Nursing Exam 2 > Application > Flashcards

Application Flashcards

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0
Q

A practitioner asks the nurse to witness an informed consent. Which patient does the nurse identify is unable to give an informed consent for surgery?

  1. 16yo boy who is married
  2. 35 yo woman who is depressed
  3. 50 yo woman who does not speak English
  4. 65 yo man who has received a narcotic for pain
A
  1. 65 yo man who has received a narcotic for pain
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1
Q

When a nurse is administering a medication to a confused patient, the patient says, “This pill looks different from the one I had before.” What should the nurse do?

A
  1. Ask what the other pill looked like
  2. Explain the purpose of the medication
  3. Check the original medication prescription
  4. Encourage the patient to take the medication
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2
Q

The nurse administers an incorrect does of medication to a patient. What is the primary purpose of documenting this event in an Incident Report?

  1. Record the event for future litigation
  2. Provide a basis for designing new policies
  3. Prevent similar situations from happening again
  4. Ensure accountability for the cause of the accident
A
  1. Prevent similar situations from happening again
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3
Q

A practitioner writes a prescription for a medication that is larger than the standard dose. What should the nurse do?

  1. Inform the supervisor
  2. Give the drug as prescribed
  3. Give the average dose of the medication
  4. Discuss the prescription with the practitioner
A
  1. Discuss the prescription with the practitioner
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4
Q

When the nurse attempts to administer a medication to a patient, the patient refuses to take the medication because it causes diarrhea. The nurse provides teaching about the medication, but the patient continues to adamantly refuse the medication. What should the nurse do first?

  1. Document the patient’s refusal to take the medication
  2. Notify the practitioner of the patient’s refusal to take the medication
  3. Discuss with a family member the need for the patient to take the medication
  4. Explain again to the patient the consequences of refusing to take the medication
A
  1. Document the patient’s refusal to take the medication
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5
Q

You are about to administer an oral medication and you question the dosage. You should:

  1. Administer the medication
  2. Notify the physician
  3. Withhold the medication
  4. Document that the dosage appears incorrect
A
  1. Notify the physician
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6
Q

A student nurse employed as a nursing assistant may perform care:

  1. As learned in school
  2. Expected of a nurse at that level
  3. Identified in the hospital’s job description
  4. Requiring technical rather than professional skills
A
  1. Identified in the hospital’s job description
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7
Q

A nurse is caring for a patient who states, “I just want to die.” For the nurse to comply with this request, the nurse should discuss:

  1. Living Wills
  2. Assisted Suicide
  3. Passive euthanasia
  4. Advance directives
A
  1. Best guess???
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8
Q

A nurse is working with a terminally ill adult patient. The nurse decides to tell the adult children that they need to decide how to advise t heir father about taking analgesics during the terminal phase of his illness. This step of processing an ethical dilemma is:

  1. Articulation of the problem
  2. Evaluation of the action
  3. Negotiation of the outcome
  4. Determination of values surrounding the problem
A
  1. Best guess??
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9
Q

If a nurse decides to withhold a medication because it might further lower a patient’s blood pressure, the nurse will be practicing the principle of:

  1. Responsibility
  2. Accountability
  3. Competency
  4. Moral Behavior
A

NO IDEA.

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10
Q

your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient’s only treatment choice. This example describes the ethical principle of:

  1. Autonomy
  2. Fidelity
  3. Justice
  4. Nonmaleficence
A
  1. I think??
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11
Q

Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following?

  1. Medication before administering it
  2. Medication after administering it
  3. Rationale for administering it
  4. Prescriber rationale for prescribing it
A
  1. Medication after administering it
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12
Q

If a nurse experiences a problem reading a physician’s medication order, the most appropriate action will be to:

  1. Call the physician to verify order
  2. Call the pharmacist to verify order
  3. Consult with other nursing staff to verify
  4. Withhold the medication until the physician makes rounds
A
  1. Call the physician to verify the order
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13
Q

A postoperative patient is receiving morphine sulfate via PCA. The nurse assesses that the patient’s respirations are depressed. The effects on the morphine sulfate can be classified as:

  1. Allergic
  2. Idiosyncratic
  3. Therapeutic
  4. Toxic
A

Dunno

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14
Q

You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with:

  1. Absorption
  2. Biotransformation
  3. Distribution
  4. Excretion
A
  1. Excretion
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15
Q

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of the incident report is to

  1. Exchange information among health care workers
  2. Provide information about patients from one unit to another unit
  3. Ensure proper care for the patient
  4. Aid the hospital’s quality improvement program
A
  1. Aid the hospital’s quality improvement program
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16
Q

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record:

  1. An interpretation of patient behavior
  2. Objective data that is observed
  3. Lengthy entry using lay terminology
  4. Abbreviations familiar to the nurse
A
  1. Objective data that is observed
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17
Q

when caring for a terminally ill patient a family member says, “I need your help to hasten my mother’s death so that she is no longer suffering.” What should the nurse do based on the position of the American Nurses Association in relation to assisted suicide.

