Nursing Test Bank 2023 with 100% correct questions and answers

What is the most influential factor that has shaped the nursing profession? 1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation 3 Which of the following is an example of an illness prevention activity? Select all that apply. 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet 3 Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession 1 All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel 1 Which statement pertaining to Benners practice model for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage. 2) Progression through the stages involves continual development of thinking and technical skills. 3) The nurse must have experience in many areas before being considered an expert. 4) The nurses progress through the stages is determined by years of experience and skills. 2 Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images of nurses. 2) There are constant changes in healthcare and the activities of nurses. 3) There is disagreement among the different nursing organizations. 4) There are different education pathways and levels of practice. 2 Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses influence? 1) Nurses are the largest health professional group. 2) Nurses have a long history of serving the public. 3) Nurses have achieved some independence from physicians in recent years. 4) Political involvement has helped refute negative images portrayed in the media. 1 Nursing was described as a distinct occupation in the sacred books of which faith? 1) Buddhism 2) Christianity 3) Hinduism 4) Judaism 3 The American Red Cross was established by 1) Louisa May Alcott 2) Clara Barton 3) Dorothea Dix 4) Harriet Tubman 2 Which of the following is the most important reason to develop a definition of nursing? 1) Recruit more informed people into the nursing profession 2) Evaluate the degree of role satisfaction 3) Dispel the stereotypical images of nurses and nursing 4) Differentiate nursing activities from those of other health professionals 4 Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department 3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternative therapies 3 Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1) Both can produce adverse effects in some patients. 2) Both use prescription medications. 3) Both are usually reimbursed by insurance programs. 4) Both are regulated by the FDA. 1 Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1) Must know what aspects of care can legally and safely be delegated to the NAP 2) May rely too heavily on information gathered by the NAP when making patient care decisions 3) Is removed from many components of direct patient care that have been delegated to the NAP 4) Still maintains responsibility for the patient care given by the NAP 2 An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility 4 The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1) Functional 2) Primary 3) Case method 4) Team 3 Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social worker 2) Occupational therapist 3) Physicians assistant 4) Technologist 1 Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1) Health maintenance organization 2) Integrated delivery network 3) Preferred provider organization 4) Employment-based private insurance 3 A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a 1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model 1 Which member of the healthcare team typically serves as the case manager? 1) Occupational therapist 2) Physician 3) Physicians assistant 4) Registered nurse 4 Which of the following is considered a primary care service? 1) Providing wound care 2) Administering childhood immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair 2 Which of the following nursing activities represent direct care? Choose all that apply. 1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift 1 An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare 2 Which of the following are examples of a health-promotion activity? Select all that apply. 1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2) Disinfecting an abraded knee after a child falls off a bicycle 3) Administering a tetanus vaccination after an injury from a car accident 4) Distributing educational brochures about the benefits of exercise 1,4 Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking 1) Requires reasoned thought 2) Asks the questions why? or how? 3) Is a hierarchical process 4) Demands specialized thinking skills 1 A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to 1) Consider all the possible advantages and disadvantages 2) Maintain an open mind about the proposed change 3) Apply the nursing process to the situation 4) Make a decision based on past experience with documentation 2 The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1) Assessment 2) Diagnosis 3) Plan outcomes 4) Plan interventions 1 Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of 21%. 3) Glucose monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse. 2 Which of the following is an example of practical knowledge? (Assume all are true.) 1) The tricuspid valve is between the right atrium and ventricle of the heart. 2) The pancreas does not produce enough insulin in type 1 diabetes. 3) When assessing the abdomen, you should auscultate before palpating. 4) Research shows pain medication given intravenously acts faster than by other routes. 3 Which of the following is an example of self-knowledge? The nurse thinks, I know that I 1) Should take the clients apical pulse for 1 minute before giving digoxin 2) Should follow the clients wishes even though it is not what I would want 3) Have religious beliefs that may make it difficult to take care of some clients 4) Need to honor the clients request not to discuss his health concern with the family 3 Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures. 2) Nurses work with other healthcare team members. 3) Nurses care for clients who have multiple health problems. 4) Nurses have to be flexible and work variable schedules. 