Test Bank Fundamentals Nursing 9th Potter
Chapter 01: Nursing Today
1. Which nurse most likely kept records on sanitation techniques and the effects on health?
a. Florence Nightingale
b. Mary Nutting
c. Clara Barton
d. Lillian Wald
2. The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following?
3. An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor?
d. Advanced beginner
4. A nurse assesses a patient’s fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating?
5. A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing?
6. The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend?
a. Doctor of Nursing Science degree (DNSc)
b. Doctor of Philosophy degree (PhD)
c. Doctor of Nursing Practice degree (DNP)
d. Doctor in the Science of Nursing degree (DSN)
7. A nurse attends a workshop on current nursing issues provided by the American Nurses Association. Which type of education did the nurse receive?
a. Graduate education
b. Inservice education
c. Continuing education
d. Registered nurse education
8. A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating?
b. Patient-centered care
c. Quality improvement
d. Teamwork and collaboration
9. A nurse has compassion fatigue. What is the nurse experiencing?
a. Lateral violence and intrapersonal conflict
b. Burnout and secondary traumatic stress
c. Short-term grief and single stressor
d. Physical and mental exhaustion
10. A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, “I have no idea what is going to happen. I couldn’t ask any questions.” The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying?
b. Patient educator
c. Patient advocate
d. Clinical nurse specialist
Chapter 02: The Health Care Delivery System
1. The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient?
a. Capitation provides the hospital with a means of recovering variable charges.
b. The hospital will be paid for the full cost of the patient’s hospitalization.
c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.
d. Medicare will pay the national average for the patient’s condition.
2. A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session?
a. Managed care insures full coverage of health care costs.
b. Managed care only assumes the financial risk involved.
c. Managed care allows providers to focus on illness care.
d. Managed care causes providers to focus on prevention.
3. A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act?
a. A family can choose whether to have health insurance with no consequences.
b. Primary care physician payments from Medicaid services can equal Medicare.
c. Adult children up to age 26 are allowed coverage on the parent’s plan.
d. Private insurance companies can deny coverage for any reason.
4. A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning?
a. When the patient is ready
b. Close to the time of discharge
c. Upon admission to the hospital
d. After an order is written/prescribed
5. The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work?
a. Secondary acute
6. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?
a. Primary care
b. Preventive care
c. Restorative care
d. Continuing care
7. A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”?
8. The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize?
a. Pew Health Professions Commission
b. Healthcare Effectiveness Data and Information Set (HEDIS)
c. American Nurses Credentialing Center (ANCC) Magnet Recognition Program
d. Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)
9. An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient?
b. Respite care
c. Assisted living
d. Skilled nursing
10. A nurse working in a community hospital’s emergency department provides care to a patient having chest pain. Which level of care is the nurse providing?
a. Continuing care
b. Restorative care
c. Preventive care
d. Tertiary care
Chapter 03: Community-Based Nursing Practice
1. A nurse is working as a public health nurse. What will be the nurse’s primary focus?
a. The individual as one member of a group
b. Individuals and families
c. Needs of a population
d. Health promotion
2. A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain?
a. A baccalaureate degree in nursing
b. Preparation at the basic entry level
c. The same level of education as the community health nurse
d. A graduate level education with a focus in public health science
3. A nurse is working as a community health nurse. Which action is a priority for this nurse?
a. Provide direct care to subpopulations.
b. Focus on the needs of the ill individual.
c. Provide first level of contact to health care systems.
d. Focus on providing care in various community settings.
4. A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing?
a. Public health
b. Community health
d. Community assessment
5. The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse’s action?
a. To prevent individual illness
b. To prevent community outbreak of illness
c. To prevent outbreak of illness in the family
d. To prevent needs of the local population groups
6. A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care?
a. It occurs in hospitals.
b. Its focus is on ill individuals.
c. Its priority is health promotion.
d. It provides services primarily to the poor.
7. A nurse is using the Healthy People 2020 to establish goals for the community. Which goal is priority?
a. Reduce health care costs.
b. Increase life expectancy.
c. Provide services close to where patients live.
d. Isolate patients to prevent the spread of disease.
8. A nurse is working in community-based nursing. Which competency is priority for this nurse?
c. Change agent
d. Case manager
9. A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use?
c. Case manager
10. A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems?
a. One who is pregnant
b. One who has excessive risks
c. One who has unlimited access to health care
d. One who uses nontraditional healing practices
Chapter 04: Theoretical Foundations of Nursing Practice
1. The nursing instructor is teaching a class on nursing theory. One of the students asks, “Why do we need to know this stuff? It doesn’t really affect patients.” What is the instructor’s bestresponse?
a. “You are correct, but we have to learn it anyway.”
b. “This keeps the focus of nursing narrow.”
c. “Theories help explain why nurses do what they do.”
d. “Exposure to theories will help you later in graduate school.”
