NURS 100/ NURS100 Assessment 1 | Fundamentals of Nursing | WCU | Latest 2026–2027 Exam Questions & Answers | Verified Solutions | Grade A

NURS100/ NURS100 Assessment 1 | Fundamentals of Nursing | WCU | Latest 2026–2027 Exam Questions & Answers | Verified Solutions | Grade A Q: Madge graduated from a hospital-based diploma nursing program in 1947. During her 3-year education, she lived in a dorm next to the hospital where she cared for patients in the wards. She proudly wore her starched white uniform and nursing cap on the day of her pinning ceremony. Madge's daughter, Kathy, graduated from a 2-year associate degree nursing (ADN) program at the local community college in 1974. She worked as a "new grad" nurse in the hospital for 4 months after graduation, awaiting the results of her NCLEX-RN® examination. Bryan, Kathy's son, graduated with his bachelor of science in nursing (BSN) degree from the state university in 2011 after a 4-week preceptorship at the end of his program. As a new grad on the acute care floor, Madge worked diligently to obtain patient information and supplies in preparation for the healthcare provider's rounds. Which image was the new nurse demonstrating? Answer handmaiden Q: When comparing the roles of Madge and Bryan as new nursing grads, which roles and functions would they have in common? Select all that apply. Direct care provider Communicator Client/family educator Counselor Leader Answer all of the above Q: At the time of Bryan's graduation with his BSN degree, Kathy decides to enroll in an RN to BSN program to obtain her degree. What new opportunities will be available for Kathy with this additional education? Select all that apply. Bryan finds himself feeling unprepared and frustrated in his new grad role. He tells his mom, "I do fine when I've done something before, but every day there seems to be a new skill that I haven't performed yet." His mom reassures him that things will get easier as he becomes exposed to more experiences. Which stage of Benner's model is Bryan demonstrating? Answer Advanced beginner Q: Over dinner one evening, Bryan asks his grandmother whether she was ever a member of the American Nurses Association (ANA). She responds by saying, "I'm not sure what that is." What is Bryan's best response? Answer 1) Applying for graduate school 2) Providing community care 3) Performing research Q: During Kathy's BSN program, she has to give a presentation about the use of informatics in nursing as a part of the Quality and Safety Education for Nurses (QSEN) standards. Which examples from her workplace could Kathy share? Select all that apply. The time clock to record her hours worked The electronic health record to record and communicate patient care The computer order entry system to communicate between departments The barcode scanner for medication input safety The security monitoring camera to track visitors Answer 1) EHR record to record & communicate pt care 2) Computer order entry system to communicate between departments 3) Barcode scanner for medication input safety Q: After a year as a medical-surgical nurse in an acute care facility, Bryan tells his mom that he's more passionate about preventive care than he is about health restoration. To which care location should Kathy direct him? Answer Community health Q: Bryan decides to advance his practice and begins applying to nurse practitioner education programs. During an interview, he is asked which factors are most influential in changing the face of healthcare. Which answer is correct? Answer "Consumers are becoming more educated & demanding more choices." Q: In which ways is a nurse able to advance his or her practice? Select all that apply. Earning a doctorate in Nursing Practice Becoming certified to work in pediatrics Obtaining certification in wound care Obtaining certification in chemotherapy Becoming certified in emergency nursing Answer all of the above Q: The nurse is explaining that she works with homebound clients who cannot get to ambulatory care for treatment. Which health care setting is the nurse working in? Answer Home care Q: Which roles are commonly used by nurses during a given shift? Select all that apply. Leader Case manager Educator Advocate Organizer Answer 1) Leader 2) Case manager 3) Educator 4) Advocate Q: A nurse who is able to identify and achieve objectives is demonstrating which aspect of Benner's model? Answer Expert Q: Which organization represents nurses around the world to ensure quality nursing care for all? Answer The International Council of Nursing This or That? For each scenario, decide whether the nurse is using critical thinking or not. The nurse gathers equipment for the insertion of a Foley catheter, obtains a verbal consent from the client, and follows the agency's procedure to complete the task. Answer Not critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. The nurse discovers abnormal findings when performing a physical assessment. She reviews the electronic health record, comparing the findings, and calls the healthcare provider with the contrasting information. The nurse practitioner then gives new medication orders. Answer Critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. The student explores the client's health record, reads the history and physical examination, and records the information on the nursing care plan. Answer Not critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. The nurse recognizes that the client has crackles in the lower lung fields from an accumulation of fluid. He further explores the patient's weight, intake and output, and medication list before documenting the findings. Answer Critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. The unlicensed assistive personnel reports to the nurse that the blood pressure for a client is very low. The nurse reports the information to the next shift. Answer Not critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. Without assistance, a student ambulates a client in the hallway who recently returned from surgery. Answer Not critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. A nurse decides to place the intravenous catheter into the client's left arm because he is right handed. Answer Critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. The nurse delivers the first dose of a new blood pressure medicine that the client has not taken previously. She assesses the blood pressure before delivery of the medication and 1 hour afterward. Prior to the second dosage, the patient's blood pressure is very low and the nurse decides to hold the medication. Answer Critical thinking Q: This or That? For each scenario, decide whether the nurse is using critical thinking or not. A client tells the nurse that the hospital food is "terrible." The nurse asks what foods the client would prefer based on his cultural customs. She then contacts the dietary department to determine whether adjustments can be made. After the next meal, the nurse asks the client whether the food has improved. Answer Critical thinking Q: Which of the following exemplify critical thinking? Select all that apply. 