Yoost & Crawford: Fundamentals of Nursing: Active Learning for
Collaborative Practice, 2nd Edition
Chapter 01: Nursing, Theory, and Professional Practice
Review Questions
1. In comparing the American Nurses Association (ANA) and the International Council of
Nurses (ICN) definitions of nursing, what component does the ICN mention that is not
included in ANA's definition and is indicative of a more global focus?
a.
Advocacy
b.
Health promotion
c.
Shaping health policy
d.
Prevention of illness
2. A profession has specific characteristics. In regard to how nursing meets these
characteristics, which criteria are consistent and standardized processes? (Select all that
apply.)
a.
Code of ethics
b.
Licensing
c.
Body of knowledge
d.
Educational preparation
e.
Altruism
3. What specific aspect of a profession does the development of theories provide?
a.
Altruism
b.
Body of knowledge
c.
Autonomy
d.
Accountability
4. Health care workers are discussing a diverse group of patients respectfully and are being
responsive to the health beliefs and practices of these patients. What important aspect of
nursing professional practice are they exhibiting?
a.
Autonomy
b.
Accountability
c.
Cultural competence
d.
Autocratic leadership
5. A nurse makes a medication error, immediately assesses the patient, and reports the error to
the nurse manager and the primary care provider (PCP). Which characteristic of a
professional is the nurse demonstrating?
a.
Autonomy
b.
Collaboration
c.
Accountability
d.
Altruism
6. Which are included in the ANA standards? (Select all that apply.)
a.
Standards of professional performance
b.
Code of ethics
c.
Standards of practice
d.
Legal scope of practice
e.
Licensure requirements
7. Which core competency of advanced practice nursing is the Master of Science in Nursing
(MSN) nurse educator exhibiting when counseling a student in therapeutic communication
techniques?
a.
Leadership
b.
Ethical decision making
c.
Direct clinical practice
d.
Expert coaching
8. Which statements describe a component discussed in nursing theories? (Select all that apply.)
a.
Optimal functioning of the patient
b.
Interaction with components of the environment
c.
The conceptual makeup of the administration of the hospital
d.
The illness and health concept
e.
Safety aspect of medication administration
9. Which factors affect the nursing shortage? (Select all that apply.)
a.
Aging faculty
b.
Increasing elderly population
c.
Job satisfaction due to adequate number of nurses
d.
Aging nursing workforce
e.
Greater autonomy for nurses
10. A nurse has performed a physical examination of the patient and reviewed the laboratory
results and diagnostics on the patient's chart. The nurse is performing which specific nursing
function?
a.
Diagnosis
b.
Assessment
c.
Education
d.
Advocacy
1. What is an example of Nightingale’s contributions to nursing?
a. Graduated as the first trained U.S. nurse
b. Practiced nursing in the Civil War
c. Established the American Red Cross
d. Emphasized respect for patients’ needs and rights
2. Nurses are most likely to utilize theories from which of the following individuals in their leadership
role?
a. Maslow
b. Rosenstock
c. Lewin
d. Erikson
3. A team meeting of providers and nurses is convened to discuss a specific patient’s problems and to
determine goals for the patient. During the meeting, specific accountability related to patient care for
both the providers and nurses involved is established. All members of the meeting show mutual respect
by valuing each other’s clinical competence that is necessary to provide quality patient care. Of the
following functions of a nurse, which one is demonstrated in the above example?
a. Delegation
b. Advocacy
c. Collaboration
d. Management
4. A nurse has graduated from a nursing school and is participating in a new graduate program at a local
hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at
this point in the nurse’s career?
a. Expert
b. Competent
c. Novice
d. Advanced beginner
5. Nursing students all belong to the National Student Nurses Association when they are attending a
specific nursing program. This is an important aspect of their socialization to the profession as it
demonstrates which criteria of a profession?
a. Providing service to society
b. Accepting responsibility for actions and omissions
c. Participating in an organization that supports and advances the profession
d. Making independent decisions based on their scope of practice
MULTIPLE RESPONSE
1. What is the nurse’s role as patient advocate? (Select all that apply.)
a. Explain to the patient the nurse’s viewpoint.
b. Communicates the patient’s wishes to other health care providers.
c. Accept the patient’s decision and support his or her wishes.
d. Give the patient the provider’s viewpoint.
e. Provide education to the patient and evaluate understanding.
2. A nurse is planning a program for educating a Hispanic community regarding nutritional practices.
What would be the most important aspects that the nurse takes into consideration first? (Select all that
apply.)
a. Change theory and Health Belief Model
b. Previous educational programs
c. Cultural influences
d. Hospital admissions from this community
e. Vital statistics such as death rates
3. How might a nurse as a researcher approach the care of the patient? (Select all that apply.)
a. Performing technical skills as learned
b. Looking for problems and questioning practices
c. Incorporating research into practice
d. Carrying out procedures according to policy
e. Designing and conducting research studies
Yoost & Crawford: Fundamentals of Nursing: Active Learning for
Collaborative Practice, 2nd Edition
Chapter 02: Values, Beliefs, and Caring
Review Questions
1. Nurses need to understand how beliefs and values are different. A nurse begins to offer
information to a patient, and the patient says, “I've already heard all of that before, and I don't
agree with any of it.” How should the nurse proceed?
a.
Ask the patient to explain his values.
b.
Ask the patient to explain what he believes.
c.
Ask the patient about his prejudicial attitude.
d.
Confront the patient about the apparent values conflict.
2. Which nursing theory of care describes how the nurse's presence in the nurse–patient
relationship transcends the physical and material world, facilitating the development of a
higher sense of self by the patient?
a.
Swanson's Theory of Caring Processes
b.
Madeline Leininger's Cultural Care Theory
c.
Watson's Theory of Human Caring
d.
Boykin and Schoenhofer's Theory of Nursing as Caring
3. Which statement best describes for new parents how and when children develop first-order
beliefs?
a.
During infancy, and once developed, such beliefs seldom change
b.
From life experiences during the toddler and preschool years
c.
Throughout life from firsthand experiences and information provided by authority
figures
d.
From teen and young-adult peer interaction and mentorship of professional role models
4. As the nurse explained the preoperative instructions to the patient, the patient's older brother
suddenly stepped into the doorway and yelled, “People who go under the knife always die.
Don't do it! They're going to kill you.” What type of higher-order belief is the patient's older
brother displaying?
a.
Distress
b.
Stereotype
c.
Prejudice
d.
Denial
5. After admitting a homeless patient to the floor, the nurse tells a colleague that “homeless
people are too dumb to understand instructions.” What action should the colleague take first?
a.
Ignore the nurse's prejudicial comment without responding.
b.
