1
Nursing 255 EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES|
EXCELLENT SCORES GRADED A+
1. 5 components of critical thinking –
-knowledge base, experience, critical thinking competencies, attitudes, and standards
2. A 63-year-old patient is retiring from his job at an accounting firm where he was in a
management role for 20 years. He was a dedicated employee with the same company for 42
years. His wife is a homemaker. She raised their five children, babysits for her grandchildren
as needed, and belongs to numerous Church committees. What are the major concerns for
this patient?
The loss of his work roll
How the wife expects household tasks to be divided in the home in retirement
3. A 71 year old patient enters the emergency department after falling down stairs in the home.
The nurse is conducting a fall history with the patient and his wife. They live in a one level
ranch home. He has had diabetes for over 15 years and experience has some numbness in his
feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not
exercise regularly and states that he experiences weakness in his legs when climbing stairs. He
is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this
patient?
Impaired vision
Leg weakness
Exercise history
4. A 72 year old male patient comes to the health clinic for an annual follow-up. The nurse enters
the patient's room notices him in a diaphoretic, holding his chest and breathing with difficulty.
The nurse immediately checks the patient's heart rate and blood pressure and asks him, "tell
me where your pain is." Which of the following assessment approaches does the scenario
describe. –
A problem-oriented approach
5. A child's immunization may cause discomfort during administration, but the benefits of
protection from disease, both for the individual and society, outweigh the temporary
discomforts. - answer-Beneficence
, 2
6. A community nurse in a diverse Community is working with Healthcare professionals to
provide prenatal care to underemployed and uninsured South African women. Which overall
goal of healthy people 2020 does this represent? - answer-Increase life expectancy and quality
of life to eliminate health disparities
7. A family member is providing care to a loved one who has an infected leg wound. What
should the nurse instruct the family member to do after providing care and handling
contaminated equipment or organic material? - answer-Perform hand hygiene Aftercare and /
or handle contaminated equipment or material.
8. A group of staff nurses notice an increased incidence of medication errors on their unit. After
further investigation it is determined that the nurses are not consistently identifying the
patient correctly. A change is needed quickly. What type of quality improvement method
would be most appropriate? - answer-Rapid Improvement event (RIE)
9. A home health nurse notices significant bruising on a two-year-old patients head, arms,
abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the
best nursing action for the home health nurse to take? - answer-1. Document her findings and
treat the patient 2. instruct the mother on safe handling of a two-year-old child 3. contact a
child abuse hotline
10. A home health nurse visits a 42 year old woman with diabetes who has a recurrent foot ulcer.
The ulcer has prevented the woman from working for over 2 weeks. The patient has had
diabetes for over 10 years. The ulcer has not been healing, it has drainage with a foul-smelling
odor. As the nurse examines the patient, she learns that the patient is not following the order
diabetic diet. Which of the following is considered a low priority goal for this patient? -
answer-Enhancing patient knowledge about the effects of diabetes
A homeless man enters the emergency department seeking Health Care. The healthcare provider
indicates that the patient needs to be transferred to the city hospital for care. This action is a violation
of? - answer-Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed
a nurse administered an antibiotic 30 minutes ago and turns to the patient's room to determine if the
patient is having any unexpected symptoms. This is an example of assessing for an? - answer-Adverse
reaction
A nurse assesses a patient who's come to the pulmonary clinic. I see that it's been over six months
since you've been here, but your appointment was for every two months. Tell me about that. Also I
, 3
see from your last visit that the doctor recommended routine exercise. Can you tell me how successful
you've been in following his plan? The nurses assessment covers which of Gordon's functional health
patterns? - answer-Health perception-health management pattern
a nurse assesses a young woman who works part-time but also cares for her mother at home. The
nurse reviews clusters of data that include the patients report of frequent a awakening at night,
reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following
diagnosis is the correct PES format? - answer-Disturbed sleep pattern related to caregiving
responsibilities as evidenced by frequent awakening and not feeling rested.
A nurse begins the night shift being assigned to five patients. She learns that the floor will be a
registered nurse (RN) short as a result of a call in. A patient care technician from another area is
coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she
begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to
approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which
factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) -
answer-1. Policy for conducting hourly rounds
2. Staffing level
3. Interruption by staff nurse colleague
A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low sodium
diet. The nurse will perform which of the following evaluation measures to determine success of her
instruction? - answer-Asking patient to identify three low sodium foods to eat for lunch
A nurse changed a patient's surgical wound dressing the day before and now prepares for another
dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing
the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing
change. Then he add some sterile saline to to loosen the cause for a few minutes before removing it.