1) Decision making following data evaluation 2) Accounting for pt considerations The steps of critical thinking include which of the following? Select all that apply. Answer 1) Explore 2) Identify 3) Analyze Which of the following describe the decision-making process of a nurse? Answer Complex maze of alternatives How can a student develop critical-thinking skills? Select all that apply. Answer 1) Play "what if?" multiple times a day 2) Question each test item, asking why it was incorrect The nurse completes the critical-thinking process but the client's care outcome has been only partially met. What should be the nurse's next action? Answer Reevaluate plan to determine whether was realistic Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. Drag and drop the step of the nursing process this represents Assessment Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. Drag and drop the step of the nursing process this represents. Diagnosis The nurse, Linda, identifies some concerns about her patient's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Drag and drop the step of the nursing process this represents. Planning outcomes Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying patient needs. Drag and drop the step of the nursing process this represents. Planning interventions Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Drag and drop the step of the nursing process this represents. Implementation Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. Drag and drop the step of the nursing process this represents. Implementation The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient's family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information Drag and drop the step of the nursing process this represents. Evaluation Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. Drag and drop the step of the nursing process this represents. Assessment Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center." Drag and drop the step of the nursing process this represents. Planning outcomes Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. Drag and drop the step of the nursing process this represents. Evaluation The diagnosis step of the nursing process includes which activity? Analyzing data Which of the following about the nursing process is correct? Works alongside an individualized plan of care Results in outcomes designed by the client Composed of a linear process with unique, distinct steps Includes only the care that the nurse will deliverWorks alongside an individualized plan of care Works alongside individualized plan of care Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." "Mr. Sullivan will be able to walk the length of the hallway before discharge." "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance." "Ambulate Mr. Sullivan in the hallway three times today, please." "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." The nurse is performing an assessment on a client. What should be included in this process? Religious and spiritual needs Which statement is correct about critical thinking and the nursing process? nursing process is critical-thinking, problem-solving model. If the body is overheating, it will compensate with: vasodilation Mr. Lu is admitted with an abdominal pain. His oral temperature is 100.4°F (38°C), pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are: Abnormal Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are: Normal Ms. Hernandez has a temperature of 102.5°F. Antipyretic medication is ordered for a temperature higher than 39°C. Can the nurse safely administer the medication? Yes When a patient's temperature increases, the pulse rate also increases. This finding would be: normal While palpating Ms. Smith's pulse, you find a rate of 116 beats/min. This finding is considered _______. tachycardia While assessing Mr. Brown's respiratory rate, you also observe that his chest expands fully on inspiration. His respiratory depth would be considered: deep At the beginning of a visit, the nurse assesses Mr. Broda's blood pressure and finds it is 116/76 mm Hg. During the visit, Mr. Broda receives some disturbing news about a diagnostic test. If his blood pressure was reassessed at that time, you would expect it to: rise Ms. Weakly presents to the emergency department with difficulty breathing. Her respiratory rate is 28 breaths/min and her pulse is 110 beats/min. Given the situation, this finding is: normal When a patient's blood pressure decreases, his pulse increases. This finding would be: normal Which blood pressure Korotkoff sound represents the systolic reading? first sound What are the primary vital signs of the nursing assessment? Select all that apply. 1) Temperature 2) Pulse 3) Respiratory rate 4) Blood pressure While palpating Mrs. Wong's pulse, you find a rate of 40 beats/min. This finding is _________. Bradycardia The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure, 107/66 mm Hg. Which findings are abnormal? Select all that apply. 1) Temperature 2) Pulse 3) Respiratory rate _____________ pressure is peak blood pressure against arterial walls. Systolic What information is needed when assessing the respiratory vital signs? Select all that apply. 1) Rhythm 2) Effort 3) Depth 4) Rate Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As Carol enters the home she visually scans the environment. Which observations are most concerning? Select all that apply. Several throw rugs on the floor. A space heater on the floor. Empty beer cans on the coffee table. Open medication bottles next to the television. A smoke detector hanging open in the kitchen. 1) Several throw rugs on floor. 2) A space heater on floor. 