Fundamentals of Nursing Practice Questions

1. A nurse working in primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply:
a. Health and illness are the same for all people
b. Health and illness are individually defined by each person
c. People with acute illnesses are actually healthy
d. People with chronic illnesses have poor health beliefs
e. Health is more than the absence of illness
f. Illness is the response of a person to a disease

b, e, f

2. A nurse working in a hospital setting cares for patients with acute and chronic conditions. which diseases states are chronic illnesses? Select all that apply:
a. Diabetes mellitus
b. Bronchial pneumonia
c. Rheumatoid arthritis
d. Cystic fibrosis
e. Fracture hip
f. Otitis media

a, c, d

3. Despite a national focus on health promotion, nurses working with patients in inner-city continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply:
a. A white male diagnosed with HIV
b. An African American teenagers who is 6 months pregnant
c. A Hispanic male who has type II diabetes
d. A low-income family living in rural America
e. A middle-class teacher living in a large city
f. A white baby who was born with cerebral palsy

b, c, d

4. A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?
a. Tertiary
b. Secondary
c. Primary
d. Promotive

c

5. A patient in a community health clinic tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the patient exhibiting?
a. Stage 1: Experiencing symptoms
b. Stage 2: Assuming the sick role
c. Stage 3: Assuming the depending role
d. Stage 4: Achieving recovery and rehabilitation

b

6. Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms?
a. Jane, whose best friend had a benign breast lump removed
b. Sarah, who lives in a low income neighborhood
c. Tricia, who has a family history of breast cancer
d. Nancy, whose family encourages regular physical examination

c

7. Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply:
a. A nurse runs an immunization clinic in the inner city
b. A nurse teaches a patient with an amputation how to care for the residual limb
c. A nurse provides range-of-motion exercises for a paralyzed patient
d. A nurse reaches parents of toddlers how to childproof their homes
e. A school nurse provides screening for scoliosis for the students
f. A nurse teaches new parents how to choose and use an infant car seat

b, c

8. The nurse uses the agent-host-environment model of health and illness to assess diseases in patients. This model is based on what concept?
a. Risk factors
b. Demographic variables
c. Behaviors to promote health
d. Stages of illness

a

9. A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept or both the health-illness continuum and the high-level wellness models?
a. Illness as a fixed point in time
b. The importance of family
c. Wellness as a passive stage
d. Health as a constantly changing state

d

10. A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility?
a. By being a role model for healthy behaviors
b. By not requiring sick days from work
c. By never exposing others to any type of illness
d. By budgeting time and resources efficiently

a

11. A nurse uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing actives is this approach most useful?
a. Making accurate nursing diagnoses
b. Establishing priorities of care
c. Communicating concerns more concisely
d. Integrating science into nursing care

b

12. The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples off nursing interventions help meet physiologic needs? Select al that apply.
a. Preventing falls in the facility
b. Changing a patient's oxygen tank
c. Providing materials for a patient who likes to draw
d. Helping a patient eat his dinner
e. Facilitating a visit from a spouse
f. Referring a patient to a cancer support group

b, d

13. The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse?
a. Physiologic
b. Safety and security
c. Self-esteem
d. love and belonging

b

14. The nurse caring for patients in long-term care facility uses available resources to help patient achieve Maslow's highest level of needs: self-acutalization needs. Which statements accurately describe these needs? Select all that apply.
a. Humans are born with a fully developed sense of self-actualization
b. Self actualization needs are met by depending on others for help
c. The self-actualization process continues throughout life
d. Loneliness and isolation occurs when she-actualixation needs are unmet
e. A person achieves self-actualization by focusing on problems outside self
f. Self-actualization needs may be met by creatively solving problems

c, e, f

15. A nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family?
a. A father, a mother, and children
b. A group whose members are biologically related
c. A unit that includes aunts, uncles, and cousins
d. A group of people who live together and depend on each other for support

d

16. A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply.
a. Who is the person you depend on for emotional support?
b. Who is the breadwinner in your family?
c. Do you plan on having any more children?
d. Who keeps your family together during times of stress?
e. What family traditions do you pass on to your children?
f. Do you live in an environment that you consider safe?

a, d

17. The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health Which example describes one of these risk factors?
a. The family does not have dental care insurance or resources to pay for it
b. Both parents work and leave a 12-year-old child to care for his younger brother
c. Both parents and their children are considerably overweight
d. The youngest member of the family has cerebral palsy and needs assistance from community services

b

18. A nurse working in a "Aging in place" facility interviews a married couple in their late seventies. Based on Duvall's Developmental Tasks of Families, which developmental task would the nurse assess for this couple?
a. Maintenance of a supportive home base
b. Strength of the marital relationship
c. Ability to cope with loss of energy and privacy
d. Adjustment to retirement years

D

19. A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community?
a. It meets all the needs of its inhabitants
b. It has mixed residential and industrial areas
c. It offers access to health care services
d. It consists of modern housing and condominiums

c

20. A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care?
a. Individual and family health care needs
b. Populations within the community
c. Local health care facilities
d. Families in crisis

a

21. Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity.
Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to think or talk about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the care plan might need to be modified.