The patient reports that the procedure was much more comfortable. Which of the following describes
a nurse's approach to the dressing change? - answer-Complex critical thinking and experience
A nurse checks an intravenous IV solution container for clarity of the solution, noting that it is infusing
into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 ml / HR as ordered. The
nurse reviews the nurse's notes from the previous shift to determine if the dressing over the site was
changed as scheduled per standard of care. While in the room the nurse inspects the condition of the
, 4
dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition
of the IV site? - answer-1. Check the IV infusion rate
2. Inspected the condition of the IV dressing at the site
a nurse collects equipment needed to administer an enema to a patient. Previously the nurse review the
procedure and the policy manual. The nurse raises the patient's bed and adjust the room lighting to
illuminate the work area. It patient care technician comes into the room to assist. Which aspect of
organizing resources and care delivery did the nurse omit? - answer-Patient
A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82
years old and has had osteoarthritis for 10 years with diabetes mellitus for 20 years. He is alert but
becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet
beagle died just two months ago. He is most likely experiencing: - answer-Depression
A nurse enters a 72 year old patients home and begins to observe her behaviors and examine her
physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg.
When watching the patient walk, the nurse notices that she has an unsteady gait and leans to one side.
The patient admits to having fallen in the past. The nurse identifies the patient as having nursing
diagnosis risk of fall. The scenario is an example of? - answer-Diagnostic reasoning
A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a
patient is tolerating a new diet plan. The nurse decides to also evaluate the patients expectations of
care. Which statement is appropriate for evaluating a patient expectations of care? - answer-The nurse
asks, did you believe that you received the information you needed to follow your diet?
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting
a problem? (Select all that apply) - answer-1. The skin around the wound is tender to touch
2. Patient has drainage from surgical wound
3. Body temperature is 101F (38.3 C)
A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the
nursing diagnosis of nausea related to effects of post-operative anesthesia. The nurse has been asking
the patient to rate his nausea over the last several hours after administering antiemetics and using
comfort measures such as for oral hygiene. The nurse reviews the patient's responses over the past 10
hours and notes how the patient self-report of nausea has changed. This review is an example of? -
answer-Comparing outcome criteria with actual response
Nursing 255 EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES|
EXCELLENT SCORES GRADED A+
1. 5 components of critical thinking –
-knowledge base, experience, critical thinking competencies, attitudes, and standards
2. A 63-year-old patient is retiring from his job at an accounting firm where he was in a
management role for 20 years. He was a dedicated employee with the same company for 42
years. His wife is a homemaker. She raised their five children, babysits for her grandchildren
as needed, and belongs to numerous Church committees. What are the major concerns for
this patient?
The loss of his work roll
How the wife expects household tasks to be divided in the home in retirement
3. A 71 year old patient enters the emergency department after falling down stairs in the home.
The nurse is conducting a fall history with the patient and his wife. They live in a one level
ranch home. He has had diabetes for over 15 years and experience has some numbness in his
feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not
exercise regularly and states that he experiences weakness in his legs when climbing stairs. He
is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this
patient?
Impaired vision
Leg weakness
Exercise history
4. A 72 year old male patient comes to the health clinic for an annual follow-up. The nurse enters
the patient's room notices him in a diaphoretic, holding his chest and breathing with difficulty.
The nurse immediately checks the patient's heart rate and blood pressure and asks him, "tell
me where your pain is." Which of the following assessment approaches does the scenario
describe. –
A problem-oriented approach
5. A child's immunization may cause discomfort during administration, but the benefits of
protection from disease, both for the individual and society, outweigh the temporary
discomforts. - answer-Beneficence
, 2
6. A community nurse in a diverse Community is working with Healthcare professionals to
provide prenatal care to underemployed and uninsured South African women. Which overall
goal of healthy people 2020 does this represent? - answer-Increase life expectancy and quality
of life to eliminate health disparities
7. A family member is providing care to a loved one who has an infected leg wound. What
should the nurse instruct the family member to do after providing care and handling
contaminated equipment or organic material? - answer-Perform hand hygiene Aftercare and /
or handle contaminated equipment or material.
