Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge goals
... [Show More] will be developed with the patients input. The patient states, How is this different from what the doctor does? Which response would be most appropriate for the nurse to make?
a. The role of the nurse is to administer medications and other treatments prescribed by your doctor.
b. The nurses job is to help the doctor by collecting information and communicating any problems that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor.
d. In addition to caring for you while you are sick, the nurses will assist you to develop an
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. Inferences from clinical research studies are used as a guide.
b. Patient care is based on clinical judgment, experience, and traditions.
c. Data are evaluated to show that the patient outcomes are consistently met.
d. Recommendations are based on research, clinical expertise, and patient preferences.
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful?
a. The nursing process is a scientific-based method of diagnosing the patients health care problems.
b. The nursing process is a problem-solving tool used to identify and treat patients health care needs.
c. The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans.
d. The nursing process is used primarily to explain nursing interventions to other health care professionals.
4. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving my children with my parents. Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patients feelings about the child-care arrangements.
d. Call the patients parents to determine whether adequate child care is being provided.
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patients health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
8. The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patients blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
13. Which task is appropriate for the nurse to delegate to a licensed
practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care.
b. Document teaching completed before a diagnostic procedure.
c. Instruct a patient about low-fat, reduced sodium dietary restrictions.
d. Obtain bedside blood glucose on a patient before insulin administration.
14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord
injury. The patient can expect the nurse functioning in this role to perform which activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home.
15. The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility?
a. A skilled care facility
b. A residential care facility
c. A transitional care facility
d. An intermediate care facility
16. A home care nurse is planning care for a patient who has just been diagnosed with
type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home health aide?
a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patients feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.
17. The nurse is providing education to nursing staff on quality care initiatives. Which
statement would be the most accurate description of the impact of health care financing on quality care?
a. Hospitals are reimbursed for all costs incurred if care is documented electronically.
b. Payment for patient care is primarily based on clinical outcomes and patient satisfaction.
c. If a patient develops a catheter-related infection, the hospital receives additional funding.
d. Because hospitals are accountable for overall care, it is not nursings responsibility to monitor care delivered by others.
18. The nurse documenting the patients progress in the care plan in the electronic health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category?
a. Patient-centered care
b. Quality improvement
c. Evidence-based practice
d. Informatics and technology
1. Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)?
a. Institutional policies
b. Stability of the patient
c. State nurse practice act
d. LPN/LVN teaching abilities
e. Experience of the LPN/LVN
2. The nurse is administering medications to a patient. Which actions by the nurse
during this process are consistent with promoting safe delivery of care (select all that apply)?
a. Throws away a medication that is not labeled
b. Uses a hand sanitizer before preparing a medication
c. Identifies the patient by the room number on the door
d. Checks lab test results before administering a diuretic
e. Gives the patient a list of current medications upon discharge
1. The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements? (Put a comma and a space between each answer choice [A, B, C, D].)
a. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low.
c. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable.
d. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.
1. The nurse is obtaining a health history from a new patient. Which data will be the focus of patient teaching?
a. Age and gender
b. Saturated fat intake
c. Hispanic/Latino ethnicity
d. Family history of diabetes
2. The nurse works in a clinic located in a community with many Hispanics. Which strategy, if implemented by the nurse, would decrease health care disparities for the Hispanic patients?
a. Improve public transportation to the clinic.
b. Update equipment and supplies at the clinic.
c. Obtain low-cost medications for clinic patients.
d. Teach clinic staff about Hispanic health beliefs.
3. What information should the nurse collect when assessing the health status of a community?
a. Air pollution levels
b. Number of health food stores
c. Most common causes of death
d. Education level of the individuals
4. The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by nurse is most appropriate?
a. Avoid asking questions unless the patient initiates the conversation.
b. Ask the patient whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the patients cultural beliefs from a family member.
5. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient?
a. Avoid eye contact with the patient.
b. Observe the patients use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patients cultural beliefs.
6. A female staff nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the charge nurse to intervene if the nurse takes which action?
a. The nurse explains the 0 to 10 intensity pain scale.
b. The nurse asks the patient when the headaches started.
c. The nurse sits down at the bedside and closes the privacy curtain.
d. The nurse calls for a male nurse to bring a hospital gown to the room.
7. The nurse cares for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is most appropriate?
a. Talk slowly so that each word is clearly heard.
b. Speak loudly in close proximity to the patients ears.
c. Repeat important words so that the patient recognizes their significance.
d. Use simple gestures to demonstrate meaning while talking to the patient.
8. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?
a. Encourage the use of diagnostic procedures.
b. Coordinate the use of folk treatments with ordered medical therapies.
c. Ask the patient to discontinue the cultural treatments during hospitalization.
d. Teach the patient that folk remedies will interfere with orders by the health care provider.
9. The nurse is caring for a newly admitted patient. Which intervention is the best
example of a culturally appropriate nursing intervention?
a. Insist family members provide most of the patients personal care.
b. Maintain a personal space of at least 2 feet when assessing the patient.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patients ethnicity as the most important factor in planning care.
10. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?
a. Remind the nurse that family support is important to this family and patient.
b. Have the nurse explain to the family that too many visitors will tire the patient.
c. Suggest that the nurse ask family members to leave the room during patient care.
d. Ask about the nurses personal beliefs about family support during hospitalization.
11. An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?
a. Include a shaman when planning the patients care.
b. Avoid direct eye contact with the patient during care.
c. Ask the patient about any special cultural beliefs or practices.
d. Involve the patients oldest son to assist with health care decisions.
12. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy information
13. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.
14. Which strategy should be a priority when the nurse is planning care for a diabetic patient who is uninsured?
a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.
15. A Hispanic patient complains of abdominal cramping caused by empacho. Which
action should the nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patients abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.
16. The nurse performs a cultural assessment with a patient from a different culture. Which action by the nurse should be taken first?
a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patients culture.
17. The nurse working in a clinic in a primarily African American community notes a
higher incidence of uncontrolled hypertension in the patients. To correct this health disparity, which action should the nurse take first?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.
1. The nurse is performing an admission assessment for a non-English speaking patient who is from China. Which actions could the nurse take to enhance communication (select all that apply)?
a. Use an electronic translation application.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patients teenage daughter to interpret.
e. Use exaggerated gestures to convey information.
1. A patient who is actively bleeding is admitted to the emergency department. Which approach is best for the nurse to use to obtain a health history?
a. Briefly interview the patient while obtaining vital signs.
b. Obtain subjective data about the patient from family members.
c. Omit subjective data collection and obtain the physical examination.
d. Use the health care providers medical history to obtain subjective data.
2. Immediate surgery is planned for a patient with acute abdominal pain. Which question by the nurse will elicit the most complete information about the patients coping-stress tolerance pattern?
a. Can you rate your pain on a 0 to 10 scale?
b. What do you think caused this abdominal pain?
c. How do you feel about yourself and your hospitalization?
d. Are there other major problems that are a concern right now?
3. During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will best elicit any associated clinical manifestations?
a. How frequently do you have the fainting spells?
b. Where are you when you have the fainting spells?
c. Do the spells tend to occur at any special time of day?
d. Do you have any other symptoms along with the spells?
4. The nurse records the following general survey of a patient: The patient is a 50- year-old Asian female attended by her husband and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to
questions. No apparent disabilities or distinguishing features. What additional information should the nurse add to this general survey?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
5. A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which assessment would be a pertinent negative finding?
a. Patient has several bruised and swollen areas on the right leg.
b. Patient states that there have been no other recent health problems.
c. Patient refuses to bend the right knee because of the associated pain.
d. Patient denies having pain when the area over the fracture is palpated.
6. The nurse who is assessing an older adult with rectal bleeding asks, Have you ever had a colonoscopy? The nurse is performing what type of assessment?
a. Focused assessment
b. Emergency assessment
c. Detailed health assessment
d. Comprehensive assessment
7. The nurse is preparing to perform a focused assessment for a patient complaining of shortness of breath. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
8. The nurse plans to complete a physical examination of an alert, older patient. Which adaptations to the examination technique should the nurse include?
a. Avoid the use of touch as much as possible.
b. Use slightly more pressure for palpation of the liver.
c. Speak softly and slowly when talking with the patient.
d. Organize the sequence to minimize the position changes.
9. While the nurse is taking the health history, a patient states, My mother and sister both had double mastectomies and were unable to be very active for weeks. Which functional health pattern is represented by this patients statement?
a. Activity-exercise
b. Cognitive-perceptual
c. Coping-stress tolerance
d. Health perceptionhealth management
10. A patient is seen in the emergency department with severe abdominal pain and hypotension. Which type of assessment should the nurse do at this time?
a. Focused assessment
b. Subjective assessment
c. Emergency assessment
d. Comprehensive assessment
11. The registered nurse (RN) cares for a patient who was admitted a few hours previously with back pain after falling. Which action can the RN delegate to unlicensed assistive personnel (UAP)?
a. Finish documenting the admission assessment.
b. Determine the patients priority nursing diagnoses.
c. Obtain the health history from the patients caregiver.
d. Take the patients temperature, pulse, and blood pressure.
12. When assessing for formation of a possible blood clot in the lower leg of a patient,
which action should the nurse take first?
a. Visually inspect the leg.
b. Feel for the temperature of the leg.
c. Check the patients pedal pulses using the fingertips.
d. Compress the nail beds to determine capillary refill time.
13. When assessing a patients abdomen during the admission assessment, which action should the nurse take first?
a. Feel for any masses.
b. Palpate the abdomen.
c. Listen for bowel sounds.
d. Percuss the liver borders.
14. When admitting a patient who has just arrived on the unit with a severe headache,
what should the nurse do first?
a. Complete only basic demographic data before addressing the patients pain.
b. Medicate the patient for the headache before doing the health history and examination.
c. Take the initial vital signs and then address the headache before completing the health history.
d. Inform the patient that the headache will be treated as soon as the health history is completed.
