.
b. The patient will demonstrate increased mobility in 2 days.
c. The patient will demonstrate increased tolerance to activity over the next month.
d. The patient will understand needed dietary changes by discharge. |
|
Definition
The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by
the end of this shift. |
|
|
Term
Which patient outcome statement includes all seven guidelines for writing goal and outcome statements?
a. The patient will ambulate in hallways.
b. The nurse will administer pain medication every 4 hours to keep the patient free
from discomfort.
c. The nurse will monitor the patient’s heart rhythm continuously this shift.
d. The patient will feed self at all mealtimes today without complaints of shortness
of breath. |
|
Definition
The patient will feed self at all mealtimes today without complaints of shortness
of breath. |
|
|
Term
A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While
developing the plan of care, which nursing diagnosis is the highest priority for this patient?
a. Risk for impaired skin integrity
b. Risk for infection
c. Spiritual distress
d. Reflex urinary incontinence |
|
Definition
| Reflex urinary incontinence |
|
|
Term
The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn’t know where to
begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse?
a. “Choose all the interventions and perform them in order of time needed for each
one.”
b. “Make sure you identify the scientific rationale for each intervention first.”
c. “Decide on goals and outcomes you have chosen for the patients.”
d. “Begin with the highest priority diagnoses, then select appropriate interventions.” |
|
Definition
| “Begin with the highest priority diagnoses, then select appropriate interventions.” |
|
|
Term
A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what
should the nurse do?
a. Individualize the care plan only according to the patient’s needs.
b. Request that the son leave at bedtime, so the patient can rest.
c. Suggest that a female member of the family stay with the patient.
d. Involve the son in the plan of care as much as possible. |
|
Definition
| Involve the son in the plan of care as much as possible. |
|
|
Term
Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed
gastrointestinal motility secondary to pain medications?
a. Patient will have one soft, formed bowel movement by end of shift.
b. Patient will not take any pain medications this shift.
c. Patient will walk unassisted to bathroom by the end of shift.
d. Patient will not take laxatives or stool softeners this shift. |
|
Definition
| Patient will have one soft, formed bowel movement by end of shift. |
|
|
Term
The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention.
a. Dependent
b. Independent
c. Interdependent
d. Physician-initiated |
|
Definition
|
|
Term
A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this
nurse implementing?
a. Collaborative
b. Independent
c. Interdependent
d. Dependent |
|
Definition
|
|
Term
The nurse describes evidence-based practice as
a. Practice based on the evidence presented in court.
b. Implementing interventions based on scientific rationale.
c. Using standardized care plans.
d. Planning care based on tradition. |
|
Definition
| Implementing interventions based on scientific rationale. |
|
|
Term
Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of
facial motor control and decreased sensation?
a. Obtain an interpreter for the patient as soon as possible.
b. Assist the patient in performing swallowing exercises each shift.
c. Ask the family to provide a sitter to remain with the patient at all times.
d. Provide the patient with a writing board each shift. |
|
Definition
| Provide the patient with a writing board each shift. |
|
|
Term
Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Perform the ordered dressing change twice daily.
c. Do not document the wound appearance in the chart.
d. Keep the bed side rails up at all times. |
|
Definition
| Perform the ordered dressing change twice daily. |
|
|
Term
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate
for the nursing diagnostic statement, Risk for falls?
a. Encourage patient to remain in bed most of the shift.
b. Keep all side rails down at all times.
c. Place patient in room away from the nurses’ station if possible.
d. Assist patient into and out of bed every 6 hours or as tolerated. |
|
Definition
| Assist patient into and out of bed every 6 hours or as tolerated. |
|
|
Term
Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed?
a. Place the original copy in the chart, so it cannot be tampered with or revised.
b. Communicate the plan of care to all health care professionals involved in the
patient’s care.
c. Send the plan of care to the administration office to be filed.
d. Send the plan of care to quality assurance for review. |
|
Definition
Communicate the plan of care to all health care professionals involved in the
patient’s care. |
|
|
Term
What is the first step in making a consult?
a. Avoid bias by not providing a lot of information based on opinion to the
consultant.
b. Identify the problem.
c. Provide the consultant with relevant information about the problem.
d. Ensure that the right professional, with the appropriate knowledge and expertise,
is contacted. |
|
Definition
|
|
Term
A hospital’s wound nurse consultant made a recommendation for nurses on the unit to continue the patient’s dressing changes as
previously ordered. The nurses on the unit should incorporate this recommendation into the patient’s plan of care by
a. Assuming that the wound nurse will perform all dressing changes.
b. Requesting that the physician look at the wound herself.
c. Including dressing change instructions and frequency in the plan of care.
d. Encouraging the patient to perform the dressing changes. |
|
Definition
| Including dressing change instructions and frequency in the plan of care. |
|
|
Term
A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing
interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when
prioritizing interventions? (Select all that apply.)
a. Put all the patients’ nursing diagnoses in order of priority.
b. Consider time as an influencing factor.
c. Set priorities based solely on physiological factors.
d. Utilize critical thinking.
e. Do not change priorities once they’ve been established. |
|
Definition
|
|
Term
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?
a. Assessment
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
After completing a thorough database and carrying out nursing interventions based on priority diagnoses, the nurse proceeds to
which step of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements
made by the nursing instructor is most accurate?