3) Open medication bottles next to television. 4) A smoke detector hanging open in kitchen. Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. Carol recognizes her primary concern is for the care of Sonia, her client. After she's completed the dressing changes she fills out a household safety assessment form. Which comments require further teaching for the safety of Sonia's grandchildren? Select all that apply. "Billy is in a rear-facing car seat. Bobby wears a shoulder seatbelt in the back seat." "Both Billy and Bobby swim with water wings at the city pool." "Billy still sucks his thumb and likes to put things in his mouth." "Bobby's favorite toys are small bricks; he leaves them everywhere." "Bobby loves his new skateboard." 1) "Billy is in rear-facing car seat. Bobby wears shoulder seatbelt in the back seat." 2) "Billy still sucks his thumb and likes to put things in his mouth." 3) "Bobby's favorite toys are small bricks; he leaves them everywhere." 4) "Bobby loves his new skateboard." Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. While discussing the surrounding community with Sonia, Carol learns that there are often drug dealers at the corner market, and there have been neighborhood drive-by shootings related to gang activity. What additional teaching should be included for the family? Select all that apply. Avoidance of touching needles if found Importance of a home security plan Purchase of a guard dog for protection Proper handling of guns and gun safety How to contact 911 for emergencies 1) Avoidance of touching needles if found 2) Importance of a home security plan 3) Proper handling of guns and gun safety 4) How to contact 911 for emergencies Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As Carol and Sonia are discussing safety, Carol shares that based upon age-group, drowning is the leading cause of death for which family member? Billy Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As an older adult, which age-related changes contribute to William's risk for injury? Select all that apply. Risk-taking behavior Sensory losses Hearing impairment Decreased mobility Increased cognitive awareness 1) Sensory losses 2) Hearing impairment 3) Decreased mobility Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. Two weeks later, Carol learns that William has been hospitalized for a fractured hip due to a fall. She visits him in the hospital and observes which safety measures in place to prevent injury? Select all that apply. 1) Antiembolism stockings to prevent a blood clot 2) Red slippers that identify him as a fall risk 3) Four siderails up on the bed to prevent him from getting up 4) Bed alarm is turned off because it's daytime 5) Bedside table near the bed 1) Antiembolism stockings to prevent a blood clot 2) Red slippers that identify him as a fall risk 3) Bedside table near bed Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As the nurse caring for William gives him an injection of pain medication, he accidently sticks himself with the used needle. What measure should the nurse have taken to prevent this injury? Select all that apply. Using a needle with a needle guard Not recapping needles Placing syringe and needle directly into the sharps container once used Confirming that the sharps container is not overfilled Not hand-passing sharps from one person to another 1) Using a needle with a needle guard 2) Not recapping needles 3) Placing syringe and needle directly into the sharps container once used 4) Confirming that the sharps container is not overfilled 5) Not hand-passing sharps from one person to another Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. William says to his nurse, "I guess I never really thought about how dangerous nursing can be" after learning of the needlestick. "Are injuries to nurses very common?" What would be correct responses by the nurse? Select all that apply. "Most injuries to healthcare workers are preventable." "Almost all nurses report chronic back pain." "The only ones who suffer injuries are the bedside nurses." "Several national organizations work to implement safety practices for nurses." "Exposure to radiation and violence are also ways a nurse can be injured." 1) "Most injuries to healthcare workers are preventable." 2) "Several national organizations work to implement safety practices for nurses." 3) "Exposure to radiation and violence are also ways a nurse can be injured." Carol, a home health nurse, is caring for a family in a low-income, inner-city neighborhood. Four generations of family live in this small, two-bedroom apartment including William, 81 years old; his daughter, Sonia, 51 years old; her daughter Tasha, 28 years old, and Tasha's sons, Bobby, 6 years old, and Billy, 2 years old. Sonia was recently discharged from the hospital with a healthcare-acquired infection of her surgical wound and requires routine dressing changes. As the nurse prepares to help William get out of bed for the first time after surgery, which safety measures should be taken? Select all that apply. Apply skid-resistant shoes on William. Place a lift belt tightly around William's waist. Get additional help. Clear area of obstacles. Place a skid-free rug at the side of the bed. 1) Apply skid-resistant shoes on William. 2) Place a lift belt tightly around William's waist. 3) Get additional help. 4) Clear area of obstacles. A nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are actions the nurse can take when caring for this client? Select all that apply. 1) Repeat fall risk assessment every 8 hours. 2)Place call light within reach. 3) Identify medications that increase falling risk. A nursing unit is receiving report for five clients being newly admitted. Which client is at the highest risk for injury and best to place close to the nurse's station? A 9-year-old child who is tearful A 16-year-old adolescent who is depressed A 62-year-old patient who is anxious An 87-year-old patient who is confused 87-year-old patient who is confused Which statements by a nurse are correct when preventing needlesticks and blood exposure? Select all that apply. 1) "I always place my used needles into puncture-proof, labeled container." 2) "I confirm that sharps container is not overfilled before placing syringe inside." 3) "I only recap with needle guard when available." The nurse knows that falls most often occur in hospitals and long-term care facilities during which time frames? Select all that apply. 