NSG 3001 Final Exam Blueprint INTRO Questions and Answers
1) Distinguish between in-service, advanced, continuing and Registered Nurse education
A
... [Show More] nurse is employed by a health care agency that provides an informal training session on how to properly use a new vital sign monitor. Which type of education did the nurse receive?
a. In-service education
b. Advanced education
c. Continuing education
d. Registered nurse education
ANS: A
(#2, chapter 1)
2) Know the differences between accountability, autonomy, licensure, and certification
A nurse listens to a patient’s lungs and determines that the patient needs to cough and deep breath. The nurse has the patient cough and deep breath. Which concept did the nurse demonstrate?
a. Accountability
b. Autonomy
c. Licensure
d. Certification
ANS: B
Autonomy is essential to professional nursing and involves the initiation of independent nursing interventions without medical orders. Accountability means that you are professionally and legally responsible for the type and quality of nursing care provided. To obtain licensure in the United States, RN candidates must pass the NCLEX-RN examination administered by the individual State Boards of Nursing to obtain a nursing license.
Beyond the NCLEX-RN, some nurses choose to work toward certification in a specific area of nursing practice. (#3, Ch 1)
3) Describe influences such as workplace hazards, nursing shortage, professionalism and emergency preparedness
A registered nurse is required to participate in a simulation to learn how to triage patients who are arriving to the hospital after exposure to an unknown gas. This is an example of a response to what type of influence on nursing?
a. Workplace hazards
b. Nursing shortage
c. Professionalism
d. Emergency preparedness ANS: D
(#4, Ch 1)
4) Know the difference between the code of ethics, nurse practice act, standards of practice and the quality and safety education for nurses
A nurse must follow legal laws that protect public health, safety, and welfare. Which law is the nurse following?
a. Code of Ethics
b. Nurse Practice Act
c. Standards of practice
d. Quality and safety education for nurses ANS: B
(#7, Ch 1)
5) Be able to identify and describe incidences of nursing professional roles
A patient does not want the treatment that was prescribed. The nurse helps the patient talk to the primary health care provider and even talks to the primary health care provider when needed. The nurse is acting in which professional role?
a. Educator
b. Manager
c. Advocate
d. Provider of care
ANS: C
As an advocate you act on behalf of your patient, securing and standing up for your patients health care rights. As an educator you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patients progress in learning. Most nurses provide direct patient care in an acute care setting, and this describes the role of provider of care. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. (#6, ch 1)
6) Be able to identify instances of primary prevention
Which nursing action best represents primary prevention?
a. Instructing a healthy individual to get a flu shot on a yearly basis
b. Instructing a patient to take blood pressure medication every day
c. Instructing a patient to live with a known disability
d. Instructing a patient to undergo physical therapy following a cerebrovascular accident ANS: A (#5, Ch 2)
A nurse who works in an inner-city health clinic is scheduling a day for student nurses to assist with a flu immunization clinic. Which of the following best describes this type of activity?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Health prevention ANS: A (#17, Ch 2)
7) How would a nurse describe a potential harmful behavior in a client?
Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding?
a. This is an example of a health belief.
b. This is an example of health promotion.
c. This is an example of a negative health behavior.
d. This is an example of a basic physiological human need.
ANS: C (#11, Ch 2)
8) Applying Maslow’s Hierarchy of Needs, describe each element, from lower to higher needs
A patient is depressed after a divorce and is not eating. The nurse is using Maslow to prioritize care. Which patient need should the nurse address first?
a. Nutrition
b. Emotional safety
c. Depression
d. Love and belonging ANS: A (#2, Ch 2)
A nurse allows a patient to place pictures of the family in the room. Which need is being met?
a. Basic needs
b. Physiological needs
c. Self-actualization
d. Love and belongingness ANS: D (#22, Ch 2)
Which order should the nurse prioritize care for the patient using Maslows theory from lower- level needs to higher-level needs?
a. Self-esteem
b. Physiological needs
c. Self-actualization
d. Love and belonging
e. Safety and security
a. b, e, d, a, c
b. d, b, c, a, e
c. b, e, d, c, a
d. d, b, a, c, e
ANS: A
Maslows (1987) model describes human needs using a hierarchical pyramid divided into five levels: physiological needs, safety and security, love and belonging, self-esteem, and self- actualization. (#35, Ch 2)
9) Be able to describe the stages of change
A nurse is teaching the staff about the stages of change. Which information should the nurse include in the teaching session?
a. Precontemplation, contemplation, preparation, action, maintenance
b. Contemplation, preparation, action, maintenance, postmaintenance
c. Contemplation, procrastination, preparation, action, maintenance
d. Precontemplation, contemplation, preparation, action, engagement ANS: A (#26, Ch 2)
10) Be able to differentiate between an acute and chronic illness
A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking. At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n):
a. acute illness.
b. tertiary prevention.
c. chronic illness.
d. internal variable.
