1. Which of the following nursing actions demonstrates that the nurse
understands the nursing process?
a) Prioritizing patient goals, documenting all
... [Show More] health records precisely,
conducting the health history, and documenting the nursing diagnosis
b) Reviewing health record, documenting patient goals, identifying etiology of
the nursing problem, and evaluating treatment outcome.
c) Assessing for allergies, administering analgesic, obtaining baseline vital
signs, and documenting nursing diagnosis as acute pain
d) Obtaining vital signs, documenting nursing diagnosis as acute pain,
administering analgesic, and evaluating comfort level
d) Obtaining vital signs, documenting nursing diagnosis as acute pain,
administering analgesic, and evaluating comfort level
Rationale: Steps of the nursing process in order are: Assessment, Diagnosis,
Planning, Implementation, and Evaluation. Assessment is the systematic
collection of data to determine the patient's health status and any actual or
potential health problems. Nursing diagnoses are actual or potential health
problems that can be managed by independent nursing interventions. Planning
is the development of goals and outcomes. Implementation is the actualization
of the plan of care through nursing interventions. Evaluation is the
determination of the patient’s responses to the nursing interventions and the
extent to which the outcomes have been achieved.
2. The nurse educator is planning a teaching session for nursing students related
to treatment and management of gestational diabetes. The nurse educator
arranges for a dietitian, pharmacist, and physician assistant to participate in the
lesson plan. Which professional nurse competency is the nurse educator
demonstrating?
a) Evidence-based practice
b) Patient-centered care
c) Interdisciplinary teamwork
d) Quality improvement measures
c) Interdisciplinary teamwork
Rationale: By integrating interdisciplinary core competencies into their
respective curricula the nurse educator is demonstrating interdisciplinary
teamwork. A case-study approach planning care around individual patient
preferences is an example of patient-centered care. Conducting an evidencebased literature review related to gestational diabetes reflects evidence-based
practice. Providing education related to measures/indicators or tools used to
assess the level of care provided within a system of care to populations of
patients with gestational diabetes exemplifies a quality improvement measure.
3. A nursing student observes the home care nurse provide education to a patient
with congestive heart failure (CHF). The nurse teaches the patient how to read
food labels and calculate sodium content. The nursing student recognizes that
the home care nurse is aware of which of the following basic principles of
patient education?
a) The home care nurse is providing hospital discharge instructions
b) The home care nurse has a physician order to teach a 2-g sodium diet
c) Patients are required to learn about their therapeutic nutritional regimen
d) Patient instruction related to self-care activities promotes patient
independence
d) Patient instruction related to self-care activities promotes patient
independence
Rationale: Teaching is a function of nursing to assist patients to alter lifestyle
patterns that increase health risk. By teaching the client how to calculate sodium
content of foods the nurse is facilitating independence in nutrition disease
management. Patients have the right to decide whether or not to learn. Teaching
is an independent function of nursing and does not require a physician’s order.
Teaching related to food labels in the patient home is an appropriate
environment for this client. The nurse can use actual foods from the patient’s
kitchen.
4. A nurse working in the intensive care unit (ICU) refers to the Institute for
Healthcare Improvement (IHI) Ventilator Bundle prior to planning patient care.
The nurse realizes nursing interventions outlined in the bundle will improve
patients’ outcomes. Which of the following statement best describes how IHIestablished nursing interventions should be included in each bundle?
a) Nursing interventions found within the IHI bundles were selected based on
the ability to provide optimal time management for the nurse
b) Best practice derived from valid and reliable research studies guided nursing
interventions being added to the IHI bundles
c) Nurse case managers serving as patient advocates recommended nursing
interventions to be included in the IHI bundles based on patient preference
d) Hospitals, physicians, and nurses worked collaboratively to design patient
care activities included in IHI bundles
b) Best practice derived from valid and reliable research studies guided nursing
interventions being added to the IHI bundles
Rationale: Bundles include evidence-based practices. Hospitals, physicians, and
nurses work collaboratively to provide care directed by bundles. Nurses
advocate on behalf of the patient. Effective time management is a key element
in the provision of care, however; IHI-based bundles on evidence-based
practice.