1) Weekends 2) Nights 3) Holidays The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? Select all that apply. 1) Apply lift belt. 2) Get additional help. 3) Clear area of obstacles. What factors influence hygiene practices? 1) Personal preference 2) Culture 3) Economic status 4) Knowledge level 5) Developmental level What types of scheduled hygiene are provided in healthcare facilities? 1) Early morning care 2) Morning care 3) Hour of sleep care 4) Hourly Rounds 5) Afternoon care Which terms are commonly used to describe types of baths delivered in healthcare? 1) Towel bath 2) Assist bath 3) Therapeutic bath 4) Partial bath 5) Bed bath Which techniques are beneficial in bathing a client with dementia? 1) Let pt know what going to do before touching or spraying w water 2) Do not rush 3) Provide proviacy 4) Provide choices 5) Explain procedure simply 6) Use gentle shower head for rinsing What are some common problems of the mouth? 1) Stomatitis 2) Halitosis 3) Oral malignancies 4) Dental caries 5) Gingivitis 6) Cracked lips The nurse is preparing to give a bath to an older adult who is unconscious and has had a fever and night sweats. Which type of bath would be the best option? Complete bed bath The nurse is caring for a client who has recently migrated to this country. The interpreter shares that the client usually bathes once a week. When your assessment is finished, the nurse plans to have the client shower. What additional information needs to be gathered? Ask about hygiene customs in client's native land. The nurse assists unlicensed assistive personnel in providing morning care to a comatose client who is bowel and bladder incontinent. The nurse should intervene if which action is observed? UAP answers telephone while wearing gloves. The nurse is directing unlicensed assistive personnel in providing morning care to a comatose client. Besides a bed bath, what care should be provided? Select all that apply. 1)Moisturizing skin 2)Cleaning fingernails 3) Brushing teeth The nurse is bathing a client with senile dementia. What action will optimize the chance of cooperation? Use quiet, calm manner, allowing for choices Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. What additional assessment findings would be important for the nurse to gather in relation to oxygenation concerns? Select all that apply. 1) Pulse oximetry reading 2) Arterial blood gas 3) Lung sounds 4) Number of years of smoking Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. Upon further assessment, the nurse discovers that Mr. Martin has conversational dyspnea and use of accessory muscles. His sputum is dark yellow-green and thick. He is having difficulty expectorating. What is the best position for Mr. Martin? High Fowler's Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. To promote mobilization of the pneumonia secretions, which actions should the nurse include in the plan of care? Select all that apply. 1) Encourage cough & deep breathing 2) Maintain hydration 3) Perform chest physiotherapy Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. The nurse performs a routine assessment on Mr. Martin and discovers that his pulse oximetry reading is 89%. She contacts the healthcare provider and receives an order for oxygen at 2 L/nasal cannula. What hazards should be considered with the use of oxygen? Select all that apply. 1) High oxygen concentration can lead to alveolar collapse 2) Toxicity can develop if too much oxygen is delivered 3) Oxygen tanks are pressurized & can turn into unguided missile 4) Oxygen is highly combustible Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. As the nurse is placing the oxygen, she reflects on the percentage of oxygen being delivered via nasal cannula (NC) at 2 L. What would be the correct amount? 28% Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. As Mr. Martin's oxygenation deteriorates, the nurse has an order to titrate pulse oximetry to keep it greater than 90%. Because Mr. Martin is currently at 6 L/NC (44% oxygen), what would be the best options for delivery of oxygen should the levels drop below 90%? Select all that apply. 1) Simple mask 2) Partial rebreather mask 3) Venturi mask 4) Face tent Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. Over the next few days, Mr. Martin's infection gets worse and he is sleeping most of the time. The nurse must place an artificial airway to suction the secretions from his lungs. Which type of artificial airway would work best? Nasopharyngeal airway Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia. As the nurse suctions Mr. Martin via the nasopharyngeal airway, what would be an anticipated response? Harsh coughing The nurse is encouraging a client to cough and deep breathe as well as use the incentive spirometer. She also performs chest physiotherapy twice a day. What is the purpose of these interventions? Mobilize secretions The home care nurse visits a client who wears oxygen at bedtime. She smells cigarette smoke when entering the home. What should she say to the client? "It smells like someone has been smoking in here. Do you realize that oxygen supports combustion?" A child has an inflamed epiglottis from a viral infection, causing stridor and partially blocking the flow of air. Which type of breathing problem is present? Altered airway The nurse is caring for a client with diabetic ketoacidosis, an acid-base disturbance. What type of breathing pattern should the nurse anticipate? Kussmaul's breathing The nurse notes that the client is experiencing respiratory distress. Which assessment changes support this finding? Select all that apply. 1) Nasal flaring 2) Grunting 3) Stridor 4) Wheezing Encourage range-of-motion exercises promote venous return Provide good foot care and prevent injury Promote peripheral arterial circulation Turn client frequently, teach the importance of changing positions prevent clot formation Promote adequate hydration prevent clot formation Pain in feet when walking Problem of peripheral arterial circulation Elevate the legs above the level of the heart promote venous return Teaching to avoid sitting with the legs crossed promote venous return Pain, warmth, redness, and swelling of the calf or thigh on one side of the body problem of clot formation Management of anticoagulation therapy prevent clot formation Apply sequential compression devices (SCDs) promote venous return The nurse knows that the electrical conduction in the heart can impact the process of circulation. What else can impact circulation? Select all that apply. 