a. “During evaluation, you determine whether all nursing interventions were
completed.”
b. “During evaluation, you determine when to downsize staffing on nursing units.”
c. “Nurses use evaluation to determine the effectiveness of nursing care.”
d. “Evaluation eliminates unnecessary paperwork and care planning.” |
|
Definition
| “Nurses use evaluation to determine the effectiveness of nursing care.” |
|
|
Term
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the
patient’s headache. What is the nurse’s next priority action for this patient?
a. Eliminate Acute pain from the nursing care plan.
b. Direct the nursing assistant to ask if the patient’s headache is relieved.
c. Reassess the patient’s pain level in 30 minutes.
d. Revise the plan of care. |
|
Definition
| Reassess the patient’s pain level in 30 minutes. |
|
|
Term
A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before
discontinuing the patient’s plan of care, what does the nurse need to do?
a. Determine whether the patient has transportation to get home.
b. Evaluate whether patient goals and outcomes have been met.
c. Establish whether the patient has a follow-up appointment scheduled.
d. Ensure that the patient’s prescriptions have been filled. |
|
Definition
| Evaluate whether patient goals and outcomes have been met. |
|
|
Term
The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a
patient with Impaired physical mobility?
a. The patient is able to ambulate in the hallway with crutches.
b. The patient’s level of mobility will improve.
c. The nurse provides assistance while the patient is walking in the hallways.
d. The patient will deny pain while walking in the hallway. |
|
Definition
| The patient is able to ambulate in the hallway with crutches. |
|
|
Term
The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which
finding indicates success of the turning schedule?
a. Staff documentation of turning the patient every 2 hours
b. Absence of skin breakdown
c. Presence of redness only on the heels of the patient
d. Patient’s eating 100% of all meals |
|
Definition
| Absence of skin breakdown |
|
|
Term
What is the primary goal of outcomes management for professional nurses?
a. To promote purposeful actions focused on improving a patient’s health condition
b. To fine-tune nursing assessment skills
c. To support the delegation of more nursing tasks to nursing assistive personnel
d. To decrease the number of medication errors in nursing |
|
Definition
| To promote purposeful actions focused on improving a patient’s health condition |
|
|
Term
A new nurse states that she is confused about using evaluative measures when caring for patients and asks the charge nurse for
examples and an explanation. Which of the following is the most accurate response from the charge nurse?
a. “Evaluative measures are multiple-page documents used to evaluate nurse
performance.”
b. “Evaluative measures include assessment data used to determine whether patients
have met their expected outcomes and goals.”
c. “Evaluative measures are used by quality assurance nurses to determine the
progress a nurse is making from novice to expert nurse.”
d. “Evaluative measures are objective views of incident reports.” |
|
Definition
“Evaluative measures include assessment data used to determine whether patients
have met their expected outcomes and goals.” |
|
|
Term
The nurse is caring for a patient who has an open wound. When evaluating the progress of wound healing, what is the nurse’s
priority action?
a. Ask the nursing assistive personnel if the wound looks better.
b. Document the progress of wound healing as “better” in the patient’s chart.
c. Measure the wound and observe for redness, swelling, or drainage.
d. Leave the dressing off the wound for easier access and more frequent assessments. |
|
Definition
| Measure the wound and observe for redness, swelling, or drainage. |
|
|
Term
The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices
that the dressing is saturated. What is the nurse’s next action?
a. Wait and change the dressing at 1800 as ordered.
b. Revise the plan of care and change the dressing now.
c. Reassess the dressing and the wound in 1 hour.
d. Discontinue the plan of care. |
|
Definition
| Revise the plan of care and change the dressing now. |
|
|
Term
A goal for a patient with a diagnosis of Ineffective coping is to demonstrate effective coping skills. Which of these patient behaviors
indicates that interventions performed to meet this outcome have been successful?
a. States he feels better after talking with his family and friends
b. Continues to consume several alcoholic beverages a day
c. Dislikes the support group meetings
d. Spends most of the day in bed |
|
Definition
| States he feels better after talking with his family and friends |
|
|
Term
A nurse is providing education to a patient about self-administering subcutaneous injections. Which of these patient statements
indicates that the patient understands the instructions?
a. “I need to use a needle 1/2 inch longer than my thumb.”
b. “I will give the medicine deep into my deltoid.”
c. “My belly is a good place to give my injection.”
d. “I need to throw the syringe and needle into the garbage when I am done giving
myself my shot.” |
|
Definition
| “My belly is a good place to give my injection.” |
|
|
Term
Which of these statements made by a patient who has Disturbed body image is the best indicator of the patient’s patient early
acceptance of body image?
a. “I just won’t go to the pool this summer.”
b. “I’m worried about what those other girls will think of me.”
c. “I can’t wear that color. It makes my hips stick out.”
d. “I’ll wear the blue dress. It matches my eyes.” |
|
Definition
| I’ll wear the blue dress. It matches my eyes.” |
|
|
Term
Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion?
a. Side rails are up with bed alarm activated.
b. Patient denies pain while ambulating with assistance.
c. Patient wanders halls at night.