2. The nurse is caring for a patient who does not follow the prescribed regimen for diabetes management. As a prescriber to Orem’s theory, the nurse interviews the patient in an attempt to identify the cause of the patient’s “noncompliance.” What is the rationale for the nurse’s behavior?
a. Orem’s theory is useful in designing interventions to promote self-care.
b. Orem’s theory focuses on cultural issues that may affect compliance.
c. Orem’s theory allows for reduction of anxiety with communication.
d. Orem’s theory helps nurses manipulate the patient’s environment.
3. A nurse is testing meditation for migraine headaches and the expected outcome of care when performing this intervention. Which type of theory is the nurse using?
4. The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin will reduce bruising at the injection site. This study involves a prescriptive theory. What is the nurse’s rationale for involving a prescriptive theory?
a. It explains why bruising occurs.
b. It is broad in scope and complex.
c. It tests a specific nursing intervention.
d. It reflects a wide variety of nursing care situations.
5. A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice?
a. Nursing theory can direct how a nurse uses the nursing process.
b. Nursing theory requires the nursing process to develop knowledge.
c. Nursing theory with the nursing process has a minor role in professional nursing.
d. Nursing theory combined with the nursing process is specific to certain ill patients.
6. The nurse views the patient as an open system that needs help in coping with stressors. Which theorist is the nurse using?
7. The nurse is caring for a patient diagnosed with essential hypertension. The health care provider prescribes blood pressure medication that the nurse administers. The nurse then monitors the patient’s blood pressure for several days to help determine effectiveness. Which system component is the nurse evaluating?
8. A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow’s hierarchy of needs is the nurse promoting when the family is encouraged to visit?
a. First level
b. Second level
c. Third level
d. Fourth level
9. A nurse is caring for pediatric patients and using the developmental theory to plan nursing care. What is the focus of this nurse’s care?
a. Humans have an orderly, predictive process of growth and development.
b. Humans respond to threats by adapting with growth and development.
c. Humans respond with cognitive principles for growth and development.
d. Humans have psychosocial domains to growth and development.
10. Upon assessment, the nurse notices that the patient’s respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient’s pulse rate is over 100 beats per minute. According to Maslow’s hierarchy of needs, which patient need should the nurse address first?
d. Love and belonging
Chapter 05: Evidence-Based Practice
1. A nurse uses evidence-based practice (EBP) to provide nursing care. What is the bestrationale for the nurse’s behavior?
a. EBP is a guide for nurses in making clinical decisions.
b. EBP is based on the latest textbook information.
c. EBP is easily attained at the bedside.
d. EBP is always right for all situations.
2. In caring for patients, what must the nurse remember about evidence-based practice (EBP)?
a. EBP is the only valid source of knowledge that should be used.
b. EBP is secondary to traditional or convenient care knowledge.
c. EBP is dependent on patient values and expectations.
d. EBP is not shown to provide better patient outcomes.
3. A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change?
a. Read all the articles found on the Internet.
b. Make a general search of the Internet.
c. Use a PICOT format for the search.
d. Start with a broad question.
4. A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use?
a. An article that uses randomized controlled trials (RCT)
b. An article that is an opinion of expert committees
c. An article that uses qualitative research
d. An article that is peer-reviewed
5. The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article?
a. Literature review
6. The nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best evidence-based practice regarding clinical guidelines for low back pain. What is the best database for the nurse to access?
7. A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question?
a. A true PICOT question regardless of the number of elements
b. A true PICOT question because the intervention comes before the control
c. Not a true PICOT question because the comparison comes after the intervention
d. Not a true PICOT question because the time is not designated
8. A nurse is reviewing literature for an evidence-based practice study. Which study should the nurse use for the most reliable level of evidence that uses statistics to show effectiveness?
b. Systematic review
c. Single random controlled trial
d. Control trial without randomization
9. A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research?
a. An article about the number of falls after use of no side rails
b. An article about infection rates after use of a new wound dressing
c. An article about the percentage of new admissions on a new floor
d. An article about emotional needs of dying patients and their families
10. A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the “C”?
a. After surgery
b. Who listen to music
c. Who receive standard nursing care
d. Achieve better control of their anxiety and pain
Chapter 06: Health and Wellness
1. A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session?
a. Eliminate health disparities in America.
b. Eliminate health behaviors in America.
c. Eliminate quality of life in America.
d. Eliminate healthy life in America.
2. A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take?
a. Allow people to continue current behaviors to reduce the stress of change.
b. Focus only on health changes that will lead to better local communities.
c. Create social and physical environments that promote good health.
d. Focus on illness treatment to provide fast recuperation.