5. A 54-year-old woman on a fixed income has had an electrocardiogram (ECG)
as part of her annual physical examination. Her physician notes an abnormal Q
wave on an otherwise unremarkable ECG. What legislation supports this focus
on disease prevention, health promotion, and management of chronic
conditions?
a) Building a Safer Health System Act
b) The Patient Protection and Affordable Care Act
c) Healthcare Research and Quality Improvement Bill
d) A New Health System for the 21st Century Bill
b) The Patient Protection and Affordable Care Act
Rationale: The Patient Protection and Affordable Care Act, also known as the
ACA, supports access to quality, affordable health care, improved access to
innovative and preventive health care programs and therapies, and expanded
insurance coverage. “To Err Is Human: Building a Safer Health System” and
“Crossing the Quality Chasm: A New Health System for the 21st Century” are
IOM reports. Centers for Medicare and Medicaid Services (CMS) partnered
with the Agency for Healthcare Research and Quality (AHRQ) to launch the
Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey.
6. According to Hood and Leddy (2007), which of the following are
components of wellness?
a) Inability to obtain personal goals
b) Expression of disharmony
c) Feelings of well-being
d) Inability to adapt to changing situations
c) Appropriateness of services
Rationale: The goals of care management are quality, appropriateness, and
timeliness of services as well as cost reduction. Case managers do not have
prescriptive authority. Fixed-price reimbursement is a feature of managed care.
Case managers do not use the nursing process.
7. The school nurse informs the mother of a second-grade student that she found
lice in her child’s hair. The mother explains to the nurse that she has another
child to pick up and cannot stay to receive education related to the treatment of
lice at this time. The mother reassures the nurse that she will “look up treatment
options on the Internet and take care of the child.” What would be the best
action of the school nurse in this situation?
a) Instruct the mother to treat the other child for lice in the same manner as the
second grade child
b) Provide the mother with a list of credible Web sites related to the treatment of
lice
c) Notify the social worker of suspected child neglect and make a referral to
child protective services
d) Perform hand hygiene and notify the second-grade teacher to wash down the
classroom
b) Provide the mother with a list of credible Web sites related to the treatment of
lice
Rationale: Providing the mother with a list of previewed Web sites related to
treating lice assist the mother to receive trustworthy, credible, and timely
information related to treatment options. Although assessing and treating the
other children in the home is indicated, it is more important to direct the mother
to accurate information related to the treatment of lice. The nurse should
perform routine hand hygiene, washing the classroom is not indicated. The
presence of lice does not warrant a referral to the social worker or child
protective services.
8. In which of the following situations is the nurse demonstrating the ethical
principle of beneficence?
a) Providing truthful and accurate information to a patient about a procedure
b) Volunteering to provide vaccinations at the local health center
c) Ensuring adequate staffing to provide care to all patients
d) Refusing to give an ordered medication based on assessment findings
b) Volunteering to provide vaccinations at the local health center
Rationale: Beneficence is the duty to do good and the active promotion of
benevolent acts. Fidelity refers to the duty to be faithful to one's commitments.
Veracity is the obligation to tell the truth. Nonmaleficence is the duty not to
inflict, as well as to prevent and remove, harm; it is more binding than
beneficence.
9. What percentage of people older than 65 years of age has one or more
chronic disease?
a) 50
b) 80
c) 70
d) 60
b) 80
Rationale: Eighty percent of people older than 65 years of age have one or more
chronic illness and many are limited in their activity
10. Which of the following examples of therapeutic communication techniques
may occur during the planning stage and increases the patient’s perception of
available options?
a) “Home health services are also available in our community if you feel an
assisted living situation is uncomfortable.”
b) “You appear confused about assisted living facilities.”
c) “Let’s discuss specific concerns you have regarding assisted living facilities.”
d) “I hear you say that you are uncomfortable with the idea of going to an
assisted living facility.”
a) “Home health services are also available in our community if you feel an
assisted living situation is uncomfortable.”
Rationale: Suggesting is the presentation of alternative ideas such as home
health services the patient's consideration and increases the perception of other
possible solutions relative to the problem. Clarification is asking the patient to
explain what he or she means or attempting to help verbalize the patient's vague
ideas or unclear thoughts to enhance the nurse's understanding. Focusing
includes questions or statements to help the patient develop or expand an idea.
