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When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
The nurses next action should be to:
a. immediately notify the patients physician
b. document the sound exactly as it was heard
c. Validate the data by asking a coworker to listen to the breath sounds
d. assess again in 20 minutes to note whether the sound is still present -ANSWERS-c.
validate the data by asking a coworker to listen to the breath sounds
The nurse is conducting a class for a new graduate nurses. During the teaching
session, the nurse should keep in mind that novice nurses, without a background of
skills and experience from which to draw, are more likely to make their decisions using:
a. Intuition
b. a set of rules
c. articles in journals
d. Advice from supervisors -ANSWERS-b. a set of rules
Expert nurses learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
a. Intuition
b. the nursing process
c. clinical knowledge
d. diagnostic reasoning -ANSWERS-a. intuition
,The nurse is reviewing information about EBP. Which statement best reflects EBP?
a. EBP relies on tradition for support of best practices
b. EBP is simply the use of best practice techniques for the treatment of patients
c. EBP emphasizes the use of best evidence with the clinicians experience
d. the patients own preferences are not important with EBP -ANSWERS-c. EBP
emphasizes the use of best evidence with the clinicians experience
The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. individual with shortness of breath and respiratory distress -ANSWERS-d. individual
with shortness of breath and respiratory distress
When considering priority setting of problems, the nurse keeps in mind that second level
priority problems include which of these aspects?
a. low self-esteem
b. lack of knowledge
c. Abnormal laboratory values
d. severely abnormal vital signs -ANSWERS-c. abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant -ANSWERS-b. clustering related cues
,The nurse knows that developing appropriate nursing interventions for a patient relies
on the appropriateness of the ______ diagnosis.
a. Nursing
b. medical
c. admission
d. collaborative -ANSWERS-a. nursing
The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow up
b. admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. assessment, diagnosis, outcome identification, planning, implementation, and
evaluation -ANSWERS-d. assessment, diagnosis, outcome identification, planning,
implementation, and evaluation
A newly admitted patient is in acute pain, has not been sleeping well lately, and is
having difficulty breathing. How should the nurse prioritize these problems?
a. breathing, pain, and sleep
b. breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing -ANSWERS-a. breathing, pain, and sleep
Which of these would be formulated by a nurse using diagnostic reasoning?
a. nursing diagnosis
b. Medical diagnosis
c. diagnostic hypothesis
d. Diagnostic assessment -ANSWERS-c. diagnostic hypothesis
Barriers to incorporating EBP include:
, a. nurses lack of research skills in evaluating the quality of research studies
b. lack of significant research studies
c. Insufficient clinical skills of nurses
d. inadequate physical assessment skills -ANSWERS-a. nurses lack of research skills in
evaluating the quality of research studies
The nurse is preparing to conduct a health history. Which of these statements best
describes the purpose of a health history?
a. to provide an opportunity for interaction between the patient and the nurse
b. to provide a form for obtaining the patients biographic information
c. to document the normal and abnormal findings of a physical assessment
d. to provide a database of subjective information about the patients past and current
health -ANSWERS-d. to provide a database of subjective information about the patients
past and current health
When the nurse is evaluating the reliability of a patients responses, which of these
statements would be correct? the patient:
a. has a history of drug abuse and therefore is not reliable
b. provided consistent information and therefore is reliable
c. Smiled throughout interview and therefore is assumed reliable
d. would not answer questions concerning stress and therefore is not reliable -
ANSWERS-b. provided consistent information and therefore is reliable
A 59 year old patient tells the nurse that he has ulcerative colitis. He has been having
black stools for the last 24 hours. How would the nurse best document his reason for
seeking care?
a. J.m is a 59 year old man seeking treatment for ulcerative colitis
b. j.m came into the clinic complaining of having black stools for the past 24 hours
c. j.m is a 59 year old man who states that he has ulcerative colitis and wants it checked
d. j.m is a 59 year old man who states that he has been having black stools for the past
24 hours -ANSWERS-d. j.m is a 59 year old man who states that he has been having
black stools for the past 24 hours