3. A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care?
a. Making sure the patients are disease free
b. Making sure to involve the whole person
c. Making sure care is strictly personal in nature
d. Making sure to focus only on the pathological state
4. The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following?
a. Health belief model
b. Holistic health model
c. Health promotion model
d. Maslow’s hierarchy of needs
5. A nurse is using Maslow’s hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?
b. Not eating
c. Mental health
d. Not seeing family members
6. The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using?
a. Health belief model
b. Holistic health model
c. Health promotion model
d. Maslow’s hierarchy of needs
7. A nurse is assessing internal variables that are affecting the patient’s health status. Which area should the nurse assess?
a. Perception of functioning
b. Socioeconomic factors
c. Cultural background
d. Family practices
8. The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse’s actions?
a. External variables have little effect on compliance.
b. A person’s compliance is affected by economic status.
c. Employment status is an internal variable that impacts compliance.
d. Noncompliant patients thrive on the disapproval of authority figures.
9. The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering?
a. Illness prevention
b. Wellness education
c. Active health promotion
d. Passive health promotion
10. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Risk factor prevention
Chapter 07: Caring in Nursing Practice
1. A nurse is caring for a patient in pain. Which nursing approach is priority?
c. High tech-centered
2. A nurse is providing pain medication to patients after surgery. Which component is key for the nurse’s personal philosophy of nursing?
3. A nurse attends a seminar on nursing theories for caring. Which information from the nurse indicates a correct understanding of these theories?
a. Benner identifies caring as highly connected involving patient and nurse.
b. Swanson develops four caring processes to convey caring in nursing.
c. Watson’s transcultural caring views inclusion of culture as caring.
d. Leininger’s theory places care before cure and is transformative.
4. The patient has a colostomy but has not yet been able to look at it. The nurse teaches the patient how to care for the colostomy. The nurse sits with the patient, and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing?
b. Doing for
d. Maintaining belief
5. A nurse is using Watson’s model to provide care to patients. Which carative factor will the nurse use?
a. Maintaining belief
b. Instilling faith-hope
c. Maintaining ethics
d. Instilling values
6. A nurse provides care that is receptive to patients’ and families’ perceptions of caring. Which action will the nurse take?
a. Provides clear, accurate information
b. Just performs nursing tasks competently
c. Does as much for the patient as possible
d. Focuses solely on the patient’s diagnosis
7. A nurse follows the “ethics of care” when working with patients. Which action will the nurse take?
a. Becomes the patient’s advocate based on the patient’s wishes
b. Makes decisions for the patient solely using analytical principles
c. Uses only intellectual principles to determine what is best for the patient
d. Ignores unequal family relationships since that is a personal matter for the family
8. A nurse is providing presence to a patient and the family. Which nursing action does this involve?
a. Focusing on the task that needs to be done
b. Providing closeness and a sense of caring
c. Jumping in to provide patient comfort
d. Being there without an identified goal
9. The patient is afraid to have a thoracentesis at the bedside. The nurse sits with the patient and asks about the fears. During the procedure, the nurse stays with the patient, explaining each step and providing encouragement. What is the nurse displaying?
a. Providing touch
b. Providing a presence
c. Providing family care
d. Providing a listening ear
10. The patient is terminal and very near death. When the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating?
a. Caring touch
b. Protective touch
c. Therapeutic touch
d. Task-oriented touch
Chapter 08: Caring for the Cancer Survivor
1. A nurse is working on a cancer unit. The unit uses the National Coalition for Cancer Survivorship definition for a cancer survivor. Which definition will the nurse use?
a. Been cancer free for 5 years after diagnosis
b. Been cancer free for 3 years after diagnosis
c. Had cancer and is declared cancer free
d. Had cancer and extends until death
2. A nurse is providing follow-up care for cancer survivors. Which condition should the nurse most monitor for in these patients?
c. Weight gain
d. Low blood pressure
3. A nurse is assessing a cancer survivor for chemotherapy-induced peripheral neurotoxicity (CPIN). Which assessment finding is consistent with CPIN?
a. Hearing loss
b. Devastating depression
c. Extreme loss of motor functioning
d. Numbness and tingling in hands and feet
4. A cancer survivor is in the intensive care unit (ICU). Some of the patient’s family is from out of town and would like to see the patient even though it is not “official” visiting hours. The patient is anxious to see family members. The nurse allows the family to visit. What is the rationale for the nurse’s actions?
a. The nurse disagrees with the established time for visiting.
b. The nurse realizes that the patient is dying.
c. The nurse feels there is no real reason to have limited visiting hours.
d. The nurse believes that the visit will help relieve psychological stress.
5. A nurse is taking a history on a patient with cancer. Which assessment is priority?
d. Blood pressure
6. A breast cancer survivor has chemotherapy-related cognitive impairment. Which area should the nurse assess?
d. Short-term memory
7. The nurse is caring for a young woman with breast cancer. The stress between the woman and spouse is obvious, as is anxiety among the children. What is the nurse’s best action in this situation?
a. Help find or develop an educational program for the patient and spouse.
b. Encourage the patient to agree with the spouse.
c. Support the spouse, and explain that the spouse knows what is best.
d. Take the children away and recommend foster care.