Reflection directs back to the patient his feelings but does not increase the
patient’s perception of available options.
11. The nurse caring for a HIV patient diagnosed with acute pneumonia
demonstrates understanding of the nurse’s role in the current focus on
management of chronic illness and disability in which of the following
situations?
a) Reviewing the patient’s CD4 count
b) Making a referral to an HIV support group
c) Administering prescribed antibiotics
d) Teaching the patient to avoid crowds
d) Teaching the patient to avoid crowds
Rationale: Current focus on chronic disease conditions is focused on disease
prevention. Teaching the patient to avoid crowds encourages the patient to take
control of their health and reduce the risk of pneumonia exacerbations.
Administering prescribed antibiotics is indicated in this situation; however, it
does not promote independence in the patient. Making a referral to a HIV
support group is indicated in this situation; however, the focus is on actions of
the nurse not the patient. Reviewing the patient’s CD4 count is important but
does not indicate the patient’s ability to control his or her health.
12. In which of the following actions is the nurse illustrating the step of the
nursing process that determines if the patient understands the health teaching
that is provided?
a) Setting short-term educational goals for the patient newly diagnosed with
diabetes
b) Teaching injection sites to a patient newly diagnosed with diabetes
c) Watching a return demonstration of insulin administration from a newly
diagnosed diabetic
d) Asking a new diabetic, “What are your questions about giving yourself an
insulin injection?”
c) Watching a return demonstration of insulin administration from a newly
diagnosed diabetic
Rationale: Evaluation includes observing the patient, asking questions, and then
comparing the patient’s behavioral responses with the expected outcomes.
Observation of a return demonstration is a form of evaluation. Assessment
includes determining the patient’s readiness regarding learning. Planning
includes identification of teaching strategies, writing the teaching plan, and
setting goals of the teaching strategies. Implementation is the step during which
the teaching plan is put into action.
13. During an interview for an ambulatory clinic position, the nurse notices that
family planning counseling is included in the job description. Being a devout
Catholic, how should the nurse proceed with the interview?
a) Continue the interview and only provide patients with information related to
abstinence
b) Continue the interview; other nurses at the center can provide family
counseling
c) Excuse herself from the interview stating she is Catholic
d) Realize the ethical obligation to provide care to all faiths, and continue the
interview process
c) Excuse herself from the interview stating she is Catholic
Rationale: One strategy a nurse can use to avoid ethical dilemmas is to inquire
about the patient population of potential employers. In this situation, being
Catholic and providing counseling regarding family planning create an ethical
dilemma for the nurse. It is appropriate for the nurse to avoid the dilemma based
on this conflict of personal values. The delegation of a specific job duty by the
nurse is not appropriate in this situation. Continuing the interview indicates the
nurse is willing to meet job duties as described. Avoiding ethical dilemmas in
providing patient care is priority. The nurse’s strong Catholic faith may interfere
with her ability to provide patients with unbiased and objective information
related to family planning options.
14. The physician asks the nurse not to disclose the patient’s diagnosis of endstage cancer with the patient until the patient’s family can be available to
provide support. During the nurse’s shift, the patient asks the nurse, “What is
wrong with me? Everyone is treating me like I am dying.” Which of the
following replies by the nurse allows the nurse to maintain integrity while
providing care for the patient?
a) “Test results indicate that you are in the end-stages of your disease process.”
b) “I will call the chaplain to talk to you about your concerns.”
c) “You are fine; I hear your family will be in town soon.”
d) “You feel like people are treating you like you are dying?”
d) “You feel like people are treating you like you are dying?”
Rationale: By using the therapeutic communication, technique of restating the
nurse demonstrates listening and validates the patients concerns allowing the
nurse to maintain integrity. Calling the chaplain defers care of the patient to the
clergy. Telling patients they are fine does not provide accurate information to
the patients. Lying to the patient jeopardizes the nurse’s integrity and ability to
develop a trusting relationship with the patient. Although information provided
at the patient’s request protects the patient’s autonomy, it does not provide
respect for others in this situation. Disclosure of sensitive information without
compassion and caring may increase the impact and distress related to a poor
diagnosis. [Show Less]