ANS: C (#6, Ch 2)
A registered nurse is working in a community clinic that provides services for chronically ill patients. Which condition would be considered chronic?
a. Appendicitis
b. Pneumonia
c. Flu
d. Diabetes
ANS: D (#29, Ch 2)
A nurse is planning to care for a patient with a disease that is a major cause of death and disability in the United States. The nurse is caring for which patient?
a. One with an acute disease
b. One with a chronic disease
c. One with an infectious disease
d. One with an exotic disease ANS: B (#30, Ch 2)
11) The NCLEX is an abbreviation for what exam?
A student nurse must pass the NCLEX before practicing as a registered nurse.
NCLEX stands for Examination.
a. Nursing Council of Licensing
b. Nightingale Code of Licensure
c. Nursing Code of Licensure
d. National Council Licensure
12) ANS: D (#2, Ch 5)
13) Be able to differentiate between assault, unintentional tort, battery, misdemeanor, negligence and a felony
The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he or she will tie the patient down if the patient does not hold still. Which action did the nurse commit?
a. Assault
b. Unintentional tort
c. Battery
d. Felony
ANS: A (#5, Ch 5)
An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed. The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law?
a. Misdemeanor
b. Tort
c. Malpractice
d. Felony
ANS: D (#4, ch 5)
A patient falls out of bed because the nurse did not raise the side rails. Which action did the nurse commit?
a. Felony
b. Assault
c. Battery
d. Negligence
ANS: D (#22, Ch 5)
- A misdemeanor is a crime that, although injurious, does not inflict serious harm.
14) How does a nurse avoid being liable for malpractice?
Which behavior is the best way for a nurse to avoid being liable for malpractice?
a. Purchasing quality malpractice insurance coverage on a yearly basis
b. Practicing nursing that meets the generally accepted standard of care
c. Not sharing his or her last name with patients and families
d. Not delegating any tasks to unlicensed assistive personnel ANS: B
(#8, Ch 5)
15) What does a nurse witnessed a deviation from the standard of care to a client what action does the nurse take?
A registered nurse is caring for a patient 2 days after a colon resection. The patient called for assistance to go to the bathroom. Instead of waiting for help, the patient decided to get up without help. The patient fell but was not injured. After contacting the patients primary health care provider, which action should the nurse take next?
a. Nothing; the patient was not injured.
b. Call the ethics committee.
c. Submit an incident report.
d. Insist that the patient have a radiograph done.
ANS: C
When there is a deviation from the standard of care, such as a patient or visitor falls or an error is made, a nurse makes specific documentation of the event or incident in the
form of an occurrence/incident report. The nurse should complete an occurrence report when anything unusual happens that could potentially cause harm to a patient, visitor, or employee.
(#11, Ch 5)
16) What protects a nurse from liability when she assists within her scope of practice an ailing victim?
A clinic nurse stopped at an automobile accident to assist. There was one victim who was not breathing. The nurse provided CPR at the scene, but the victim died. The victims family sued the nurse. Which will provide the best protection to the nurse in this case?
a. Clinics malpractice insurance policy
b. Good Samaritan Law
c. State Board of Nursing
d. Institute of Medicine ANS: B
(#13, Ch 5)
17) What is another way to describe an advanced directive?
As part of the admission process the nurse asks if the patient has an advance directive. The patient doesnt know for sure. What is the nurses best response?
a. It is autopsy permission.
b. It is a living will.
c. It is informed consent.
d. It is an organ donation card.
ANS: B (#16, Ch 5)
18) Best action when a nurse receives an erroneous order from a primary health care provider
An RN has been caring for a patient. The nurse received an erroneous order for a medication. The primary health care provider has a reputation for impatience and irritability. Knowing this health care providers nature, which action by the nurse would be most appropriate?
a. Clarify the order with the pharmacy.
b. Ask the patient to remember.
c. Clarify the order with the primary health care provider.
d. Ask another nurse to look at the order to try to clarify it.
ANS: C (#18, Ch 5)
A nurse is about to administer a medication and notices that the physicians or primary health care providers order looks incorrect regarding the amount of the medication. What should the nurse do? (Select all that apply.)
a. Notify the physician or health care provider.
b. Do not carry out the order.
c. Document the suspicion that the dosage is incorrect.
d. Administer the medication.
e. Notify the supervisor or nurse manager.
ANS: A, B, E (MC #1, Ch 5)
19) When does the institution’s malpractice insurance cover the nurse?
Which information indicates the nurse has an accurate understanding of when the institutions malpractice insurance covers the nurse?
a. While driving to work
b. While driving home from work
c. While tending to people in the neighborhood
d. While working within the scope of employment ANS: D
(#24, Ch 5)
20) By law what action does a nurse perform when a patient is admitted?
Which action is the nurse required by law to perform when a patient is admitted?
a. Notify the family.
b. Notify the attorney.
c. Ask how payment will be made.
d. Ask about advance directives.
