Certified Medical-Surgical Registered Nurse Sample 138 Questions with Verified Answers
- CORRECT ANSWER
Christine Warren, 45 years old, has a long
... [Show More] history of ulcerative colitis, and non-surgical treatment no longer relieved her symptoms. She underwent a total proctocolectomy and a permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma. - CORRECT ANSWER 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter per day.
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic. - CORRECT ANSWER 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties, should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries." - CORRECT ANSWER 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and determines how the person interacts with others. One does not need to purchase special clothing after ileostomy surgery, although some minor adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals. - CORRECT ANSWER 4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What were you doing before the pain began?" - CORRECT ANSWER 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse should find out if the patient has had this time of pain previously.
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram. - CORRECT ANSWER Rationale: The nurse should questions the order for Lovenox because the patient is receiving a heparin drip.
Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes mellitus. Her blood glucose has been stabilized, and the nurse is preparing her for discharge. Her discharge orders will include metformin (Glucophage). Mrs. Clark is also being treated for hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts. - CORRECT ANSWER 1) monitor her glomerular filtration rate.
Rationale: The estimated glomerular filtration rate (eGFR) is one way to measure the adequacy of kidney function. Glucophage is excreted by the kidney and the risk of lactic acidosis increases in patients with impaired kidney function. The drug may be used if the eGFR is between 45 and 60 mL/min/1.73 m2, i.e., in mild chronic kidney disease. Glucophage is absolutely contraindicated if the eGFR is below 30 mL/min/1.73 m2.
Mrs. Clark is prescribed metoprolol tartrate (Lopressor) for hypertension. Which symptom of hypoglycemia would be masked by Lopressor?
1) Diaphoresis.
2) Tingling.
3) Diplopia.
4) Tachycardia. - CORRECT ANSWER 4) Tachycardia.
Rationale: A side effect of Lopressor, a beta blocker, is bradycardia. The Lopressor-induced bradycardia can mask tachycardia, a symptom of hypoglycemia.
Charles Haverford is diagnosed with prostate cancer and is to have a radical prostatectomy.
Mr. Haverford has been researching his diagnosis and now asks the nurse to recommend a reliable web source for accurate prostate cancer information. The nurse should identify which of these websites as most reliable?
1) www.wikipedia.org.
2) www.cancer.gov.
3) www.caringbridge.org.
4) www.google.com. - CORRECT ANSWER 2) www.cancer.gov.
Rationale: When a patient asks about researching information on the internet, the patient should be instructed to look at reliable sites. Sites that are most reliable are those sponsored by the government (.gov).
Mr. Haverford has the planned surgery and immediately postoperatively he has a urinary catheter inserted. After the urinary catheter is removed Mr. Haverford is urinating normally, however he is experiencing occasional incontinence with dribbling. Mr. Haverford is to be discharged.
Mr. Haverford says to the nurse, "I'm so embarrassed. What will my wife think about this dribbling?" In addition to acknowledging his feelings, the nurse should encourage the patient to
1) limit oral intake of fluids before bedtime.
2) palpate his bladder to check for distention three times a day.
3) perform pelvic floor exercises several times daily.
4) avoid interrupting the urinary stream during voiding. - CORRECT ANSWER 3) perform pelvic floor exercises several times daily.
Rationale: It is not unusual for a patient who has had a prostatectomy, to complain of not having complete bladder control after catheter removal. To help the patient regain urinary control, pelvic floor strengthening exercises are recommended.
A patient's wife is visibly upset and says to the nurse, "I thought my husband only broke his hip, but the doctor thinks he might have had a stroke." Which of the following would be an appropriate response by the nurse?
1) "It's really too early to be concerned about that. Let's wait until the test results come back."
2) "If it is a stroke, your husband is in the right hospital for treatment."
3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out."
4) "I'm going to get you some information to read about strokes and their treatment." - CORRECT ANSWER 3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out."
Rationale: Symptoms of stroke vary greatly and the initial diagnosis is made after a non-contrast CT scan is done to determine if the event was ischemic or hemorrhagic. Then, further tests are done to confirm the diagnosis and decide on treatment.