1) Strength of heart's contractions 2) Volume of blood in body 3) Resistance that heart pumps against What is needed for perfusion to the tissues to be adequate? Select all that apply. 1) adequate circulation system w good blood flow 2) Oxygen-saturated hemoglobin traveling in blood Which events can create imbalance of circulation and perfusion? Select all that apply. 1) Stress 2) Pregnancy 3) Obesity 4) Medications 5) Illness Carl has poor arterial circulation, and the nurse is providing patient teaching regarding proper foot care. What should the nurse include in her teaching? Select all that apply. 1) Wear smooth, dry socks 2) Wear well fitting shoes 3) Apply lotion to feet After a hip fracture, Joseph has become more sedentary. He notices an area on his right calf that is painful, warm to the touch, red, and swollen, and he shows it to the visiting nurse. What action should the nurse take? Encourage Joseph to go to emergency department decide whether the action promotes or inhibits normal bowel habits. Stanley is recovering from knee surgery and has not had a bowel movement for 3 days. The nurse places him on the bathroom toilet rather than having him use the bedside commode or a bedpan. promotes decide whether the action promotes or inhibits normal bowel habits. The nurse assists Martha to the restroom and leaves the door open a crack so she can be heard if she needs help. inhibits decide whether the action promotes or inhibits normal bowel habits. Jeremy has a digestive disorder that causes a lot of gas. He is in a semiprivate room and mentions how disturbing it must be for his roommate. The nurse sprays some odor reducing product and leaves it with Jeremy to use as needed. promotes decide whether the action promotes or inhibits normal bowel habits. Bonita tells the nurse she needs to use the restroom. The nurse cannot find adequate help to get Bonita out of bed so she is placed on a bedpan. inhibits decide whether the action promotes or inhibits normal bowel habits. The nurse has an order to deliver an enema to a constipated client. The nurse enters the room and slides the lunch tray to the side, explaining there is an order for an enema. inhibits decide whether the action promotes or inhibits normal bowel habits. Joe is constipated and asking for a snack. The nurse offers an apple or orange. promotes decide whether the action promotes or inhibits normal bowel habits. Clay is constipated, so the nurse suggests increasing his water intake to 1 liter per day. inhibits decide whether the action promotes or inhibits normal bowel habits. Natasha is recovering from surgery and is constipated from the regular opioid pain medications she receives. The nurse requests high fiber in her diet from the dietitian. inhibits decide whether the action promotes or inhibits normal bowel habits. Knute is in a care center and tells the nurse he has not had a bowel movement for 2 days. The nurse suggests they go for a walk later. promotes Which action is most appropriate for a client experiencing constipation? Select all that apply. 1)Increase intake of fruits and vegetables 2) Increase intake of beans and legumes A client is diagnosed with an intestinal infection after traveling to a developing country. The nurse should encourage the intake of which food to optimize the gut's normal flora, creating a healthier environment? yogurt A nurse is teaching wellness to a church group. How many daily 8-ounce servings of water should be encouraged for normal bowel health? 6 to 8 servings The nurse is assisting a client in the emergency department who needs to use the restroom for a bowel movement. Which option is best? Private restroom The nurse is reviewing the medical record of a client who has not had a bowel movement for 3 days. What factors are concerning? Select all that apply. 1) Client has not eaten for 48 hours. 2) Client is on bedrest. 3) Client is receiving an iron supplement. 4) Client is in a semiprivate room. 5) Client took a laxative prior to hospitalization. Risk factors for urinary tract infection 1) Sexual intercourse for women 2) Kidney stones 3) Diabetes 4) Enlarged prostate 5) Pregnancy Symptoms of a urinary tract infection 1) Urgency 2) Urinary frequency 3) Dysuria 4) Fever & chills 5) N/V 6) Back pain Causes of urinary retention 1) Obstruction 2) Meds 3) Anxiety 4) Neurological probs 5) Inflammation Types of urinary incontinence 1) Urge incontinence 2) Nocturnal enuresis 3) Functional incontinence 4) Stress incontinence 5) Overflow incontinence Treatments for urinary incontinence 1) Timed voiding 2) Kegel exercises 3) Meds 4) Surgical tx 5) Sacral nerve stimulation 6) Devices Mandy is collecting a urinary history for an older adult client admitted to the hospital with renal insufficiency and a urinary tract infection. What should be included in the questioning? Select all that apply. 1)Changes in urinary habits 2) History of urinary infection 3) Frequency of urination 4) Fluid intake The nurse is tallying the intake and output record for the shift. What should be included on the intake record? Select all that apply. 1) Intravenous fluids 2) Hot tea 3) Ice chips 4) Ice cream What is considered a risk factor for a urinary tract infection? Diabetes The nurse admits a client with fever and chills. The nurse is concerned the client may have a urinary tract infection, so which other symptoms should the nurse ask about? Select all that apply. 1) Back pain 2) Painful urination 3) Bladder spasms 4) Urgency An instructor asks the student nurse about common reasons for urinary incontinence. How should the student respond? Select all that apply. 