ANS: D (#27, Ch 5)
21) Be able to describe the differences between autonomy, justice, fidelity, non-maleficence and beneficence
A 73-year-old patient with hypertension is awaiting a triple cardiac bypass surgery. The patient is hard of hearing and did not understand what the surgeon said regarding the surgery. The daughter is concerned that the patient does not understand the risks of the surgery. If not clarified, this would be a violation of what principle?
a. Autonomy
b. Justice
c. Fidelity
d. Nonmaleficence
ANS: A (#1, Ch 6)
A 45-year-old mother of two children has cirrhosis of the liver and is on a waiting list for a liver transplant. She had to meet certain criteria to be eligible to receive a liver. She understands that she is next on the list for a donor liver that matches. This is an example of which ethical principle?
a. Autonomy
b. Justice
c. Fidelity
d. Nonmaleficence
ANS: B (#2, Ch 6)
A registered nurse who works on an oncology unit discussed pain control options that the primary health care provider had ordered with a patient undergoing treatment for pancreatic cancer. The patient requested that the intravenous (IV) pain medication be given on a regular basis. The nurse agreed to provide the IV pain medication as requested and continued to reevaluate the pain levels. The nurse is following which ethical principle?
a. Autonomy
b. Justice
c. Fidelity
d. Nonmaleficence
ANS: C (#3, Ch 6)
A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications and may not recover. The nurse ensures that the patient has been given information regarding the risks and potential benefits of the procedure. The nurse is following which ethical principle?
a. Autonomy
b. Justice
c. Fidelity
d. Nonmaleficence
ANS: D
(#4, Ch 6)
A patient is about to undergo a new, controversial bone marrow transplant procedure. The procedure may cause periods of pain and suffering. Although nurses agree to do no harm, this procedure may be necessary to promote health. This is an example of which ethnical principle?
a. Autonomy
b. Justice
c. Fidelity
d. Nonmaleficence
ANS: D (#13, Ch 6)
.A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride the wounds. The patient is crying and does not want to go to the physical therapy department for treatment. The registered nurse caring for the patient knows that, even though it is uncomfortable, the patient needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which ethical principle?
a. Autonomy
b. Bioethics
c. Justice
d. Beneficence
ANS: D (#9, Ch 6)
22) Distinguish between deontology, feminist ethic, utilitarianism and ethics of care
A community health nurse states, I wish we had just a portion of the dollars spent repairing atherosclerotic hearts to teach the community about cardiovascular risk factors. The nurses statement stems from what philosophy?
a. Deontology
b. Feminist ethic
c. Utilitarianism
d. Ethics of care
ANS: C (#14, Ch 6)
23) What organization developed the code of ethics?
The code of ethics for nursing sets forth ideals of nursing conduct and was developed by what organization?
a. The Board of Nursing
b. The American Medical Association
c. The National League for Nursing
d. The American Nurses Association ANS: D
(#16, Ch 6)
24) Describe the levels of critical thinking according to the Kataoka-Yahiro and Saylor’s model
A student nurse is administering an enema with an instructor in the room. The patient states that he or she can no longer hold the enema solution. The student nurse acknowledges the patients request and begins to tell the patient to go to the bathroom but asks the instructor if this is OK. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylors model?
a. Level 1: Basic
b. Level 2: Complex
c. Level 3: Commitment
d. Level 4: Expert
ANS: A (#4, Ch 8)
25) What skill is the nurse using when she comes up with a nursing diagnosis?
A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patients white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection. The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation?
a. Medical diagnosis
b. Scientific method
c. Diagnostic reasoning
d. Data collection
ANS: C (#10, Ch 8)
26) What does the nurse do in order to strengthen critical thinking skills?
A student nurse in the last semester of nursing school found that keeping a journal of clinical experiences helped the student nurse understand why certain actions were taken and to evaluate whether there was a better way of approaching the task. The student nurse has found that this has helped strengthen critical thinking skills. Which skill for developing critical thinking did the student nurse use?
a. Professional standards
b. Nursing process
c. Concept mapping
d. Purposeful reflection ANS: D
(#17, Ch 8)
A nurse is using scientific knowledge and experience to choose strategies to use in the care of a patient. Which critical thinking skill is the nurse using?
a. Analysis
b. Evaluation
c. Explanation
d. Self-regulation
ANS: C (#20, Ch 8)
27) Be able to describe reflective journaling, concept mapping, care planning and intellectual standards
A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patients problems and appropriate nursing interventions. What is the best tool that the nurse can use to synthesize data into meaningful information?
a. Concept map
b. Reflective journal
c. Plan of care
d. Intellectual standards ANS: A
(#18, Ch 8)
A nurse walks into a room and finds a patient to be severely confused. The nurse examines and observes the patient closely and thinks about other situations with severely confused patients before making a nursing diagnosis. Which skill is the nurse using?
a. Clinical inferences
b. Reflective journaling
c. Accountability
d. Intuition
ANS: A (#19, Ch 8)
28) What is a critical thinker?