In the event of a fire in a hospital's dialysis unit, which of these actions should the nurse take first?
1) Extinguish the fire if possible.
2) Activate the fire response system.
3) Confine the fire by closing all fire doors.
4) Remove patients or staff in danger. - CORRECT ANSWER 4) Remove patients or staff in danger.
Rationale: When a fire occurs in a patient area within the hospital, the nurses' first actions are to protect patients and staff. This usually involves removing the patients and staff from exposure to the fire.
An 80-year-old male who has mild dementia is readmitted for the third time with multiple pressure ulcers. During the nursing assessment, multiple bruises are also observed on his body. He lives with his son and daughter-in-law. The nurse suspects elder abuse/neglect. Which of these actions should the nurse take?
1) Have a staff member present during family visits.
2) Report the findings.
3) Discuss the situation with the family.
4) Ask the patient who is providing his care. - CORRECT ANSWER 2) Report the findings.
Rationale: Most states require that health care workers report suspected elder abuse to an official agency, such as Adult Protective Services.
A patient who has active pulmonary tuberculosis (TB) states, "I'm not going to take these TB pills!" Which of these responses by the nurse would be appropriate?
1) "You have a legal right to refuse to take this medication."
2) "You need to sign a Refusal of Treatment Form."
3) "You need to ask your doctor about the possibility of discontinuing the medication."
4) "You should know that the health department can require you to take the medication." - CORRECT ANSWER 4) "You should know that the health department can require you to take the medication."
Rationale: Tuberculosis (TB) is a public health problem that requires reporting of the disease to the health department. It is essential that the patient understand the need to take prescribed TB medications as directed. Patients who are unwilling or unable to adhere to treatment may be required to do so by law or may be quarantined or isolated until noninfectious. State governments have legal responsibility for TB control activities, including treatment protocols for nonadherent patients. Health care workers should be familiar with the law in their particular states for these procedures.
When a patient is having a chest tube removed, which of these instructions would be appropriate?
1) "Take short quick breaths with your mouth open."
2) "Take a deep breath and hold it."
3) "Breathe only through your mouth."
4) "Breathe as you normally do." - CORRECT ANSWER 2) "Take a deep breath and hold it."
Rationale: Taking a deep breath and holding it (or performing the Valsalva maneuver) will prevent air from being pulled back into the pleural space as the tube is removed.
Using the average cost of a problem and the cost of intervention to demonstrate savings is:
A. A cost-benefit analysis
B. An efficacy study
C. A product evaluation
D. A cost-effective analysis - CORRECT ANSWER A. A cost-benefit analysis uses average cost of a problem (such as wound infections) and the average cost of intervention to demonstrate savings. For example, if a surgical unit averaged 10 surgical site infections annually at an additional average cost of $27,000 each, the total annual cost would be $270,000. If the total cost for interventions, (new staff person, benefits, education, and software) totals $92,000, and the goal is to reduce infections by 50% (0.5 X $270,000 for a total projected savings of $135,000), cost benefit is demonstrated by subtracting the proposed savings from the intervention costs ($135,000 - $92,000) for a savings of $43,000 annually.
In Erikson's psychosocial model of development, which stage is typical of those entering young adulthood?
A.Identify vs role confusion
B.Initiative vs guilt
C.Ego integrity vs despair
D.Intimacy vs isolation - CORRECT ANSWER D. Erickson's psychosocial development model focuses on conflicts at each stage of the lifespan and the virtue that results from finding balance in the conflict. The first 5 stages refer to infancy and childhood and the last 3 stages to adulthood:
Intimacy vs isolation (Young adulthood): Love/intimacy or lack of close relationships.
Generativity vs stagnation (Middle age): Caring and achievements or stagnation.
Ego integrity vs despair (Older adulthood): Acceptance and wisdom or failure to accept changes of aging/despair.
A 30-year old patient has been diagnosed with advanced ovarian cancer. The patient says, "This is all my fault." Which of Kubler-Ross's five stages of grief is the patient probably experiencing?