1. In what order will the nurse perform these actions when doing a physical assessment for a patient admitted with abdominal pain? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Percuss the abdomen to locate any areas of dullness.
b. Palpate the abdomen to check for tenderness or masses.
c. Inspect the abdomen for distention or other abnormalities.
d. Auscultate the abdomen for the presence of bowel sounds.
1. A patient with newly diagnosed colon cancer has a nursing diagnosis of deficient knowledge about colon cancer. The nurse should initially focus on which learning goal for this patient?
a. The patient will select the most appropriate colon cancer therapy.
b. The patient will state ways of preventing the recurrence of the cancer.
c. The patient will demonstrate coping skills needed to manage the disease.
d. The patient will choose methods to minimize adverse effects of treatment.
2. After the nurse provides dietary instructions for a patient with diabetes, the patient can explain the information but fails to make the recommended dietary changes. How would the nurse evaluate the patients situation?
a. Learning did not occur because the patients behavior did not change.
b. Choosing not to follow the diet is the behavior that resulted from learning.
c. The nursing responsibility for helping the patient make dietary changes has been fulfilled.
d. The teaching methods were ineffective in helping the patient learn the dietary instructions.
3. A patient is diagnosed with heart failure after being admitted to the hospital for shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse, is most likely to be effective?
a. Assure the patient that the nurse is an expert on management of heart failure.
b. Teach the patient at each meal about the amounts of sodium in various foods.
c. Discuss the importance of medication control in maintenance of long- term health.
d. Refer the patient to a home health nurse for instructions on diet and fluid restrictions.
4. A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing patient teaching, what is the priority action for the nurse?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
5. A patient states, I told my husband I wouldnt buy as much prepared food snacks, so I will go the grocery store to buy fresh fruit, vegetables, and whole grains. When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change?
a. Preparation
b. Termination
c. Maintenance
d. Contemplation
6. While admitting a patient to the medical unit, the nurse determines that the patient is hard of hearing. How should the nurse use this information to plan teaching and learning strategies?
a. Motivation and readiness to learn will be affected.
b. The family must be included in the teaching process.
c. The patient will have problems understanding information.
d. Written materials should be provided with verbal instructions.
7. A patient who is morbidly obese states, Ive recently made some changes in my life. Ive decreased my fat intake and Ive stopped smoking. Which statement, if made by the nurse, is the best initial response?
a. Although those are important, it is essential that you make other changes, too.
b. Are you having any difficulty in maintaining the changes you have already made?
c. Which additional changes in your lifestyle would you like to implement at this time?
d. You have already accomplished changes that are important for the health of your heart.
8. The nurse is planning a teaching session with a patient newly diagnosed with migraine headaches. To assess a patients readiness to learn, which question should the nurse ask?
a. What kind of work and leisure activities do you do?
b. What information do you think you need right now?
c. Can you describe the types of activities that help you learn new information?
d. Do you have any religious beliefs that are inconsistent with the planned treatment?
9. The nurse considers a nursing diagnosis of ineffective health maintenance related to low motivation for a patient with diabetes. Which finding would the nurse most likely use to support this nursing diagnosis?
a. The patient does not perform capillary blood glucose tests as directed.
b. The patient occasionally forgets to take the daily prescribed medication.
c. The patient states that dietary changes have not made any difference at all.
d. The patient cannot identify signs or symptoms of high and low blood glucose.
10. A patient with diabetic neuropathy requires teaching about foot care. Which learning goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will list three ways to protect the feet from injury by discharge.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will understand the rationale for proper foot care after instruction.
11. The nurse educator teaches students how to be more assertive. Which teaching strategy, if implemented by the nurse educator, would be most effective?
a. Role playing
b. Peer teaching
c. Printed materials
d. Lecture-discussion
12. The nurse and the patient who is diagnosed with hypertension develop this goal: The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days. Which evaluation method will be best for the nurse to use when determining whether teaching was effective?
a. Have the patient list substitutes for favorite foods that are high in sodium.
b. Check the sodium content of the patients menu choices over the next 3 days.
c. Ask the patient to identify which foods on the hospital menus are high in sodium.
d. Compare the patients sodium intake before and after the teaching was implemented.
13. The nurse prepares written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. What statement would be appropriate to include in the handouts?
a. Eating the right foods can help in keeping blood glucose at a near- normal level.
b. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes mellitus.
c. Some diabetics control blood glucose with oral medications, injections, or nutritional interventions.
d. Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms than can lead to long-term complications.
14. The hospital nurse implements a teaching plan to assist an older patient who lives alone to independently accomplish daily activities. How would the nurse best evaluate the patients long-term response to the teaching?
a. Make a referral to the home health nursing department for home visits.
b. Have the patient demonstrate the learned skills at the end of the teaching session.
c. Arrange a physical therapy visit before the patient is discharged from the hospital.
d. Check the patients ability to bathe and get dressed without any assistance the next day. [Show Less]