8. The nurse is caring for a patient who is undergoing chemotherapy and radiation for cancer. The patient asks the nurse about the value of cancer screening when therapy is over. What is the nurse’s best response?
a. “It should be done on an ongoing schedule.”
b. “It is not something that should be discussed right now.”
c. “It probably will not be needed since the cancer has been cured.”
d. “It usually is not done but can be done if the patient wants peace of mind.”
9. The nurse is caring for a patient diagnosed with cancer. The family of the patient asks the nurse for resources about the cancer. What should the nurse do?
a. Refer family members to the health care provider.
b. Inform them that few options are available.
c. Maintain confidentiality by keeping silent.
d. Provide the family with the information.
10. The nurse is caring for a patient with known coronary artery disease who has recently been diagnosed with lung cancer. What should the nurse do?
a. Focus the assessment solely on the cancer diagnosis since it is the newer diagnosis.
b. Ask questions about cardiac symptoms and their relationship to the cancer.
c. Ignore symptom management and focus on palliative care.
d. Say nothing because cancer survivors dislike prying.
Chapter 09: Cultural Awareness
1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer?
b. Asian Americans
c. Non-Hispanic Caucasians
d. Non-Hispanic African-Americans
2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient?
a. There is a decreased frequency of morbidity.
b. There is an increased incidence of disease.
c. There is an increased level of health.
d. There is a decreased mortality rate.
3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring?
a. Accessibility of health care services
b. Outcomes of health conditions
c. Prevalence of complications
d. Incidence of diseases
4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence?
a. Communicates effectively in a multicultural context
b. Functions effectively in a multicultural context
c. Visits a foreign country
d. Speaks a different language
5. The nurse learns about cultural issues involved in the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
a. Marginalized groups
b. Health care disparity
c. Transcultural nursing
d. Culturally congruent care
6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first?
a. Assessing own biases and attitude
b. Learning about the world view of others
c. Understanding organizational forces
d. Developing cultural skills
7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
a. Use long sentences when talking.
b. Look at the patient when talking.
c. Use breaks in sentences when talking.
d. Look at only nonverbal behaviors when talking.
9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients?
a. Provides care to transgender patients
b. Provides care to restore relationships
c. Provides care to patients that is individualized
d. Provides care to surgical patients
10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of this technique?
a. Asks, “Does this make sense?”
b. Asks, “Do you think you can do this at home?”
c. Asks, “What will you tell your spouse about changing the dressing?”
d. Asks, “Would you tell me if you don’t understand something so we can go over it?”
Chapter 10: Caring for Families
1. A nurse is assessing the family unit to determine the family’s ability to adapt to the change of a member having surgery. Which area is the nurse monitoring?
a. Family durability
b. Family resiliency
c. Family diversity
d. Family forms
2. A nurse reviews the current trends affecting the family. Which trend will the nurse find?
a. Mothers are staying at home.
b. Adolescent mothers usually live on their own.
c. More grandparents are raising their grandchildren.
d. Teenage fathers usually have stronger support systems.
3. A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, “None of her jobs are getting done, and I don’t do those jobs, so the house and the kids are falling apart.” How will the nurse interpret this finding?
a. The family structure is resilient.
b. The family structure is flexible.
c. The family structure is hardy.
d. The family structure is rigid.
4. A nurse cares for the family’s as well as the patient’s needs using available resources. Which approach is the nurse using?
a. Family as context
b. Family as patient
c. Family as system
d. Family as caregivers
5. A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient’s family. Which action should the nurse take to help relieve stress?
a. Encourage caregiver to do as much as possible.
b. Focus primarily on the patient.
c. Point out weaknesses.
d. Provide education.
6. A nurse is working with a patient. When the nurse asks about family members, the patient states that it includes my spouse, children, and aunt and uncle. How will the nurse describe this type of family?
7. A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely?
8. The nurse is interviewing a patient who is being admitted to the hospital. The patient’s family went home before the nurse’s interview. The nurse asks the patient, “Who decides when to come to the hospital?” What is the rationale for the nurse’s action?
a. To assess the family form
b. To assess the family function
c. To assess the family structure
d. To assess the family generalization
9. A nurse is caring for a patient from a motor vehicle accident. Which action by the unlicensed assistive personnel will cause the nurse to intervene?
a. Tells the family not to leave the bedside
b. Offers the family a sandwich
c. Gives the family a blanket
d. Sits with the family
10. A nurse is using the family as context approach to provide care to a patient. What should the nurse do next?
a. Assess family patterns versus individual characteristics.
b. Assess how much the family provides the patient’s basic needs.
c. Use “family as patient” and “family as context” approaches simultaneously.
d. Plan care to meet not only the patient’s needs but those of the family as well.