  1. Not participate in active euthanasia
  2. Participate based on personal values and beliefs
  3. Participate when the patient is experiencing severe pain
  4. Not participate unless two practitioners are consulted and the patient has had counseling
A
  1. Not participate in active euthanasia
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18
Q

Which organization is responsible for ensuring that Registered Nurses are minimally qualified to practice nursing?

  1. Sigma Theta Tau
  2. State Boards of Nursing
  3. American Nurses Association
  4. Constituent Leagues of the National League for Nursing
A
  1. State Board of Nursing
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19
Q

The nurse initiates a visit from a member of the clergy for a patient. How is the nurse functioning when initiating this visit?

  1. Interdependently
  2. Independently
  3. Dependently
  4. Collegially
A
  1. Independently
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20
Q

A patient is asked to participate in a medical research study. The nurse describes to the patient and family members how the patient is protected by the:

  1. Codes of Ethics
  2. Informed Consent
  3. Nurse Practice Act
  4. Constitution of the United States
A
  1. Informed Consent
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21
Q

The nurse is implementing an ordered bowel preparation for a patient who is scheduled for a colonoscopy. Which is the most serious consequence that is prevented by an effective bowel preparation?

  1. Discomfort
  2. Misdiagnosis
  3. Wasted expense
  4. Psychological stress
A
  1. Misdiagnosis
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22
Q

The practitioner orders OOB for a patient. How is the nurse functioning when moving this patient out of bed to a chair?

  1. Dependently
  2. Independently
  3. Collaboratively
  4. Interdependently
A
  1. Dependently
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23
Q

A Registered Nurse witness an accident and assists the victim who has a life-threatening injury. What should the nurse do to meet the most important standard when acting as a Good Samaritan at the scene of an accident?

