Q&A Hero

Q: The nurse is preparing a consent form for a client's signature. For which reason is this form most likely needed? 1. Chest x-ray 2. Drawing a blood sample 3. Measuring blood pressure 4. Biopsy of an abdominal mass

Q: The nurse manager notes that documentation in the medical record about a client's fall does not match the information identified on the occurrence report. What could be the potential outcome of this inconsistency? 1. A court case would not occur 2. Valuable information would be forgotten 3. Client's hospitalization could be prolonged 4. Termination of the nurse completing the occurrence form

Q: During morning care a client states that pain medication has been ineffective and wants to talk with the healthcare provider. How should the nurse categorize this information? 1. A variance 2. A complaint 3. Adverse effect 4. Subjective data

Q: The preceptor is reviewing the content of a new graduate's documentation of client care. What areas should the preceptor easily identify in this notation? Select all that apply. 1. Questions asked by the family 2. Changes in the client's condition 3. Teaching and the client's response 4. Reactions to non-routine medications 5. Assessment made at the beginning of the shift

Q: An organization uses the SOAP documentation format. In which area should the nurse document the appearance of a client's abdominal wound? 1. Plan 2. Objective 3. Subjective 4. Assessment

Q: The nurse is preparing to make an entry into a client's medical record after completing morning care and providing medications. What should the nurse ensure when completing this documentation? Select all that apply. 1. Time care was provided 2. Client's response to care provided 3. Time medications were administered 4. Estimated date for goals to be achieved 5. Client's reaction to medications provided

Q: After providing medications and changing a dressing the nurse accesses the client's computerized medical record and enters the information about the care provided. Why is the nurse documenting at this time? Select all that apply. 1. Evaluates individual performance 2. Helps determine the staffing needs of the care area 3. Estimates the amount of time required to provide care 4. Communicates information to other members of the team 5. Provides a permanent record of the care provided to the client

Q: The nurse is meeting with physical therapist and a dietitian to review care for a client recovering from a stroke. Which tool is the nurse most likely using to coordinate this client's care? 1. Critical pathway 2. Variance analysis 3. Standardized care plan 4. Individualized care plan

Q: The nurse notes that a client intervention has a deadline occurring in 3 days. What should this information indicate to the nurse? 1. The action should be observed every 3 days 2. The action should be completed every 3 days 3. The action should be documented every 3 days 4. The action will no longer be necessary in 3 days

Q: The nurse identifies problems for a specific client. What action should the nurse perform next when planning this client's care? 1. Identify outcomes for care 2. Determine resources needed for care 3. Translate the needs into nursing diagnoses 4. Select appropriate interventions to address the needs

Q: The nurse is reviewing data collected during a client assessment. Which information should the nurse identify as a client need? Select all that apply. 1. Desires to walk without a cane 2. License to drive has been suspended 3. Attends religious services every Sunday 4. Spends time with family every winter in Florida 5. Experiences shortness of breath with ambulation

Q: After report the nurse reviews a standardized care plan for an assigned client. Where should the nurse find the current active problems identified for the client? 1. Look at the problem list area on the Kardex 2. Read the notes written about specific problems 3. Ask the charge nurse where the problems are located 4. Identify the areas with check marks placed on the care plan

Q: A newly admitted client says desires to have surgery to replace a knee and then return home as soon as possible to resume living. On which part of the care plan should the nurse document this information? 1. Client problems 2. Short-term goals 3. Assessment data 4. Nursing interventions

Q: The nurse manager determines that a staff nurse uses critical thinking when planning the outcomes for a client's care. What did the manager observe to come to this conclusion? 1. Prioritized client problems 2. Critically analyzed all client outcomes 3. Clustered data to determine relationships 4. Used a systematic approach to collect data

Q: The nurse is explaining evidence-based practice to a group of new nursing students. Which statement should the nurse use during this explanation? 1. "Evidence-based nursing practice generates new knowledge." 2. "Evidence-based nursing practice applies knowledge to practice." 3. "Evidence-based nursing practice is measurable, time specific, quantifiable, and realistic." 4. "Evidence-based nursing practice is based on the best evidence available from nursing research."