1) Sneezing and laughing 2) Overfilled bladder 3) Physical disabilities The nurse is performing passive range of motion for a client with osteoarthritis and feels a grating sound in the left knee. How would the nurse document this finding? Crepitus Which electrolytes would be found in the intracellular fluid? Select all that apply. phosphate, potassium & magnesium What does the "Q" refer to in the SBARQ communication tool? Questions Which techniques are barriers to communication with clients? Select All That Apply. Allowing silence Expressing approval Providing false hope Asking "why" questions Interpreting body language Expressing approval Providing false hope Asking "why" questions Which factors control the growth of microorganisms? Select all that apply. pH Light Oxygen Temperature Which factors can decrease cardiac tissue perfusion? Select all that apply. Hyperlipidemia Substance abuse Birth control pills Which intervention has been found to greatly decrease the risk of ventilator associated pneumonia (VAP) for clients who are mechanically ventilated? Chlorhexidine oral solution use Which conditions do beta blockers treat? Select all that apply. Angina, congestive heart failure & acute myocardial infarction What are the functions of body fluids? Select all that apply. 1) body fluids maintain blood volume 2) body fluids regulate body temp 3) body fluids transport materials to & from cells 4) body fluids facilitate excretion of bodily wastes Which health-care related infections is the U.S. Department of Health and Human Services (USDHHS) working to reduce? Select all that apply. 1) Surgical site infections 2) Multidrug-resistance organisms 3) Ventilator associated pneumonia 4) Catheter associated urinary tract infections How would the nurse assess for costovertebral angle tenderness? Percuss between the 12th rib and spine. Which are components of caring? Select all that apply. Knowing Being with Doing without Enabling Maintaining belief knowing, being with, enabling & maintaining belief A nurse has asked the unlicensed assistant personnel (UAP) to take vital signs on six clients. Which traditional measurements do vital signs include? Temperature, pulse, respirations, and blood pressure When washing a client's legs, which direction is correct? Distal to proximal Which type of data should be included in the discharge planning? Select All That Apply. Functional and self-care limitations Emotional stability and ability to learn Family or other caregivers available Use of community services before admission Which describe types of muscle? Select all that apply. skeletal, smooth & cardiac There are several communication styles that can interfere with therapeutic relationships. What are the characteristics of a passive style? To avoid conflict and let others take lead A nurse is teaching a client who is started on digoxin before discharge. Which statements by the client indicate correct understanding of the teaching? Select all that apply. 1) I will take my pulse before every pulse & contact my HCP for pulse less than 50 2) I will notify my HCP if I have blurred, yellow vision 3) My blood levels will have to be checked every month An older adult client had been admitted with a diagnosis of emphysema and COPD, and the client has been experiencing shortness of breath and low SaO2 levels evidenced by pallor and a SaO2 reading of 88%. What would be an appropriate nursing diagnosis for this client? Altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels How is critical-thinking used in nursing other than in the nursing process? Select all that apply. 1) In determining how many nurses to staff during shift 2) When creating list of inventory needed for unit How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds? 3 minutes What is the term for the amount of blood that is filtered in a minute? Glomerular filtration rate What is the most common cause of infectious pharyngitis? Streptococcal pyogenes Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply. Weather Pollutants Financial strains Medical diseases Congenital disorders Weather Pollutants Financial strains According to the Centers for Disease Control (CDC), how often should the nurse change the intravenous (IV) tubing for a continuous infusion? Every 96 hours Which part of the ECG complex represents the SA node firing and conducting the impulse through the atria? P wave What are the goals of infection prevention and control in health care? Select all that apply. 1) Protect clients from contagions. 2) Lower the cost of health care services. 3) Meet professional standards and guidelines. 4) Protect employees from contracting infections. The nurse is reviewing the structures of the heart. Which part is the pericardium? sac of connective tissue that encases the heart What should the nurse include when trying to motivate a group of adolescents to include exercise in their daily regimen? Select all that apply. Recognize barriers to exercise. Reward yourself when goals are met. Tailor the exercise regimen to meet needs. For which client would the nurse need to don protective eyewear? Select all that apply. A client with MRSA who the nurse is bathing A client with C-diff. who is being assisted to the bathroom A client with tuberculosis who has frequent productive cough A client with hepatitis who has frequent nosebleeds A client with tuberculosis who has frequent productive cough A client with hepatitis who has frequent nosebleeds A nurse is teaching a group of clients about different cardiovascular medications. Which cardiac medications are considered vasodilators? Select all that apply. ACE inhibitors Diuretics Beta-adrenergic blockers Angiotensin II receptor blockers Nitrates Statins ACE inhibitors Angiotensin II receptor blockers Nitrates In a client's health record, the nurse documents, "Nutritional status will improve as evidenced by a weight gain of 3 lb (1.4 kg) by July 1." This statement is an example of which step of the nursing process? planning The nurse is assigned to care for a client who reports nausea, vomiting, and diarrhea. The client's vital signs are as follows: T 100.6°F, AP 100, RR 20, BP 92/69, O2 saturation 98%. Which nursing actions represent the nurse using critical-thinking skills to separate important from unimportant data? Select all that apply. asks what client has eaten in past 24 hours. nurse administers antiemetic to client. nurse asks client how long symptoms have been present. nurse assesses skin turgor of client. The nurse is educating a group of clients about risks for food poisoning. Which statement made by a client indicates understanding? "I should not consume raw cookie dough." "It is fine to eat raw sushi in a restaurant." "I sometimes drink milk straight from the cow." "I can leave food out for three hours before consumption." "I should not consume raw cookie dough." A nurse makes a home-care visit for a client who had total hip replacement surgery 1 week ago. During which of the