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

22. A female patient who is reciting chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come fore my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process?
a. The nurse judges whether the patient database is adequate to address the problem
b. The nurse considers whether or not to suggest a counseling session for the patient
c. The nurse reassesses the patient and decides how best to intervene in her care
d. The nurse identifies several options for intervening in the patients care and critiques the merit of each of each option

c

23. The nursing processes ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrate which characteristic of the nursing process?
a. Systemic
b. Interpersonal
c. Dynamic
d. Universally applicable in nursing situations

b

24. An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response?
a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific
b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning
c. The emphasis on logical, scientific, evidenced-based research has held nursing back for years; it is time to champion intuitive, creative thinking
It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers

a

25. The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply.
a. The nurse uses critical thinking skills to plan care for a patient
b. The nurse correctly administers IV saline to a patient who is dehydrated
c. The nurse assists a patient to fill out an informed consent form
d. The nurse learns the correct dosages for patient pain medication
e. The nurse comforts a mother whose baby was born Down syndrome
f. The nurse uses the proper procedure to categorize a female patient

a, d

26. A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply
a. It functions independently of nursing standards, ethics, and state practice arts
b. It is based on the principles of the nursing process, problem solving, and the scientific method
c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care
d. It is not designed to compensate for problems created by human nature, such as medication errors
e. It is constantly re-evaluating, self-correcting, and striving for improvement
f. It focuses on the big picture rather than identifying the key problems, issues and risks involved with patient care

b, c, e

27. A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent?
a. Patient centered care
b. Evidence based practice
c. Quality improvement
d. Informatics

c

28. A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of:
a. Clinical judgement
b. Clinical reasoning
c. Critical thinking
d. Blended competencies

a

29. A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory?
a. Travelbee's
b. Watson's
c. Benner's
d. Swanson's

d

30. The nurse practices using critical thinking indicators (CTIs) when caring for patient sin the hospital setting. The bestsellers description of CTIs is:
a. Evidence based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice
b. Evidence based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice
c. Evidence based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice
d. Evidence based descriptors of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c

31.Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided.
The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy.

1. Purposeful
2. Priortized
3. Complete
4. Systematic
5. Accurate and relevant
6. Recorded to standard format

32. The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. what type of assessment has the nurse performed?
a. Comprehensive
b. Initial
c. Time-lapsed
d. Quick priority

d

The nurse is admitted a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply.
a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths."
b."It's hospital policy. I know it must be tiresome, but I will try to make this quick!"
c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care."
d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate."
e."We need to check your health status and see what kind of nursing care you may need."
f. "We need to see if you require a referral to a physician or other health care professional."

a, e, f

34. A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate?
a. Correct the initial assessment form.
b. Redo the initial assessment and document current findings.
c. Conduct and document an emergency assessment.
d. Perform and document a focused assessment of skin integrity.

d

35. A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply?
a."There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!"
b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."
c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient."
d. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

b

36. The nurse collects objective and subjective data when conducting patient assessments. which patient situations are examples of subjective data. Select all that apply.
a. A patient tells the nurse that she is feeling nauseous
b. A patient's ankles are swollen
c. A patient tells the nurse that she is nervous about her tests results
d. A patient complains that the skin on her arms is tingling
e. A patient rates his pain as a 7 on a scale of 1 to 10
f. A patent vomits after eating supper

a, c, d, e

37. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do?
a. Thank the wife for being present
b. Ask the wife if she wants to remain
c. Ask the wife to leave
d. Ask the patient if he would like the wife to stay

d

38. A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following?
a. Maslow's human needs
b. Gordon's functional health patterns
c. Human response patterns
d. Body systems model

b

39. The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action?
a. Inform the charge nurse
b. inform the surgeon
c. Validate the finding
d. Document the finding

c

40. A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response?
a. "You made an inference that she is fine because she had no complaints. How did you validate this?"
b. "She probably just doesn't trust you enough to share what she is feeling. I'd work developing a trusting relationship."
c. "Sometimes everyone gets luck. Why don't you try to help another patient?"
d. "Maybe you should reassess the patient. She has to have a problem: why else would she be here?"

