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The nurse is educating parents about firearm safety. Which parent statement indicates to
the nurse a need for further education?
A. "I should make sure I obtain the proper permits."
B. "It is okay to store firearms with ammunition loaded."
C. "I should store all firearms without ammunition."
D. "I should make sure all firearms are stored in a secure location."
B. "It is okay to store firearms with ammunition loaded."
The nurse is teaching a student nurse about restraint use in patients. Which statement by
the student nurse indicates a learning need regarding restraints?
A. "Having all four side rails up on the bed is considered a restraint."
B. "The use of restraints has been shown to decrease fall-related injuries."
C. "Death has been associated with the use of restraints."
D. "Medications administered to control behavior are considered a chemical restraint."
B. "The use of restraints has been shown to decrease fall-related injuries."
Which statement by the patient indicates to the nurse a teaching need regarding safety in
the home?
A. "I will put a night-light in every room."
B. "I will not use an extension cord to plug in multiple items."
C. "I will wash my throw rugs in the bathroom regularly."
D. "I will keep all cleaning supplies out of reach of children."
C. "I will wash my throw rugs in the bathroom regularly."
The nurse recognizes which term to identify the second line of defense that leads to local
capillary dilation and leukocyte infiltration?
A. Normal flora
B. Inflammatory response
C. Immune response
D. Humoral immunity
B. Inflammatory response
The nurse is explaining to the patient why antibiotics are being administered. The answer
would be correct if the nnurse stated antibiotics are effective against which
microorganism?
A. Viruses
B. Fungi
C. Parasites
D. Bacteria
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D. Bacteria
The nurse recognizes that the stethoscope most correctly represents which possible link in
the chain of infection?
A. Source
B. Portal of exit
C. Portal of entry
D. Mode of transmission
D. Mode of transmission
Excessively dry skin can lead to cracks and openings in the integumentatry system. Based
on this, what is the most applicable nursing diagnosis for a patient with excessively dry
skin?
A. Impaired health maintenance
B. Risk for injury
C. Risk for infection
D. Acute pain
C. Risk for infection
The UAP asks why the arms are washed from distal to proximal. Which response by the
nurse is appropriate?
A. To promote circulation
B. To maintain asepsis
C. To maintain comfort
D. To maintain tradition
A. To promote circulation
The nurse is implementing generalized fall precautions for patients who are at risk for falls.
Which intervention indicates a lack of understanding of these precautions?
A. The bed is placed in the low position.
B. The patient is wearing socks
C. The patient's cell phone is by the bedside.
D. The patient's call light is within reach.
B. The patient is wearing socks
The nurse is educating the family of a patient on fall risk precautions. Which statement by
he family indicates a need for further education?
A. "I should keep the wheelchair locked unless using it to move Mom."
B. "I should leave the bathroom light on as she does at her home."
C. "I should leave her slippers by the wheelchair."
D. "I should keep her cell phone close to her bed."
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C. "I should leave her slippers by the wheelchair."
The nurse identifies which goal to be appropriate for the patient who is postoperative day
one from abdominal surgery and on bed rest with the nursing diagnosis of impaired skin
integrity?
A. Patient will ambulate twice a day.
B. Patient will eat 50% of meals.
C. Patient will have no further skin breakdown.
D. Patient will interact with others.
C. Patient will have no further skin breakdown.
The nurse identifies which instruction to be appropriate to delegate to the UAP (unlicensed
assistive personnel)?
A. Assess the patient's skin during a bath.
B. Reposition the patient using a trapeze.
C. Assess the patient's ability to perform range-of-motion exercises.
D. Notify the health care provider of any changes.
B. Reposition the patient using a trapeze.
Which of the following is an example of subjective data?
A.Vital signs
B. Intake and output
C. Physical examination
D. A patient stating "I have pain in my arm"
D. A patient stating "I have pain in my arm"
Which of the following is an example of objective data?
A. Description of a patient's symptoms
B. Blood pressure is 124/65
C. Medical history
D. A patient's feelings
B. Blood pressure is 124/65
What is the purpose of a nursing assessment?
A. To diagnose a disease
B. To give information to the physician
C. To assess a patient's overall health and nursing needs
D. To assess vital signs
C. To assess a patient's overall health and nursing needs
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Which of the following is included in the diagnosis part of the nursing process?
A. Perform a physical examination
B. Gather data about a patients actual or potential health problem to formulate a nursing
diagnosis
C. To assess vital signs
D. Make a care plan
B. Gather data about a patients actual or potential health problem to formulate a nursing
diagnosis
Which of the following is an example of a problem focused assessment?
A. A nurse is assessing a patient's respiratory system and proceeds to ask "Are you a
smoker?"
B. A nurse obtaining vital signs
C. A nurse performing a head-to-toe examination
D. A nurse obtaining information such as past medical history, family medical history, and
allergies
A. A nurse is assessing a patient's respiratory system and proceeds to ask "Are you a smoker?"
A nurse is discussing preoperative procedures with a Japenese American client. The client
continually nods and smiles during this discussion. How should the nurse interpret this
nonverbal behavior?
A. Reflecting cultural value
B. An acceptance of treatment
C. Client agreement to the procedure
D. Client understanding of the procedure
A. Reflecting cultural value
Which of the following is a correctly written NANDA nursing diagnosis?
A.Risk for injury due to cataract surgery
B. Impaired physical mobility related to decreased muscle control as evidenced by the
inability to control lower extremities
C. Anger R/T diagnosis of cancer
D. Ineffective breathing patterns R/T pneumonia
B. Impaired physical mobility related to decreased muscle control as evidenced by the inability
to control lower extremities
The nurse identifies the nursing process as the foundation of professional nursing practice
and can define it in which appropriate terms?
A. A complex process during which nurses think about their thinking.
B. The process that allows nurses to collect essential data.