Offer to trade assignments and care for the homeless patient.
c.
Ask the nurse about the patient's personal history assessment data.
d.
Challenge the nurse's thinking, pointing out the ability of all people.
6. The nurse in the emergency department is caring for an 8-year-old who has had a serious
asthma attack. When the nurse attempts to explain the problem to the child's mother, she
smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been
smoking, and the mother responds, “Yes, and I know they've told me before I can't smoke
around him.” What should the nurse do next?
a.
Ask the patient's mother what she values more, her child or her habit.
b.
Ask the patient's mother to explain what she believes about smoking and asthma.
c.
Ask the patient's mother about her prejudicial attitude toward smoking.
d.
Confront the patient's mother about the values conflict she's experiencing.
7. A nurse is working with a 35-year-old patient who needs to decide whether to donate a
kidney to his brother who has been in renal failure for 5 years. The patient shares with the
nurse that the decision is especially difficult because he would not be able to continue to
work in his current profession and would be unable to support his three small children if he
ever needed dialysis. Which interventions would be most appropriate for the nurse to
implement in this situation? (Select all that apply.)
a.
Explain that it is unlikely that he will ever need dialysis even if he has only one kidney.
b.
Guide the patient through a values clarification process to help him make a decision
based on his values.
c.
Provide information the patient needs to help him make an informed decision.
d.
Ask for his permission to contact the kidney donation team to answer any questions he
may have.
e.
Assure him that everything will be alright since he is helping his brother.
8. A 57-year-old male patient who was hospitalized with an admitting blood pressure of
240/120 asked the nurse if his family could bring in some meat and vegetable dishes from
home. He explained that he cannot eat the foods on the hospital menu, because it is summer
and the hospital is only offering chicken and fish, which in his culture are “hot” foods that
will interfere with his healing. Which response by the nurse would best demonstrate an
application of Leininger's theory?
a.
Discourage the family from bringing in food, explaining that the idea of “hot” and
“cold” foods is a superstition without scientific basis.
b.
Negotiate home-prepared food options with the patient and his family to ensure that
treatment for the patient's blood pressure is supported.
c.
Explain that the patient will need to have home-prepared foods evaluated by the dietary
staff to ensure that they are acceptable options.
d.
Tell the family to bring in any foods they want, to help preserve the patient's cultural
practices and dietary preferences.
9. In Swanson's Caring Theory, the nurse demonstrates caring using several techniques. Which
intervention is appropriate and most important for the nurse to include in a patient's plan of
care?
a.
Call patients by their first name to demonstrate a caring attitude.
b.
Sit at the bedside for at least 5 minutes each hour.
c.
Use touch based on the nurse's judgment of what is appropriate.
d.
Ask the patient to identify the most important thing to accomplish during the nurse's
shift.
10. A new nurse is about to insert a nasogastric (NG) tube for the first time but is not sure what
equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who
is frightened and slightly confused. Which actions by the nurse would best demonstrate
caring? (Select all that apply.)
a.
Offer the patient pain medication to help her calm down.
b.
Hold the patient's hand while inserting the nasogastric tube.
c.
Speak calmly while explaining the procedure to the patient beforehand.
d.
Ask another, more experienced nurse for assistance before initiating care.
e.
Delay inserting the nasogastric tube until the patient's husband comes to visit.
Chapter 02: Values, Beliefs, and Caring
Review Questions (Online-Only)
MULTIPLE CHOICE
1. The best approach for a nurse who is performing an assessment on a patient from an ethnic group the
nurse knows nothing about is to:
a. use the information the nurse already knows about the other ethnic groups that may be similar
to the patient’s group to come up with assessment questions.
b. ask the same questions the nurse typically asks of all patients and not deviate from the
questions on the assessment form.
c. ask the patient to explain what he/she believes his/her health problem is and what he/she
thinks caused it.
d. ask the patient to help the nurse understand anything about the patient’s ethnic group that may
have a bearing on the patient’s health care needs.
2. A nurse who has always provided excellent patient care has become irritable, has made several errors
in care, and appears to undermine new policies and processes. What action by the nurse manager would
be most appropriate?
a. Discuss these new behavior traits and ask if the nurse has personal problems.
b. Gently remind the nurse of how important self-care activities are.
c. Confront the nurse and explain why these behaviors are not acceptable.
d. Gather data from the other staff members about how the nurse is functioning.
3. Which of the following actions by the nurse describes active listening?
a. Sitting at the patient’s bedside and listening to the patient talk while inserting an IV
b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation
c. Listening to what the patient says and what he/she means while conducting the early morning
assessment
d. Engaging both the patient and the family members while taking careful notes of the conversation
4. Which of the following actions by the nurse demonstrates “doing for” as described in Swanson’s
theory?
a. Going the distance
b. Thoroughly assessing
c. Seeking cues
d. Preserving dignity
5. A nursing student walks into the patient’s room and is unsure about when it is appropriate to use
caring touch in a nurse–patient care situation. What would the student do?
a. Ask the clinical instructor when and where touch would be appropriate.
b. Ask the patient for permission to touch him/her before proceeding.
c. Withhold touch to maintain professional boundaries.
d. Assume all patients want to be touched and that they see it as an act of caring.
6. A nurse shares with patients the tests and procedures they have scheduled for that day as well as when
to expect their medications or treatments. Even though the hospital is a hectic and unpredictable, the
nurse regards this information sharing as a way to demonstrate caring. What rationale behind these
actions is best?
a. Increases the patients’ sense of security.
b. Ease the patients’ fears.
c. Increases the odds of a favorable survey result.
d. Allows patients some flexibility in their schedules.
MULTIPLE RESPONSE
1. The nurse recognizes the importance of a patient’s beliefs in influencing the patient’s behaviors and
responses to health care problems. Which of the following are examples of a patient’s beliefs? (Select all
that apply.)
a. A patient explains that medication is reducing anxiety.
b. A patient reflects on her values to decide on breast reconstruction surgery.
c. A patient expresses a feeling of dread about the future to the nurse.
d. A patient who states he/she will go to heaven upon death.
e. A patient who states that most illnesses can be prevented or cured through diet.
2. A nurse is assessing a patient who recently emigrated from Japan and is a Buddhist. The patient told
the nurse that normally daily meditation and walking are part of a daily routine. Which questions would
be important for the nurse to ask before planning and implementing nursing care? (Select all that apply.)
a. What have you done to cope with your health problem?
b. What do you call your health problem?
c. What concerns you most about the recommended treatment plan?
d. What do you think caused your health problem?
e. What is the significance of walking daily?
Chapter 03: Communication
Review Questions
1. A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both
the patient and his wife become very concerned, and the patient's call light is activated. What
referent initiated communication between the patient and the nurse?
a.