A student nurse is administering an enema with an instructor in the room. The patient states that he or she can no longer hold the enema solution. The student nurse acknowledges the patients request and begins to tell the patient to go to the bathroom but asks the instructor if this is OK. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylors model?
a. Level 1: Basic
b. Level 2: Complex
c. Level 3: Commitment
d. Level 4: Expert
ANS: A (#4, Ch 8)
A nurse is describing risk taking, creativity, and integrity in nursing care. What is the nurse explaining?
a. Attitudes of critical thinking
b. Competencies of critical thinking
c. Standards for critical thinking
d. Nursing process for critical thinking ANS: A
(#5, Ch 8)
A registered nurse is explaining a procedure to a patient who speaks another language. Which action by the nurse reflects critical thinking?
a. Teach with unfamiliar explanations.
b. Explain using medical jargon.
c. Use vague descriptions.
d. Obtain an interpreter.
ANS: D (#7, Ch 8)
A nurse is caring for a patient who underwent an above-the-knee amputation that requires a dressing change, a skill the nurse has never done. The nurse asks another nurse to help with the dressing change for the amputated leg. The nurse is demonstrating which critical thinking attitude?
a. Humility
b. Confidence
c. Risk-taking
d. Fairness
ANS: A (#16, Ch 8)
A student nurse in the last semester of nursing school found that keeping a journal of clinical experiences helped the student nurse understand why certain actions were taken and to evaluate whether there was a better way of approaching the task. The student nurse has found that this has helped strengthen critical thinking skills. Which skill for developing critical thinking did the student nurse use?
a. Professional standards
b. Nursing process
c. Concept mapping
d. Purposeful reflection
ANS: D (#17, Ch 8)
.A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge. Which concept for a critical thinker is the nurse using?
a. Maturity
b. Analyticity
c. Systematicity
d. Inquisitiveness
ANS: B (#21, Ch 8)
A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge. Which concept for a critical thinker is the nurse using?
a. Maturity
b. Analyticity
c. Systematicity
d. Inquisitiveness
ANS: B (#21, Ch 8)
29) Describe maturity, analyticity, intuition and inquisitiveness
A nurse is alert to potentially problematic situations in a patient and is using evidence- based knowledge. Which concept for a critical thinker is the nurse using?
a. Maturity
b. Analyticity
c. Systematicity
d. Inquisitiveness
ANS: B (#21, Ch 8)
A nurse is admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patients daughter and son-in-law are present. The nurse notices that the patient does not make eye contact when answering questions and the nurse senses that something is not right about the situation. Which technique did the nurse use?
a. Intuition
b. Critical thinking
c. Nursing process
d. Reflection
ANS: A
(#3, Ch 8)
30) Describe the scientific method
A nurse is using the scientific method to solve a patient situation. Which action should the nurse take first?
a. Collect data.
b. Identify a problem.
c. Formulate a question.
d. Evaluate the results.
ANS: B (#6, Ch 8)
A surgical unit uses Betadine to prep the skin before surgery. A nurse is using the scientific method to decide if soap and water is better than Betadine for preparing the skin for surgery. A nurse washes one group of patients with soap and water and washes another group of patients with Betadine. Which step did the nurse implement?
a. Identifying the problem
b. Forming the question or hypothesis
c. Answering the question or hypothesis
d. Evaluating the results of the test or study ANS: C
(#22, Ch 8)
31) Be able to identify a nurse use of attitudes in critical thinking
A nurse is describing risk taking, creativity, and integrity in nursing care. What is the nurse explaining?
a. Attitudes of critical thinking
b. Competencies of critical thinking
c. Standards for critical thinking
d. Nursing process for critical thinking ANS: A
(#5, Ch 8)
32) Recognize demographic, subjective and objective data
Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg. The nurse obtained which type of data?
a. Personal
b. Demographic
c. Subjective
d. Objective
ANS: D (#22, Ch 9)
A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data?
a. Heart rate of 96
b. Incisional erythema
c. Emesis of 150 mL
d. Sharp, burning pain ANS: D
(#5, ch 9)
The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective?
a. The patients toes of right foot are warm and pink.
b. The patient reports a dull ache in the right hip.
c. The patient says feels tired all the time.
d. The patient is concerned about insurance coverage.
ANS: A (#6, ch 9)
33) Proper thorough documentation components and accurate and safe documentation of patient care
Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?
a. Sm. amt. of emesis.
b. 150 mL of cloudy dark yellow urine.
c. Had a good day.
d. Looks bad.
ANS: B (#10, ch 10)
Which documentation by the nurse best describes patient data?
a. Moderate amount of clear yellow urine voided.
b. Voided 220 mL clear yellow urine.
c. A small amount of urine voided into absorbent pad.
d. Patient incontinent of urine.