A.Denial
B.Anger
C.Depression
D.Acceptance - CORRECT ANSWER B. The patient is experiencing the stage of anger. People grieve individually and may not go through all stages, but most go through at least 2 stages. Kubler-Ross's 5 stages of grief include:
Denial: Refusal to believe, confused, stunned, detached.
Anger: Directed inward (self-blame) or outward.
Bargaining: If - then thinking. ("If I go to church, then I will heal.")
Depression: Sad, withdrawn.
Acceptance: Resolution.
A 68-year old man with mild COPD refuses to exercise because he tires easily. He spends most of every day sitting in a chair watching television. What is the most appropriate nursing diagnosis?
A.Ineffective health maintenance
B.Impaired physical mobility
C.Risk for disuse syndrome
D.Activity intolerance - CORRECT ANSWER C. The most appropriate nursing diagnosis for a person who is able to exercise but remains sedentary is risk of disuse syndrome because the patient is putting himself at risk for the development of circulatory impairment and muscle atrophy. Failure to exercise may also exacerbate his condition. While his health maintenance may be ineffective, it is directly due to of his lack of activity. He does not have impaired physical mobility or activity intolerance that precludes exercise.
Measuring the effectiveness of an intervention rather than the monetary savings is:
A.A cost-benefit analysis.
B.An efficacy study.
C.A product evaluation.
D.A cost-effective analysis. - CORRECT ANSWER D. A cost-effective analysis measures the effectiveness of an intervention rather than the monetary savings. For example, annually 2 million nosocomial infections result in 90,000 deaths and an estimated $6.7 billion in additional health costs. From that perspective, decreasing infections should reduce costs, but there are human savings in suffering as well, and it can be difficult to place a dollar value on that. If each infection adds about 12 days to hospitalization, then a reduction of 5 infections (5 X 12 = 60) would result in a cost-effective savings of 60 fewer patient infection days.
The main goal of treatment for acute glomerulonephritis is to:
1. Encourage activity.
2. Encourage high protein intake.
3. Maintain fluid balance.
4. Teach intermittent urinary catheterization. - CORRECT ANSWER 3. Maintain fluid balance.
Nursing diagnoses mostly differ from medical diagnoses in that they are:
1. Dependent upon medical diagnoses for the direction of appropriate interventions.
2. Primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
3. Primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
4. Primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters. - CORRECT ANSWER 3. Primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient's blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to:
1. Medicate the patient for pain.
2. Place the patient in a high Fowler position and administer oxygen.
3. Place the patient in a reverse Trendelenburg position and open the IV line.
4. Report the findings to the provider. - CORRECT ANSWER 1. Medicate the patient for pain.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to:
1. Avoid crowds and obtain an annual influenza vaccination.
2. Drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
3. Eat a potassium-rich, low sodium diet.
4. Practice good dental hygiene and report gum swelling or bleeding. - CORRECT ANSWER 4. Practice good dental hygiene and report gum swelling or bleeding.
The most common, preventable complication of abdominal surgery is:
1. Atelectasis.
2. Fluid and electrolyte imbalance.
3. Thrombophlebitis.
4. Urinary retention. - CORRECT ANSWER 1. Atelectasis.
A 78-year-old patient is scheduled for transition to home after treatment for heart disease. The patient's spouse, who has chronic obstructive pulmonary disease, plans to care for the patient at home. The spouse says that their grown children, who live nearby, will help. The best approach to discharge planning is to:
1. Arrange nursing home placement for the couple.
2. Consult the spouse's healthcare provider about the spouse's ability to care for the patient.
3. Contact the children to ascertain their commitment to help.
4. Discuss community resources with the spouse and offer to make referrals. - CORRECT ANSWER 4. Discuss community resources with the spouse and offer to make referrals.
During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to:
1. Continue the hourly neurologic assessments.
2. Inform the neurosurgeon of the patient's status.
3. Prepare the patient for emergency surgery.
4. Recheck the patient's neurologic status in 15 minutes. - CORRECT ANSWER 2. Inform the neurosurgeon of the patient's status.