Interaction between the patient and his wife
b.
Concern on the part of the patient's spouse
c.
Pain experienced by the patient
d.
Activation of the call light
2. Which factors influence whether a message is effectively communicated? (Select all that
apply.)
a.
Timing of the conversation
b.
Educational level of participants
c.
Mode of communication used
d.
Physical environment of discussion
3. If a patient is grimacing, what assessment statement or question would be most beneficial in
identifying the underlying cause of the nonverbal communication?
a.
“Did you lose something?”
b.
“You appear to be having pain.”
c.
“I will turn off the lights and let you rest.”
d.
“May I get you something to relieve your tension?”
4. What action by the nurse would most ensure accurate interpretation of patient
communication?
a.
Providing feedback regarding the conveyed message
b.
Writing down the patient's conversational highlights
c.
Assuming significant cultural differences exist
d.
Verifying the patient's emotional state
5. If a patient's verbal and nonverbal communications are inconsistent, which form of
communication is most likely to convey the true feelings of the patient?
a.
Written notes
b.
Facial expressions
c.
Implied inferences
d.
Spoken words
6. What strategy would be most effective in communicating with a highly anxious adult
immediately before surgery?
a.
Providing specific, concise instructions
b.
Detailing likely causes of their anxiety
c.
Focusing on postoperative details
d.
Using instructional multimedia DVDs
7. What action should the nurse take if an alert and oriented patient asks the nurse for personal
contact information?
a.
Ask the patient why the personal information is needed.
b.
Report the interaction to the nursing supervisor immediately.
c.
State that it would not be appropriate to share that information.
d.
Change the subject, and hope that the patient does not ask again.
8. What would be the best therapeutic response to a patient who expresses indecision about
recommended chemotherapy treatments?
a.
“Can you tell me why you are undecided?”
b.
“It's always a good idea to have chemotherapy.”
c.
“What are you thinking about the treatments at this point?”
d.
“You should follow whatever your health care provider recommends.”
9. Which statement is most accurate regarding symbolic expression?
a.
Skills confidence can be shared most effectively by nurses through wearing distinctive
clothing.
b.
Clothing choices by a hospitalized patient rarely reflects his or her economic resources.
c.
Make-up use by a patient is unnecessary for any reason during hospitalization.
d.
Nondramatic make-up use and minimal accessorizing by nurses demonstrates
professionalism.
10. Which defense mechanism is being exhibited when a 27-year-old patient insists on having a
parent present during routine care?
a.
Denial
b.
Regression
c.
Repression
d.
Displacement
MULTIPLE CHOICE
1. When a patient with stool incontinence and significant body odor is admitted to the floor from the
Emergency Department, what is the most appropriate first response of the nurse?
a. Treat the incontinence episode in a matter-of-fact manner.
b. Notify the ED personnel that transporting a patient in this condition is inexcusable.
c. Explain how daily hygiene is important while assessing the patient.
d. Assist the patient in getting cleaned up without expressing frustration.
2. Physical assessment of a patient requires the nurse to function most often in which area of a patient’s
space?
a. Personal
b. Social
c. Intimate
d. Public
3. Which action by a nurse demonstrates an understanding of diversity factors related to proxemics?
a. Assigning a male nurse to care for a young female Middle Eastern patient who needs total care
b. Standing at least 18” away from English-speaking patients when discussing medical concerns
c. Recognizing the need for greater personal space of people born in highly populated areas
d. Acknowledging the need of teens for greater physical contact than toddlers during hospitalization
4. In order to effectively communicate via written e-mail with patients from an outpatient facility, a
clinic nurse must implement which strategy?
a. Look for visual cues.
b. Verify shared information.
c. Listen for voice inflection.
d. Validate nonverbal signs.
5. In relationship to a nurse’s ability to communicate, effectiveness in which type of communication
most demonstrates professional competence?
a. Public
b. Small group
c. Interpersonal
d. Intrapersonal
6. Which action by a patient indicates participation in the working phase of an effective nurse–patient
helping relationship?
a. Sharing of pertinent demographic data
b. Exchanging of personal e-mail addresses
c. Reflecting on the emotional aspects of illness
d. Transitioning care to another health care provider
7. Which Nursing diagnosis would be most appropriate for a patient expressing frustration with his
inability to function independently following shoulder surgery?
a. Powerlessness
b. Social isolation
c. Anxiety
d. Fear
8. Which action by the nurse best demonstrates patient advocacy?
a. Asking a hospitalized patient’s name preference prior to care
b. Fostering autonomy and independent decision making
c. Arranging transportation home for a patient who is unable to drive
d. Sharing evidence-based practice data with other health care professionals
9. Which statement by the nurse best promotes reflection on a patient’s statement?
a. “I don’t quite follow what you are asking.”
b. “Tell me when you started having pain.”
c. “You seem excited to be going home.”
d. “Your vital signs are excellent today.”
MULTIPLE RESPONSE
1. What strategies would promote effective communication with a patient who is blind or deaf? (Select
all that apply.)
a. Provide adequate lighting when conversing with deaf patients.
b. Stay within 3 to 6 feet while speaking to a visually impaired patient.
c. Stay within 3 to 6 feet while speaking to a hearing-impaired patient.
d. Utilize an interpreter to explain medical procedures to a deaf patient.
e. Use light touch to arouse blind patients sleeping in a noisy environment.
Review Questions
1. The nurse receives change-of-shift report on the five assigned patients and reviews
prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this
information, the nurse chooses which patient to assess first. Which process of critical
thinking best describes the nurse's action?
a.
Problem solving
b.
Decision making
c.
Inference
d.
Reasoning
2. In approaching a new clinical situation, the nurse uses which question to facilitate precision
in critical thinking?
a.
“What do I know about this situation?”
b.
“What additional details do I need to gather?”
c.
“Does the clinical presentation correlate with the diagnosis?”
d.
“Are the treatments appropriate for the diagnosis?”
3. Which question would be most appropriate for the nurse to ask while evaluating the
relevance of patient data?
a.
Do these findings make sense?
b.
How can this information be verified?
c.
What are the most significant factors in the problem?
d.
What is the relationship of this information to other data?
4. The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is
unknown to the nurse. Guided by critical thinking, which action should the nurse take first?
a.
Ask the patient to describe the chief complaint
b.
Request that another nurse be assigned to this patient
c.
Review information about the medical diagnosis and routine management
d.
Complete a physical assessment of the patient
5. The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a
patient. Which actions by the nurse result from accurately employing the critical-thinking
skill of analysis in the nursing process? (Select all that apply.)
a.
Assessing the patient for symptoms of hypoxia
b.