Chapter 11: Developmental Theories
1. When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient’s behavior. Which information from a growth and development perspective should the nurse consider when planning care?
a. Individuals have uniform patterns of growth and development.
b. Culture usually has no effect on predictable patterns of growth and development.
c. Health is promoted based on how many developmental failures a patient experiences.
d. When individuals experience repeated developmental failures, inadequacies sometimes result.
2. A nurse is measuring an infant’s head circumference and height. Which area is the nurse assessing?
a. Moral development
b. Cognitive development
c. Biophysical development
d. Psychosocial development
3. Which question will be most appropriate for a nurse to ask when assessing an adult patient for growth and developmental delays?
a. “How many times per week do you exercise?”
b. “Are you able to stand on one foot for 5 seconds?”
c. “Would you please describe your usual activities during the day?”
d. “How many hours a day do you spend watching television or sitting in front of a computer?”
4. A nurse is using the proximodistal pattern to assess an infant’s growth and development as normal. Which assessment finding will the nurse determine as normal?
a. Bangs objects before turns
b. Lifts head before grasps
c. Walks before crawls
d. Laughs before coos
5. A nurse is assessing an 18-month-old toddler. The nurse distinguishes normal from abnormal findings by remembering Gesell’s theory of development. Which information will the nurse consider?
a. Growth in humans is determined solely by heredity.
b. Environmental influence does not influence development.
c. The cephalocaudal pattern describes the sequence in which growth is fastest at the top.
d. Gene activity influences development but does not affect the sequence of development.
6. A nurse is working with a patient who wants needs to be met and is impatient and demanding when these needs are not met immediately. How should the nurse interpret this finding according to Freud?
a. The id is functioning.
b. The ego is functioning.
c. The superego is functioning.
d. The Oedipus complex is functioning.
7. The nurse is teaching a young-adult couple about promoting the health and psychosocial development of their 8-year-old child. Which information from the parent indicates a correct understanding of the teaching?
a. “We will provide consistent, devoted relationships to meet needs.”
b. “We will limit choices and provide punishment for mistakes.”
c. “We will provide proper support for learning new skills.”
d. “We will instill a strong identity of who our child is.”
8. A nurse is using Jean Piaget’s developmental theory to focus on cognitive development. Which area will the nurse assess in this patient?
b. Formal operations
c. Intimacy versus isolation
d. The postconventional level
9. A nurse is assessing a 17-year-old adolescent’s cognitive development. Which behavior indicates the adolescent has reached formal operations?
a. Uses play to understand surroundings
b. Discusses the topic of justice in society
c. Hits other students to deal with environmental change
d. Questions where the ice is hiding when ice has melted in a drink
10. A nurse is caring for a 4-year-old patient. Which object will the nurse allow the child to play with safely to foster cognitive development?
a. The pump administering intravenous fluids
b. A book to read alone in a quiet place
c. The blood pressure cuff
d. A baseball bat
Chapter 12: Conception Through Adolescence
1. A mother has delivered a healthy newborn. Which action is priority?
a. Encourage close physical contact as soon as possible after birth.
b. Isolate the newborn in the nursery during the first hour after delivery.
c. Never leave the newborn alone with the mother during the first 8 hours after delivery.
d. Do not allow the newborn to remain with parents until the second hour after delivery.
2. A nurse teaches a new mother about the associated health risks to the infant. Which statement by the mother indicates a correct understanding of the teaching?
a. “I will feed my baby every 4 hours around-the-clock.”
b. “I need to leave the blankets off my baby to prevent smothering.”
c. “I need to remind friends who want to hold my baby to wash their hands.”
d. “I will throw away the bulb syringe now because my baby is breathing fine.”
3. A nurse is working in the delivery room. Which action is priority immediately after birth?
a. Open the airway.
b. Determine gestational age.
c. Monitor infant-parent interactions.
d. Promote parent-newborn physical contact.
4. A nurse is assessing a newborn that was just born. Which newborn finding will cause the nurse to intervene immediately?
b. A lack of reflexes
c. Cyanotic hands and feet
d. A soft, protuberant abdomen
5. A nurse performs an assessment on a healthy newborn. Which assessment finding will the nurse document as normal?
a. Cyanosis of the feet and hands for the first 48 hours
b. Triangle-shaped anterior fontanel
c. Sporadic motor movements
d. Weight of 4800 grams
6. A nurse is teaching the staff about development. Which information indicates the nurse needs to follow up?
a. “Development proceeds in a cephalocaudal pattern.”
b. “Development proceeds in a proximal-distal pattern.”
c. “Development proceeds at a slower rate during the embryonic stage.”
d. “Development proceeds at a predictive rate from the moment of conception.”
7. A nurse is comparing physical growth patterns between school-aged children and adolescents. Which principle should the nurse consider?
a. Physical growth usually slows during the adolescent period.
b. Secondary sex characteristics usually develop during the adolescent years.
c. Boys usually exceed girls in height and weight by the end of the school years.
d. The distribution of muscle and fat remains constant during the adolescent years.