  1. Seek consent from the injured party before rendering assistance
  2. Implement every critical-care intervention necessary to sustain life
  3. Stay at the scene until another qualified person takes over responsibility
  4. Insist on helping because a nurse is the best-qualified person to provide care
A
  1. stay at the scene until another qualified person takes over responsibility.
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24
The nurse is informed that a credentialing team has arrived and is in the process of assessing quality of care delivered at the hospital. What is the organization associated with the credentialing of hospitals? 1. The Joint Commission 2. National League for Nursing 3. American Nurses Association 4. National Council Licensure Examination
1. The Joint Commission
25
The nurse changes a patient's dry sterile dressing. How is the nurse functioning when performing this task? 1. Interdependently 2. Collaboratively 3. Independently 4. Dependently
4. Dependently
26
The nurse must administer a medication. What should the nurse do first? 1. Check the patient's identification armband 2. Ensure the medication is in the medication cart 3. Verify the practitioner's prescription for accuracy 4. Determine the appropriateness of the prescribed medication
3. Verify the practitioner's prescription for accuracy
27
When choosing a nursing school in the United States that awards an associate degree, a future student nurse should consider schools that have met the standards of nursing education established by which organization? 1. National League for Nursing Accrediting Commission 2. North American Nursing Diagnosis Association 3. American Nurse Association 4. Sigma Theta Tau
1. National League for Nursing Accrediting Commission
28
The patient's diet order is "clear liquids to regular as tolerated." How is the nurse functioning when progressing the patient's diet to full liquid? 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently
4. Interdependently
29
Licensure of Registered Professional Nurses is required primarily to protect: 1. Nurses 2. Patients 3. Common Law 4. Health-care agencies
2. Patients
30
Which factor is unique to malpractice when comparing negligence and malpractice? 1. The action did not meet standards of care 2. The inappropriate care is an act of commission 3. There is harm to the patient as a result of the care 4. There is a contractual relationship between the nurse and patient
4. There is a contractual relationship between the nurse and patient
31
The nurse completes an Incident Report after a patient false while getting out of bed unassisted. What is the main purpose of this report? 1. Ensure that all parties have an opportunity to document what happened. 2. Help establish who is responsible for the incident 3. Make data available for quality-control analysis 4. Document the incident on the patient's chart
3. Make data available for quality-control analysis
32
How is the nurse functioning when administering a drug that has PRN as part of the prescription? 1. Collegially 2. Dependently 3. Independently 4. Interdependently
4. Interdependently
33
What is the main purpose of the American Nurses Association? 1. Establish standards of nursing practice 2. Recognize academic achievement in nursing 3. Monitor educational instructions granting degrees in nursing 4. Prepare nurses to become members of the nursing profession
1. Establish standards of nursing practice
34
The nurses says, "If you do not let me do this dressing change, I will not let you eat dinner with the other residents in the dining room." What legal term is related to this statement? 1. Battery 2. Assault 3. Negligence 4. Malpractice
2. Assault
35
State legislatures are responsible for: 1. Standardized care plans 2. Enactment of Nurse Practice Acts 3. Accreditation of educational nursing programs 4. Certification in specialty areas of nursing practice
2. Enactment of Nurse Practice Acts
36
When attempting to administer a 10:00PM sleeping medication, the nurse assesses that the patient appears to be asleep. What should the nurse do? 1. Withhold the drug 2. Notify the practitioner 3. Awaken the patient to administer the drug 4. Administer it later if the patient awakens during the night
3. Awaken the patient to administer the drug
37
What is the primary purpose of the American Nurses Association Standards of Clinical Nursing Practice? 1. Establish criteria for quality practice 2. Define the philosophy of nursing practice 3. Identify the legal definition of nursing practice 4. Determine educational standards for nursing practice
1. Establish criteria for quality practice
38
The client who requires a co-signatures for a valid consent for surgery is a: 1. 15 yo mother whose infant requires exploratory surgery 2. 40 yo resident in a home for developmentally disabled adults 3. 90yo adult who wants more information about the risks of surgery 4. 50yo unconscious trauma victim who needs insertion of a chest tube
2. 40yo resident in a home for developmentally disabled adults
39
A patient is scheduled to have surgery, and informed consent is to be obtained. Place these steps in the order in which they should be performed. 1. The patient is willing to sign the consent voluntarily 2. The patient signs the consent in the presence of the nurse 3. The nurse determines that the patient is alert and competent to give consent 4. The practitioner informs the patient of the risks and benefits of the procedure
4. The practitioner informs the patient of the risks and benefits of the procedure 3. The nurse determines that the patient is alert and competent to give consent 1. The patient is willing to sign the consent voluntarily 2. The patient signs the consent in the presence of the nurse
40
Identify the actions that are examples of slander. Select all that apply 1. Volunteer telling another volunteer a patient's age 2. Nurse explaining to a patient that another nurse is incompetent 3. Personal care assistant sharing information about a patient with another patient 4. Unit manager documenting a nurse's medication error in a performance appraisal 5. Housekeeper who is angry at a nurse erroneously telling another staff member that the nurse uses cocaine
2. Nurse explaining to a patient that another nurse is incompetent 5. Housekeeper who is angry at a nurse erroneously telling another staff member that the nurse uses cocaine