a

41. A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply.
a. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN
b. 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN
c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN
d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN
e. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN
f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c, d, f

42. A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation?
a. Erase or use correcting fluid to completely delete the error
b. Mark the entry "mistaken entry"; add correct information; date and initial
c. Use permanent marker to black out the mistaken entry and rewrite it
d. Remove the page with the error and rewrite the data on the page correctly

b

43. A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?
a. "I'm sorry, but patients are not allowed to copy their medical records"
b. "I can make a copy of your record for you right now"
c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules"
d. "I will need to check with our records department to get you a copy"

d

44. When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply.
a. News media are preparing a report on the condition of a patient who is a public figure
b. Data are needed for the tracking and notification of disease outbreaks
c. Protected health information is needed by a coroner
d. Child abuse and neglect are suspected
e. Protected health information is need to facilitate organ donation
f. The sister of a patient with Alzheimer's diseases wants to help provide care

b, c, d, e

45. A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make?
a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information"
b. "Sorry, but I'm not able to give information abut patients to the public: even when my best friend or family member asks"
c. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!"
d. "Why do you think sue isn't talking about her worries?"

b

46. A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?
a. Every 3 hours
b. Every 4 hours
c. Daily
d. As needed

d

47. A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response?
a. State: "Thank you for taking care of this! Ill be happy to document the order on the health care provider's order sheet."
b. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it
c. State: " I am sorry, but Pos can only be given in an emergency situation that prevents us from writing them out. ill being the chart and we can do this quickly"
d. Try calling another resident for the order or wait until the next shift

c

48. A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first?
a. Admission sheet
b. Admission nursing assessment
c. Flow sheet
d. Graphic record

d

49. A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation?
a. A patient problem list
b. Narrative notes describing the patient's condition
c. overall trends in patient status
d. Planned interventions and patient outcomes

a

50. A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order.
a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer."
b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump."
c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds."
d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital."
e. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer."
f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

IN ORDER: d, a, e, b, f, c (Identity/Introduction, Situation, Background, Assessment, Recommendation, Read-back)

51. A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines?
a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air
b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed
c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal
d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c

52.A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection?
a. Incubation period
b. Prodromal stage
c. Full stage of illness
d. Convalescent period

b

53. A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply.
a. Providing a bed bath for a patient
b. Visibly soiled hands after changing the bedding of a patient
c. Removing gloves when patient care is completed
d. Inserting a urinary catheter for a female patient
e. assisting with a surgical placement of a cardiac stent
f. Removing old magazines from a patient's table

a, c, d, f

54. A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply.
a. Removes all jewelry including a platinum wedding band
b. Washes hands to 1 in above the wrists
c. Uses approximately one teaspoon of liquid soap
d. Keeps hands higher than elbows when placing under faucet
e. Uses friction motion when washing for at least 20 seconds
f. Rinses thoroughly with water flowing toward fingertips

b, c, e, f

55.The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate?
a. Keep splashes on the sterile field to a minimum
b. Cover the nose and mouth with gloved hands if a sneeze is imminent
c. Use forceps soaked in a disinfectant
d. Consider the outer 1 in co the sterile field as contaminated

d

56. The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?
a. Only patients with diagnosed infections
b. Only patients with visible blood, body fluids, or sweat
c. Only patients with non-intact skin
d. All patients receiving care in hospitals

d

57. In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply.
a. A patient diagnosed with rubella
b. A patient diagnosed with diphtheria
c. A patient diagnosed with varicella
d. A patient diagnosed with tuberculosis
e. A patient diagnosed with MRSA
f. An infant diagnosed with adenovirus infection

a, b, f

58. A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation?
a. Ask another nurse to hold the hand of the patient and continue setting up the field
b. Remove the instrument that was touched by the patient and continue setting up the sterile field
c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand
d. No action is necessary since the patient has touched his or her own sterile field

c

59. A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task?
a. Place the bottle cap on the table with the edges down
b. Hold the bottle inside the edge of the sterile field
c. Hold the bottle with the label side opposite to the palm of the hand
d. Pour the solution form a heigh of 4 to 6 in (10 to 15 cm)

d

60. A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
a. Remove gown, goggles, mask gloves and exit the room
b. Remove gloves perfume hand hygiene, then remove gown, mask and goggles
c. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene
d. Remove goggles, mask, gloves, and gown and perform hand hygiene

c

61. A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure?
a. Report the incident to the appropriate person and file an incident report
b. Wash the exposed area with warm water and soap
c. Consent to PEP at appropriate time
d. Set up counseling sessions regarding safe practice to protect self