For the evaluation feedback process to be effective, a manager:
1. Conducts weekly meetings with staff members.
2. Considers staff members' interests and abilities when delegating tasks.
3. Informs staff members regularly of how well they are performing their jobs.
4. Provides goals for staff members to meet. - CORRECT ANSWER 3. Informs staff members regularly of how well they are performing their jobs.
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to:
1. A fluid and electrolyte imbalance.
2. A stimulating environment.
3. Sensory deprivation.
4. Sundowning. - CORRECT ANSWER 3. Sensory deprivation.
To prepare a patient on the unit for a bronchoscopic procedure, a medical-surgical nurse administers the IV sedative. The medical-surgical nurse then instructs the licensed practical nurse to:
1. Educate the patient about the pending procedure.
2. Give the patient small sips of water only.
3. Measure the patient's blood pressure and pulse readings.
4. Take the patient to the bathroom one more time. - CORRECT ANSWER 3. Measure the patient's blood pressure and pulse readings.
Which physiological response is often associated with surgery-related stress?
1. Bronchial constriction
2. Decreased cortisol levels
3. Peripheral vasodilation
4. Sodium and water retention - CORRECT ANSWER 4. Sodium and water retention
A patient's family does not know the patient's end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects:
1. Justice.
2. Paternalism.
3. Pragmatism.
4. Veracity. - CORRECT ANSWER 2. Paternalism.
Which statement by a patient with diabetes mellitus indicates an understanding of the medication insulin glargine (Lantus)?
1. "Lantus causes weight loss."
2. "Lantus is used only at night."
3. "The duration of Lantus is six hours."
4. "There is no peak time for Lantus." - CORRECT ANSWER 4. "There is no peak time for Lantus."
Which action occurs primarily during the evaluation phase of the nursing process?
1. Data collection
2. Decision-making and judgment
3. Priority-setting and expected outcomes
4. Reassessment and audit - CORRECT ANSWER 4. Reassessment and audit
Which action best describes a sentinel event alert?
1. Documenting the breakdown in communication during a shift report
2. Indicating that a community or institution is unsafe
3. Recording the harm done when a medication error occurs
4. Signaling the need for immediate investigation and response - CORRECT ANSWER 4. Signaling the need for immediate investigation and response
Which is primarily a developmental task of middle age?
1. Learning and acquiring new skills and information
2. Rediscovering or developing satisfaction in one's relationship with a significant other
3. Relying strongly upon spiritual beliefs
4. Risk taking and its perceived consequences - CORRECT ANSWER 2. Rediscovering or developing satisfaction in one's relationship with a significant other
A medical-surgical nurse, who is caring for a patient with a new diagnosis of cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to:
1. Allow the patient and family members time to be alone.
2. Arrange time for the patient to speak with another patient with cancer.
3. Direct the discussion and validation of emotion, without false reassurance.
4. Request a consultation from a social worker on the oncology unit. - CORRECT ANSWER 3. Direct the discussion and validation of emotion, without false reassurance.
It is hospital policy to assess and record a patient's pulse before administering digoxin (Lanoxin). By auditing the nursing records to determine the frequency of compliance with this policy, the quality assessment and improvement committee is conducting:
1. A process analysis.
2. A quality analysis.
3. A system analysis.
4. An outcome analysis. - CORRECT ANSWER 1. A process analysis.
The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of:
1. Agreeing to discontinue smoking.
2. Ambulating 50 feet without experiencing dyspnea.
3. Experiencing no dyspnea on exertion.
4. Tolerating activity well. - CORRECT ANSWER 2. Ambulating 50 feet without experiencing dyspnea.
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
1. Erikson
2. Maslow
3. Rogers
4. Watson - CORRECT ANSWER 4. Watson
Which statement by a patient demonstrates an accurate understanding about herbal supplements?
1. "Herbs may interact with prescribed medications but not other herbs."
2. "Most herbs have been tested and found to be safe and therapeutic."
3. "The Food and Drug Administration regulates herbs and allows advertising."
4. "There is no standardization among the manufacturers of herbs in this country." - CORRECT ANSWER 4. "There is no standardization among the manufacturers of herbs in this country."