3 The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention 4 How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1) Terminology for the clients disease or injury 2) A part of the clients medical diagnosis 3) The clients presenting signs and symptoms 4) A clients response to a health problem 4 Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give. 2 What do critical thinking and the nursing process have in common? 1) They are both linear processes used to guide ones thinking. 2) They are both thinking methods used to solve a problem. 3) They both use specific steps to solve a problem. 4) They both use similar steps to solve a problem. 2 A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem 1 The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1) Determine whether she has gathered enough assessment data. 2) Judge whether the interventions achieved the stated outcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patients condition. 2 In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge 1 The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process 2 Which aspects of healthcare are affected by a clients culture? Select all that apply. 1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) The types of treatments the client will accept 5) When the client will seek healthcare services 6) The environment where the healthcare services are provided 7) The ease of accessibility of healthcare services 1,2,4,5 1. Independent thinking Questioning the reason for a new staffing policy 2. Intellectual curiosity Reading the instruction manual of a new glucose monitoring machine 3. Intellectual humility Asking for help with a procedure because you have not done it before 4. Intellectual empathy Asking a patients feelings about his cancer diagnosis 5. Intellectual courage Questioning your feelings when a patients family requests withholding nutrition for a terminally ill client 6. Intellectual perseverance Obtaining the latest research about a new diagnostic procedure even though the articles are difficult to find ... What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1) States what assessments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented 4) Sets standards for what and when to assess the patient 4 Which of the following is an example of data that should be validated? 1) The clients weight measures 185 lb at the clinic. 2) The clients liver function test results are elevated. 3) The clients blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food. 4 Which of the following examples includes both objective and subjective data? 1) The clients blood pressure is 132/68 and her heart rate is 88. 2) The clients cholesterol is elevated, and he states he likes fried food. 3) The client states she has trouble sleeping and that she drinks coffee in the evening. 4) The client states he gets frequent headaches and that he takes aspirin for the pain. 2 The Joint Commission requires which type of assessment to be performed on all patients? 1) Functional ability 2) Pain 3) Cultural 4) Wellness 2 Which of the following is an example of an ongoing assessment? 1) Taking the patients temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities 1 When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient 4 Which of the following is an example of an open-ended question? 1) Have you had surgery before? 2) When was your last menstrual period? 3) What happens when you have a headache? 4) Do you have a family history of heart disease? 3 Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening 4 Which of the following is an example of the most basic motivation in Maslows hierarchy of needs? 1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood 2 What makes a nursing history different from a medical history? 1) A nursing history focuses on the patients responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information. 1 Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies 4 What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of Care. 1 Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious 3 A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? 1) My patient is a young adult, so I plan to talk to her without her parents in the room. 2) Because my patient is old enough to be my grandfather, I will call him Mr. 3) When reading my patients health record, I thought of a few questions to ask. 4) When I give my patient his pain medication, I will have time to ask questions. 4 A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs 3 A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1) Family 2) Functional 3) Community 4) Psychosocial 2 The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) When did your migraines begin? 2) Tell me about your family history of migraines. 3) What are the types of things that trigger your headaches? 4) Describe what your headaches feel like. 1 Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed 3 A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1) I find it difficult to avoid using phrases like, The patient tolerated the procedure well. 2) Its confusing to have to remember which abbreviations this hospital allows. 3) I need to work on charting assessments and interventions right after they are done. 4) My patient was really quiet and didnt say much, so I charted that he acted depressed. 4 For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vital signs 2) Seeing the patterns of a patients fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken 2 The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data 2 Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. 1) Provide enough chairs so the family and you are able to sit facing the client. 2) Introduce yourself and ask, Dear, what name do you prefer to go by? before asking any questions. 3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions. 4) Ask the client if you can talk with her while her family is watching the television. 3 Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) How did this happen to you? 2) What was your first symptom? 3) Why didnt you seek healthcare earlier? 4) When did you start having symptoms? 1,2,4 A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Associations Scope and Standards of Practice 1,4 Which of the following are cues rather than inferences? Choose all correct answers. 