Providing oxygen according to standing orders
c.
Elevating the head of the bed, if not contraindicated
d.
Allowing the patient to be alone to rest more comfortably
e.
Discussing adaptations needed for daily activities with the patient
6. Which of the following actions reflects inductive reasoning?
a.
Using subjective and objective data to confirm a diagnosis
b.
Assessing for specific clinical presentations based on a disease process
c.
Correlating elevated blood pressure to pathophysiology
d.
Validating an automatic blood pressure cuff reading with a manual measurement
7. The nurse is completing an assessment on a patient with sudden onset of abdominal pain.
During the assessment, the nurse considers similar presentations and the underlying
pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill
should the nurse use first to determine the cause of the patient's abdominal pain?
a.
Evaluation
b.
Interpretation
c.
Reflection
d.
Inference
8. The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select
all that apply.)
a.
Teamwork
b.
Intuition
c.
Judgment
d.
Conflict management
e.
Advocacy
f.
Reasoning
9. In providing care to a patient admitted to rule out human immunodeficiency virus (HIV)
infection, wearing gloves during which activity may be an indication of bias?
a.
Collecting the patient's medical history
b.
Initiating intravenous access
c.
Performing oral care
d.
Completing a bed bath
10. During the assessment of a patient admitted for a total hip replacement, the nurse asks the
patient to explain prior hospital experiences and, more specifically, any operative
experiences. These questions reflect the nurse's use of which intellectual standard of critical
thinking?
a.
Clarity
b.
Logic
c.
Precision
d.
Significance
Chapter 04: Critical Thinking in Nursing MULTIPLE CHOICE
1. A nurse is caring for a patient just diagnosed with diabetes mellitus. Which question by the nurse
demonstrates the use of the critical-thinking intellectual standard of significance?
a. “What information do I need to provide to teach the patient?”
b. “Do you understand how to administer your insulin?”
c. “What are the signs of low blood glucose?”
d. “How will this diagnosis impact your career?”
2. In providing care to a newly admitted patient, the nurse’s inferences are more accurate if based upon
which of the following?
a. Objective data
b. Assumptions
c. Intuition
d. Experience
3. During the postoperative assessment on a patient, the nurse has a “hunch” that the patient has a
postoperative complication based upon:
a. intuition.
b. interpretation.
c. information processing.
d. inference.
4. In using intuition to address a clinical problem, the expert nurse bases his/her approach upon which of
the following?
a. Judgment
b. Data collection
c. Experiential knowledge
d. Logical deduction
5. A new graduate nurse explains a new approach in the positioning of patients with chronic low back
pain. The nurse preceptor responds, “That is not the way we do it here.” The preceptor’s response
illustrates which error in critical thinking?
a. Lack of information
b. Erroneous assumptions
c. Illogical thinking
d. Bias
6. The nurse uses a case study presentation to present an educational offering to the staff on the unit.
This strategy improves the staff nurses’ critical thinking through which of the following?
a. Reviewing the literature
b. Practicing application of knowledge
c. Discussing with colleagues
d. Role playing
7. In preparing to administer medications to a patient, the nurse notes an unfamiliar medication. If the
nurse administers the medication without researching it first, this represents which error in critical
thinking?
a. Lack of information
b. Illogical thinking
c. Close-mindedness
d. Erroneous assumptions
MULTIPLE RESPONSE
1. The nurse uses critical thinking to interpret data. Which of the following data sources are objective?
(Select all that apply.)
a. Patient interview
b. Laboratory values
c. Body language
d. X-ray results
e. Vital signs
f. Breath sounds
2. In preparing for a certification examination, the nurse chooses to develop a concept map to help
understand the content. This strategy is based upon which characteristics of concept maps? (Select all
that apply.)
a. Facilitates note taking.
b. Requires thinking aloud.
c. Fosters making correlations between concepts.
d. Validates content with an expert.
e. Organizes visual data.
Yoost & Crawford: Fundamentals of Nursing: Active Learning for
Collaborative Practice, 2nd Edition
Chapter 05: Introduction to the Nursing Process
Review Questions
1. What is the purpose of the nursing process?
a.
Providing patient-centered care
b.
Identifying members of the health care team
c.
Organizing the way nurses think about patient care
d.
Facilitating communication among members of the health care team
2. A patient comes to the emergency department complaining of nausea and vomiting. What
should the nurse ask the patient about first?
a.
Family history of diabetes
b.
Medications the patient is taking
c.
Operations the patient has had in the past
d.
Severity and duration of the nausea and vomiting
3. An alert, oriented patient is admitted to the hospital with chest pain. From whom should the
nurse collect primary data on this patient?
a.
Family member
b.
Physician
c.
Another nurse
d.
Patient
4. What is the primary purpose of the nursing diagnosis?
a.
Resolving patient confusion
b.
Communicating patient needs
c.
Meeting accreditation requirements
d.
Articulating the nursing scope of practice
5. On what premise is a nursing diagnosis identified for a patient?
a.
First impressions
b.
Nursing intuition
c.
Clustered data
d.
Medical diagnoses
6. Which statement is an appropriately written short-term goal?
a.
Patient will walk to the bathroom independently without falling within 2 days after
surgery.
b.
Nurse will watch patient demonstrate proper insulin injection technique each morning.
c.
Patient's spouse will express satisfaction with patient's progress before discharge.
d.
Patient's incision will be well approximated each time it is assessed by the nurse.
7. What should be the primary focus for nursing interventions?
a.
Patient needs
b.
Nurse concerns
c.
Physician priorities
d.
Patient's family requests
8. Which nursing action is critical before delegating interventions to another member of the
health care team?
a.
Locate all members of the health care team.
b.
Notify the physician of potential complications.
c.
Know the scope of practice and competency of the other team member.
d.
Call a meeting of the health care team to determine the needs of the patient.
9. A patient reports feeling tired and complains of not sleeping at night. What action should the
nurse perform first?
a.
Identify reasons the patient is unable to sleep.
b.
Request medication to help the patient sleep.
c.
Tell the patient that sleep will come with relaxation.
d.
Notify the physician that the patient is restless and anxious.
10. What action should the nurse take regarding a patient's plan of care if the patient appears to
have met the short-term goal of urinating within 1 hour after surgery?
a.
Consult the surgeon to see if the clinical pathway is being followed.
b.
Discontinue the plan of care, because the patient has met the established goal.
c.
Monitor patient urine output to evaluate the need for the current plan of care.
d.
Notify the patient that the goal has been attained and no further intervention is needed.