ANS: B
(#9, Ch 10)
34) Best primary source of information
A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed?
a. Patient chart
b. Patient
c. Parents
d. Surgeon
ANS: C (#9, Ch 9)
35) Proper way to chart a nurse client interaction
A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior
b. Behavior is inappropriate, requests registered nurse do the assessment
c. States, I want a registered nurse to do my assessment
d. Is grumpy, registered nurse notified ANS: C
(#7, ch 9)
36) Describe the interview techniques which include; cues, inferences, back-channeling and termination
As a nurse is obtaining a health history from a patient, the nurse uses comments such as go on. Which technique is the nurse using?
a. Cues
b. Inferences
c. Back-channeling
d. Termination
ANS: C (#13, Ch 9)
37) Be able to describe validation, clustering, reviewing, and documentation
A patient states, Im burning up, and I have a fever. The nurse takes the patients temperature, observes the skin for flushing, and feels the skin temperature. This is an example of subjective data.
a. validating
b. clustering
c. reviewing
d. documenting
ANS: A (#21, ch 9)
38) Be able to recognize an independent nursing intervention and physical care technique
A home health nurse is providing care to a patient. Which action by the nurse is a physical care technique?
a. Dressing a patient
b. Assisting a patient to learn how to shop
c. Performing range-of-motion exercises
d. Administering cardiopulmonary resuscitation ANS: C
(#28, Ch 9)
A nurse is caring for a patient and performs several interventions. Which action by the nurse is an independent nursing intervention?
a. Turning every 2 hours
b. Administering a medication
c. Inserting an indwelling catheter
d. Starting an intravenous (IV) for intravenous fluids ANS: A
(#26, ch 9)
39) What does the nurse do when a patient does not meet a prescribed goal?
A patient has an outcome of ambulating three times a day. The patient does not ambulate the entire day. What should the nurse do next?
a. Walk the patient.
b. Reassess the patient.
c. Change the goal for the patient.
d. Continue with the plan for the patient.
ANS: B (#30, ch 9)
40) What are the components of PIE charting?
A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE. What will the nurse be charting?
a. Problem, intervention, evaluation
b. Patient, interview, evaluation
c. Population, intervention, encourage
d. Plan, interview, enhance ANS: A
PIE is an acronym for problem, interventions, evaluation as follows: P: Problem or nursing diagnosis applicable to patient
I: Interventions or actions taken
E: Evaluation of the outcomes of nursing interventions (#15, ch 15)
41) To obtain insurance reimbursement when documenting care, what should the nurse chart?
A registered nurse recently changed jobs and is now working in home health. What must the nurse chart to obtain reimbursement from Medicare, Medicaid, and private insurance companies?
a. Patients response to care
b. Whether patient had a good or bad day
c. Whether family liked nurse or not
d. Patients number of marriages ANS: A
(#17, ch 10)
42) How do you properly take a telephone order?
After a nurse receives a medication telephone order for a patient, what is the proper action?
a. Withholding the medication until the physician or health care provider signs the order
b. Verifying the physicians or health care providers order with the pharmacy
c. Reading it back to the person who gave the order
d. Clarifying the new medication order with another registered nurse ANS: C
(#23, ch 10)
43) Items included in a discharge summary
A nurse is preparing a discharge summary. Which item should the nurse include?
a. Provision for follow-up care
b. Patient status at admission
c. Standardized nursing care plan
d. Detailed description of nursing procedures ANS: A
(#26, ch 10)
44) What are the five rights of delegation, and attributes a nurse should demonstrate when delegating?
A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia (VAP). To achieve this outcome, the nurse delegates the following to the unlicensed assistive personnel: Please perform oral care on the patient every 2 hours. In this situation oral care would include using the special swabs we have for our patients on VAP precautions so we can prevent pneumonia. Which of the five rights of delegation did the nurse use?
a. Right route
b. Right direction/communication
c. Right dose
d. Right supervision ANS: B
(#6, ch 13)
.A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patients diet. As the staff delivers the plan of care the primary nurse evaluates whether the plan is working.
Which attribute is the primary nurse displaying?
a. Responsibility
b. Interprofessional collaboration
c. Delegation
d. Staff involvement ANS: A (#3, ch 13)
A registered nurse delegates vital signs on a patient to the unlicensed assistive personnel (UAP). The nurse reviews the documented vital signs from the UAP to determine if they are within normal parameters for the patient. The nurse in this example is demonstrating which attribute when following up on the vital signs?
a. Interprofessional collaboration
b. Staff education
c. Accountability
d. Delegation
ANS: C (#4, ch 13)
A patient is admitted to the hospital for hip replacement surgery after falling at home and breaking a hip. The patient has developed pneumonia while in the hospital and has required frequent suctioning from the tracheostomy. The nurse decides to delegate I&O to the unlicensed assistive personnel but does not delegate suctioning. This is an example of which of the five rights of delegation?
a. Right task
b. Right direction/communication
c. Right intervention
d. Right supervision ANS: A
(#7, ch 13)
A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patients diet. As the staff delivers the plan of care the primary nurse evaluates whether the plan is working.