five steps in the nursing process does the nurse determine whether outcomes of care are achieved? Evaluation When considering the nursing process, the word "observe" is to "assess" as the word "explore" is to which of the following words? analyze Which statement is related to the concept that is central to the nursing process? it is dynamic rather than static Which word best describes the role of the nurse when using the nursing process to meet the needs of the client holistically? advocate Which word is most closely associated with scientific principles? rationale A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is directly related to this concept? etiology A nurse teaches a client to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention? Implementation A nurse is caring for several clients. Which nursing action reflects the assessment step of the nursing process? Examining a client for injury after a fall in the bathroom A nurse is caring for a client with a fever. Which is a well-designed goal for this client? Health A state of optimal well-being Licensure The legal authority to practice as a professional nurse Nurse Practice Acts Laws established in each state to regulate the practice of nursing Nursing Describes the nurse as a person who nourishes, fosters, and protects; and who is prepared to take care of sick, injured, and aged people Nursing process The essential activities involved in the nursing process are assessing, diagnosing, planning, implementing, and evaluating process Profession Based on being a well-defined body of specific and unique knowledge. Strong service orientation. Recognized authority by a professional group. Code of ethics. Professional organization that sets standards. Ongoing research. Autonomy & self regulation. Recipprcity Allows a nurse to apply for endorsed as a registered nurse by another state Standards Allows nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where Healthcare is provided What does NCLEX stand for? National Council Licensure Examination Why do you take the NCLEX? To obtain your license as a Registered Nurse What is the NCLEX testing for? Minimum competency, based on behaviors that are needed for entry level practice What is CAT? Computer Adaptive Test What does CAT do? Each test is interactively based on accuracy of the candidates response to the questions. Ensuring that the questions you are answering are not "too hard" or "too easy". To pass maintain minimum competency What types of Questions are on the NCLEX? *Multiple choice *Select all that apply *Chart/Exhibit *Drag and drop *Fill in the blank calculations *Hot spots *Audio *Graphics What are the NCLEX question guidelines? *Cannot skip a question *Cannot return to a question *As long as you are still getting questions you are still in the game! How many questions does the NCLEX have? 75 - 265 What are the rules for NCLEX? *White board (do not brain dump) *No electronic devices or watches *prefer you take only your keys, best not to access locker during exam *get the attendants attention by raising your hand Pre-Civilization Nursing Nurse portrayed as mother caring for family. Belief that good and bad spirits bring health or illness. Physician as medicine man Early Christian Period Nursing Nurses were viewed as slaves carrying out menial tasks ordered by the priest (physician). The belief existed that illness is cause by sin and gods' displeasure. 16th century Shortage of Nurses so, criminals were recruited which made nurses disreputable. The focus was more toward warfare than religion 19th-20th Century Florence Nightingale founded modern nursing education, elevated the status of nursing to a respected occupation, and improved quality of nursing. 1950s to Present WWII brought large amounts of women into the workforce. Nursing broadened to become a profession. Emphasis on Evidence-based practice, health promotion, service orientation, a specific body of knowledge, and nursing research. What are the contributions of Florence Nightingale to modern medicine? Defined nursing as both an art & a science. Defined & practiced holistic nursing. Identified personal needs of PT and role of nurse. Established standards for hospital management. Established nursing education & nursing as an occupation. 2 components of nursing health & illness. Recognized nutrition as important The beginning of nursing research. Definition of Nursing A blend of science and art Science provides the knowledge base for care that is given. Art is the skilled application of the knowledge to help others reach their maximum health. QSEN Competencies Patient-centered care Teamwork and collaboration Quality improvement Safety Evidence-based practice Informatics Nursing Aims 1. To promote health (state of optimal functioning) 2. To prevent illness 3. To restore health 4. To facilitate coping with disability or death Interrelated roles of nurses Communication Teacher/Educator Counselor Leader Researcher Collaborator LPN requires what kind of schooling? Practical and vocational nursing Education What kind of schooling does an Registered Nurse need? An ADN or a BSN What degrees can you get after your BSN? MSN, NP, PhD, or DNP After graduating what degree do you get? ADN form ameritech. How do you get your license to practice as an RN? Take the NCLEX and pass Nurse Practice acts Defines legal scope of nursing Provide legal requirements and titles for RNs and LPNs Create a state Board of nursing. Establish criteria for education and licensure of nurses Health A state of complete physical, mental, and social well-being. Not merely the absence of disease or informity Illness The unique response of a person to a disease; an abnormal process involving changed level of function Wellness An active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health Acute illness Generally has a rapid onset of symptoms and lasts only a relatively short time. Chronic illness Usually has a slow onset and may have periods of remission and exacerbation Characteristics of Chronic illness Usually a permanent change It causes or is caused by irreversible alterations in normal A&P Special patient education for rehab Requires a long period of care or support Stages of illness Stage 1 Experiencing symptoms: Pain most significant symptom Stages of illness Stage 2 Assuming the sick role: Individual may focus on symptoms. (May call in sick) Stages of illness