d. Patient correctly states names of family members in the room. |
|
Definition
| Patient correctly states names of family members in the room. |
|
|
Term
A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission. The nurse and the patient agree that
the goal is for the patient to remain free from falls. However, the patient fell just before shift change. What is the nurse’s priority
action when evaluating the patient’s plan of care?
a. Counsel the nursing assistive personnel on duty when the patient fell.
b. Identify factors interfering with goal achievement.
c. Remove the fall risk sign from the patient’s door because the patient has suffered
a fall.
d. Request that the more experienced charge nurse complete the documentation
about the fall. |
|
Definition
| Identify factors interfering with goal achievement. |
|
|
Term
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not
experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48
hours. Which of the following is an appropriate evaluative measure demonstrating progress toward this goal?
a. Nonproductive cough present in 4 days
b. Scattered rhonchi throughout all lung fields in 2 days
c. Respirations 30/minute in 1 day
d. Lungs clear to auscultation following use of inhaler |
|
Definition
| Lungs clear to auscultation following use of inhaler |
|
|
Term
A nurse administrator is at a meeting with nurses on the quality council. Several new members are sitting on the council. They ask
the nurse administrator to clarify what a nursing-sensitive outcome is. Which response by the nurse administrator best defines
nursing-sensitive outcomes?
a. “Nursing-sensitive outcomes determine the patient’s progress as a result of
prescribed treatments, such as medications.”
b. “Patient falls is an example of a nursing-sensitive outcome because they are
directly affected by nursing interventions.”
c. “Nursing-sensitive outcomes promote universal health care.”
d. “We use nursing-sensitive outcomes at this hospital to evaluate nursing tasks and
to determine safe staffing ratios.” |
|
Definition
Patient falls is an example of a nursing-sensitive outcome because they are
directly affected by nursing interventions.” |
|
|
Term
Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient’s response to
nursing care? (Select all that apply.)
a. Observations of wound healing
b. Assessment of respiratory rate and depth
c. Blood pressure measurement
d. Implementation of nursing interventions
e. Patient’s subjective report of feelings about a new diagnosis of cancer |
|
Definition
|
|
Term
Identify elements of the evaluation process. (Select all that apply.)
a. Setting priorities for patient care
b. Collecting subjective and objective data to determine whether criteria or standards
are met
c. Ambulating 25 feet in the hallway with the patient
d. Documenting findings
e. Terminating, continuing, or revising the care plan |
|
Definition
|
|
Term
In which step of the nursing process does the nurse provide nursing care interventions to patients?
a. Assessment
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
The nurse defines a clinical guideline or protocol as a
a. Guideline to follow that replaces the nursing care plan.
b. Document that assists the clinician in making decisions and choosing
interventions for specific health care problems or conditions.
c. Hospital policy designating each nurse’s duty according to standards of care and a
code of ethics.
d. Prescriptive order form that individualizes the plan of care. |
|
Definition
Document that assists the clinician in making decisions and choosing
interventions for specific health care problems or conditions. |
|
|
Term
The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the
patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse
a. Notifies the health care provider to obtain a verbal order.
b. Directs the nursing assistant to give the Tylenol.
c. Administers the Tylenol.
d. Performs a pain assessment only after administering the Tylenol. |
|
Definition
|
|
Term
Before implementing any intervention, the nurse uses critical thinking to
a. Determine whether an intervention is correct and appropriate for the given
situation.
b. Evaluate the effectiveness of interventions.
c. Establish goals for a particular patient without the need for reassessment.
d. Read over the steps and perform a procedure despite lack of clinical competency. |
|
Definition
Determine whether an intervention is correct and appropriate for the given
situation. |
|
|
Term
Which of the following is a nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg
c. Provide assistance while the patient walks in the hallway twice this shift with
crutches.
d. The patient is unable to bear weight on right lower extremity. |
|
Definition
Provide assistance while the patient walks in the hallway twice this shift with
crutches. |
|
|
Term
A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10
scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing
intervention for this patient?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication. |
|
Definition
| Administer pain medication. |
|
|
Term
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change
the dressing. What does the nurse do just before changing the dressing?
a. Assesses the patient’s readiness for the procedure
b. Gathers and organizes needed supplies
c. Decides on goals and outcomes for the patient
d. Calls for assistance from another nursing staff member |
|
Definition
| Assesses the patient’s readiness for the procedure |
|
|
Term
A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the
nurse do first?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Offer the patient a walker.
d. Review the patient’s activity orders. |
|
Definition
| Review the patient’s activity orders. |
|
|
Term
Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, “The patient will
verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift.”?
a. Medicate the patient immediately after all procedures.
b. Discuss only nonpharmacological methods of pain relief.
c. Teach the patient about side effects of pain medications.
d. Medicate the patient based on previous shift assessment findings. |
|
Definition
| Teach the patient about side effects of pain medications. |
|
|
Term
What is the first intervention included on any patient’s plan of care?
a. Determine patient outcomes and goals.
b. Prioritize the patient’s nursing diagnoses.
c. Reassess the patient.
d. Assess for a patent airway. |
|
Definition
|
|
Term
Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood
pressure greater than 90. What is the nurse’s first action?
a. Assess the patient for other symptoms or problems, and then notify the health care
provider.
b. Review the most recent lab results for the patient’s potassium level.
c. Follow the clinical protocol for a stroke.