8. The parent brings a child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. Which finding will cause the nurse to intervene?
a. Height of 30 inches
b. Weight of 16 pounds
c. Is not yet potty-trained
d. Is not yet walking up stairs
9. A nurse is assessing the cognitive changes in a preschooler. Which standard will the nurse use to determine normal?
a. The ability to think abstractly and deal effectively with hypothetical problems
b. The ability to think in a logical manner about the here and now
c. The ability to assume the view of another person
d. The ability to classify objects by size or color
10. The nurse is teaching a parenting class. One of the topics is development. Which statement from a parent indicates more teaching is needed?
a. “The toddler may use parallel play.”
b. “The preschooler has the ability to play in small groups.”
c. “The school-aged child still needs total assistance in all safety activities.”
d. “The toddler may have temper tantrums from parent’s acting on safety rules.”
Chapter 13: Young and Middle Adults
1. A nurse is caring for a young adult. Which goal is priority?
a. Maintain peer relationships.
b. Maintain family relationships.
c. Maintain parenteral relationships.
d. Maintain recreational relationships.
2. The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local restaurant. He states that he would like to get a better job but has no education. How can the nurse best assist this patient psychosocially?
a. By providing information and referrals
b. By focusing on the patient’s medical diagnoses
c. By telling the patient that he needs to go back to school
d. By expecting the patient to be flexible in decision making
3. Which goal is priority when the nurse is caring for a middle-aged adult?
a. Maintain immediate family relationships.
b. Maintain future generation relationships.
c. Maintain personal career relationships.
d. Maintain work relationships.
4. A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching?
a. “It’s probably safe for me to start smoking. At my age, there’s not enough time for cancer to develop.”
b. “My mother had appendicitis so this increases my chance for developing appendicitis.”
c. “Controlling the amount of stress in my life may decrease the risk of illness.”
d. “I don’t do drugs. I do drink coffee, but caffeine is not a drug.”
5. A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include?
c. Climacteric factors
d. Unplanned pregnancies
6. A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP?
a. White males
b. Pregnant females
c. Middle-aged adults
d. Nonsubstance abusers
7. A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. Which information should the nurse share with the patient?
a. Lamaze classes can prepare pregnant women and their partners for what is coming.
b. The frequency of sexual intercourse is key to helping the husband feel valued.
c. After the birth, the stress of pregnancy will disappear and will be replaced by relief.
d. After the baby is born, the wife should accept the extra responsibilities of motherhood.
8. Which information from the nurse indicates a correct understanding of emerging adulthood?
a. It is a type of young adulthood.
b. It is a type of extended adolescence.
c. It is a type of independent exploration.
d. It is a type of marriage and parenthood.
9. A nurse is planning care for a 30 year old. Which goal is priority?
a. Refine self-perception.
b. Master career plans.
c. Examine life goals.
d. Achieve intimacy.
10. A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care?
a. Fertility issues do not occur in young adulthood.
b. Young adults tend to suffer more from severe illness.
c. Substance abuse is easy to observe in young-adult patients.
d. Young adults are quite active but are at risk for illness in later years.
Chapter 14: Older Adult
1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?
a. Lives in a nursing home
b. Lives with a spouse
c. Lives divorced
d. Lives alone
2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
a. Should be standardized because most geriatric patients have the same needs
b. Needs to be individualized to the patient’s unique needs
c. Focuses on the disabilities that all aging persons face
d. Must be based on chronological age alone
3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene?
a. Most older people have dependent functioning.
b. Most older people have strengths we should focus on.
c. Most older people should be involved in care decision.
d. Most older people should be encouraged to have independence.
4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse’s suspicions?
a. Flea bites and lice infestation
b. Left at a grocery store
c. Refuses to take a bath
d. Cuts and bruises
5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use?
a. Provide several topics of discussion at once to promote independence and making choices.
b. Avoid uncomfortable silences after questions by helping patients complete their statements.
c. Ask patients to recall past experiences that correspond with their interests.
d. Speak in a high pitch to help patients hear better.
6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned about the patient’s ability to care for self, especially during this convalescence. What should the nurse do?
a. Stress that older patients usually ask for help when needed.
b. Inform the family that placement in a nursing center is a permanent solution.
c. Tell the family to enroll the patient in a ceramics class to maintain quality of life.
d. Provide information and answer questions as family members make choices among care options.
7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center?
a. Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely.
b. Make sure that nursing home staff members get patients out of bed and dressed according to staff’s preferences.
c. Explain that it is important for the family to visit the center and inspect it personally.
d. Suggest a nursing center that has standards as close to hospital standards as possible.