8. A group of staff nurses notice an increased incidence of medication errors on their unit. After
further investigation it is determined that the nurses are not consistently identifying the
patient correctly. A change is needed quickly. What type of quality improvement method
would be most appropriate? - answer-Rapid Improvement event (RIE)
9. A home health nurse notices significant bruising on a two-year-old patients head, arms,
abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the
best nursing action for the home health nurse to take? - answer-1. Document her findings and
treat the patient 2. instruct the mother on safe handling of a two-year-old child 3. contact a
child abuse hotline
10. A home health nurse visits a 42 year old woman with diabetes who has a recurrent foot ulcer.
The ulcer has prevented the woman from working for over 2 weeks. The patient has had
diabetes for over 10 years. The ulcer has not been healing, it has drainage with a foul-smelling
odor. As the nurse examines the patient, she learns that the patient is not following the order
diabetic diet. Which of the following is considered a low priority goal for this patient? -
answer-Enhancing patient knowledge about the effects of diabetes
A homeless man enters the emergency department seeking Health Care. The healthcare provider
indicates that the patient needs to be transferred to the city hospital for care. This action is a violation
of? - answer-Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed
a nurse administered an antibiotic 30 minutes ago and turns to the patient's room to determine if the
patient is having any unexpected symptoms. This is an example of assessing for an? - answer-Adverse
reaction
A nurse assesses a patient who's come to the pulmonary clinic. I see that it's been over six months
since you've been here, but your appointment was for every two months. Tell me about that. Also I
, 3
see from your last visit that the doctor recommended routine exercise. Can you tell me how successful
you've been in following his plan? The nurses assessment covers which of Gordon's functional health
patterns? - answer-Health perception-health management pattern
a nurse assesses a young woman who works part-time but also cares for her mother at home. The
nurse reviews clusters of data that include the patients report of frequent a awakening at night,
reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following
diagnosis is the correct PES format? - answer-Disturbed sleep pattern related to caregiving
responsibilities as evidenced by frequent awakening and not feeling rested.
A nurse begins the night shift being assigned to five patients. She learns that the floor will be a
registered nurse (RN) short as a result of a call in. A patient care technician from another area is
coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she
begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to
approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which
factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) -
answer-1. Policy for conducting hourly rounds
2. Staffing level
3. Interruption by staff nurse colleague
A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low sodium
diet. The nurse will perform which of the following evaluation measures to determine success of her
instruction? - answer-Asking patient to identify three low sodium foods to eat for lunch
A nurse changed a patient's surgical wound dressing the day before and now prepares for another
dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing
the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing
change. Then he add some sterile saline to to loosen the cause for a few minutes before removing it.
The patient reports that the procedure was much more comfortable. Which of the following describes
a nurse's approach to the dressing change? - answer-Complex critical thinking and experience
A nurse checks an intravenous IV solution container for clarity of the solution, noting that it is infusing
into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 ml / HR as ordered. The
nurse reviews the nurse's notes from the previous shift to determine if the dressing over the site was
changed as scheduled per standard of care. While in the room the nurse inspects the condition of the
, 4
dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition
of the IV site? - answer-1. Check the IV infusion rate
2. Inspected the condition of the IV dressing at the site
a nurse collects equipment needed to administer an enema to a patient. Previously the nurse review the
procedure and the policy manual. The nurse raises the patient's bed and adjust the room lighting to
illuminate the work area. It patient care technician comes into the room to assist. Which aspect of
organizing resources and care delivery did the nurse omit? - answer-Patient
A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82
years old and has had osteoarthritis for 10 years with diabetes mellitus for 20 years. He is alert but
becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet
beagle died just two months ago. He is most likely experiencing: - answer-Depression
A nurse enters a 72 year old patients home and begins to observe her behaviors and examine her
physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg.
When watching the patient walk, the nurse notices that she has an unsteady gait and leans to one side.
The patient admits to having fallen in the past. The nurse identifies the patient as having nursing
diagnosis risk of fall. The scenario is an example of? - answer-Diagnostic reasoning
A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a
patient is tolerating a new diet plan. The nurse decides to also evaluate the patients expectations of
care. Which statement is appropriate for evaluating a patient expectations of care? - answer-The nurse
asks, did you believe that you received the information you needed to follow your diet?
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting
a problem? (Select all that apply) - answer-1. The skin around the wound is tender to touch
2. Patient has drainage from surgical wound
3. Body temperature is 101F (38.3 C)
A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the
nursing diagnosis of nausea related to effects of post-operative anesthesia. The nurse has been asking
the patient to rate his nausea over the last several hours after administering antiemetics and using
comfort measures such as for oral hygiene. The nurse reviews the patient's responses over the past 10
hours and notes how the patient self-report of nausea has changed. This review is an example of? -
answer-Comparing outcome criteria with actual response