Stage 3 Assuming a dependent role: accepts diagnosis and treatment plan. (May enter hospital if needed for treatment Stages of illness Stage 4 Achieving recovery and rehabilitation: (May begin at the hospital but ends at home) Factors influencing health disparities Racial and ethnic groups, poverty, Gender, age, mental health, education level, disabilities, Sexual orientation, health insurance and access to health care Factors affecting health and illness Basic human needs, the human dimensions, self-confessed and risk factors for illness or injury. Physical Dimension Genetic inheritance, age, developmental level, race and gender Emotional Dimension How the mind affects the body function and responds to body conditions Intellectual Dimension Cognitive abilities, educational background, and past experiences Environmental Dimension Housing, Sanitation, Climate, pollution of air, food, and water Sociocultural Economic level, lifestyle, family, and culture Spiritual Dimension Spiritual beliefs and values Primary health promotion and illness prevention Promote optimal health and prevent disease (Weight loss, diet, exercise, smoking cessation) Secondary health promotion and illness prevention Screening for early detection and treatment (Screening, examination, family counseling) Tertiary health promotion and illness prevention Reduce disability and rehabilitation to maximal functioning (Medications, surgical treatment, occupational therapy) The health illness continuum Health as a constantly changing state, with high-level wellness and death being on opposite ends of a graduate scale or continuum. Risk factors for illness 1. Age 2. Genetic factors 3. Physiologic factors 4. Health habits 5. Lifestyle 6. Environment Disease Pathologic changes in the structure or function of the mind and body. Exacerbation The symptoms of the disease reappear Health disparity Particular type of health difference that is closely linked with social, economic, and or environmental changes Health promotion Behavior of a person who is motivated by a personal desire to increase well-being and health potential Holistic care Care that addresses the many dimensions that comprise the whole person Illness The response of the person to a disease Morbidity How frequent a disease occurs Remission When the disease is present but the person does not experience symptoms Risk factor Something that increases a persons chances for illness or injury Person-centered nursing process -The person -The professional nurse -Reflective practice leading to personal learning -Clinical reasoning, judgement, and decision making -The nurse's action in response to individual clinical needs Principles of Person-centered care Part 1 All team members are caregivers Care is based on continously healing relationships Care is customized and reflects pt needs, values, and choices Principles of Person-centered care Part 2 Knowledge and info are freely shared between and among pts, care partners, physicians, and other caregivers Care is provided by healing environment of comfort, peace, and support Families and friends of the pt are considered an essential part of the care team Principles of Person-centered care Part 3 Pt safety is a visible priority Transparency is the rule in the care of pt All caregivers cooperate with one another through a common focus on the best interests and personal goals of the pt. The pt is the source of control for one's care Cognitive Skills Offer scientific rationale for pt plan of care, use critical thinking to solve problems creatively Critical Thinking A systematic way to form and shape one's thinking Technical skills Manipulating equipment skillfully to produce desired outcome Interpersonal skills Promoting dignity and respect of pts and establishing caring relationships Ethical/Legal skills Establishing a personal moral code and professional roles responsibilities Systemic method Provides a framework for the nurse and pt to develop a holistic plan of care What does ADPIE mean? Assessing Diagnosing Planning Implementing Evaluating Assessing Collecting, validating, and communicating of patient data Diagnosing Analyzing patient data to identify patient strengths and problems Planning Specifying patient outcomes and related nursing interventions Implementing Carrying out the plan of care Evaluating Measuring extent to which patient achieved outcomes Systematic Part of an ordered sequence of activities Dynamic Great interaction and overlapping on all 5 steps Interpersonal Human being is always at the heart of nursing Outcome oriented Nurses and patients work together to identify outcomes Universally applicable A framework for all nursing activities Characteristics of the nursing process Systematic, dynamic, interpersonal, outcome oriented, and universally applicable Benefits of nursing process Patient Scientifically based, holistic individualized patient care, continuity of care, clear, efficient, cost-effective plan of action Benefits of nursing process Nurse Opportunity to work collaboratively with other health care workers Satisfaction of making a difference in lives of patients Opportunity to grow professionally Blended competencies Cognitive, technical, interpersonal, & ethical/Legal competencies. Using some or all of them at a time. Caring In nursing is a special way of being, knowing, and doing with the goal of protection, enhancement, and preservation of human dignity Clinical judgment The decision or opinion you make using critical thinking or clinical reasoning Clinical reasoning Ways of thinking about patient issues (determining, preventing, and managing patient problems) Concept mapping Instructional strategy in which learners identify, graphically display, and link key concepts Creative thinking Imagination, intuition, and spontaneity. Factors that underpin the art of nursing Critical thinking indicators Behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Decision making Purposeful, goal directed effort applied in a systematic way to make a choice among alternatives Intuitive problem solving A direct understanding of a situation based on a background of experience, knowledge, and skills that make expert decision making possible Nursing diagnosis Analysis of patient data to identify pt strengths and health problems that independent nursing interventions can prevent or resolve Nursing process Systematic method that directs t