For a patient with Crohn's disease, the medical-surgical nurse recommends a diet that is:
1. High in fiber, and low in protein and calories.
2. High in potassium.
3. Low in fiber, and high in protein and calories.
4. Low in potassium. - CORRECT ANSWER 3. Low in fiber, and high in protein and calories.
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find:
1. Flaccidity of the upper extremities.
2. Hyperreflexia and spasticity of the upper extremities.
3. Impaired diaphragmatic function requiring ventilator support.
4. Independent use of upper extremities and efficient cough. - CORRECT ANSWER 4. Independent use of upper extremities and efficient cough.
After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, a medical-surgical nurse anticipates the next step in the immediate care of this patient to include:
1. Administering tissue plasminogen activator.
2. Obtaining a computed tomography scan of the head without contrast.
3. Obtaining a neurosurgical consultation.
4. Preparing for carotid Doppler ultrasonography. - CORRECT ANSWER 2. Obtaining a computed tomography scan of the head without contrast.
The first step in applying the quality improvement process to an activity in a clinical setting is to:
1. Assemble a team to review and revise the activity.
2. Collect data to measure the status of the activity.
3. Select an activity for improvement.
4. Set a measurable standard for the activity. - CORRECT ANSWER 3. Select an activity for improvement.
The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the
nurse understands that the unlicensed assistant:
A. interprets clinical data.
B. collects clinical data.
C. is trained in the nursing process.
D. can function independently - CORRECT ANSWER B. collects clinical data.
Rationale: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse.
Option A is incorrect because the registered nurse, who has learned critical thinking skills, interprets the data.
Option C is incorrect because although unlicensed assistants are trained to perform
skills, they don't learn the nursing process. Option D is incorrect because unlicensed assistants don't function independently; they're assigned tasks by a registered nurse who retains overall responsibility for the patient.
When performing an assessment, the nurse identifi es the following signs and symptoms: impaired coordination,
decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms
indicate which nursing diagnosis?
A. Health-seeking behaviors
B. Impaired physical mobility
C. Disturbed sensory perception
D. Deficient knowledge - CORRECT ANSWER B. Impaired physical mobility
Rationale:Impaired physical mobility is a limitation of physical movement and is defined by the patient's signs and symptoms.
Options A, C, and D are nursing diagnoses with different defining signs and symptoms.
When prioritizing a patient's care plan based on Maslow's hierarchy of needs, the nurse's fi rst priority
would be:
A. allowing the family to see a newly admitted patient.
B. ambulating the patient in the hallway.
C. administering pain medication.
D. using two nurses to transfer the patient. - CORRECT ANSWER C. administering pain medication.
Rationale: In Maslow's hierarchy of needs, pain relief is on the first layer.
Activity (Option B) is on the second layer.
Safety (Option D) is on the third layer.
Love and belonging (Option A) are on the
fourth layer
When a nurse asks another nurse for advice on handling a particular patient problem, she's seeking what
type of consultation?
A. Patient-centered case consultation
B. Consultee-centered case consultation
C. Program-centered administrative consultation
D. Consultee-centered administrative consultation - CORRECT ANSWER A. Patient-centered case consultation
Rationale: Patient-centered case consultation (Option A) provides expert advice on handling a
particular patient or group of patients. Consultee-centered case consultation (Option B) focuses on work difficulties with patients, which are used as a learning opportunity. Program-centered administrative consultation (Option C) provides expert advice on developing new programs or improving existing ones.
Consultee-centered administrative consultation (Option D) considers work problems in the areas of program development and organization.
When implementing an evidence-based nursing program to decrease the incidence of pressure ulcers on a
medical-surgical unit, which of the following is the most important to ensure its success?
A. Obtaining support from management, administration, and physicians
B. Determining and documenting patient outcomes
C. Identifying a significant problem that needs to be addressed
D. Evaluating research based on its validity and reliability - CORRECT ANSWER A. Obtaining support from management, administration, and physicians
Rationale: To successfully implement an evidence-based nursing program, it's important
to obtain the support of management, administration, and physicians.