d. Administer an antihypertensive medication from the stock supply, and then notify
the health care provider. |
|
Definition
Assess the patient for other symptoms or problems, and then notify the health care
provider. |
|
|
Term
Which intervention is most appropriate for a patient who has a new onset of chest pain?
a. Administer a prn medication for pain.
b. Reassess the patient because of the change in condition.
c. Notify the health care provider.
d. Call radiology for a portable chest x-ray. |
|
Definition
| Reassess the patient because of the change in condition. |
|
|
Term
Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound
healing?
a. Reinforce the wound dressing as needed with 4 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Document wound characteristics.
d. Assess wound appearance each shift. |
|
Definition
| Assess wound appearance each shift. |
|
|
Term
The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which
type of implementation skill?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental |
|
Definition
|
|
Term
The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards
of care and hospital policy. This is demonstrating which type of implementation skill?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental |
|
Definition
|
|
Term
A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing
Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the
room requires the staff nurse to clarify the information provided?
a. “This system can help medical students determine the cost of the care they
provide.”
b. “If the nursing department uses this system, communication among nurses who
work throughout the hospital may be enhanced.”
c. “We could use this system to help us better organize orientation for new nursing
employees because we can better explain the nursing interventions we use most
frequently on our unit.”
d. “The NIC system provides one way to improve safe and effective documentation
in the hospital’s electronic health record.” |
|
Definition
“This system can help medical students determine the cost of the care they
provide.” |
|
|
Term
The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most
appropriate?
a. Assisting with activities of daily living
b. Counseling about respite care options
c. Teaching range-of-motion exercises
d. Emphasizing the importance of exercise |
|
Definition
| Counseling about respite care options |
|
|
Term
The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most
appropriate?
a. Teaching the family proper handwashing technique
b. Leaving side rails up at all times
c. Teaching the patient how to use crutches
d. Counseling the family on stress reduction techniques |
|
Definition
| Teaching the family proper handwashing technique |
|
|
Term
Which of the following are nursing interventions? (Select all that apply.)
a. Order chest x-ray for suspected humerus fracture.
b. Order antibiotics for a respiratory infection.
c. Reposition a patient who is on bed rest.
d. Remind a patient to cough and deep breathe after surgery.
e. Write transfer orders to move a patient to another hospital unit. |
|
Definition
|
|
Term
Which of the following are direct care interventions? (Select all that apply.)
a. Turning a patient
b. Counseling a patient
c. Performing resuscitation
d. Documenting wound care
e. Teaching wound care |
|
Definition
|
|
Term
Before implementing care, the nurse needs to ensure that which resources are available? (Select all that apply.)
a. Equipment
b. Safe environment
c. Patient readiness
d. Assistive personnel
e. Creativity |
|
Definition
|
|
Term
Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to
diabetes? (Select all that apply.)
a. Teach the patient about signs and symptoms of infection.
b. Help the patient cope with changes in body image that result from the wound.
c. Perform dressing changes twice a day as ordered.
d. Administer medications to control the patient’s blood sugar as ordered.
e. Teach the family how to perform dressing changes. |
|
Definition
|
|
Term
In which step of the nursing process does the nurse provide nursing care interventions to patients?
a. Assessment
b. Planning
c. Implementation
d. Evaluation |
|
Definition
|
|
Term
The nurse defines a clinical guideline or protocol as a
a. Guideline to follow that replaces the nursing care plan.
b. Document that assists the clinician in making decisions and choosing
interventions for specific health care problems or conditions.
c. Hospital policy designating each nurse’s duty according to standards of care and a
code of ethics.
d. Prescriptive order form that individualizes the plan of care. |
|
Definition
Document that assists the clinician in making decisions and choosing
interventions for specific health care problems or conditions. |
|
|
Term
The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the
patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse
a. Notifies the health care provider to obtain a verbal order.
b. Directs the nursing assistant to give the Tylenol.
c. Administers the Tylenol.
d. Performs a pain assessment only after administering the Tylenol. |
|
Definition
|
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Term
Before implementing any intervention, the nurse uses critical thinking to
a. Determine whether an intervention is correct and appropriate for the given
situation.
b. Evaluate the effectiveness of interventions.
c. Establish goals for a particular patient without the need for reassessment.
d. Read over the steps and perform a procedure despite lack of clinical competency. |
|
Definition
Determine whether an intervention is correct and appropriate for the given
situation. |
|
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Term
Which of the following is a nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg
c. Provide assistance while the patient walks in the hallway twice this shift with
crutches.
d. The patient is unable to bear weight on right lower extremity. |
|
Definition
Provide assistance while the patient walks in the hallway twice this shift with
crutches. |
|
|
Term
A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10
scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing
intervention for this patient?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication. |
|
Definition
| Administer pain medication. |
|
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Term
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change
the dressing. What does the nurse do just before changing the dressing?
a. Assesses the patient’s readiness for the procedure
b. Gathers and organizes needed supplies
c. Decides on goals and outcomes for the patient
d. Calls for assistance from another nursing staff member |
|
Definition
| Assesses the patient’s readiness for the procedure |
|
|
Term
A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening,
what should the nurse do?
a. Ask the patient to return to his room so the nurse can inspect his abdomen.
b. Request that the family leave, so the patient can rest.
