Socratives
1. Which instructions do you include when educating a person with chronic
constipation? Select all that apply.
a. - Increase fiber and fluids in the diet
- Exercise for 30 minutes every day
- Schedule time to use the toilet at the same time every day
2. When repositioning an immobile patient, the nurse notices redness over the hip
bone. What is indicated when a reddened area blanches on fingertip touch?
a. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode.
Rationale: When repositioning an immobile patient, it is important to assess all
bony prominences for the presence of redness, which can be the first sign of
impaired skin integrity. Pressing over the area compresses the blood vessels in the
area; and, if the integrity of the vessels is good, the area turns lighter in color and
then returns to the red color. However, if the area does not blanch when pressure
is applied, tissue damage is likely.
3. When does implementation, the fourth step of the nursing process, begin? (ADPIE)
after you develop a patient’s plan of care
ADPI --- five preparatory activities -- E
After you develop a patient's plan of care, then you will implement it. Adverse events
can be avoided or minimized with proper preparation and implementation of any
intervention. Perform these five preparatory activities:
(1) reassess the patient before a procedure
(2) review the nursing care plan and consider whether revision to interventions is
necessary based on patient’s current condition
(3) organize necessary resources and your delivery of care (especially with multiple
patients (4) anticipate and prevent complications based on what you know about the
patient, and
(5) implement the intervention(s) correctly.
4. The nurse assesses pain, edema, and redness at a vascular access device (VAD) site.
Which action is taken first?
Discontinue the intravenous infusion.
Explanation:
We always want to ensure the safety of the patient first. Discontinuing the IV infusion is
the best way to eliminate any further damage to the skin and surrounding tissues.
5. The assistive personnel (AP) is preparing to assist in feeding a client. How will the
nurse direct the AP? Select all that apply.



Position patient upright (45 to 90 degrees preferred) or according to medical restrictions
during and after feeding
Use aspiration precautions while feeding patients who need help and explain feeding
techniques that are successful for specific patients.
Immediately report any onset of coughing, gagging, or a wet voice or pocketing of food
to the nurse.
6. Which of the following is an example of a clinical practice guideline or protocol?
pressure injury prevention
Explanation:
A clinical practice guideline or protocol is a systematically developed set of statements
about appropriate health care for specific health care problems or clinical situations (e.g.,
pressure injury prevention, DVT prevention, fall prevention). Evidence-based research
provides the basis for sound clinical practice guidelines and associated recommendations
that often improve quality of care.
7. Which symptoms are warning signs of possible colorectal cancer according to the
American Cancer Society guidelines? Select all that apply.
Unexplained abdominal or back pain
Incomplete emptying of the colon
Blood in the stool
Change in bowel habits
8. Which of the following tools provides a holistic view of a patient’s health care
experiences and current health habits?
health history
Explanation:
The nursing health history is a formal method used to collect data about a patient. The
format, required content, and length of a nursing health history will vary by health care
setting. However, the history typically contains similar categories of information
regardless of the setting and EHR software or format. Most health history forms
(electronic and written) are structured. However, on the basis of information you gain as
you conduct the patient-centered interview, you learn which components of the history to
explore fully and which require less detail. As you gain more experience, you will learn
to refine and broaden questions as needed to correctly identify a patient’s unique needs.
Your patient’s priorities and needs and the amount of time you have available determine
how complete a history will be. A comprehensive history covers all health dimensions
(Fig. 16.4).
9. Which statement is true regarding leading questions?
Correct Answer:
are risky because they can limit the information a patient will provide to what a patient
thinks you want to know
Explanation:
These types of interview questions are risky because they can limit the information a
patient will provide to what a patient thinks you want to know (Ball et al., 2019). Two
examples of leading questions are (1) “It seems to me this is bothering you quite a bit. Is
that true?” and (2) “That wasn’t very hard to do, do you agree?” When asking how often
a symptom or problem occurs, allow a patient to define “often.” Do not ask, “It didn’t
happen too often, did it?” A patient may not understand what you are asking and may say
so (Ball et al., 2019).
Explanation:
Know about low-fat, low-cholesterol, and low-saturated fat diets and examples of these
types of foods.