Which attribute is the primary nurse displaying?
a. Responsibility
b. Interprofessional collaboration
c. Delegation
d. Staff involvement
ANS: A
(#3, ch 13)
A nurse is teaching a patient the side effects of a medication as the nurse is giving the medication to the patient. Which attribute did the nurse display?
a. Efficient care
b. Effective care
c. Using resources
d. Using team communication ANS: A
(#21, ch 13)
45) Know the difference between team nursing, case management, primary nursing and total patient care
A registered nurse (RN) works on a unit with other registered nurses, licensed practical nurses (LPN), and nursing assistive technicians. Usually a RN, LPN, and nursing assistive technician provide direct care for a group of patients. The RN coordinates all of the care the others provide. Which type of nursing care delivery models is the RN using?
a. Team nursing
b. Case management
c. Primary nursing
d. Total patient care
ANS: A (#11, ch 13)
46) When assessing a patient during rounds what action should the nurse perform first?
A nursing student is seeing a patient for the first time this morning. Which action should the nursing student perform first?
a. Focused patient assessment
b. Patient health history
c. Medication administration
d. Documentation ANS: A
(#16, ch 13)
47) What should the nurse focus on to establish how to prioritize her time
A new nurse is learning how to prioritize time. One of the best ways that this can be accomplished is for the new nurse to focus on which of the following?
a. Nursing tasks
b. Patient priorities
c. Medication schedule
d. Ancillary procedures ANS: B
(#18, ch 13)
48) Know the definition of a spiritual, agnostic, and atheist
A patient who has been diagnosed with terminal liver cancer states that he does not believe in God, but he has had a meaningful life by contributing to the lives of those around him. This person is most likely which of the following?
a. Buddhist
b. Christian
c. Agnostic
d. Atheist
ANS: D (#6, ch 21)
The nurse is caring for a patient who states that he does not believe in the existence of God. The nurse realizes that this person:
a. is not a spiritual person.
b. is an agnostic.
c. believes that people bring meaning into the world.
d. finds meaning in life through work and relationships.
ANS: D (#2, ch 21)
To assess, evaluate, and support a patients spirituality the best action a nurse should take includes:
a. recognizing that spirituality does not enhance therapeutic relationships.
b. performing a definitive spiritual assessment once because spirituality does not vary.
c. focusing the assessment on religious doctrine and faith.
d. remembering that spirituality is very subjective.
ANS: D (#10, ch 21)
49) Define the word “faith.”
A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a:
a. system of organized beliefs and worship.
b. relationship with a higher power, authority, or spirit.
c. source of energy needed to cope with difficult situations.
d. multidimensional concept that gives comfort while a person endures hardship.
ANS: B
(#4, ch 21)
50) To assist a client to deal with a major medical experience ie; surgery what does a nurse do first?
51) What should the nurse do when dealing with a body image problem?
Body image is an important concept relative to psychosocial development. In dealing with body image issues, the nurse must do which of the following?
a. Understand that skinny people always see themselves as thin.
b. Realize that body image is never associated with self-esteem.
c. Recognize that physical changes always lead to changes in body image.
d. Be aware that female adolescents more frequently struggle with issues than males.
52) ANS: D (#3, ch 23)
53) How does chronic pain affect self- image?
The nurse is caring for a patient who has been diagnosed with chronic pain. The nurse is especially concerned about the patients self-concept because chronic pain does which of the following?
a. Normally has no effect on the ability to function once patients learn to deal with it
b. Can often cause increased irritability that can affect self-concept
c. Often leads to increased sleep as patients try to escape the pain
d. Requires pain medication that prevents self-concept alterations ANS: B
(#10, ch 23)
54) What does a nurse do when preparing to obtain sexual history on a client?
The nurse is attempting to obtain a sexual history on a patient who is being evaluated for a possible hysterectomy. The nurse should do which of the following?
a. Assume that the patient will not appreciate questions about sexual practices.
b. Avoid information relative to medication effect on sexuality.
c. Use specific gender terms to emphasize sexuality.
d. Recognize that many patients welcome the chance to talk about their sexuality.
ANS: D (#11, ch 23)
55) What do you do when preparing to work with a client who experienced multiple traumatic surgeries?
The nurse is caring for a 65-year-old mother of three who recently underwent abdominal surgery and has a colostomy as a result. The patient has a history of multiple surgeries, including a tracheostomy after lung surgery about 20 years earlier that has since healed over. To determine how to best work with this patient, the nurse should do which of the following?
a. Determine how the patient dealt with her previous surgeries.
b. Realize that past coping mechanisms are always positive in nature.
c. Approach care in a standard method because all patients are the same.
d. Avoid using family input in determining the course of care.