c. Ask the patient when his last bowel movement was and to lie down on the sofa.
d. Tell the patient that his dinner tray will be ready in 15 minutes. |
|
Definition
| Ask the patient to return to his room so the nurse can inspect his abdomen. |
|
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Term
A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the
nurse do first?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Offer the patient a walker.
d. Review the patient’s activity orders. |
|
Definition
| Review the patient’s activity orders. |
|
|
Term
Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, “The patient will
verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift.”?
a. Medicate the patient immediately after all procedures.
b. Discuss only nonpharmacological methods of pain relief.
c. Teach the patient about side effects of pain medications.
d. Medicate the patient based on previous shift assessment findings. |
|
Definition
| Teach the patient about side effects of pain medications. |
|
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Term
What is the first intervention included on any patient’s plan of care?
a. Determine patient outcomes and goals.
b. Prioritize the patient’s nursing diagnoses.
c. Reassess the patient.
d. Assess for a patent airway. |
|
Definition
|
|
Term
Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood
pressure greater than 90. What is the nurse’s first action?
a. Assess the patient for other symptoms or problems, and then notify the health care
provider.
b. Review the most recent lab results for the patient’s potassium level.
c. Follow the clinical protocol for a stroke.
d. Administer an antihypertensive medication from the stock supply, and then notify
the health care provider. |
|
Definition
Assess the patient for other symptoms or problems, and then notify the health care
provider. |
|
|
Term
Which intervention is most appropriate for a patient who has a new onset of chest pain?
a. Administer a prn medication for pain.
b. Reassess the patient because of the change in condition.
c. Notify the health care provider.
d. Call radiology for a portable chest x-ray. |
|
Definition
| Reassess the patient because of the change in condition. |
|
|
Term
Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound
healing?
a. Reinforce the wound dressing as needed with 4 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Document wound characteristics.
d. Assess wound appearance each shift. |
|
Definition
| Assess wound appearance each shift. |
|
|
Term
The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which
type of implementation skill?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental |
|
Definition
|
|
Term
The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards
of care and hospital policy. This is demonstrating which type of implementation skill?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental |
|
Definition
|
|
Term
A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing
Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the
room requires the staff nurse to clarify the information provided?
a. “This system can help medical students determine the cost of the care they
provide.”
b. “If the nursing department uses this system, communication among nurses who
work throughout the hospital may be enhanced.”
c. “We could use this system to help us better organize orientation for new nursing
employees because we can better explain the nursing interventions we use most
frequently on our unit.”
d. “The NIC system provides one way to improve safe and effective documentation
in the hospital’s electronic health record.” |
|
Definition
“This system can help medical students determine the cost of the care they
provide.” |
|
|
Term
The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most
appropriate?
a. Assisting with activities of daily living
b. Counseling about respite care options
c. Teaching range-of-motion exercises
d. Emphasizing the importance of exercise |
|
Definition
| Counseling about respite care options |
|
|
Term
The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most
appropriate?
a. Teaching the family proper handwashing technique
b. Leaving side rails up at all times
c. Teaching the patient how to use crutches
d. Counseling the family on stress reduction techniques |
|
Definition
| Teaching the family proper handwashing technique |
|
|
Term
Which of the following are nursing interventions? (Select all that apply.)
a. Order chest x-ray for suspected humerus fracture.
b. Order antibiotics for a respiratory infection.
c. Reposition a patient who is on bed rest.
d. Remind a patient to cough and deep breathe after surgery.
e. Write transfer orders to move a patient to another hospital unit. |
|
Definition
|
|
Term
Which of the following are direct care interventions? (Select all that apply.)
a. Turning a patient
b. Counseling a patient
c. Performing resuscitation
d. Documenting wound care
e. Teaching wound care |
|
Definition
|
|
Term
Before implementing care, the nurse needs to ensure that which resources are available? (Select all that apply.)
a. Equipment
b. Safe environment
c. Patient readiness
d. Assistive personnel
e. Creativity |
|
Definition
|
|
Term
Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to
diabetes? (Select all that apply.)
a. Teach the patient about signs and symptoms of infection.
b. Help the patient cope with changes in body image that result from the wound.
c. Perform dressing changes twice a day as ordered.
d. Administer medications to control the patient’s blood sugar as ordered.
e. Teach the family how to perform dressing changes. |
|
Definition
|
|
Term
A nurse knows that patient education has been effective when the patient states
a. “I must take my parenteral medication with food.”
b. “If I am 30 minutes late taking my medication, I should skip that dose.”
c. “I will rotate the location where I give myself injections.”
d. “Once I start feeling better, I will stop taking my medication.” |
|
Definition
| “I will rotate the location where I give myself injections.” |
|
|
Term
Which statement by the patient is an indication to use the Z-track method?
a. “I’m really afraid that a big needle will hurt.”
b. “The last shot like that turned my skin colors.”
c. “I am allergic to many medications.”
d. “My legs are too obese for the needle to go through.” |
|
Definition
| “The last shot like that turned my skin colors.” |
|
|
Term
A 2-year-old child is ordered to have ear irrigation performed daily. The nurse correctly performs the procedure by
a. Pulling the auricle down and back to straighten the ear canal.
b. Pulling the auricle upward and outward to straighten the ear canal.