41
Which nursing action best reflects the concept of therapeutic communication? 1. Using interviewing skills to discuss the patient's concerns 2. Letting the patient control the focus of conversation 3. Setting time aside to talk with the patient 4. Agreeing with a patient's statements
1. Using interviewing skills to discuss the patient's concerns
42
A nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion? 1. What brought you to the hospital? 2 Would it help to discuss your feelings? 3. Do you want to talk about your concerns? 4. Would you like to talk about why you are here?
1. What brought you to the hospital?
43
The nurse understand that the statement that is most accurate about communication is: 1. Communication is inevitable 2. Behavior clearly reflects feelings 3. Hands are the most expressive part of the body 4. Verbal communication is essential for human relationships
1. Communication is inevitable
44
When providing nursing care, humor should be used to: 1. Diminish feelings of anger 2. Refocus the patient's attention 3. Maintain a balanced perspective 4. Delay dealing with the inevitable
3. Maintain a balanced perspective
45
The nurse is conducting an admission interview with a patient. Which outcome identified by the nurse indicates that therapeutic communication is effective? 1. Verbal and nonverbal communication is congruent 2. Interaction is conducted in a professional manner 3. Common understanding is achieved 4. Thoughts are put into words
3. Common understanding is achieved
46
What is communicated when the nurse leans forward during a patient interview? 1. Privacy 2. Interest 3. Anxiety 4. Aggression
2. Interest
47
What best describes the following proverb? What you do speaks so loudly I cannot hear what you say. 1. Hearing ability is an important factor when communicating 2. Nonverbal messages are often more meaningful than words 3. Listening to what people say requires attention to what is being said 4. When people talk too loudly it is ahrd to understand what is being said
2. Nonverbal messages are often more meaningful than words
48
A mother whose young daughter has died of leukemia is crying an dis unable to talk about her feelings. What is the best repsonse by the nurse? 1. "Everyone will remember her because she was so cute. She was one of our favorites." 2. "As hard as this is, it is probably for the best because she was in a lot of pain." 3. "She put up the good fight but now she is out of pain and in heaven." 4. "I feel so sad. It can be hard to deal with such a precious loss."
4. I feel so sad. It can be hard to deal with such a precious loss
49
The goals of therapeutic communication mainly should depend on the: 1. Environment in which communication takes place 2. Role of the nurse in the particular clinical setting 3. Skill level of the nurse in the situation 4. Patient's verbalized concerns
4. Patient's verbalized concerns
50
The nurse is changing a patient's dressing over an abdominal wound. Which level of space around the patient is entered during the dressing change? 1. Public 2. Social 3. Intimate 4. Personal
3. Intimate
51
The patient says, "I am really nervous about having a spinal tap tomorrow." What is the best response by the nurse? 1. I'll ask the doctor for a little medication to help you relax 2. Patients who have had a spinal tap say it is not that uncomfortable 3. It is all right to be nervous, and I don't remember anyone who wasn't 4. The physician is excellent and is very careful when spinal taps are done
3. It is all right to be nervous and I don't remember anyone who wasn't
52
Which ability of the nurse is most important to achieve effective therapeutic communication? 1. Sending a verbal message 2. Using interviewing skills 3. Being assertive when collecting data 4. Displaying sympathy when communicating
2. Using interviewing skills
53
the nurse is attempting to develop a helping relationship with a patient who was recently diagnoses with cancer. The nurse determines that a factor that is unique to this helping relationship is that it is: 1. Characterized by allowing the patient to assume the dominant role 2. Distinguished by an equal sharing of information 3. Specific to a person while guided by a purpose 4. based on the needs of both participants
3. Specific to a person while guided by a purpose
54
The nurse must conduct a focused interview to complete an admission history. Which interviewing technique should be used? 1. Probing 2. Clarification 3. Direct questions 4. Paraphrasing statements
3. Direct Questions
55
An agitated 80 yo patient states, "I'm having trouble with my bowels." Which response by the nurse incorporates the interviewing skill of reflection? 1. You seem distressed about your bowels. 2. You're having trouble with your bowels 3. It's common to have problems with the bowels at your age 4. When did you first notice having trouble with your bowels?
1. You seem distressed about your bowels
56
The patient is extremely upset and mentions something about a work-related issue that the nurse cannot understand. What is the nurse's best response? 1. It's natural to be worried about your job. 2. Your job must be very important to you 3. Calm down so that I can understand what you are saying 4. I'm not quite sure I heard what you were saying about your work.
4. I'm not quite sure I heard what you were saying about your work.
57
A patent is admitted to the hospital with cirrhosis of the liver caused by long-term alcohol abuse. what is the best response by the nurse when the patient says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem." 1. How long have you been drinking several beers a day 2. You find it hard to believe that beers can damage the liver 3. Each beer is equivalent to one shot of liquor so it's just as damaging to the liver as hard liquor 4. you may believe that beer is not harmful but research shows that it is just as bad for you as hard liquor.
2. You find it hard to believe that beers can damage the liver
58
The patient states, "I can't believe that I couldn't even eat half my breakfast." Which statement by the nurse uses the interviewing skill of reflection? 1. Let's talk about your inability to eat 2. What part of your breakfast were you able to eat? 3. How long have you been unable to eat most of your breakfast? 4. You seem surprised that you were unable to eat all your breakfast.