ANS: A (#13, ch 23)
56) Be able to distinguish between family resilience, diversity, durability and the nuclear family
The student nurse is talking to her friends about holiday plans with their families. One friend described her family as her mother, brother, and sister-in-law. Another stated her family consisted of her mother, father, grandmother, and her aunt. The student nurses family is her mother, stepfather, sister, and stepsister. The uniqueness of these families is known as which of the following?
a. Family resilience
b. Nuclear family
c. Family diversity
d. Family durability
ANS: C (#1, ch 24)
57) What does a nurse know about teenage pregnancy?
A nurse is admitting a teen-aged woman to the Labor and Delivery unit to have her baby. She is not married but is holding hands with her boyfriend who is the babys father. The nurse realizes that:
a. adolescent pregnancy is a decreasing concern in modern society.
b. teenage pregnancies are little more than a temporary bump in the road of life.
c. increased numbers of children mean greater income and a way out of poverty.
d. teenage pregnancies affect teenage fathers as well as mothers.
ANS: D (#5, ch 24)
58) How does caregiver stress manifest?
The nurse is caring for a 78-year-old patient with liver cancer. The patient and his wife live at home. In addition to caring for the patient, the nurse also assesses caregiver stress in the patients wife. Which of the following indicates caregiver stress?
a. Increased visits from church members
b. Asking her daughter for help with shopping
c. Remaining cheerful and without depression
d. Contracting pneumonia ANS: D
(#7, ch 24)
59) Distinguish between family approaches to stress such as hardiness, resiliency and heredity/genetics.
The parents of an 18-year-old who joined the military and is being deployed overseas, discuss with him how they plan to stay in touch and purchase a laptop computer for him to take with him so they can e-mail and use the webcam to see each other. What approach to stress does this family exhibit?
a. Resiliency
b. Hardiness
c. Heredity
d. Genetics
ANS: B (#9, ch 9)
60) What should a nurse do when planning familial goals?
What should the nurse do when planning goals for a family?
a. View the family as a group of individuals rather than a system.
b. Make the goals as vague as possible so that they are attainable.
c. Be flexible since families are continually changing.
d. Recognize that, although individuals go through developmental stages, families do not.
ANS: C (#10, ch 24)
61) Describe approaches to family nursing such as family as a context, family as a patient, and family as a system
A student nurse is caring for a 4-year-old patient who has been admitted to the pediatric unit with acute asthma. As the student nurse admits the patient, he learns that both parents smoke in the home. The nurse plans to discuss with the parents the implications of smoking around the patient and to provide them with information on smoking cessation. This is an example of what approach to family nursing?
a. Family as context
b. Family as patient
c. Family as system
d. Family as a stagnated group ANS: A
(#11, ch 24)
62) What does a nurse do to complete the nursing admission data on a client?
A nurse is attempting to complete the nursing admission data on a patient. To complete the admission and formulate a plan of care, the nurse needs to do which of the following?
a. Know that the individual is the same as the family as a whole.
b. Realize that family health is the summation of the health of all members.
c. Evaluate the form, structure, and function of the family.
d. Discount negative views by the patient toward the family.
ANS: C (#14, ch 24)
63) Describe the definitions of a nuclear, extended, blended and alternate pattern relationship
The nurse is admitting a 45-year-old patient and asks about her family. The patient states that she lives with her daughter and son-in-law. The nurseknows that this is an example of which of the following family forms?
a. Nuclear
b. Extended
c. Blended
d. Alternate pattern relationship ANS: B
(#16, ch 24)
A married couple takes four children to an immunization clinic. The nurse notes that the childrens permission slips include three children with one last name and one child with a different last name. On questioning the parents the nurse discovers that this family group is an example of a(n) family.
a. nuclear
b. blended
c. extended
d. single-parent
ANS: B
(#18, ch 24)
A nursing instructor is raising her two granddaughters after her daughter and son-in-law were killed in a motor vehicle accident. How is this family form best described?
a. Extended family
b. Single-parent family
c. Blended family
d. Alternative pattern of relationship ANS: D
(#17, ch 24)
A nuclear family consists of a husband and wife (and perhaps one or more children).
64) Know the stages of GAS (general adaptation system).
The patient has severe injuries. The nurse knows that the general adaptation syndrome (GAS) was viewed as a reaction to stress consisting of: (Select all that apply.)
a. a pattern of alarm.
b. deleterious consequences.
c. a stage of resistance.
d. developmental impairment.
e. a state of exhaustion.
ANS: A, C, E (MC #1, ch 25)
65) Describe the types of crisis in a counseling session ie; situational, maturational and sociocultural factors
A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is caused by:
a. situational factors.
b. maturational factors.
c. sociocultural factors.
d. compassion fatigue.