c. Instilling the irrigation solution by holding the syringe just inside the ear canal.
d. Holding the fluid in the canal for 2 to 3 minutes with a cotton swab. |
|
Definition
| Pulling the auricle down and back to straighten the ear canal. |
|
|
Term
A patient has an order to receive 10 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse
draw up in the syringe and administer?
a. 0.2 units
b. 2 units
c. 5 units
d. 20 units |
|
Definition
|
|
Term
A patient has an order to receive 20 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse
draw up in the syringe and administer?
a. 0.04 mL
b. 0.4 mL
c. 4 mL
d. 10 mL |
|
Definition
|
|
Term
The patient is to receive phenytoin (Dilantin) at 0900. The nurse knows that the ideal time to draw a trough level is
a. 0800.
b. 0830.
c. 0900.
d. 0930. |
|
Definition
|
|
Term
A patient who has been receiving intermittent chemotherapy through a peripheral IV site is ordered to receive a high dose of
vancomycin through the same vein. Why does this concern the nurse?
a. Chemotherapy is irritating to the vascular system and may cause the vein to
infiltrate.
b. Two medications should never be placed into the same IV site.
c. Once chemotherapy is in a patient’s system, any additional medicine given will
cause a synergistic effect.
d. Chemotherapy treatments require a special pump designed solely for
chemotherapy. |
|
Definition
Chemotherapy is irritating to the vascular system and may cause the vein to
infiltrate. |
|
|
Term
The nurse is preparing to administer a 0.5-mL rabies vaccine into the deltoid muscle of a patient. Which needle size is best for the
procedure?
a. 20 gauge 1 1/2 inch
b. 23 gauge 1/2 inch
c. 25 gauge 5/8 inch
d. 27 gauge 3/8 inch |
|
Definition
|
|
Term
The nurse knows that the purpose of aspiration on IM injections is to
a. Ensure proper placement of the needle.
b. Increase the force of the injection.
c. Reduce the discomfort of the injection.
d. Prolong the absorption time of the medication. |
|
Definition
| Ensure proper placement of the needle. |
|
|
Term
The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?
a. Administer the injection at a slower rate.
b. Withdraw the needle and prepare the injection again.
c. Pull the needle back slightly and inject the medication.
d. Give the injection and hold pressure over the site for 3 minutes. |
|
Definition
| Withdraw the needle and prepare the injection again. |
|
|
Term
The nurse knows to assess for signs of medication toxicity within older adults because of which physiological change?
a. Reduced glomerular filtration
b. Delayed esophageal clearance
c. Decreased gastric peristalsis
d. Decreased cognitive function |
|
Definition
| Reduced glomerular filtration |
|
|
Term
A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a
patient, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for
the error?
a. Physician
b. Pharmacist
c. Nurse
d. No fault |
|
Definition
|
|
Term
A patient is to receive medication through a nasogastric tube. What is the most important nursing action to ensure effective
absorption?
a. Thoroughly shake the medication before administering.
b. After all medications are administered, flush tube with 15 to 30 mL of water.
c. Position patient in the supine position for 30 minutes.
d. Clamp suction for 30 to 60 minutes after medication administration. |
|
Definition
| Clamp suction for 30 to 60 minutes after medication administration. |
|
|
Term
Aspirin is an analgesic, antipyretic, antiplatelet, and anti-inflammatory agent. A physician writes for aspirin 650 mg every 4 to 6
hours prn: febrile. For which patient would this order be appropriate?
a. 7-year-old with hemophilia
b. 21-year-old with a sprained ankle
c. 35-year-old with a severe headache
d. 62-year-old female with pneumonia |
|
Definition
| 62-year-old female with pneumonia |
|
|
Term
A patient is in need of immediate pain relief for a severe headache. The nurse knows that which medication will be absorbed the
quickest?
a. Tylenol 650 mg PO
b. Morphine 4 mg SQ
c. Ketorolac (Toradol) 8 mg IM
d. Hydromorphone (Dilaudid) 4 mg IV |
|
Definition
| Hydromorphone (Dilaudid) 4 mg IV |
|
|
Term
A drug requires a low pH to be metabolized. Knowing this, the nurse anticipates that the medication will be administered by which
route?
a. Oral
b. Parenteral
c. Buccal
d. Inhalation |
|
Definition
|
|
Term
The nurse knows that an idiosyncratic event with the stimulant pseudoephedrine (Sudafed) is occurring when the patient
a. Experiences blurred vision while driving.
b. Falls asleep during daily activities.
c. Presents with a pruritus rash.
d. Develops xerostomia. |
|
Definition
| Falls asleep during daily activities. |
|
|
Term
An order is written for (phenytoin) Dilantin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a
standard therapeutic indication for this drug. The nurse believes that the prescriber meant to write for hydromorphone (Dilaudid).