4. You seem surprised that you were unable to eat all your breakfast
59
What is the best response by the nurse when the patient's husband says, "I just don't know what to say to my wife if she asks hwo I feel about her breast cancer." 1. How do you feel about your wife's diagnosis? 2. This is a difficult topic. However, let's talk about it. 3. Do you think you could be as supportive as you can possibly be 4. Men don't always understand what women are going through. Ask her about how she feels.
2. This is a difficult topic. However, let's talk about it.
60
A nurse refuses to give prescribed pain medication to a youngAfrican male with sickle cell anemia because the nurse beliefs that young male Africans are likely to be drug abuses. This is an example of: 1. Cultural competence 2. Culturally congruent care 3. Ethnocentrism 4. Etic worldview
3. Ethnocentrism
61
A nurse believes that people should bear pain quietly as a demonstration of strong moral character and is annoyed when a patient insists on having pain medication and denies the patient's comfort. This is an example of: 1. Cultural imposition 2. Ethnocentrism 3. Emic worldview 4. Culture-bound syndrom
1. Cultural imposition
62
A Korean woman requests seaweed soup for her first meal after giving birth. The nurse is puzzled at the request. This is an example of: 1. Culturally congruent care 2. Ethnocentrism 3. Cultural imposition 4. Etic worldview
4. Etic worldview
63
The term "going postal" is an example of: 1. Cultural imposition 2. Ethnocentrism 3. Cultural competence 4. Culture-bound syndrome 5. Assimilation
4. Culture-bound syndrome
64
A patient is refusing pain medication. the nurse recognizes that the patient has options for pain relief and discusses them with the patient. This is: 1. Basic critical thinking 2. Complex critical thinking 3. Commitment
2. Complex critical thinking
65
A nurse notices that there is no urine draining from the catheter. She concludes that the catheter tip must not be in the bladder. This is: 1. Basic critical thinking 2. Complex critical thinking 3. Commitment
1. Basic critical thinking
66
A patient is less mobile and develops redness over his hip. The nurse identifies the problem as impaired skin integrity in the form of a pressure ulcer and chooses the nursing interventions: skin care and a turning schedule. This is an example of: 1. Diagnostic reasoning 2. Clinical decision making 3. Nursing practice as a competency
2. Clinical decision making
67
A patient is feeling light-headed with blurred vision and has a history of diabetes. The nurse determines the patient is possibly experiencing a problem with blood glucose levels because these symptoms suggest hypoglycemia. The nurse offers the patient a food source containing glucose. This is an example of: 1. Diagnostic reasoning 2. Clinical decision making 3. Nursing process as a competency
1. Diagnostic reasoning
68
The nurse is changing a patient's dressing over an abdominal wound. Which level of space around the patient is entered during the dressing change? 1. Public 2. Social 3. Intimate 4. Personal
3. Intimate
69
Which interviewing skill is used when the nurse says, "You mentioned before that you are having a problem with your colostomy?" 1. Focusing 2. Clarifying 3. Paraphrasing 4. Acknowledging
1. Focusing
70
The patient says, "I am really nervous about having a spinal tap tomorrow." What is the best response by the nurse? 1. I'll ask the doctor for a little medication to help you relax 2. Patients who have had a spinal tap say it is not that uncomfortable 3. It's all right to be nervous, and I don't remember anyone who wasn't 4. The physician is excellent and is very careful when spinal taps are done
3. It's all right to be nervous, and I don't remember anyone who wasn't
71
Which ability of the nurse is most important to achieve effective therapeutic communication? 1. Sending verbal messages 2. Using interviewing skills 3. Being assertive when collecting data 4. Displaying sympathy when communicating
2. using interviewing skills
72
What is the nurse doing when using the interviewing technique of active listening? 1. Identifying the patient's concerns and exploring them with why questions 2. Determining the content and feeling of the patient's message 3. Employing silence to encourage the patient to talk 4. Using nonverbal skills to display interest
2. Determining the content and feeling of the patient's message
73
A patient who has had a number of postoperative complication appears upset and agitated, yet withdrawn. What is the most appropriate statement by the nurse? 1. You seem agitated. Tell me why you are upset 2. You've been having a pretty rough time of it since surgery 3. Its not uncommon to have complications after the kind of surgery you had 4. I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery.
2. you've been having a pretty rough time of it since surgery
74
The nurse is admitting a patient to the unit who was transferred from the Emergency Department. What should the nurse do to facilitate communication? 1. Ensure that the patient has an effective way to communicate with health-care team members 2. Using interviewing techniques to control the direction of the patient's communication 3. Minimize energy spent by the patient on negative feelings and concerns. 4. Refocus to the positive aspects of the patient's situation and prognosis
1. Ensure that the patient has an effective way to communicate with health-care team members
75
The nurse is caring for a confused patient with a diagnosis of demntia of the Alzheimer's type. What should the nurse say when assisting the patient to eat? 1. Please eat your meat 2. It's important that you eat 3. What would you like to eat 4. If you don't eat, you can't have dessert
1. Please eat your meat
76
A patient says, "I don't know if i'll make it through this surgery." which response by the nurse may block further communication by the patient? 1. You sound scared. 2. You think you will die 3. Everything will be all right 4. Surgery often can be frightening
3. Everything will be all right
77
A nurse is caring for a patient with a urinary elimination problem. Which is the most accurately stated goal? The patient will: 1. Be taught how to use a bedpan when on bed rest 2. Experience fewer incontinence episodes at night 3. Transfer independently and safely to a toilet before discharge 4. Be assisted to the commode every two hours and whenever necessary