ANS: A
(#9, ch 25)
A 48-year-old nurse is complaining of being continually exhausted because of the workload on her unit. She states that the patients are getting heavier and the halls are getting longer. Sometimes I just dont think I can get through the day. The nurse is dealing with stress caused by:
a. situational factors.
b. maturational factors.
c. sociocultural factors.
d. compassion fatigue.
ANS: A
(#7, ch 25)
66) Describe the ego defense mechanisms conversion, compensation, denial, regression, and displacement.
The student nurse was late for clinical rounds because she had to change the tire on her car. She is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the medication that she is preparing. The student nurse is very frustrated, becomes tearful, and states, I cant seem to crush this tablet correctly. This reaction to the instructor is most likely a result of what ego-defense mechanism?
a. Compensation
b. Displacement
c. Denial
d. Dissociation
ANS: B (#15, ch 25)
A 4-year-old boy has been admitted to the hospital with pneumonia. He has been in the hospital for 3 days and has suddenly started to become incontinent of urine. The nurse knows that this is most likely a result of what ego-defense mechanism?
a. Compensation
b. Conversion
c. Denial
d. Regression
ANS: D
(#17, ch 25)
The nurse has recently been promoted to a new management position in her hospital. She is concerned about her new responsibilities and has found that she is having difficulty sleeping at night. This is an example of what ego-defense mechanism?
a. Compensation
b. Denial
c. Conversion
d. Displacement
ANS: C
(#18, ch 25)
The nurse works in a small clinic with two other nurses and a nurse practitioner. Recently the nurse has been staying at work longer than usual. His neighbor, a patient at the clinic, asks one of the other employees at the clinic how the nurse is coping since his wife left him. The nurse had not shared this information with his co-workers. The nurse may be coping with his loss with which of the following?
a. Compensation
b. Conversion
c. Denial
d. Dissociation
ANS: C
(#16, ch 25)
Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset.
67) Know the difference between the types of loss ie; maturational, situational, actual and perceived
A 48-year-old nurse is complaining of being continually exhausted because of the workload on her unit. She states that the patients are getting heavier and the halls are getting longer. Sometimes I just dont think I can get through the day. The nurse is dealing with stress caused by:
a. situational factors.
b. maturational factors.
c. sociocultural factors.
d. compassion fatigue.
ANS: A
(#7, ch 25)
A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is caused by:
a. situational factors.
b. maturational factors.
c. sociocultural factors.
d. compassion fatigue.
ANS: A (#9, ch 25)
A nurse works on an oncology unit and has a lot of stress in her life. Which of the following situational factors would be considered work stress?
a. Caring for a family member who has Alzheimers disease
b. Being diagnosed with a chronic back injury
c. Finding out that a parent has lung cancer
d. Having a disagreement with her nurse manager ANS: D
(#8, ch 25)
68) Describe each stage of Kubler Ross’s stages of dying in order
The nurse identifies that this patient is experiencing the second stage of Kbler-Ross stages of dying. What is the second stage?
a. Anger
b. Denial
c. Bargaining
d. Acceptance
e. Depression
ANS: A
five responses to loss: denial, anger, bargaining, depression, and acceptance. Individuals in the denial stage act as though nothing has changed. They cannot believe or understand that a loss has occurred. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.
(#5, ch 26)
69) Know and describe Bowlby’s phases of mourning
A widow, whose spouse died 3 years ago, has recently started dating and is thinking about going back to school to complete a degree she had started at an earlier age. Which of Bowlbys phases of mourning best describes this behavior?
a. Numbing
b. Yearning and searching
c. Disorganization and despair
d. Reorganization ANS: D (#7, ch 26)
Bowlbys phases of mourning are founded on which of the following human instincts?
a. Attachment
b. Numbing
c. Searching
d. Grief
ANS: A
(#6, ch 26)
The parent of a child who drowned in a neighbors pool that was not secured, would most likely file a wrongful death lawsuit against the neighbor during which of Bowlbys phases of mourning?
a. Numbing
b. Yearning and searching
c. Disorganization and despair
d. Reorganization ANS: C
(#8, ch 26)
The parent of a child who drowned in a neighbors pool that was not secured, would most likely file a wrongful death lawsuit against the neighbor during which of Bowlbys phases of mourning?
a. Numbing
b. Yearning and searching
c. Disorganization and despair
d. Reorganization
ANS: C
(#9, ch 26)
70) Know the Worden’s tasks of mourning
A young widower who lost his wife in Afghanistan has worked through the first task of Wordens mourning theory. He asks you if he will ever feel able to move forward with his life. According to Wordens theory, what is your best response?
a. You will never love anyone as much as your wife.
b. Nobody will ever be able to take your wifes place.
c. It takes time to adjust to this type of loss, typically at least a year.
d. Some people are able to move forward faster by suppressing the pain.
ANS: C (#11, ch 26)
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