Chapter 05: Introduction to the Nursing Process
Review Questions (Online-Only)
MULTIPLE CHOICE
1. What term best describes the nature of the nursing process?
a. Static
b. Linear
c. Dynamic
d. Predictable
2. A disoriented patient is admitted to the hospital accompanied by the spouse. From whom would the
nurse collect subjective data on this patient?
a. An experienced nurse on the unit
b. The patient’s medical record
c. The patient’s spouse
d. The provider
3. Prior to identifying accurate Nursing diagnoses, what action must be taken by the nurse?
a. Reading the patient’s history
b. Setting realistic, measurable goals
c. Comparing evidence-based practices
d. Clustering related patient data
4. A nurse has admitted a 5 year old to the post anesthesia unit following a tonsillectomy. The child is
stable but crying. What action does the nurse take first?
a. Tell the child that if he/she stops crying, the parents can visit.
b. Check to see what pain medication is ordered for the child.
c. Notify the surgeon of the child’s postoperative condition.
d. Assess the child to determine why he/she is crying.
5. Which statement is a correctly written example of an actual Nursing diagnosis?
a. Impaired memory related to patient complaint of becoming confused with the time change
b. Risk for injury related to stumbling when walking as evidenced by patient report of occasional
difficulty playing basketball
c. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by
dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity
d. Impaired health maintenance as evidenced by inability to complete activities of daily living related to
lack of familial support system
6. Which long-term goal is written correctly?
a. Patient will remain afebrile throughout hospitalization.
b. Patient will return to professional sports activities within 6 months.
c. Nurse will prevent bone infection through antibiotic therapy for 3 weeks.
d. Patient will demonstrate accurate use of crutches before discharge.
7. What phrase best describes the essence of critical thinking?
a. Understanding without conscious reasoning
b. Providing care based on nursing experience
c. Consulting with a primary care provider
d. Seeking solutions to problems
8. Which body is responsible for defining and disseminating information on Nursing diagnoses?
a. North American Nursing Diagnosis Association International
b. International and American Nurses Association
c. Individual State Boards of Nursing
d. The Joint Commission
9. The statement “ongoing collection of data” best describes which phase of the nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
10. Which statement illustrates the most measurable outcome indicator?
a. Demonstrates dressing change.
b. Shares innermost thoughts.
c. Understands instructions.
d. Shows personal remorse.
11. A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which
step of the nursing process does the nurse do first?
a. Planning
b. Assessment
c. Evaluation
d. Implementation
12. What is the focus of all nursing interventions?
a. Early hospital discharge for patients
b. Providing patient-centered care
c. Reduction of health care spending
d. Delegating appropriate nursing care
13. Which action will the nurse take 30 minutes after administering oral pain medication to a patient?
a. Evaluate the effectiveness of the administered pain medication.
b. Teach progressive relaxation strategies to relieve muscle tension.
c. Assess the patient’s coping skills to reduce expressed anxiety.
d. Encourage the patient to read or watch TV to provide pain distraction.
Chapter 16: Health and Wellness
Review Questions
1. Which of the listed basic needs identified by Maslow must be addressed first when providing
nursing care?
a.
Self-esteem
b.
Love and belonging
c.
Self-actualization
d.
Nutrition and elimination
2. Which activity best illustrates the use of the Health Promotion Model (HPM) by the nurse to
increase the level of well-being for a patient immediately after surgery?
a.
Holding a pillow across his chest when coughing and deep breathing
b.
Encouraging the patient to eat his entire evening meal
c.
Changing his surgical dressing daily as ordered by the physician
d.
Asking his family to step out of the room during dressing changes
3. A nurse providing preventive care to an overweight patient with a family history of diabetes
should engage in which priority care-planning activity for this patient?
a.
Calculating the patient's body mass index (BMI) and recommending a daily exercise
routine
b.
Instructing the patient to perform blood glucose monitoring once daily
c.
Giving the patient a month's supply of insulin needles and syringes
d.
Suggesting the patient participate in diabetes education classes offered at a local health
facility
4. An active older patient has been frequently evaluated for minor problems at the clinic since
the death of her husband 3 months earlier. During one of her visits, she states that she has no
energy to get through the day and no desire to keep up with her Tuesday night bridge club.
Which type of holistic health model intervention should the nurse employ to help the patient
cope with the loss of her husband?
a.
Encouraging prn use of antianxiety medication ordered by her provider
b.
Sharing the value of music therapy to address anxiety about her loss
c.
Explaining that she will be over the loss of her husband in a few months
d.
Encouraging a gradual reentry into social interaction and activities with friends
5. An 8-year-old girl is newly diagnosed with type 1 diabetes. The nurse may expect fear and
crying when teaching the child how to self-administer insulin injections due to which
influencing factor?
a.
Self-concept
b.
Self-esteem
c.
Developmental level
d.
Hierarchy of needs
6. Three weeks after delivery, a patient started a diet of 800 calories per day and started jogging
2 miles twice per day. The nurse recognizes the patient's behavior may be most influenced by
which motivating factor?
a.
Body image
b.
Environment
c.
Illness behavior
d.
Chronic illness
7. A 65-year-old male patient has been a one-pack-per-day smoker for 40 years. He was
recently diagnosed with chronic obstructive pulmonary disease (COPD) and would like to
attend a smoking cessation class. The nurse recognizes smoking cessation as which level of
prevention for this patient?
a.
Primary prevention
b.
Secondary prevention
c.
Statutory prevention
d.
Tertiary prevention
8. A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two
months later, the patient's wife calls the nurse's office because she is upset that her husband
has taken up motorcycle racing and has already been injured twice. The nurse knows that the
patient is experiencing a behavioral change in which factor due to the prognosis of his
illness?
a.
Spirituality
b.
Physical attributes
c.
Self-concept
d.
Personal affect
9. The nurse enters a patient's room and notices that the patient has not been out of bed since
the previous day. The patient states that his condition has made him bedridden, although the
nurse knows that he is capable of independent ambulation. Which type of reaction is the
patient exhibiting?
a.
Ambivalence to symptoms
b.
Illness behavior
c.
Diminished functional ability
d.
Overreaction to illness
10. A patient is seeking information about leading indicators that show the importance of health
promotion and illness prevention in the United States. To which government-sponsored
resource would the nurse refer the patient for the best comprehensive source of information?
a.
The American Cancer Society website
b.
The Healthy People 2020 website
c.
The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly
Report
d.