3. Transfer independently and safely to a toilet before discharge
78
A patient is admitted to the hospital with a tentative medical diagnosis and multiple diagnostic tests are performed. Where in the patient's chart can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the practitioner? 1. Progress Notes 2. Admission sheet 3. History and Physical 4. Social Service Record
1. Progress notes
79
A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? Patient will: 1. Have a lower temperature 2. be taught how to take an accurate temperature 3. maintain fluid intake sufficient to prevent dehydration 4. be given aspirin every eight hours whenever necessary
3. Maintain fluid intake sufficient to prevent dehydration
80
Which human response identified by the nurse is an example of objective data? 1. Irregular radial pulse of 50bpm 2. Pain rate 5 on scale of 0-5 3. Shortness of breath 4. Dizziness
1. Irregular radial pulse of 50 bpm
81
What patient statement provides subjective data? 1. Im not sure that I am going to be able to manage at home by myself 2. I can call a home-care agency if I feel I need help at home 3. What should I do if I have uncontrollable pain at home? 4. Will a home health aid help me with my care at home?
1. I'm not sure that I am going to be able to manage at home by myself
82
A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspecting 3. Auscultation 4. Interviewing
4 .Interviewing
83
A nurse is interviewing a patient. Which patient statement is an example of objective data? 1. I am hungry 2. I feel warm 3. I ate half of my lunch 4. I have the urge to urinate
3 .I ate half of my lunch
84
A nurse responds to a patient's call bell. Which patient statement is subjective data? 1. I just went to the urinal and it needs to be emptied 2. My pain feels like a 5 on a scale of 0 to 5 3. The physician said I can go home today 4. I ate only 50% of my breakfast
2. My pain feels like a 5 on a scale of 0 to 5
85
The nurse asses a patient and collects a variety of data. Identify the human responses that are subjective data. Select all that apply 1. Nausea 2. Jaundice 3. Dizziness 4. Diaphoresis 5. Hypotension
1. Nausea | 3. Dizziness
86
The instructions with a medication states to use the Z-track method. What should the nurse do that is specific to this procedure? 1. Pinch the site throughout the procedure 2. Massage the site after the needle is removed 3. Remove the needle immediately after this medication is injected 4. Change the needle after the medication is drawn into the syringe
4. Change the needle after the medication is drawn into the syringe
87
A nurse instructs the patient to close the eyes after the administration of eye drops. What rationale for this instruction should the nurse explain to the patient? 1. Limits corneal irritation 2. Squeezes excess medication from the eye 3 .Disperses the medication over the eyeball 4. Prevents medication from entering the lacrimal duct
3. Disperses the medication over the eyeballs
88
Which route is unrelated to the parental administration of medications? 1. Buccal 2. Z-trac 3. Intravenous 4. Intradermal
1. Buccal
89
How often should "docusate sodium (Colace) 100mg b.i.d. be given? 1. Three times a day 2. Two times a day 3. Every other day 4. At bedtime
2. Two times a day
90
A nurse is preparing to reconstitute a medication in a multiple-dose vial. What is the most essential step in the preparation of this medication? 1. Instilling an accurate amount of diluent into the vial 2. Using a filtered needle when drawing up the medication from the vial 3. Instilling air into the vial before withdrawing the reconstituted solution 4. Wiping the rubber seal of the vial with alcohol before and after each needle insertion
1. Instilling an accurate amount of diluent into the vial
91
Which characteristic is associated with a subcutaneous injection of 5000 units of heparin? 1. 3-mL syringe 2. 22 gauge needle 3. 1 1/2 inch needle 4. 90 degree angle
4. 90 degree angle
92
A nurse is assessing a patient for the appropriateness of administering a medication via the oral route. What clinical manifestation indicates that the nurse should ask the practitioner for a change in route? 1. Nausea 2. Unconsciousness 3. Gastric suctioning 4. Difficulty swallowing
2. Unconsciousness
93
A practitioner prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering intramuscular injections? 1. Vastus lateralis 2. Rectus femoris 3. Ventrogluteal 4. Dorsogluteal
4. Dorsogluteal
94
It is most important for the nurse to use a filtered needle when preparing a parental medication that: 1. Has to be reconstituted 2. Is supplied in an ampule 3. Appears cloudy in the vial 4. Is to be mixed with another medication
2. Is supplied in an ampule
95
What should the nurse use when administering a subcutaneous injection? 1. 5mL syringe 2. 25 gauge needle 3. TB syringe 4. 1 1/2 inch needle
2. 25 gauge needle
96
A practitioner prescribes nose drops to be administered twice a day. What should the nurse do when instilling the drops? 1. Place the patient in the supine position with the head tilted backward 2. Pinch the nares of the nose together briefly after the drops are instilled 3. Instruct the patient to blow the nose 5 minutes after the drops are instilled 4. Insert the drop applicator 1/8 inch into the nose toward the base of the nasal cavity
1. Place the patient in the supine position with the head tilted backward
97
A nurse teaches a patient how to self-administer a coritcosteroid via a metered-dose inhaler with an extender. Which behavior indicates to the nurse that the patient understands the teaching? 1. Rinses mouth with water after the treatment 2. Rolls the canister between the hands slowly before using the inhaler 3. Positions the mouthpiece directly in the front of the mouth while inhaling 4. Assumes the semi-Fowler position with the head supported on a pillow
1. Rinses mouth with water after the treatment
98
What route is inappropriate for a topical medication? 1. Intradermal 2. Bladder 3. Rectum 4. Vagina
1. Intradermal
99
A nurse adds a medication to an intravenous fluid bag. Which nursing action is the priority? 1. Attaching a completed IV additive label to the bag 2. Mixing the medication and solution by rotating the bag 3. Maintaining sterile technique throughout the procedure 4. Ensuring that the drug and the IV solution are compatible