Q: The manager is reviewing care plans created for newly admitted clients. Which nursing diagnostic statement should the manager review with the nurse as needing to be amended? 1. Risk for injury related to left sided paralysis 2. Fluid volume overload related to congestive heart failure 3. Impaired coping related to recent death of spouse and son 4. Imbalanced nutrition: Less than body requirements related to mouth and throat ulcers

Q: The nurse is identifying nursing diagnoses appropriate for a client's health issues. Which information should the nurse include when creating a three-part diagnostic statement? 1. Interventions 2. Learning needs 3. Expected outcomes 4. Signs and symptoms

Q: The nurse is researching nursing interventions appropriate for a particular nursing diagnosis. Which classification system should the nurse use when researching this information? 1. NIC 2. PES 3. NOC 4. NANDA

Q: The nurse is explaining nursing diagnoses to a group of first-year nursing students. What should the nurse include in this explanation? Select all that apply. 1. Focuses on client responses 2. Focuses on injury, illness, or disease 3. Requires physician orders to address 4. Remains the same until client discharge 5. Changes according to the client's needs

Q: A client is being prepared for discharge. What should the nurse perform when evaluating this client's care? Select all that apply. 1. Reassess care plan 2. Record client responses 3. Determine effects of nursing actions 4. Communicate to client and client's family 5. Examine appropriateness of nursing actions

Q: The nurse is implementing a client's plan of care. Which action should the nurse perform at this time? 1. Record relevant information 2. Motivate and maintain optimum wellness 3. Coordinate care and community resources 4. Anticipate needs of client and family based on priorities

Q: The nurse is completing the planning phase of the nursing process with a client. Which should the nurse perform during this phase? Select all that apply. 1. Identify short- and long-term goals 2. Strategize approaches for goal outcomes 3. List nursing measures when delivering care 4. Create outcomes that are measurable and realistic 5. Organize defining characteristics of data into meaningful patterns

Q: The instructor is preparing a lecture on the nursing process. Which statement should the instructor use that best describes nursing diagnosis? 1. It is an educated judgment about a client's potential or actual health problems 2. It refers to the priority nursing actions or interventions performed to accomplish a specified goal 3. It involves the careful acquisition and interpretation and use of information to reach a conclusion 4. It is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn"t work, and determining if this information is helpful in the current situation

Q: After completing an assessment the nurse analyzes all data collected. What is the significance of the nurse performing this analysis? 1. Confirms observations 2. Identifies client outcomes 3. Establishes a foundation for the client's care 4. Prioritizes interventions according to client needs

Q: The nurse is preparing to assess a client new to the out-patient care environment. Which actions should the nurse expect to complete during this phase of the nursing process? Select all that apply. 1. Complete a client interview 2. Conduct a physical examination 3. Analyze test results and findings 4. Categorize data into meaningful patterns 5. Identify pertinent family health history issues

Q: The nurse collects data slowly and methodically from a new client. Why is the nurse using this approach during this phase of the nursing process? 1. Ensures accuracy of data 2. Identifies client outcomes 3. Establishes a rapport with the client 4. Highlights the importance of the therapeutic relationship

Q: After receiving morning report the nurse categorizes an assigned client's care according to priority needs. How does this behavior support the nursing process? 1. Organizes and structures care 2. Emphasizes client preferences 3. Follows Maslow's hierarchy of needs 4. Considers time needs for each nursing action

Q: The nurse is reviewing care provided to a client. Which behavior indicates that the nurse is using critical thinking? 1. Administers prescribed medications 2. Studies the results of diagnostic tests 3. Individually analyzes client problems 4. Documents responses to care provided

Q: The nurse is assigned to care for a newly admitted client. Which approach should be used to address the client's responses to the illness? 1. Best practices 2. Nursing process 3. Critical thinking 4. Evidence-based practice

Q: The nurse is planning care for a newly admitted client. Which behavior indicates that the nurse is using critical thinking? 1. Recalls a similar client situation 2. Asks the healthcare provider for suggestions 3. Looks at a care plan written for another client 4. Expects the oncoming nurse to complete the care plan

Q: A client refuses to complete an advance directive because he is not "ready to die." What should the nurse respond to this statement? 1> "It's best to be safe than sorry." 2> "You are right " it is more appropriate for someone who has a terminal illness." 3> "That's fine. I"ll just document that you refuse to decide your medical treatment." 4> "It is a document that allows you to make legal decisions about how you wish to receive future medical treatment."