8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient’s only son. What will the nurse suggest?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
d. That placement is irrelevant because the patient is retreating to a place of inactivity
9. A nurse is caring for an older adult. Which goal is priority?
a. Adjusting to career
b. Adjusting to divorce
c. Adjusting to retirement
d. Adjusting to grandchildren
10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing?
a. Loss of finances through changes in income
b. Loss of relationships through death
c. Loss of career through retirement
d. Loss of home through relocation
Chapter 15: Critical Thinking in Nursing Practice
1. Which action should the nurse take when using critical thinking to make clinical decisions?
a. Make decisions based on intuition.
b. Accept one established way to provide care.
c. Consider what is important in a given situation.
d. Read and follow the heath care provider’s orders.
2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking?
a. Administering pain-relief medication according to what was given last shift
b. Offering pain-relief medication based on the health care provider’s orders
c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past
d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed
3. Which action indicates a registered nurse is being responsible for making clinical decisions?
a. Applies clear textbook solutions to patients’ problems
b. Takes immediate action when a patient’s condition worsens
c. Uses only traditional methods of providing care to patients
d. Formulates standardized care plans solely for groups of patients
4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?
a. Making an ethical clinical decision
b. Making an informed clinical decision
c. Making a clinical decision in the patient’s best interest
d. Making a clinical decision based on previous shift assessments
5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making?
a. Obtains data in an orderly fashion
b. Uses an objective approach in patient situations
c. Improves a plan of care while thinking back on interventions effectiveness
d. Provides evidence-based explanations and research for care of assigned patients
6. A nursing instructor needs to evaluate students’ abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor’s needs?
a. Concept mapping
b. Reflective journaling
c. Lecture and discussion
d. Reading assignment with a written summary
7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions?
c. Nursing process
d. Specific knowledge base
8. Which action by a nurse indicates application of the critical thinking model to make the bestclinical decisions?
a. Drawing on past clinical experiences to formulate standardized care plans
b. Relying on recall of information from past lectures and textbooks
c. Depending on the charge nurse to determine priorities of care
d. Using the nursing process
9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?
a. Examine the meaning of data.
b. Support findings and conclusions.
c. Review the effectiveness of nursing actions.
d. Search for links between the data and the nurse’s assumptions.
10. The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill?
Chapter 16: Nursing Assessment
1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
a. Completes a comprehensive database
b. Identifies pertinent nursing diagnoses
c. Intervenes based on priorities of patient care
d. Determines whether outcomes have been achieved
2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
a. Complete the questions in chronological order.
b. Focus on the patient’s presenting situation.
c. Make accurate interpretations of the data.
d. Conduct an observational overview.
3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?
a. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs.
b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return.
c. Ask the NAP to record the patient’s vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress.
4. The nurse is gathering data on a patient. Which data will the nurse report as objective data?
a. States “doesn’t feel good”
b. Reports a headache
c. Respirations 16
5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
a. The patient can now perform the dressing changes without help.
b. The patient can begin retaking all of the previous medications.
c. The patient is apprehensive about discharge.
d. The patient’s surgery was not successful.
6. Which method of data collection will the nurse use to establish a patient’s database?
a. Reviewing the current literature to determine evidence-based nursing actions
b. Checking orders for diagnostic and laboratory tests
c. Performing a physical examination
d. Ordering medications
7. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?
a. Carefully review lab results.
b. Conduct the physical assessment.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
a. Consider cultural differences during this assessment.
b. Ask the patient to make eye contact to determine her affect.
c. Continue with the interview and document that the patient is depressed.
d. Notify the health care provider to recommend a psychological evaluation.
9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
a. Begin with introductions.
b. Ask about the chief concerns or problems.
c. Explain that the interview will be over in a few minutes.
d. Tell the patient “I will be back to administer medications in 1 hour.”
10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
a. “Is there anything that you are stressed about right now that I should know?”
b. “What reasons do you think are contributing to your fatigue?”
c. “What are your normal work hours?”
d. “Are you sleeping 8 hours a night?”
Chapter 17: Nursing Diagnosis
1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
a. To form a language that can be encoded only by nurses
b. To distinguish the nurse’s role from the physician’s role
c. To develop clinical judgment based on other’s intuition
d. To help nurses focus on the scope of medical practice
2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
a. Sore throat
b. Acute pain
c. Sleep apnea
d. Heart failure
3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
a. Ineffective breathing pattern related to pneumonia
b. Risk for infection related to chest x-ray procedure
c. Risk for deficient fluid volume related to dehydration
d. Impaired gas exchange related to alveolar-capillary membrane changes
4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
b. Nursing diagnosis
c. Collaborative problem
d. Defining characteristic
5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
a. Assigning clinical cues
b. Defining characteristics
c. Diagnostic reasoning
d. Diagnostic labeling
6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the mostpertinent nursing diagnosis the nurse will include in the plan of care?
a. Posttrauma syndrome
c. Acute pain
7. The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
b. Problem focused
c. Health promotion
d. Collaborative problem
9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?
10. A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
a. Decreased gastrointestinal motility
b. Pain medication
c. Abdominal distention
Chapter 18: Planning Nursing Care
1. The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
2. A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initialaction will the nurse take next to revise the plan of care?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.