1) Ate 50% of his meal 2) Patient feels better today 3) States, I slept well 4) White blood cell count 15,000/mm3 1,3,4 Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection 2 Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 1 Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference 3 How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop. 2 Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician. 4 Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the clients family confirm it. 3 What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data 1 When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? 1) Etiology 2) Related factors 3) Diagnostic label 4) Defining characteristics 4 Based only on Maslows hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception 2 Which of the following describes the most important use of nursing diagnosis? (All statements are true.) 1) Differentiates the nurses role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the clients needs for nursing care 4 Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states nurse practice acts. 4) Other professions do not recognize nursing diagnoses. 1 Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurses diagnostic reasoning 2) Supports the clients medical diagnosis 3) Identifies a clients response to a health problem 4) Identifies a clients health problem 3 The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology 1 Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities 3 What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom. 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic. 2 Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours 3 The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook. 3 The clients weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I dont like to take supplements, and I think I could really improve my nutrition. Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition 4 The patient verbalizes an overwhelming lack of energy. He says, I still feel exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily activities or sleep during the day. Ive been a little depressed lately, too. The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy 1 Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, On a scale of 1 to 5, its a 5. 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever 1 Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms 2,3,5 Using Maslows hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation 4,2,1,3 For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident 2 The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team. 3 What do initial, ongoing, and discharge planning have in common? 1) They are based on assessment and diagnosis. 2) They focus on the patients perception of his needs. 3) They require input from a multidisciplinary team. 4) They have specific timelines in which to be completed. 1 Which client has the greatest need for comprehensive discharge planning? 1) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter 2) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease 3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4) A woman who was just diagnosed with renal failure and has started peritoneal dialysis 4 Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked 4 How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans 1) Describe the care needed by patients in defined situations 2) Include specific goals and nursing orders 3) Become a part of the patients comprehensive care plan 4) Usually describe ideal nursing care 1 The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient? 1) Validate conflicting data with the patient. 2) Transcribe medical orders. 3) State the frequency for ambulation. 4) Perform a comprehensive assessment. 3 Which of the following is the best example of an outcome statement? The patient will 1) Use the incentive spirometer when awake 2) Walk two times during day and evening shifts 3) Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy 3 How are critical pathways and standardized nursing care plans similar? Both 1) Specify daily, or even hourly, outcomes and interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions 3 How is NOC different from the Omaha System? 1) NOC can be used to write health restoration outcomes. 2) NOC can be used in all specialty and practice areas. 3) NOC can be used for individuals, families, or groups. 4) NOC formulates goals based on nursing diagnoses. 2 How are short-term goals different from long-term goals? Short-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/dates 4) Specify desired client responses to interventions 1 What do standardized nursing care plans and individualized care plans have in common? They both 1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group of patients 3) Address a patients individual needs 4) Provide detailed nursing interventions 4 The nurse is individualizing Mr. Wus plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe 1) Desired changes in the patients health status 2) Specific patient responses to medical interventions 3) Specific nursing behaviors to improve a patients health 4) Criteria to evaluate the appropriateness of a nursing diagnosis 1 Which of the following outcome statements contains the best example of performance criteria? The patient will 1) Turn herself in bed frequently while awake 2) Understand how to use crutches by day 2 3) State that pain is decreased after being medicated 4) Eat 75% of each meal without complaint of nausea 4 Which of the following is true for goals/outcomes for collaborative problems? 1) They are monitored only by other disciplines. 2) They are usually sensitive to nursing interventions. 3) They state that a complication will not occur. 4) They state only broad performance criteria. 3 How are NANDA-I problem labels and NOC outcome labels alike? Both describe 1) Health status in terms of human responses 2) Patient response before interventions are done 3) Patient response in positive terms 4) A pattern of related cues 1 The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan? 1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memory loss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements with meals 2 A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning 4) Initial planning 2 A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Choosing the best outcome for the patient, regardless of the costs involved in bringing it about 4) Involving the patient and family in formulating the outcomes 1,4 Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care 3 Which nursing intervention is considered an independent intervention? 