10. A patient has hypokalemia with stable cardiac function. What are the priority
nursing interventions? Select all that apply.
Correct Answers
Fall prevention interventions
Monitoring for constipation
Explanation:
Hypokalemia: When blood potassium levels are low, the brain cannot relay signals as
effectively. Thus, contractions in the digestive system may become weaker and slow the
movement of food. This may cause digestive problems like bloating and constipation.
You should know the signs and symptoms of constipation! Increased water consumption
helps eliminate potassium, which would be important in hyperkalemia, but not if the
patient has hypokalemia. You would not need to teach the patient about restricting
sodium because hypokalemia means low potassium. Explaining how to take daily weight
refers to understanding a patient's total fluid volume status and is not indicated for
hypokalemia.
Physical examination: Bilateral muscle weakness that begins in quadriceps and may
ascend to respiratory muscles, abdominal distention, decreased bowel sounds,
constipation, dysrhythmias
Laboratory findings: Serum K+ level below 3.5 mEq/L (3.5 mmol/L); ECG abnormalities:
U waves, flattened or inverted T waves; ST segment depression
11. What is a nursing assessment?
Correct Answer:
*is the deliberate and systematic collection of data about a patient.*
Explanation:
The first step of the nursing process, assessment (see Fig. 16.1), involves the collection of
as much information as possible about a patient, family, or community. A thorough and
comprehensive assessment allows you to sort the data (cues), recognize patterns, and
make judgments that allow you to identify the type of health problems your patient is
experiencing. Your initial assessment of a patient is critical to identify or confirm as
quickly as possible a patient’s health problems, but nursing assessment is ongoing. You
will update your assessment of the patient as you continue to provide patient care.
12. The nursing assistant asks you the difference between a wound that heals by
primary or secondary intention. You will reply that a wound heals by primary
intention when the skin edges:
A. are approximated.
B. migrate across the incision.
C. appear slightly pink.
D. slightly overlap each other.
Rationale: A clean surgical incision is an example of a wound with little tissue loss. The
surgical incision heals by primary intention. The skin edges are approximated, or closed,
and the risk of infection is low.
13. A postoperative patient arrives at an ambulatory care center and states, “I am not
feeling good.” Upon assessment, you note an elevated temperature. An indication
that the wound is infected would be:
A. it has no odor.
B. a culture is negative.
C. the edges reveal the presence of fluid.
D. it shows purulent drainage coming from the incision site.
1. Related factors for NANDA-I (5-1 to remember) diagnosis include how many
categories
a. 4
2. What did the Quality and Safety Education for Nurses (QSEN) establish?
3. Correct Answer:
standard competencies in knowledge, skills, and attitudes (KSAs) for the preparation of
future nurses
Explanation:
The QSEN Institute established standard competencies in knowledge, skills, and
attitudes (KSAs) for the preparation of future nurses (QSEN, 2020). The goal of QSEN
is to prepare nurses so that they can continuously improve the quality and safety of the
health care systems within which they work. Examples of QSEN skills include providing
patient-centered care with sensitivity and respect for the diversity of the human
experience, initiating effective treatments to relieve pain and suffering, and participating
in building consensus or resolving conflict in the context of patient care (QSEN, 2020).
4. A complete diagnostic statement will also include a related factor. What is the
related factor?
Correct Answer:
Both A & B
Explanation:
Critically review your assessment data to identify the related factor that applies to your
patient. The value of having a related factor in a diagnostic statement is that it directs the
type of interventions appropriate for a patient’s care.
5. What is a nursing diagnosis?
a. a clinical judgment made by a nurse to describe a patient’s response or
vulnerability to health conditions or life events that a nurse is licensed and
competent to treat
6. What is a nursing assessment?
a. is the deliberate and systematic collection of data about a patient.
7. Which statement is true about carbohydrates?
Correct Answer:
they are the main source of energy in the diet
8. Consultation occurs when the nurse does which of the following?
a. identifies a problem that the nurse or the interprofessional team are unable to
solve
9. Which signs and symptoms would indicate to the nurse that the client has a
potential infection? Select all that apply.
Coughing up green sputum
Temperature 100.7 degrees F
Burning or pain with urination
10. Which assessment data will the nurse document as an objective finding? Select all
that apply.