The American Association of Hospitals home page
Chapter 16: Health and Wellness
Review Questions (Online-Only)
MULTIPLE CHOICE
1. According to Maslow’s hierarchy of needs, the nurse understands that which element(s) must be
maintained first before a patient can reach self-actualization?
a. Self-esteem
b. Safety
c. Love and belonging
d. Nutrition
2. A patient recognizes that a family history of a terminal disease predisposes him to the same disease.
The nurse recognizes this realization as which component of the Health Belief Model?
a. Perception of susceptibility
b. Likelihood of action
c. Modification of factors
d. Adherence to factors
3. A patient undergoing chemotherapy for bone cancer states that using guided imagery in conjunction
with pain medications helps in tolerating bone marrow aspirations. The nurse recognizes guided imagery
as a component of which health promotion model?
a. The Health Function Model
b. Lifestyle Fatality Model
c. Model for Human Disease Progression
d. Holistic Health Model
4. A nurse approached an overweight patient about lifestyle modifications to reduce the risk for heart
disease. The patient demonstrates lack of perceived susceptibility by making which statement?
a. “I’m only a little overweight; there is no way I can have a heart attack.”
b. “I should lose a few pounds and try to exercise more often.”
c. “I don’t think a little weight loss is related to heart disease.”
d. “I will investigate the online Weight Watchers programs that helped me in the past.”
5. The nurse has assessed that the patient has the confidence in the ability to take action. What is this
concept is called?
a. Perceived benefits
b. Cues to action
c. Perceived severity
d. Self-efficacy
MULTIPLE RESPONSE
1. The nurse conducting community wellness events recognizes that which elements contribute to an
individual’s health and wellness? (Select all that apply.)
a. Age
b. Genetics
c. Access to health care
d. Culture
e. Environmental
f. Health policies
Chapter 19: Vital Signs
Review Questions
1. The nurse is measuring blood pressures as part of a community health fair. Which blood
pressure reading would cause the nurse to refer the patient for follow-up regarding
hypertension?
a.
108/70
b.
116/78
c.
128/80
d.
138/88
2. The nurse is admitting a stable patient for a minor outpatient procedure. What site would the
nurse most commonly use to assess pulse rate?
a.
Radial site
b.
Apical site
c.
Brachial site
d.
Carotid site
3. The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature
of 99.2° F (37.3° C) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular,
blood pressure of 178/112 mm Hg, and oxygen saturation of 96%. Which vital sign should
the nurse be most concerned about?
a.
Temperature
b.
Pulse
c.
Respirations
d.
Blood pressure
4. From the nurse's understanding, which statements regarding temperature and heat production
in the body are accurate? (Select all that apply.)
a.
Heat generates energy for cellular functions.
b.
Hormones, such as thyroid hormones, decrease metabolism and heat production.
c.
Exercise decreases heat production through muscular activity.
d.
Expected temperature readings vary by the route selected for measurement.
e.
Women tend to have more fluctuations in temperature than do men.
5. The nurse is performing an initial assessment of a patient with a severe infection at hospital
admission. Vital signs for the patient indicate hypotension and tachycardia. Which data
would support this evaluation?
a.
Pulse 78, blood pressure 140/88
b.
Pulse 86, blood pressure 120/76
c.
Pulse 100, blood pressure 118/68
d.
Pulse 114, blood pressure 88/56
6. The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved
with this treatment?
a.
Radiation
b.
Convection
c.
Conduction
d.
Evaporation
7. Which clinical patient scenario is associated with the most critical need for the nurse to
obtain vital signs?
a.
Ambulating for the first time after surgery
b.
Complaining of pressure in the chest
c.
Completing ambulating 100 feet after a stroke
d.
Complaining of hunger while NPO (nothing by mouth)
8. The nurse understands that which statement is correct regarding respiratory rates?
a.
Infants have a lower respiratory rate than adults.
b.
Healthy adults breathe between 12 and 20 times a minute.
c.
A compensatory response to a fever is to breathe at a slower rate.
d.
An increase in intracranial pressure results in an increased rate.
9. The nurse is caring for a patient who has a blood pressure of 184/110. An hour after
administering an antihypertensive medication, the nurse returns to recheck the blood
pressure, only to find the patient in the chair pale, sweaty, and feeling faint. Which is the
expected explanation for the nurse's observations?
a.
The blood pressure is 184/110; the medication has not had an effect.
b.
The blood pressure is 118/76; the sudden drop has caused the signs.
c.
The blood pressure is 174/96; the medication has made the patient sick.
d.
The blood pressure is 130/82; the symptoms are from another cause.
10. It is 6 a.m. and the unlicensed assistive personnel reports to the nurse that the patient has a
temperature of 96.7° F (35.9° C) tympanic. Which factor explains this reading?
a.
The patient's room is cold.
b.
The patient was drinking cold water.
c.
The patient is exhibiting a normal circadian rhythm.
d.
The patient just completed a warm shower.
Chapter 19: Vital Signs
Review Questions (Online-Only)
MULTIPLE CHOICE
1. The nurse notes that the patient has an irregular pulse. What action does the nurse take first?
a. Obtain the patient’s blood pressure.
b. Ask another nurse to take the pulse.
c. Assess the pulse for a full minute.
d. Finish the rest of the vital signs
2. Which assessment findings would require the nurse to assess the patient further?
a. A 20-year-old male with a pulse rate of 136 after running 2 miles
b. A 40 year old with a blood pressure of 110/70 when first awakened
c. A 72 year old with a respiratory rate of 10 breaths/min
d. A 50 year old with a pulse rate of 88 beats/min
3. The nurse is completing a postoperative assessment on a patient in the postanesthesia recovery unit.
Which vital sign requires further assessment by the nurse for possible hypovolemic (low blood volume)
shock?
a. An increase in heart rate
b. An increased temperature
c. A decrease in blood pressure
d. A decrease in respiratory rate
4. The nurse is caring for a patient with a temperature of 103°F (30.4°C), respirations of 30 per minute,
pulse rate of 50 beats/min, and blood pressure of 100/60 mmHg. The patient is cold and clammy. What
does the nurse conclude about these findings?
a. The temperature is causing a lowered pulse rate; it will improve if the temperature decreases.
b. The low pulse rate is causing a decreased cardiac output, which has caused a low blood pressure.
c. The pulse rate and blood pressure are compensatory mechanisms to decrease the increased metabolic
rate from the temperature.
d. The cool, clammy skin will help to increase the blood pressure and pulse as the body tries to warm the
skin.
5. The nurse is caring for a patient who was burned in a house fire. The right arm is heavily bandaged
and there is an intravenous line that was placed in the left forearm after three attempts. Which action
does the nurse take related to obtaining VS?
a. Use a Doppler machine to listen over the bandages.
b. A smaller cuff should be used to cover less of the upper arm.
c. The blood pressure should be taken on the popliteal artery.
d. The systolic pressure should be palpated from the radial artery.