1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain 2 A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? 1) Collaborative 2) Interdependent 3) Dependent 4) Independent 4 The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurses teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing? 1) Health promotion 2) Treatment 3) Prevention 4) Assessment 3 Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice 1 A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient? 1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awakeD. Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the clientJ. Smith, RN 1 A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay? 1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the clients dietary concerns 3 Which definition best describes a critical pathway? 1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something 1 A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowlers position. 1 Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse 3 A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written. 2 The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patients individual needs. What should the nurse do? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give her recommendation. 4) Restart the computer; it is probably a program malfunction. 1 Which statement(s) about nursing interventions is/are true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client. 1,3 An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is The client will maintain urine output of at least 30 mL/hour. Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer IV fluids as prescribed. 4) Keep oral fluids within the patients reach, and encourage the patient to drink. 1,3,4 A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed? 1) Administer the medication as prescribed. 2) Hold the medication and notify the prescriber. 3) Consult with a pharmacist before administering it. 4) Ask the patients nurse for information about the medication. 3 Which task can be delegated to nursing assistive personnel (NAP)? 1) Turn and reposition the client every 2 hours. 2) Assess the clients skin condition. 3) Change pressure ulcer dressings every shift. 4) Apply hydrocolloid dressing to the pressure ulcer. 1 The nurse has just finished documenting that he removed a patients nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis 3 Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner. 4 The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused. 1 A patient underwent surgery 3 days ago for colorectal cancer. The patients critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site. 1 Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking 2 Which intervention depends almost entirely on the clients adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet 4 The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the clients main concerns about his diabetes 4 Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway 1 Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) Record how much the patient drinks today, please. 2) Take the patients vital signs every 2 hours today. 3) Take the patients temperature every 4 hours; notify me if it is greater than 100.5F (38.1C). 4) Assist the patient with all of her meals. 3 Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift 1 Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care. 3 Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30. 2 When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour 4 Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process 1 Which of the following is the most valid criterion for determining the status of a patients anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care 2 The nurse works with the respiratory therapist to administer a patients breathing treatments. He reports the patients breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care 2 The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range 1,3,4 Which commonly accepted practice came out of the Framingham study? Use of 1) Mammography in breast cancer screening 2) Colonoscopy in colon cancer screening 3) Pap testing in cervical cancer screening 4) Digital rectal examination in prostate cancer screening 1 Which theorist developed the nursing theory known as the science of human caring? 1) Florence Nightingale 2) Patricia Benner 3) Jean Watson 4) Nola Pender 3 A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n) 1) Phenomenon 2) Concept 3) Assumption 4) Definition 2 Hildegard Peplau was a nursing theorist whose major contribution to nursing was 1) Transcultural nursing 2) Health promotion 3) Nurse-patient relationship 4) Holistic comfort 3 The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist? 1) Virginia Henderson 2) Imogene Rigdon 3) Katherine Kolcaba 4) Florence Nightingale 4 A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse if her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is utilizing the theory developed by which nurse theorist? 1) Betty Neuman 2) Dorothea Orem 3) Callista Roy 4) Madeline Leininger 4 According to Maslows hierarchy of needs, which patient need should the nurse address first? 1) Protecting the patient against falls 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change 3 A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next? 1) Perform a literature review. 2) Develop a conceptual framework. 3) Formulate the hypothesis. 4) Define the study variables. 1 The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? The right 1) Not to be harmed 2) To self-determination 3) To full disclosure 4) Of confidentiality 2 After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslows hierarchy of needs, cardiac rehabilitation most directly addresses which need? 1) Safety and security 2) Physiological 3) Self-actualization 4) Self-esteem 2 In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include 1) Cognitive and aesthetic needs 2) Love and belonging needs 3) Safety and security needs 4) Physiological and self-esteem needs 1