The client ambulates 50 feet.
The client's blood pressure is 110/70.
11. The patient states, “I have diarrhea and cramping every time I have ice cream. I am
sure this is because the food is cold.” Based on this assessment data, which health
problem does the nurse suspect?
a. Lactose intolerance
12. You are the nurse taking care of a patient with a surgical wound where you have
identified two significant nursing diagnoses: Acute Pain and Risk for Infection.
Which diagnosis is likely your first priority?
Correct Answer:
Acute Pain, because the patient currently has pain that needs to be treated
13. Which assessment will the nurse document as a subjective finding? Select all that
apply.
The client states he has had a fever for three days.
The client reports 3/10 pain in the left lower leg.
14. What is the traditional way to measure a patient for an NG tube?
Correct Answer:
Measure distance from tip of nose to earlobe to xyphoid process
15. An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set
correctly. Which factors could cause this slowing? Select all that apply.
Infiltration at vascular access device (VAD) site
Patient lying on tubing
Tubing kinked in bedrails
16. As the nurse caring for a client with parenteral nutrition (PN), which actions take
priority? Select all that apply.
Changing the CVC dressing per facility protocol and whenever visibly contaminated
Adherence to principles of asepsis and infusion management
Clinical and laboratory monitoring of the client
Consistent reevaluation for the continuation of PN
Careful management of the central venous catheter (CVC)
Explanation:
Parenteral nutrition (PN), also called total PN (TPN), is IV administration of a complex,
highly concentrated solution containing nutrients and electrolytes that is formulated to
meet a patient’s needs. Depending on their osmolality, PN solutions are administered
through a CVC in cases of high osmolality or through a peripheral intravenous (IV) line
for lower osmolality solutions. Safe administration depends on appropriate assessment of
nutrition needs, meticulous management of the CVC or IV to prevent infection, and
careful monitoring to prevent metabolic complications.
17. Which assessment does the nurse use as a clinical marker of vascular volume in a
patient at high risk of extracellular fluid volume (ECV) excess? Select all that apply.
Correct Answers
Fullness of neck veins when upright
Sudden weight gain
18. When thinking about setting priorities, in general which of the following statements
is true?
problem-focused diagnoses and problems take priority over wellness, possible risk, and
health promotion problems
19. What is the purpose of stopping a nasogastric tube feeding and checking gastric
residuals?
Correct Answer:
ensure that the feeding is being properly absorbed
Explanation:
You need to measure gastric residual volumes (GRVs) every 4 to 6 hours in patients receiving
continuous feedings and immediately before the feeding in patients receiving intermittent
feedings (Lewis et al., 2017). Delayed gastric emptying is a concern if 250 mL or more remains
in a patient’s stomach on two consecutive assessments (1 hour apart) or if a single GRV
measurement exceeds 500 mL (Stewart, 2014). A gastric residual volume of between 250 and
500 mL should lead to implementation of measures to reduce the risk of aspiration (Boullata et
al., 2017). High gastric residuals can indicate that the feeding is not being properly absorbed,
which can lead to the risk for aspiration.
20. What will the nurse do during the planning phase?
Correct Answer:
make clinical decisions by choosing the nursing interventions most appropriate for a
patient’s nursing diagnosis and collaborative problems
21. How does the renin-angiotensin-aldosterone system (RAAS) regulate extracellular
fluid (ECF) volume?
Correct Answer:
Influences how much sodium and water are excreted in urine
Explanation:
The renin-angiotensin-aldosterone system (RAAS) regulates ECF volume by influencing
how much sodium and water are excreted in urine. It also contributes to regulation of
blood pressure. Specialized cells in the kidneys release the enzyme renin, which acts on
angiotensinogen, an inactive protein secreted by the liver that circulates in the blood.
Renin converts angiotensinogen to angiotensin I, which is converted to angiotensin II by
other enzymes in the lung capillaries (Hall, 2016). Angiotensin II has several functions,
one of which is vasoconstriction in some vascular beds. The important fluid homeostasis
functions of angiotensin II include stimulation of aldosterone release from the adrenal
cortex.