4. Ensuring that the drug and the IV solution are compatible
100
A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. What is the rationale for this action? 1. Conceal the label from the curiosity of others 2. Prevent soiling of the label by spilled liquid 3. Ensure the accuracy of the measurement of the dose 4. Guarantee the label is read before pouring the liquid
2 .Prevent soiling of the label by spilled liquid
101
A practitioner prescribes a medicated powder to be applied to a patient's skin. What is the most essential for the nurse to do when applying the medicated powder? 1. Apply a thin layer in the direction of hair growth 2. Protect the patient's face with a towel 3. Dress the area with dry sterile gauze 4. Ensure that the skin surface is dry
4. Ensure that the skin surface is dry
102
a nurse must administer a medication that is supplied in an ampule. What should the nurse do first to access the ampule? 1. Inject the same amount of air as the fluid to be removed 2. Wipe the constricted neck with an alcohol swab 3. Break the constricted neck using a barrier 4. Insert the needle into the rubber seal
3. Break the constricted neck using a barrier
103
A nurse must administer a medication into the ear of an adult. What should the nurse do to limit patient discomfort when administering ear drops? 1. warm the solution to body temperature 2. Place the patient in a comfortable position 3. Pull the pinna of the ear upward and backward 4. Instill the fluid in the center of the auditory canal
1. Warm the solution to body temperature
104
A nurse instructs a patient to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The patient asks "Why do I have to hold my breath?" The nurse responds, "This technique will: 1. Prolong treatment" 2. Limit hyperventilation" 3. Disperse the medication" 4. Prevent bronchial spasms"
3. Disperse the medication
105
Which abbreviation indicates that the practitioner wants a medication administered before meals? 1. pc 2. qh 3. po 4. ac
4. ac
106
A hoome care nurse is helping a patient with short-term memory loss how to remember to take multiple drugs throughout the day. What should the nurse do when teaching this patient? 1. Suggest the patient wear a watch with an alarm 2. Ask a family member to call the patient when medications are to be taken 3. Design a chart of the medications the patient takes each day during the week 4. Instruct the patient to put medications in a weekly organizational pill container
4. Instruct patient to put medications in a weekly organizational pill container
107
A nurse is to administer an eye irrigation to a patient's right eye. What should the nurse do? 1. Direct the flow of solution from the inner to the outer canthus 2. Irrigate with an asepto syringe several inches from the ye 3. Don sterile gloves before beginning the procedure 4. Position the patient in a right lateral position
1. Direct the flow of solution from the inner to the outer canthus
108
A medication is delivered by the Z-track method when the nurse: 1. Uses a special syringe designed for Z-track injections 2. Pulls laterally and downward on the skin before inserting the needle 3. Administers the injection in the muscle on the anterolateral aspect of the thigh 4. Injects the needle in a separate spot for each dose on a z-shaped grid on the abdomen
2. Pulls laterally and downward on the skin before inserting the needle
109
A nurse must reconstitute a powered medication. What should the nurse do? 1. Keep the needle below the initial fluid level as the rest of the fluid is injected. 2. Instill the solvent that is consistent with the manufacturer's directions 3. Score the neck of the ampule before breaking it 4. Shake the vial to dissolve the powder.
2. Instill the solvent that is consistent with the manufacturer's directions
110
A nurse is preparing to administer a table to a patient. When should the nurse remove the medication from its unit dose package? 1. Outside the door to the patient's room 2. At the patient's bedside 3. In the medication room 4. At the medication cart
2. At the patient's bedside
111
A nurse teaches a patient about taking a sublingual nitroglycerin tablet. The nurse evaluates that the patient understands the teaching when the patient states, "I should place it: 1. On my skin" 2. Inside my cheek" 3. Under my tongue" 4. In my eye on the lower lid"
3. Under my tongue
112
A nurse plans to administer a 3mL intramuscular injection. Which muscle is least desirable to use for the administration of this medication? 1. Deltoid 2. Dorsogluteal 3. Ventrogluteal 4. Vastus lateralis
1. Deltoid
113
A nurse is preparing to administer a subcutaneous injection of insulin. What site should the nurse use to best promote its absorption? 1. Upper lateral arms 2. Anterior thighs 3. Upper chest 4. Abdomen
4. Abdomen
114
What should a nurse do to limit discomfort when administering an injection? 1. Pull back on the plunger before injecting 2. Apply ice to the area before injection 3. Pinch the area while inserting the needle 4. Inject the medication slowly
4. Inject the medication slowly
115
A nurse is preparing to draw up medication from a vial. what should the nurse do firsT? 1. Ensure the needle is firmly attached to the syringe 2. Rub vigorously back and forth over the rubber cap with an alcohol swab 3. Inject air into the vial with the needle bevel below the surface of the medication 4. Draw up slightly more air than the volume of the medication to be withdrawn from the vial
1. Ensure that the needle is firmly attached to the syringe
116
A nurse is interviewing a newly admitted client in the process of completing a nursing admission history and physical. What information should be included in the medication reconciliation? Select all that apply. 1. Vitamins 2. Drug allergies 3. Food supplement 4. OTC herbs 5. Prescribed medications
1, 3, 4, 5
117
An in-depth self-examination of one's own background, recognizing biases, prejudices and assumptions about other people
Cultural awareness
118
Obtaining sufficient comparative knowledge of diverse groups, including their indigenous values, health beliefs, care practices, worldview, and bicultural ecology.
Cultural knowledge
119