What should the nurse do?
a. Give the patient Dilaudid, as it was meant to be written.
b. Call the prescriber to clarify and justify the order.
c. Administer the medication and monitor the patient frequently.
d. Refuse to give the medication and notify the nurse supervisor. |
|
Definition
| Call the prescriber to clarify and justify the order. |
|
|
Term
A patient needs assistance excreting a gaseous medication. What is the correct nursing action?
a. Encourage the patient to cough and deep-breathe.
b. Suction the patient’s respiratory secretions.
c. Administer the antidote via inhalation.
d. Administer 100% FiO2 via simple face mask. |
|
Definition
| Encourage the patient to cough and deep-breathe. |
|
|
Term
A nurse has withdrawn a narcotic from the medication dispenser. Upon checking the drug against the medication administration
record, the nurse notices that the narcotic order has expired. What should be the nurse’s first action?
a. Return the medication to the medication dispenser according to protocol.
b. Exit the medication room to call the physician to request a reorder of the narcotic.
c. Assess the patient to see if the narcotic is still needed; if so, administer the
medication.
d. Call the pharmacy and request that the narcotic be removed from the patient
profile. |
|
Definition
| Return the medication to the medication dispenser according to protocol. |
|
|
Term
The nurse knows that patient education about a buccal medication has been effective when the patient states
a. “I should let the medication dissolve completely.”
b. “I can only drink water, not juice, with this medication.”
c. “For faster distribution, I should chew my medication first.”
d. “I should place the medication in the same location.” |
|
Definition
| “I should let the medication dissolve completely.” |
|
|
Term
What is the nurse’s priority action to protect a patient from medication error?
a. Requesting that the prescriber write out an order, rather than giving a verbal order
b. Asking anxious family members to leave the room before giving a medication
c. Checking the patient’s room number against the medication administration record
d. Administering as many of the medications as possible at one time |
|
Definition
| Requesting that the prescriber write out an order, rather than giving a verbal order |
|
|
Term
The patient is in severe pain and is requesting a prn medication before the prn time interval has elapsed. The nurse’s priority is to
a. Give the medication early for any pain score greater than 8.
b. Call the prescriber and request a stat order.
c. Explain to the patient why he will have to wait for the medication.
d. Document the patient’s request and pain score. |
|
Definition
| Call the prescriber and request a stat order. |
|
|
Term
A patient is at risk for aspiration. What nursing action is most appropriate?
a. Hold the patient’s cup for him so he can concentrate on taking pills.
b. Thin out liquids so they are easier to swallow.
c. Give the patient a straw to control the flow of liquids.
d. Have the patient self-administer the medication. |
|
Definition
| Have the patient self-administer the medication. |
|
|
Term
A confused patient refuses his medication. What is the nurse’s first response?
a. Agrees with the patient’s decision and documents it in his chart
b. Educates the patient about the importance of the medication
c. Discreetly hides the medication in the patient’s favorite Jell-O
d. Informs the patient that he must take the medication whether he wants to or not |
|
Definition
| Educates the patient about the importance of the medication |
|
|
Term
A patient who is being discharged today is going home with an inhaler. The patient is to administer 2 puffs of his inhaler twice
daily. The inhaler contains 200 puffs. When should the nurse appropriately advise the patient to refill his medication?
a. As soon as he leaves the hospital
b. When the inhaler is half empty
c. 6 weeks from the start of using the inhaler
d. 50 days after discharge |
|
Definition
| 6 weeks from the start of using the inhaler |
|
|
Term
The nurse knows that a subcutaneous injection takes longer to absorb because
a. Fewer blood vessels are found under the subcutaneous level.
b. Adipose tissue takes longer to metabolize medication.
c. Connective tissue holds medication in place longer.
d. Some medication leaks out after instillation. |
|
Definition
| Fewer blood vessels are found under the subcutaneous level. |
|
|
Term
The nurse realizes which patient is at greatest risk for an unintended synergistic effect?
a. 72-year-old who is seeing four different specialists
b. 4-year-old who has mistakenly taken the entire packet of his mother’s birth
control pills
c. 50-year-old who was prescribed a second blood pressure medication
d. 35-year-old drug addict who has ingested meth mixed with several household
chemicals |
|
Definition
| 72-year-old who is seeing four different specialists |
|
|
Term
Which patient using an inhaler would benefit most from using a spacer?
a. 3-year-old with a cleft palate
b. 25-year-old with multiple sclerosis
c. 50-year-old with hearing impairment
d. 72-year-old with left-sided hemiparesis |
|
Definition
| 25-year-old with multiple sclerosis |
|
|
Term
The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day.
What is the nurse’s priority?
a. Administer the medication because it is within the therapeutic range.
b. Notify the physician that the prescribed dose is in the toxic range.
c. Notify the physician that the prescribed dose is below the therapeutic range.
d. Change the dose to one that is within range. |
|
Definition
| Notify the physician that the prescribed dose is below the therapeutic range. |
|
|
Term
The nurse is administering an intravenous medication that is to be administered over 10 minutes. Which method should the nurse
choose to efficiently administer the medication?
a. Place the medication in a large-volume cath-tipped syringe.
b. Mix the medication into the patient’s maintenance fluids.
c. Attach separate tubing and set the medication syringe in a mini-infusion pump.
d. Stand at the patient’s bedside and carefully watch the clock while pushing the
medication. |
|
Definition
| Attach separate tubing and set the medication syringe in a mini-infusion pump. |
|
|
Term
A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient’s peripheral IV, the patient
complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?
a. Notify the physician.
b. Administer pain medication.
c. Discontinue the IV.
d. Apply a cool compress to the site. |
|
Definition
| Apply a cool compress to the site. |
|
|
Term
The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse
realizes that she did not check the identification of the patient before administering medication. Which of the following actions
should the nurse complete first?