22. A patient is receiving total parenteral nutrition (TPN). What are the primary
interventions the nurse should follow to prevent a central line infection? Select all
that apply.
Correct Answers
Change the dressing using sterile technique
Change the TPN tubing every 24 hours
Explanation:
To prevent infection, change the TPN infusion tubing every 24 hours. Do not hang a
single container of PN for more than 24 hours or lipids more than 12 hours. Change the
administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours
for a 3-in-1 solution (Lewis et al., 2017). During CVC dressing changes always use a
sterile mask and gloves and assess insertion sites for signs and symptoms of infection
(see Chapter 42). Change the CVC dressing per institution policy and any time it
becomes wet or contaminated. It's important to know that TPN (not enteral feedings)
allow for bowel rest while supplying adequate calorie intake and essential nutrients, and
removes antigenic mucosal stimuli.
We do monitor glucose levels, but that doesn't help prevent central line infections.
Elevating the head of the bed is important to preventing aspiration in enteral feedings, not
parenteral feedings.
23. What assessments does a nurse make before hanging an intravenous (IV) fluid that
contains potassium? Select all that apply.
Correct Answers
Serum potassium level
Urine output
Explanation:
Hyperkalemia is abnormally high potassium ion concentration in the blood. Its general
causes are increased potassium intake and absorption, shift of potassium from cells into
the ECF, and decreased potassium output (see Table 42.5, p. 1049). People who have
oliguria (decreased urine output) are at high risk of hyperkalemia from the resultant
decreased potassium output unless their potassium intake also decreases substantially.
Understanding this principle helps you remember to check urine output before you
administer IV solutions containing potassium.
• The osmolality imbalances hyponatremia and hypernatremia
manifest as decreased level of consciousness and abnormal serum Na+ levels.
• Potassium imbalances manifest as bilateral muscle
weakness, cardiac dysrhythmias, and abnormal serum K+ levels.
• Calcium and magnesium imbalances manifest as altered
neuromuscular excitability and abnormal serum Ca++or Mg++levels.
Table 42.5, p. 1049, Electrolyte imbalances
An arterial blood gases (ABG) test measures the acidity (pH) and the levels of
oxygen and carbon dioxide in the blood from an artery. This test is used to find out how
well your lungs are able to move oxygen into the blood and remove carbon dioxide from
the blood.
Fullness of neck veins is a clinical marker of vascular volume, not hyperkalemia.
Checking a patient's level of consciousness would not apply in this situation. The IV fluid
is running intravenously, which does not require the patient to be awake and alert.
24. Which statement below reflects what you are accountable for as a nurse?
individualizing standardized interventions based on your patients’ needs and preferences
Explanation:
Care should be person-centered, holistic, and individualized for your patient.
Individualizing standardized interventions will help meet this goal of person-centered
care.
25. What factor is the most important when determining a patient's total fluid volume
status?
Daily weights
26. When choosing interventions, which factors will the nurse consider? Select all that
apply.
Correct Answers
the nurse's own competency
characteristics of the nursing diagnosis
research base knowledge for the intervention
feasibility for doing the intervention
desired patient outcomes
Explanation:
When choosing interventions, consider six important factors: (1) desired patient outcomes, (2)
characteristics of the nursing diagnosis, (3) research base knowledge for the intervention, (4)
feasibility for doing the intervention, (5) acceptability to the patient, and (6) your own
competency (Butcher et al., 2018) (Box 18.2). Read the section "Planning nursing interventions"
in Potter et al. (2023), e-book page 264.
27. When would a patient need an enteral feeding?
Correct Answer:
Patient is unable to ingest food but has a functioning GI tract
Explanation:
Enteral nutrition (EN) provides nutrients into the GI tract. It is the preferred method of meeting
nutritional needs if a patient is unable to swallow or take in nutrients orally yet has a functioning
GI tract. EN provides physiological, safe, and economical nutritional support. Patients
with enteral feedings receive formula via nasogastric, jejunal, or gastric tubes.
28. Which interventions will the nurse include for a client with a nursing diagnosis of
"Risk for falls related to impaired mobility"? Select all that apply.
Correct Answers
Transfer the patient to a room near the nurses’ station, if available.