b

62. The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?
a. A 60-year-old patient who smokes two packs of cigarettes daily
b. A 40-year-old patient who has a white blood cell count of 6,000/mm3
c. A 65-year-old patient who has an indwelling urinary catheter in place
d. A 60-year-old patient who is a vegetarian and slightly underweight

c

63. A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient?
a. Imbalanced nutrition
b. Impaired physical mobility
c. Chronic pain
d. Infection

d

64. A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan?
a. It is the personal preference of the nurse whether or not to use clean technique
b. The use of clean technique is safe for the home setting
c. Surgical asepsis is the only safe method to use in a home setting
d. It is grossly negligent to recommend clean technique for changing a would dressing

b

65. A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficileinfection. Which nursing action related to this activity promotes safe, effective patient care?
a. The nurse puts on PPE after entering the patients room
b. The nurse works from "clean" areas to "dirty" areas during bath
c. The nurse personalizes the care by substituting glasses for goggles
d. The nurse removes PPE after the bath and talk with patient in room

b

66. The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.
a. A patient who is older than 50
b. A patient who has already fallen twice
c. A patient who is taking antibiotics
d. A patient who experiences postural hypotension
e. A patient who is experiencing nausea from chemotherapy
f. A 70 year old patient sho is transferred to long term care

b, d, f

67. A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply.
a. Sixty percent of U.S. fire deaths occur in the home
b. Most fatal fires occur when people are cooking
c. Most people who die in fires die of smoke inhalation
d. Fire-related injury and death have declined due to the availability and use of smoke alarms
e. Fires are more likely to occur in homes without electricity or gas
f. Fires are less likely to spread if bedroom doors are key open when sleeping

c, d, e

68. A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?
a. A toddler playing with his 9-year-old brother's construction set
b. A 4-year-old eating yogurt for lunch
c. An infant covered with a small blanket and asleep in the crib
d. A 3-year-old drinking a glass of juice

a

69. While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient?
a. Impaired gas exchange related to cigarette smoking
b. Anxiety related to inability to stop smoking
c. Risk for suffocation related to unfamiliarity with fire prevention guidelines
d. Deficient knowledge related to lack of follow-through of recommendation to stop smoking

c

70. A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response?
a. Administer activated charcoal in tablet form and take child to the ED
b. Administer syrup of ipeacac and take child to the ED
c. Bring the child to the primary care provider for gastric lavage
d. Call the PCC immediately before attempting any home remedy

d

71. A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan?
a. Booster seats should be used for children until they are 4'9'' tall and weigh between 80 and 100 lbs
b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle
c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in front-facing safety seat
d. Children older than 6 years may be restrained using a car seat belt in the back seat

a

72. Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home?
a. Checking to make sure fire alarms are working properly
b. Preventing exposure to temperature extremes
c. Screening for partner or elder abuse
d. Making patient rooms are decluttered

d

73. What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused?
a. They prevent confused patients from wandering
b. A history of a pervious fall from a bed with raise side rails is insignificant
c. Alternative measures are ineffective to prevent wandering
d. A person of small stature is at increased risk for injury from entrapment

d

74. When a fire occurs in a patient's room, what would be the nurse's priority action?
a. Rescue the patient
b. Extinguish the fire
c. Sound the alarm
d. Run for help

a

75. A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately?
a. The nurse includes suggestions on how to prevent the incident from recurring
b. The nurse provides minimal information about the incident
c. The nurse discusses the details with the patient before documenting them
d. The nurse records the circumstances and effect on the patient in the medical record

a

76. When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack?
a. PTSD disorders can be expected in most survivors of a terrorist attack
b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs
c. Even small doses of radiation result in bone marrow depression and cancer
d. BLI is a serious consequence following detonation of an explosive device

d

77. An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints?
a. Sitting him in a geriatric chair near the nurses's station
b. Using the sheets to secure him snugly in his bed
c. Keeping the bed in the high position
d. Identifying his door with his picture and a balloon

d

78. The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used?
a. The nurse positions a patient in a supine position prior to applying wrist restraints
b. The nurse ensures that two fingers can be inserted between the restraint and the patients ankle
c. The nurse applies a cloth restrain to the left hand of a patient with an IV catheter in the right wrist
d. The nurse ties an elbow restraint to the raised side rail of a patients bed

b

79. A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine?
a. Explain how to use the telephone
b. Introduce the patient to her roommate
c. Review the hospital policy on visiting hours
d. Explain how to operate the call bell