Q: What should the nurse include when reviewing the Patient Care Partnership brochure with a newly admitted client? 1> Visiting hours 2> Times for meals 3> Help with billing claims 4> How to avoid paying for medications

Q: A client asks for a copy of the medical record to take home upon discharge. What action should the nurse take regarding this request? 1> Prepare the requested documentation 2> Tell the client that the record belongs to the hospital 3> Explain to the client that the record cannot be provided 4> Ask the health care provider if the medical record can be provided

Q: What action should the nurse take to ensure the safe administration of prescribed medications to a client? Select all that apply. 1> Validating the healthcare provider's order 2> Checking two forms of client identification 3> Leaving a client's medications at the bedside 4> Returning a mislabeled medication to the Pharmacy 5> Deciding to report a medication error later in the shift

Q: The nurse manager is contacting the Board of Registered Nursing (BRN) to report a staff member. Which action did the manager most likely observe the staff member perform?1> Changing a client's abdominal wound dressing2> Instructed a client on self-administration of insulin3> Assisting a client with ambulation to the bathroom4> Informing a client to stop taking a prescribed medication

Q: For which reasons should a registered nurse contact the Board of Registered Nursing (BRN)? Select all that apply? 1> Renewing nursing license 2> Determining nursing standards 3> Identifying the date for a disciplinary hearing 4> Checking the dates for continuing education programs 5> Ascertaining when a nurse applicant became licensed

Q: The nurse is asked to perform a task that is beyond the scope of practice. What should the nurse use as a reason when refusing to complete the task? 1> "It is not a part of the National Patient Safety Goals." 2> "The Joint Commission does not identify it as a nursing task." 3> "It is not identified as permitted within the Nurse Practice Act." 4> "The task can be delegated to unlicensed assistive personnel (UAP)."

Q: Which document should the nurse refer to ensure safe care is being provided to a client? 1> Core measure sets 2> Nurse practice act 3> Joint Commission standards 4> National patient safety goals (NPSGs)

Q: What actions should the nurse take to assist a client adapt to being hospitalized? Select all that apply. 1> Ensuring for the client's comfort 2> Completing the admission assessment 3> Attempting to accommodate the client's wishes 4> Communicating with the client as an individual 5> Accepting the client's perception of the environment

Q: Which behavior indicates that the nurse is practicing as a professional? 1> Documenting that a client needs pain medication 2> Visiting with family of a client on another part of the care area 3> Telling a client to ask the next nurse for help getting out of bed 4> Directing unlicensed assistive personnel (UAP) to measure urine output

Q: The nurse is caring for several clients during the shift. Which action demonstrates appropriate hand hygiene? 1> Putting on gloves 2> Washing hands with soap and water 3> Wiping hands off when entering room 4> Using the client's soap on hands

Q: For which situation should the nurse apply clean disposable gloves? 1> Providing denture care 2> Bathing a client 3> Applying antiemboli stockings 4> Assessing vital signs

Q: The nurse is working in a day care center where there recently has been an outbreak of viral conjunctivitis. What should the nurse instruct the staff to stop the spread of this infection? 1> Require all children with conjunctivitis to stay home until there is a reduction in drainage. 2> Require all children with an infection to be on otic antibiotics for at least 24 hours prior to returning to school. 3> Isolate all children with conjunctivitis in the same room away from those who are not infected. 4> Perform hand hygiene after providing personal care for all children.

Q: The nurse observing the unlicensed assistive personnel (UAP) using alcohol-based rubs for hand hygiene would recognize that further teaching is required when the UAP performs which act? 1> Rubs palm against palm when washing hands. 2> Applies a palmful of product into cupped hands. 3> Interlaces fingers palm to palm. 4> Dries hands with clean paper towel.

Q: Which statement indicates that unlicensed assistive personnel (UAP) understand directions provided regarding client care? Standard Text: Select all that apply. 1> "I will bathe the client in room 402." 2> "I am done with the assigned tasks for Mr. Wells." 3> "I can give the medication for you." 4> "I will note all orders." 5> "I understand my assignment is to take and document the vital signs."

Q: Which procedure should the registered nurse delegate to unlicensed assistive personnel (UAP)? 1> Making a nursing diagnosis 2> Assisting a client to bedside commode 3> Performing assessments on client 4> Giving the client pain medication

Q: Which tasks would be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Standard Text: Select all that apply. 1> Taking vital signs 2> Measuring and recording intake and output 3> Postmortem care 4> Providing telephone advice 5> Weighing the client

Q: The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? Select all that apply. a. Feeding oneself b. Preparing a meal c. Balancing a checkbook d. Walking e. Toileting f. Grocery shopping

Q: The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? a. Pain is inevitable with aging. b. Older adults with cognitive impairments feel less pain. c. Alleviating pain should be a priority over other aspects of the assessment. d. The assessment should take priority so that care decisions can be made.