Provide signs or secure a wristband identification to remind healthcare providers to implement
fall precaution behaviors.
Move items used by the patient within easy reach, such as call light, urinal, water, and telephone.
29. Your client has a history of heart disease and stroke. Which foods would be
appropriate to incorporate into this client's diet? Select all that apply.
Correct Answers
Steamed vegetables
Fresh fruit
Explanation:
Review low-fat, low-cholesterol diets. To your professor's dismay, sadly, baked desserts are not
any healthier than regular desserts and should not be included in this client's diet.
30. A client complains of pain 7/10 after having a knee replacement, has trouble
walking, and is unsteady on her feet. Which nursing diagnosis best reflects the
nurse's concern about the client's mobility?
Correct Answer:
Risk of falls related to impaired mobility
Explanation:
Risk of falls relate to impaired mobility speaks to the nurse's concern about mobility. The other
diagnoses, risk for impaired skin integrity, acute pain, and risk of falls (related to pain) do not
address the concern about mobility.
31. Which assessment does the nurse use as a clinical marker of vascular volume in a
patient at high risk of extracellular fluid volume (ECV) deficit? Select all that apply.
Correct Answers
Dryness of mucous membranes
Skin turgor
Fullness of neck veins when supine
Explanation:
Extracellular fluid volume deficit:
Sodium and Water Intake Less Than Output, Causing Isotonic Loss: Severely decreased
oral intake of water and salt
Increased GI output: vomiting, diarrhea, laxative overuse, drainage from fistulas or tubes
Increased renal output: use of diuretics, adrenal insufficiency (deficit of cortisol and
aldosterone)
Loss of blood or plasma: hemorrhage, burns
Massive sweating without water and salt intake
Physical examination: Sudden weight loss (overnight), postural hypotension, tachycardia,
thready pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when
supine, dark yellow urine
If severe: thirst, restlessness, confusion, hypotension; oliguria (urine output below 30 mL/hr);
cold, clammy skin; hypovolemic shock
32. A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume
(GVR) in 4 hours was 125 mL. What is the priority nursing intervention?
Correct Answer:
Continue the feedings; this is normal gastric residual for this feeding
Explanation:
You need to measure gastric residual volumes (GRVs) every 4 to 6 hours in patients receiving
continuous feedings and immediately before the feeding in patients receiving intermittent
feedings (Lewis et al., 2017). Delayed gastric emptying (lack of absorption) is a concern if 250
mL or more remains in a patient’s stomach on two consecutive assessments (1 hour apart) or if a
single GRV measurement exceeds 500 mL (Stewart, 2014). High gastric residuals can indicate
that the feeding is not being properly absorbed, which can lead to the risk for aspiration.
Therefore, a gastric residual volume of between 250 and 500 mL should lead to implementation
of measures to reduce the risk of aspiration (Boullata et al., 2017).
Why do we check GRV? You should know the rationale for checking GRV. Also, you should
understand how to assess a client's bowel function (what questions to ask a patient, etc.).
33. What is an important function of potassium in the body?
Correct Answer:
Maintains resting membrane potential of skeletal, smooth, and cardiac muscle, allowing normal
muscle function
Explanation:
Review table 42.4, Potter et al. (2021) p. 1047.
34. An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects
new onset of crackles in the lung bases. What is the priority action?
Correct Answer:
Decrease the IV flow rate.
Explanation:
In this case, the patient is developing crackles, which could be a sign of pulmonary fluid
overload. It's important to decrease the IV flow rate in order to protect this patient's safety. You
would then notify the healthcare provider about the crackles and your intervention, and obtain
further orders from the provider. Lowering the head of the bed could worsen the condition and
cause breathing issues. Discontinuing the IV site is not appropriate at this time as there is no
mention of infiltration. Patients need IV access for medication, fluids, and emergency treatment,
so removing it is not appropriate.
Review stool colors and potential issues (Potter Table 47.1, Fecal Characteristics, p. 1284).
35. What is the importance of calcium in the diet? Select all that apply.
Correct Answers
Helps protect against osteoporosis
Important in pregnancy, especially the third trimester
Important for healthy bone growth
Explanation:
Review potassium and calcium-rich foods. Be sure to review table 42.4 on page 1047.