Option B is part of evaluating evidence-based nursing program implementation.
Option C is part of the first step of the evidence-based nursing program process. Option D is part of the critical evaluation of resources.
When planning the implementation of evidence-based practices to prevent falls, which of the following
steps should the nurse take fi rst?
A. Identify the common causes of falls.
B. Gather and review currently existing literature and guidelines for the prevention of falls.
C. Identify fall prevention practices that are applicable to the patient care setting.
D. Gather data to identify the effectiveness of the new practice guidelines. - CORRECT ANSWER B. Gather and review currently existing literature and guidelines for the prevention of falls.
Rationale: Options A, B, and C are correct steps in planning for the implementation of evidence-based practices; however, Option B would be the initial step, followed by Options A and C. Option D is part of the evaluation phase of evidence-based practice implementation
Which measure most effectively reduces the risk of health care-associated infections?
A. Keeping employee health records up-to-date
B. Performing hand hygiene
C. Providing annual influenza vaccinations
D. Always wearing a mask when caring for patients - CORRECT ANSWER B. Performing hand hygiene
Rationale: Performing hand hygiene in compliance with the World Health Organization or Centers for Disease Control and Prevention guidelines is the most effective in reducing the risk of health care-associated infections. Keeping employee health records up-to-date (Option A), providing annual influenza vaccinations (Option C), and always wearing a mask when caring for patients (Option D) aren't
the most effective ways to reduce the risk of health care-associated infections.
Which action should the nurse take when receiving a telephone order from a physician?
A. Inform the physician that telephone orders are not permitted.
B. Write the order in the patient's medical record immediately.
C. Write down the order and then read back the complete order to the physician.
D. Immediately carry out the order. - CORRECT ANSWER C. Write down the order and then read back the complete order to the physician.
Rationale: When receiving a telephone or other verbal order, the nurse should write down the
order and then read back the complete order to the physician to verify its accuracy.
Options A, B, and D aren't appropriate actions for the nurse to take when receiving a telephone order from a physician.
A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase
is referred to as:
A. remission.
B. convalescence.
C. the acute phase.
D. the subclinical acute phase. - CORRECT ANSWER A. remission.
Rationale: A secondary latency phase that occurs in some diseases that is commonly followed by another acute phase is referred to as remission.
Convalescence (Option B) is progression toward
recovery.
The acute phase (Option C) refers to the disease at its full intensity, possibly with complications.
The subclinical acute phase (Option D) occurs when the patient is in the acute phase but still functions as if the disease weren't present.
Qualitative research emphasizes developing new insights, theories, and knowledge. Which term in qualitative
research describes the researcher laying aside what is known about the experience being studied?
A. Bracketing
B. Saturation
C. Intuiting
D. Theoretical sampling - CORRECT ANSWER A. Bracketing
Rationale: Bracketing requires the researcher to lay aside what's known about the experience
being studied and be open to new insights. Saturation
(Option B) describes the point at which data collection is ended because continuing would result in acquiring more of the same information or data.
Intuiting (Option C) refers to the focused awareness on the phenomena being studied. Theoretical sampling (Option D) is the selecting of subjects on the basis of concepts that have theoretical relevance to an evolving theory.
The nurse leaves a patient who is elderly and confused to fi nd someone to assist with transferring the
patient to bed. While the nurse is gone, the patient falls and hurts herself. The nurse is at fault because she
hasn't:
A. properly educated the patient about safety measures.
B. restrained the patient.
C. documented that she left the patient.
D. arranged for continual care of the patient. - CORRECT ANSWER D. arranged for continual care of the patient.
Rationale: By leaving the patient, the nurse is at fault for abandonment. The better courses
of action are to turn on the call bell or elicit help on the way to the patient's room.
Options A and C are incorrect because neither excuses the nurse from her responsibility for ensuring the patient's safety.
Option B is incorrect because restraints are only to be used as a last resort, when all other alternatives for ensuring patient safety have been tried and have failed; moreover, restraints won't ensure the patient's safety. [Show Less]