Q: When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? a. "Do you believe in God?" b. "How does your spirituality relate to your health care decisions?" c. "What religious faith do you follow?" d. "Do you believe in the power of prayer?"

Q: During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? a. "These low toilet seats are safe because they are nearer to the ground in case of falls." b. "Do you have a relative or friend who can help to install grab bars in your shower?" c. "These small rugs are ideal for preventing you from slipping on the hard floor." d. "It would be safer to keep the lighting low in this room to avoid glare in your eyes."

Q: An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? a. Lawton IADL instrument b. Hospital Admission Risk Profile (HARP) c. Mini-Cog d. NEECHAM Confusion Scale

Q: During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? a. Geriatric Depression Scale, short form b. Rapid Disability Rating Scale-2 c. Mini-Cog d. Get Up and Go Test

Q: An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: a. Depression. b. Weight gain. c. Hypertension. d. Social phobias.

Q: The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? a. Local senior center b. Patient's Medicare check c. Meals on Wheels meal delivery service d. Patient's neighbor, who visits with her daily

Q: A patient will be ready to be discharged from the hospital soon, and the patient's family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this? a. Get Up and Go Test b. Performance ADLs c. Physical Performance Test d. Tinetti Gait and Balance Evaluation

Q: When using the various instruments to assess an older person's ADLs, the nurse needs to remember that a disadvantage of these instruments includes: a. Reliability of the tools. b. Self or proxy reporting of functional activities. c. Lack of confidentiality during the assessment. d. Insufficient details concerning the deficiencies identified.

Q: The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include: a. Recreational activities. b. Meal preparation. c. Balancing the checkbook. d. Self-grooming activities.

Q: The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? a. The nurse uses direct observation to implement this tool. b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. c. This instrument is not useful in the acute hospital setting. d. This tool is best used for those residing in an institutional setting.

Q: The nurse needs to assess a patient's ability to perform activities of daily living (ADLs) and should choose which tool for this assessment? a. Direct Assessment of Functional Abilities (DAFA) b. Lawton Instrumental Activities of Daily Living (IADL) scale c. Barthel Index d. Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire"IADL (OMFAQ-IADL)

Q: The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: a. Observe the patient's ability to perform the tasks. b. Ask the patient's wife how he does when performing tasks. c. Review the medical record for information on the patient's abilities. d. Ask the patient's physician for information on the patient's abilities.

Q: The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? Functional ability: a. Is the measure of the expected changes of aging that one is experiencing. b. Refers to the individual's motivation to live independently. c. Refers to the level of cognition present in an older person. d. Refers to one's ability to perform activities necessary to live in modern society.

Q: During a group prenatal teaching session, the nurse teaches Kegel exercises. Which statements would be appropriate for this teaching session? Select all that apply. a. "Kegel exercises help keep your uterus strong during the pregnancy." b. "Kegel exercises should be performed twice a day." c. "Kegel exercises should be performed 50 to 100 times a day." d. "To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and then slowly release to a count of eight." e. "To perform Kegel exercises, rapidly perform alternating squeeze-release exercises up to the count of eight."

Q: During a woman's 34th week of pregnancy, she is told that she has preeclampsia. The nurse knows which statement concerning preeclampsia is true? a. Preeclampsia has little effect on the fetus. b. Edema is one of the main indications of preeclampsia. c. Eclampsia only occurs before delivery of the baby. d. Untreated preeclampsia may contribute to restriction of fetal growth.

Q: During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. The nurse's next action should be to: a. Document the results, which are within normal range. b. Take the maternal pulse to verify these findings as the uterine souffle. c. Have the patient change positions and count the FHTs again. d. Immediately notify the physician for possible fetal distress.