Being able to asses social, cultural, and biophysical factors influencing treatment and care of patients
Cultural skills
120
Engaging in cross-cultural interactions that provide learning of other cultures and opportunities for effective intercultural communication development
Cultural encounters
121
The motivation and commitment to caring that moves an individual to learn from others, accept the role as learner, be open and accepting of cultural differences, and build on cultural similarities
Cultural desire
122
Five steps towards cultural competence
``` Cultural awareness Cultural knowledge Cultural skills Cultural encounters Cultural desire ```
123
Nursing interventions that achieve culturally congruent care:
Cultural care preservation or maintenance Cultural care accommodation or negotiation Cultural care re patterning or restructuring
124
Retain and/or preserve relevant care values so patients maintain their wellbeing, recover from illness, or face handicaps or/and death
Cultural care preservation or maintenance
125
Adapt or negotiate with others for a beneficial or satisfying health outcome
Cultural care accommodation or negotiation
126
Reorder, change, or greatly modify patients' lifestyles for anew, different, and beneficial health care pattern
Cultural care re patterning or restructuring
127
List 4 contemporary ethical issues:
Quality of life Genetic screening Care at the end of life Access to care
128
The legal requirements for nursing practice that describe minimum acceptable nursing care
Standards of care
129
A person's agreement to allow something to happen such as surgery or an invasive diagnostic procedure, based on full disclosure of risks, benefits, alternatives, and consequences of refusal
Informed Consent
130
What would a nurse do if a patient has a DNR and requires CPR?
Nothing
131
Which of these are Therapeutic communication techniques: 1. Clarifying 2. Sympathy 3. Asking Personal questions 4. Paraphrasing 5. Summarizing 6. Self- disclosure
1, 4, 5, 6
132
Which of these are Non-therapeutic Communication techniques: 1. Arguing 2. Asking relevant questions 3. Silence 4. Sharing observations 5. Confrontation 6. Asking for Explanations
1, 6
133
Which of these are Non-therapeutic communication techniques: 1. Approval or Disapproval 2. Summarizing 3. False Reassurance 4. Changing the Subject 5. Asking personal questions 6. Automatic responses
1, 3, 4, 5, 6
134
Three nursing care measures for clients with special communication needs:
1. Use simple words 2. Use large print 3. Use multiple communication techniques 4. Use assistive devices 5. Collaborate with the patient and family 6. Environmental considerations
135
Methods of Documentation:
``` Paper EHR Narrative POMR Source Records CBE ```
136
Which of these are NOT legal guidelines for documentation: 1. Record all fact 2. Chart for others 3. Share your computer password 4. Erase Errors 5. Do not document retaliatory comments 6. Record entries using felt-tip pens
2, 3, 4, 6
137
Which of these are legal guidelines for recording: 1. Enter personal opinions 2 .Use black ink 3. Use phrases such as "had a good day" and "status unchanged" 4. Begin entries with date and time 5. End entries with only your signature. 6. Leave spaces
2, 4
138
Which of these do you DO at a change-of-shift report 1. Use critical comments about patient's behavior 2. Describe basic steps of a procedure 3. Review ongoing discharge plan 4. Verbalize priorities to which oncoming staff must attend 5. Provide essential background information about patient 6. Engage in idle gossip
3, 4, 5
139
Which of these do you DO in a change-of-shift report 1. Review all biographical information already available in written form 2. Review all routine care procedures or tasks 3. Describe objective measurements or observations about patient's condition and response to health problem, emphasize recent changes 4. Share significant information about family members as it relates to patient's problems 5. Force oncoming staff to guess what to do first 6. Describe detailed content only if staff members ask for clarification
3, 4, 6
140
Which of these do you DO during a change-of-shift report: 1. Identify patient's nursing diagnoses/health care problems and related causes 2. Describe results as "good" or "poor" 3. Make assumptions about relationships among family members 4. Evaluate results of nursing or medical care measures 5. Describe instructions given in teaching plan and patient's response 6. Relay significant changes to staff in the way therapies are to be given
1,4,5,6
141
When a patient faces surgery, the surgeon has an obligation to review the surgical procedure, including risks and benefits, out of respect for the patient's ______. The consent that patients read and sign before surgery document this respect. 1. Ethics 2. Nonmaleficence 3. Fidelity 4. Beneficence 5. Autonomy
5. Autonomy
142
A nurse tries to make a decision about the ethics of a controversial medical procedure. What guides the nurse to focus on how the procedure ensures fidelity to the patient, truthfulness, justice and beneficence? 1. Consequentialism 2. Deontology 3. Consequentialism 4. Utilitarianism
2. Deontology
143
This process is like deontology, but focuses on outcomes. Select all that apply 1. Teleology 2. Accountability 3. Consequentialism 4. Utilitarianism
1, 3, 4
144
__________ develops rules regarding intravenous therapy and the use of CNAs. 1. Nurse Practice Acts 2. ANA 3. The Joint Commission 4. OBRA 5. Federal Law
1. Nurse Practice Acts
145
The patient gives consent for an appendectomy and the surgeon performs a tonsillectomy. This is an example of: 1. Assault 2. Battery 3. False-Imprisonment 4. Malpractice
2. Battery
146
A nurse gives and injection without the patient's consent. This is: 1. Assault 2. Battery 3. False-Imprisonment 4. Malpractice
2. Battery
147
A patient's medical record is given to their family without their consent. This is: 1. Libel 2. Negligence 3. Invasion of Privacy 4. Slander
3. Invasion of Privacy
148
A driver of a car does not stop at a stop sign and hits another car. This is: 1. Assault 2. Battery 3. Negligence 4. Intentional tort
3. Negligence
149
A nurse gives a wrong injection and that patient dies. This is: 1. Negligence 2. Malpractice 3. Libel 4. Assault
2. Malpractice
Nursing Exam 2
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