6. The nurse is working in a rural community hospital that serves patients of all ages. Which decision by
the nurse shows the best judgment?
a. Taking an oral temperature in a 6-month-old infant
b. Taking a rectal temperature in a confused 78-year-old patient
c. Taking an axillary temperature in a newborn
d. Taking an oral temperature in a 26-year-old patient with dental extractions
7. After obtaining vital signs, which patient would the nurse see as the priority?
a. 1 year old, blood pressure 75/55 mmHg
b. 15 year old, blood pressure 115/70 mmHg
c. 6 year old, pulse of 125 beats/min
d. Newborn, pulse of 150 beats/min
MULTIPLE RESPONSE
1. Which actions by the nurse could result in a blood pressure measurement error? (Select all that
apply.)
a. Placing the diaphragm of the stethoscope over the brachial artery
b. Using the same cuff for all patients
c. Wrapping the bottom edge of the cuff over the antecubital space
d. Releasing the valve quickly to prevent patient discomfort
e. Taking a measurement after the patient rests quietly for 5 minutes
2. The nurse is caring for a patient who experienced a major trauma and has lost approximately 2 units
of blood. Which initial compensatory mechanisms would the nurse expect the patient to exhibit? (Select
all that apply.)
a. Increased blood pressure
b. Increased urinary output
c. Increased pulse rate
d. Decreased temperature
e. Decreased respirations
3. The nurse understands that which statements regarding blood pressure and blood pressure
measurement are true? (Select all that apply.)
a. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure.
b. The patient should be in a comfortable lying or sitting position when taking the blood pressure.
c. Maximum blood pressure is created in the arteries when the right ventricle pushes blood into the
aorta.
d. The difference between systolic pressure and diastolic pressure is known as pulse deficit.
e. The point on the gauge where the first faint but clear sound appears is known as diastolic
pressure
Chapter 20: Health History and Physical Assessment
Review Questions
1. Objective data can be gathered from the patient during which aspects of the physical
assessment process? (Select all that apply.)
a.
Patient interview
b.
Health history
c.
General survey
d.
Physical examination
e.
Laboratory testing
2. Which sequence best identifies the order in which the nurse should complete an abdominal
assessment?
a.
Inspection, palpation, percussion, auscultation
b.
Auscultation, inspection, palpation, percussion
c.
Auscultation, palpation, percussion, inspection
d.
Inspection, auscultation, palpation, percussion
3. During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a
carotid bruit. When are bruits audible in the neck?
a.
When jugular vein distention is present
b.
During normal examination of the neck
c.
When the carotid artery is partially occluded
d.
With complete occlusion of both carotid arteries
4. A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to
evaluate the patient's aortic valve?
a.
Second right intercostal space
b.
Third left intercostal space
c.
Fifth right intercostal space
d.
Fifth left intercostal space along the midclavicular line
5. Which assessment finding would be most important to document in a patient with known
liver disease who has a distended, taut abdomen?
a.
Abdominal girth
b.
Dentition condition
c.
Benign cardiac murmurs
d.
Daily ambulatory distance
6. The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which
potential cause would be considered of most concern, requiring further evaluation as soon as
possible?
a.
Loss of skin elasticity
b.
Levator muscle weakness
c.
Congenital ocular abnormality
d.
Oculomotor cranial nerve III paralysis
7. Which action by a patient with a family history of macular degeneration would demonstrate
use of a prevention strategy that has been found to help prevent deterioration of the macula?
a.
Using medicated eyedrops
b.
Avoiding the use of sunglasses
c.
Taking vitamin B6 and B12 supplements
d.
Minimizing dietary intake of antioxidants
8. The nurse begins the assessment of patient breath sounds and notes diminished breath sounds
at the base of the right lung. What action should the nurse take next?
a.
Refer the patient for a chest x-ray.
b.
Listen to the base of the patient's left lung.
c.
Notify the patient's primary care provider.
d.
Palpate the patient's lung fields bilaterally.
9. What actions should the nurse take to assess whether a patient with a left above-the-knee
amputation has adequate lower extremity circulation to the stump? (Select all that apply.)
a.
Palpate the stump for warmth.
b.
Assess pedal pulses bilaterally.
c.
Evaluate the left popliteal pulse rate.
d.
Inspect the stump and right leg for color.
e.
Check the left femoral pulse for strength.
10. Which action by the nurse would be most effective in determining whether a patient has
muscle hypertonicity?
a.
Watching the patient walk to the bathroom
b.
Asking the patient to squeeze both hands of the nurse
c.
Performing passive range-of-motion exercises with the patient
d.
Checking the patient's spine for the presence of postural irregularities
Chapter 20: Health History and Physical Assessment
Review Questions (Online-Only)
MULTIPLE CHOICE
1. When examining a patient’s hearing using the Weber test, the nurse would expect which of the
following results if the patient had an obstruction in the right ear?
a. The tone from a tuning fork is louder in the right ear.
b. The tone from a tuning fork is louder in the left ear.
c. The tone from a tuning fork is absent bilaterally.
d. The tone from a tuning fork is present equally in both ears.
2. When inspecting a patient with suspected nasal rhinitis, physical assessment of the nares would most
likely reveal:
a. patent nares with pink, moist membranes and clear discharge.
b. bright red, swollen mucosa and an upper respiratory infection.
c. pain with nasal breathing and nasal flaring when breathing cool air.
d. a lower respiratory infection and difficulty swallowing liquids.
3. When examining a patient’s cornea, which of the following physical assessment findings is a normal
occurrence?
a. The cornea is tested for visual acuity.
b. Corneal sensitivity is diminished in dark lighting.
c. No blood vessels should be present.
d. Absence of a blink response with stimulation.
4. Which type of lung sounds does the nurse expect to auscultate over most of the lung fields?
a. Vesicular
b. Resonant
c. Dull
d. Flat
5. A nurse is performing abdominal assessment in the following order: inspection, percussion and
palpation, and auscultation. Which effect can influence the nurse’s assessment results?
a. The intestines have been manipulated internally.
b. Peristalsis has increased due to external stimulation.
c. Bowel sounds can no longer be heard in all four quadrants.
d. The patient’s bladder was empty at the beginning of the exam.
6. A nurse is examining a 60-year-old female patient and notes swollen, hard, lymph nodes in the right
axilla. After documenting her results and reporting them to the patient’s provider, which question would
provide further insight into the patient’s condition?
a. “Do you perform monthly breast self-examinations?”
b. “Have you ever had strep throat?”
c. “Do you ever have heart palpitations?”
d. “When was your last pneumococcal vaccination?”
7. When evaluating a patient’s posterior thorax excursion, the nurse notices her right hand does not
move when the patient inhales deeply. What is the significance of this result?
a. The liver is damaged and blocking the diaphragm on the right side.
b. The right lung is inflated more than the left lung with inhalation.
c. The left lung has collapsed and is pushing against the right lung tissue.
d. The right lung is not expanding with inhalation.