Q: A woman at 25 weeks' gestation comes to the clinic for her prenatal visit. The nurse notices that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. The woman states that she has had headaches and blurry vision but thought she was just tired. What should the nurse suspect? a. Eclampsia b. Preeclampsia c. Diabetes type 1 d. Preterm labor

Q: A 25-year-old woman is in the clinic for her first prenatal visit. The nurse will prepare to obtain which laboratory screening test at this time? a. Urine toxicology b. Complete blood cell count c. Alpha-fetoprotein d. Carrier screening for cystic fibrosis

Q: During a health history interview, a 38-year-old woman shares that she is thinking about having another baby. The nurse knows which statement to be true regarding pregnancy after 35 years of age? a. Fertility does not start to decline until age 40 years. b. Occurrence of Down syndrome is significantly more frequent after the age of 35 years. c. Genetic counseling and prenatal screening are not routine until after age 40 years. d. Women older than 35 years who are pregnant have the same rate of pregnancy-related complications as those who are younger than 35 years.

Q: A patient who is 24 weeks' pregnant asks about wearing a seat belt while driving. Which response by the nurse is correct? a. "Seat belts should not be worn during pregnancy." b. "Place the lap belt below the uterus and use the shoulder strap at the same time." c. "Place the lap belt below the uterus but omit the shoulder strap during pregnancy." d. "Place the lap belt at your waist above the uterus and use the shoulder strap at the same time."

Q: During the assessment of a woman in her 22ndweek of pregnancy, the nurse is unable to hear fetal heart tones with the fetoscope. The nurse should: a. Immediately notify the physician, then wait 10 minutes and try again. b. Ask the woman if she has felt the baby move today. c. Wait 10 minutes, and try again. d. Use ultrasound to verify cardiac activity.

Q: A patient's pregnancy test is positive, and she wants to know when the baby is due. The first day of her last menstrual period was June 14, and that period ended June 20. Using the Ngele rule, what is her expected date of delivery? a. March 7 b. March 14 c. March 21 d. March 27

Q: Which of these correctly describes the average length of pregnancy? a. 38 weeks b. 9 lunar months c. 280 days from the last day of the last menstrual period d. 280 days from the first day of the last menstrual period

Q: The nurse is palpating the uterus of a woman who is 8 weeks' pregnant. Which finding would be considered to be most consistent with this stage of pregnancy? a. The uterus seems slightly enlarged and softened. b. It reaches the pelvic brim and is approximately the size of a grapefruit. c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe. d. It is about the size of an avocado, approximately 8 cm across the fundus.

Q: The nurse is palpating the abdomen of a woman who is 35 weeks' pregnant and notices that the fetal head is facing downward toward the pelvis. The nurse would document this as fetal: a. Lie. b. Variety. c. Attitude. d. Presentation.

Q: The nurse is palpating the fundus of a pregnant woman. Which statement about palpation of the fundus is true? a. The fundus should be hard and slightly tender to palpation during the first trimester. b. Fetal movement may not be felt by the examiner until the end of the second trimester. c. After 20 weeks' gestation, the number of centimeters should approximate the number of weeks' gestation. d. Fundal height is usually less than the number of weeks' gestation, unless an abnormal condition such as excessive amniotic fluid is present.

Q: When performing an examination of a woman who is 34 weeks' pregnant, the nurse notices a midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the woman raises her head and shoulders off of the bed. Which response by the nurse is correct? a. The presence of diastasis recti should be documented. b. This condition should be discussed with the physician because it will most likely need to be surgically repaired. c. The possibility that the woman has a hernia attributable to the increased pressure within the abdomen from the pregnancy should be suspected. d. The woman should be told that she may have a difficult time with delivery because of the weakness in her abdominal muscles.

Q: When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32 weeks' pregnant, which of these would be considered a normal finding on a 0 to 4+ scale? a. Absent DTRs b. 2+ c. 4+ d. Brisk reflexes and the presence of clonus

Q: When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur. The nurse interprets this finding to be: a. Murmur of aortic stenosis. b. Most likely a mammary souffle. c. Associated with aortic insufficiency. d. Indication of a patent ductus arteriosus.

Q: Which finding is considered normal and expected when the nurse is performing a physical examination on a pregnant woman? a. Palpable, full thyroid b. Edema in one lower leg c. Significant diffuse enlargement of the thyroid d. Pale mucous membranes of the mouth

Q: When examining the face of a woman who is 28 weeks' pregnant, the nurse notices the presence of a butterfly-shaped increase in pigmentation on the face. The proper term for this finding in the documentation is: a. Striae. b. Chloasma. c. Linea nigra. d. Mask of pregnancy.