3. Which information indicates a nurse has a good understanding of a goal?
a. It is a statement describing the patient’s accomplishments without a time restriction.
b. It is a realistic statement predicting any negative responses to treatments.
c. It is a broad statement describing a desired change in a patient’s behavior.
d. It is a measurable change in a patient’s physical state.
4. A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?
a. Patient will increase activity level this shift.
b. Patient will turn side to back to side with assistance every 2 hours.
c. Patient will use the walker correctly to ambulate to the bathroom as needed.
d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.
5. The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care?
a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
b. The patient will demonstrate increased tolerance to activity over the next month.
c. The patient will understand needed dietary changes by discharge.
d. The patient will demonstrate increased mobility in 2 days.
6. A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
a. The patient will ambulate in hallways.
b. The nurse will monitor the patient’s heart rhythm continuously this shift.
c. The patient will feed self at all mealtimes today without reports of shortness of breath.
d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.
7. A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
a. Risk for impaired skin integrity
b. Risk for infection
c. Spiritual distress
d. Reflex urinary incontinence
8. The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
a. “Choose all the interventions and perform them in order of time needed for each one.”
b. “Make sure you identify the scientific rationale for each intervention first.”
c. “Decide on goals and outcomes you have chosen for the patients.”
d. “Begin with the highest priority diagnoses, then select appropriate interventions.”
9. A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
a. Individualize the care plan only according to the patient’s needs.
b. Request that the son leave at bedtime, so the patient can rest.
c. Suggest that a female member of the family stay with the patient.
d. Involve the son in the plan of care as much as possible.
10. A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
a. Patient will have one soft, formed bowel movement by end of shift.
b. Patient will walk unassisted to bathroom by the end of shift.
c. Patient will be offered laxatives or stool softeners this shift.
d. Patient will not take any pain medications this shift.
Chapter 19: Implementing Nursing Care
1. A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
2. The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care.
3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.
4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
a. Determines whether an intervention is correct and appropriate for the given situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions
5. A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg.
c. Provide assistance while the patient walks in the hallway twice this shift with crutches.
d. The patient is unable to bear weight on right lower extremity.
6. A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
a. Assist the patient to walk in the room with crutches.
b. Obtain a walker for the patient.
c. Consult physical therapy.
d. Administer pain medication.
7. The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
a. Gathers and organizes needed supplies
b. Decides on goals and outcomes for the patient
c. Assesses the patient’s readiness for the procedure
d. Calls for assistance from another nursing staff member
8. A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
a. Request that the family leave, so the patient can rest.
b. Ask the patient to return to the room, so the nurse can inspect the abdomen.
c. Ask the patient when the last bowel movement was and to lie down on the sofa.
d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.
9. A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Review the patient’s activity orders.
d. Offer the patient a walker.
10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
a. Act as a leader of the health care team.
b. Develop good communication skills.
c. Work solely with nurses.
d. Avoid conflict.
Chapter 20: Evaluation
1. A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
a. “An evaluation helps you determine whether all nursing interventions were completed.”
b. “During evaluation, you determine when to downsize staffing on nursing units.”
c. “Nurses use evaluation to determine the effectiveness of nursing care.”
d. “Evaluation eliminates unnecessary paperwork and care planning.”
4. After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient’s headache. Which action by the nurse is priorityfor this patient?
a. Eliminate headache from the nursing care plan.
b. Direct the nursing assistive personnel to ask if the headache is relieved.
c. Reassess the patient’s pain level in 30 minutes.
d. Revise the plan of care.
5. A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient’s plan of care?
a. Determine whether the patient has transportation to get home.
b. Evaluate whether patient goals and outcomes have been met.
c. Establish whether the patient has a follow-up appointment scheduled.
d. Ensure that the patient’s prescriptions have been filled to take home.
6. The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
a. The nurse provides assistance while the patient is walking in the hallways.
b. The patient is able to ambulate in the hallway with crutches.
c. The patient will deny pain while walking in the hallway.
d. The patient’s level of mobility will improve.
7. The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
a. Staff documentation of turning the patient every 2 hours
b. Presence of redness only on the heels of the patient
c. Patient’s eating 100% of all meals
d. Absence of skin breakdown
8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
a. Reassess the patient and situation.
b. Revise the turning schedule to increase the frequency.
c. Delegate turning to the nursing assistive personnel.
d. Apply medication to the area of skin that is broken down.
9. A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?
a. “Evaluative measures are multiple-page documents used to evaluate nurse performance.”
b. “Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals.”
c. “Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse.”
d. “Evaluative measures are objective views for completion of nursing interventions.”
10. The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
a. Ask the nursing assistive personnel if the wound looks better.
b. Document the progress of wound healing as “better” in the chart.
c. Measure the wound and observe for redness, swelling, or drainage.
d. Leave the dressing off the wound for easier access and more frequent assessments.
AND MUCH MORE