d

80. Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?
a. Document the findings and continue to monitor the patient
b. Administer antipyretics, as prescribed
c. Increase the frequency of assessment to every hour and notify the patient's primary care provider
d. Increase the frequency of wound care and contact the primary care provider

a

81. A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply.
a. Serous drainage is composed of the clear portion of the blood and serous membranes
b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood
c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding
d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria

a, b, c, d

82. A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.
a. Notify the health care provider of the situation
b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution
c. Place the patient in the low Fowler's position

c, b, a

83. A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?
a. Pain
b. Impaired Skin Integrity
c. Disturbed Body Image
d. Disturbed Thought Process

c

84. A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?
a. Using sterile dressing supplies
b. Suggesting dietary supplements
c. Applying antibiotic ointment
d. Performing careful hand hygiene

d

85. A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.
a. Hemostasis occurs immediately after the initial injury.
b. A liquid called exudate is formed during the proliferation phase.
c. White blood cells move to the wound in the inflammatory phase.
d. Granulation tissue forms in the inflammatory phase.
e. During the inflammatory phase, the patient has generalized body response.
f. A scar forms during the proliferation ph

a, c, e

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply.
a. Enhanced healing due to the presence of sugars and proteins
b. Delayed healing due to dead tissue present in the wound
c. Decreased effectiveness of antibiotics against the bacteria
d. Impaired skin integrity due to overhydration of the cells of the wound
e. Delayed healing due to cells dehydrating and dying
f. Decreased effectiveness of the patient's normal immune process

c, f

87. The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.
a. Use standard precautions or transmission-based precautions when indicated.
b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.
c. Clean the wound in full or half circles beginning on the outside and working toward the center.
d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area.
e. Clean to at least 1 in beyond the end of the new dressing if one is being applied.
f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e

88. A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply.
a. The patient takes time to think about responses to questions.
b. The patient is 86 years old.
c. The patient reports inability to control urine.
d. The patient is scheduled for a hip arthroplasty.
e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL).
f. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f

89. A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?
a. "I can expect to have more discomfort in the area where the cold is applied."
b."I should expect more drainage from the incision after the ice has been in place."
c."I should see less swelling and redness with the cold treatment."
d."My incision may bleed more when the ice is first applied."

c

90. A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient?
a. The therapy is used to collect excess blood loss and prevent the formation of a scab.
b.The therapy will prevent infection, ensuring that the wound heals with less scar tissue.
c. The therapy provides a moist environment and stimulates blood flow to the wound.
d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c

91. After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as:
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4

b

92. The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?
a. Irrigate the wound.
b. Provide gentle cleansing of the wound.
c. Debride the wound.
d. Change the dressing frequently

b

93. A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury?
a.Keeping the head of the bed elevated as often as possible
b. Massaging over bony prominences
c. Repositioning bed-bound patients every 4 hours
d. Using a mild cleansing agent when cleansing the skin

d

94. A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended?
a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.
b. Draw the shape of the wound and describe how deep it appears in centimeters.
c. Gently insert a sterile applicator into the wound and move it in a clockwise direction.
d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a

95. A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply.
a. Instruct the patient to avoid sudden position changes that may cause dizziness.
b.Recommend that the patient restrict fluid until after exercising is finished.
c. Instruct the patient to push a little further beyond fatigue each session.
d. Instruct the patient to avoid exercising in very cold or very hot temperatures.
e. Encourage the patient to modify exercise if weak or ill.
f. Recommend that the patient consume a high-carb, low-protein diet.

a, d

96. A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply.
a. Stop performing the exercises.
b. Decrease the number of repetitions performed.
c. Reevaluate the nursing care plan.
d. Move to the patient's other side to perform exercises.
e. Encourage the patient to finish the exercises and then rest.
f. Assess the patient for other symptoms.

a, c, f

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:
a. Grasp the gait belt.
b. Stay with the patient and call for help.
c. Place feet wide apart with one foot in front.
d. Gently slide patient down to the floor, protecting her head.
e. Pull the weight of the patient backward against your body.
f. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b

98. A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones?
a. A 4-month-old infant who is unable to roll over
b. A 6-month-old infant who is unable to hold his head up himself
c. An 11-month-old infant who cannot walk unassisted
d. An 18-month-old toddler who cannot jump

b

99. A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side?
a. Have the patient extend his arms outward and cross his legs on top of a pillow.
b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side.
c. Have the patient cross his arms on his chest and place a pillow between his knees.
d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

b, c, f

100. A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient?
a. Improved renal blood supply to the kidneys
b. Urinary stasis
c. Decreased urinary calcium
d. Acidic urine formation

b