a. Return to the room to check and assess the patient.
b. Administer the antidote to the patient immediately.
c. Alert the charge nurse that a medication error has occurred.
d. Complete proper documentation of the medication error in the patient’s chart. |
|
Definition
| Return to the room to check and assess the patient. |
|
|
Term
The nurse knows that caring for two patients with the same last name can lead to a medication error involving which right of
medication administration?
a. Right medication
b. Right patient
c. Right dose
d. Right route |
|
Definition
|
|
Term
A patients states that she would prefer not to take her daily allergy pill this morning because it makes her too drowsy throughout the
day. The nurse responds therapeutically by saying,
a. “The physician ordered it; therefore you must take your medication every morning
at the same time whether you’re drowsy or not.”
b. “Let’s change the time you take your pill to 9 PM, so the drowsiness occurs when
you would normally be sleeping.”
c. “You can skip this medication on days when you need to be awake and alert.”
d. “Try to get as much done as you can before you take your pill, so you can sleep in
the afternoon.” |
|
Definition
Let’s change the time you take your pill to 9 PM, so the drowsiness occurs when
you would normally be sleeping.” |
|
|
Term
A provider has ordered a STAT medication to be administered. The nurse knows that the best route of administration is
a. IV.
b. IM.
c. SQ.
d. PO. |
|
Definition
|
|
Term
A nurse is attempting to administer medication to a child, but the child refuses to take the medication. The nurse asks for the
parent’s cooperation by saying
a. “Please hold your child’s arms down at her sides, so I can get the full dose of
medication into her mouth.”
b. “I will prepare the medication for you and observe if you would like to try to
administer the medication.”
c. “Let’s turn the lights off and give the child a moment to fall asleep before
administering the medication.”
d. “Since your child loves applesauce, let’s add the medication to it, so your child
doesn’t resist.” |
|
Definition
“I will prepare the medication for you and observe if you would like to try to
administer the medication.” |
|
|
Term
A 64-year-old quadriplegic patient needs an IM injection of antibiotic. What is the best site for the administration?
a. Deltoid
b. Dorsal gluteal
c. Ventrogluteal
d. Vastus lateralis |
|
Definition
|
|
Term
Which nursing action is the number one priority for ensuring that medication stays in the target therapeutic range?
a. Drawing the peak and trough levels at the same time each day
b. Administering a double dose after a dose was missed
c. Delivering the same amount of the drug at the same time each day
d. Increasing absorption by holding all other medications 1 hour before
administration |
|
Definition
| Drawing the peak and trough levels at the same time each day |
|
|
Term
Which of the following demonstrates proper oral medication administration?
a. Removing the medication from the wrapper and placing it in a cup labeled with
the patient’s information
b. Using the edge of the medicine cup to fill with 0.5 mL of liquid medication
c. Placing all of the patient’s medications in the same cup, except medications with
assessments
d. Combining liquid medications from 2 single dose cups into 1 medicine cup |
|
Definition
Placing all of the patient’s medications in the same cup, except medications with
assessments |
|
|
Term
A patient who is receiving IV fluids notifies the nurse that his arm feels tight. Upon assessment, the nurse notes that the arm is
swollen and cool to the touch. What should the nurse’s first action be?
a. Discontinue the IV site, and apply a warm compress.
b. Attached a syringe, and pull back on the plunger to aspirate the IV fluid.
c. Start a new IV site distal from the site.
d. Stop the IV fluids, and notify the physician immediately. |
|
Definition
| Discontinue the IV site, and apply a warm compress. |
|
|
Term
A patient informs the nurse that his urine is starting to look discolored. How should the nurse respond?
a. “Don’t worry, that is a normal side effect of your medication.”
b. “That is an unusual side effect. I’ll notify your provider immediately.”
c. “You need to drink more fluids to flush the medication from your system.”
d. “Other than the discoloration, has anything changed with your urination?” |
|
Definition
| Other than the discoloration, has anything changed with your urination?” |
|
|
Term
The physician orders 4 mg of oxycodone to be delivered every 6 hours. After 4 hours, the patient is complaining that she is in more
pain. The nurse advises the physician to make which medication adjustment?
a. Add an additional narcotic on top of the oxycodone.
b. Divide the dose in half and administer 2 mg every 3 hours.
c. Give another 4 mg of oxycodone after 4 hours.
d. Change the medication being administered for pain relief. |
|
Definition
| Divide the dose in half and administer 2 mg every 3 hours. |
|
|
Term
Which of the following are methods to reduce the risk of needlestick injury? (Select all that apply.)
a. Recap the needle after giving an injection.
b. Have sharps boxes emptied when three-quarters full.
c. Use two hands to dispose of sharps into the disposal.
d. Never force a needle into the sharps disposal.
e. Clearly mark sharps disposal containers.
f. Use needleless devices whenever possible. |
|
Definition
|
|
Term
What methods are used to properly discard narcotics? (Select all that apply.)
a. Placing the syringe of narcotics in the sharps container
b. Washing liquids down the sink
c. Flushing tablets down the toilet
d. Returning the open tablet to the medication dispenser
e. Locking the narcotic in a secure cabinet
f. Throwing tablets into the trash |
|
Definition
|
|