8. An older patient complains about blurred vision and “halos” around lights at nighttime that have been
gradually worsening each year. The patient’s pupils are cloudy. The nurse recognizes the symptoms the
patient is experiencing can be caused by which of the following conditions?
a. Diabetic retinopathy
b. Strabismus
c. Hyperopia
d. Cataracts
Chapter 25: Safety
Review Questions
1. When teaching a patient about fire safety, which activity does the nurse know is the leading
cause of fire-related death?
a.
Cooking
b.
Playing with matches
c.
Smoking
d.
Heating with kerosene heaters
2. Which measures can the nurse teach to prevent poisoning of children? (Select all that apply.)
a.
Install safety latches on reachable cabinets.
b.
Keep syrup of ipecac on hand.
c.
Use childproof caps on medications.
d.
Use a plunger rather than a chemical drain cleaner.
e.
Keep cleaning supplies under the kitchen sink.
3. Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip
replacement who has confusion and incontinence?
a.
A room near the nurses’ station and decreased sensory stimuli
b.
A pressure sensor alarm and a room near the nurses’ station
c.
Side rails up and decreased sensory stimuli
d.
A 24-hour sitter and the patient's favorite TV program
4. The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is
a greater known risk factor for falls?
a.
Taking aspirin
b.
Urinary incontinence
c.
Multiple comorbidities
d.
Malnutrition
5. The nurse is aware that parents are being safety advocates when they do which of the
following?
a.
Keep a rear-facing car seat until the child is at least 12 months old.
b.
Limits the amount of TV and video viewing of school age children to 3 to 4 hours per
day.
c.
Asks the teenager to turn the headphone volume down when the music is audible to
others.
d.
Avoid painting in a house unless the temperature is above 60 degrees Fahrenheit.
6. An elderly client residing in the community with cardiopulmonary compromise and impaired
ability to perform activities of daily living (ADLs) presents safety concerns to the nurse.
Which is the greatest concern?
a.
Ability to obtain and take medications correctly
b.
Ability to safely get on and off a toilet
c.
Ability to safely procure food and prepare meals
d.
Ability to safely eat without choking
7. What other health care professional should the nurse consult first when a patient has
difficulty with activities of daily living (ADLs) such as bathing and dressing and why?
a.
Occupational therapist to evaluate the ability to perform ADLs
b.
Physical therapist to evaluate the patient's need for assistive devices
c.
Social worker to arrange for needed assistive devices
d.
Area agency on aging to arrange for Meals on Wheels
8. A 56-year-old man who has been staying at a cabin while hunting arrives at the emergency
department with complaints of dizziness, light-headedness, and nausea. What does the nurse
initially suspect?
a.
Lead poisoning
b.
Radon exposure
c.
Food poisoning
d.
Carbon monoxide poinsoning
9. Which activity would be most appropriate for the registered nurse (RN) to delegate to
unlicensed assistive personnel (UAP)?
a.
Assessing the patient for fall risk and complications of restraint use
b.
Evaluating the patient's ability to perform activities of daily living (ADLs)
c.
Assisting with or performing the patient's ADLs
d.
Teaching the patient use of assistive devices
10. When working with radiation diagnostics or treatments, which preventive measures should
be followed to avoid exposure? (Select all that apply.)
a.
Using lead shielding of patients and staff
b.
Keeping staff at the farthest distance possible from the radiation source
c.
Limiting the length of exposure
d.
Wearing a badge to monitor the length of exposure
e.
Following procedures and safety checks
Chapter 25: Safety
Review Questions (Online-Only)
MULTIPLE CHOICE
1. Which patient appears to be at greatest risk for falls?
a. 66 year old post-op, oriented x 3, taking opioid pain meds
b. 71 year old with pneumonia, oriented x 2, on oxygen and IV
c. 76 year old with acute confusion, knows name, incontinent, has an IV
d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications
2. A new nurse is caring for a patient who is restrained. Which action shows a good understanding of
caring for this patient?
a. Remove restraints q1h and inspect the skin.
b. Check on the patient every 30 minutes and ensure needs are met.
c. Renew restraint orders every shift.
d. Remove restraints as soon as patient’s condition allows.
3. When a fire occurs in a health care agency in which sequence should actions be performed?
a. Pull the alarm. Assist patients. Secure area by closing doors. Spray extinguisher.
b. Remove oxygen source. Aerate the fire. Call the operator. Evacuate patients.
c. Rescue the patients. Alarm sounded. Contain the fire. Extinguish fire.
d. Remove fire source. Alarm sounded. Close the doors. Evacuate patients.
4. For a school-age child who enjoys riding a bicycle, which is the priority Nursing diagnosis?
a. Risk for injury
b. Risk for acute pain
c. Risk for impaired skin integrity
d. Risk for impaired mobility
5. Select the most appropriate side rail regime for an elderly patient who intermittently calls for
assistance:
a. one top side rail raised on the patient’s dominant side.
b. two top side rails raised to promote bed mobility.
c. three side rails up with bottom rail closest to bathroom down.
d. four side rails up to prevent the patient getting up without assistance.
MULTIPLE RESPONSE
1. Which behavior by the nurse during medication administration is most likely to cause a medication
error? (Select all that apply.)
a. Verifies the patient’s identity calling the patient by name.
b. Calls the pharmacist to check on the medication dosage.
c. Takes a telephone call while preparing the medication.
d. Fails to weigh the patient prior to giving the medication.
e. Double-checks the right route before administering medication.
2. Which results from a form of pollution? (Select all that apply.)
a. Air pollution: hearing loss and elevated blood pressure
b. Land pollution: birth defects and cancer
c. Water pollution: disease and infection
d. Noise pollution: chronic lung disease and allergic symptoms
e. Agricultural pollution: birth defects
3. How can the nurse reduce procedure-related events? (Select all that apply.)
a. Maintaining clean technique when inserting an indwelling catheter
b. Checking nasogastric tube placement prior to a feeding
c. Identifying anatomical landmarks prior to giving IM injections
d. Performing quality control checks on blood glucose monitors
e. Using sterile technique when changing surgical dressings
4. Which clients present concerns for suffocation to the nurse? (Select all that apply.)
a. A toddler who is eating grapes
b. A school-age child eating a hot dog
c. A teenager who plays the “choking game”
d. An older adult who inadequately chews food
e. A middle aged adult with dentures
Chapter 26: Asepsis and Infection Control
Review Questions
1. The nurse is caring for a patient who has been diagnosed with methicillin-resistant
Staphylococcus aureus located in her incision. What transmission-based precautions will the
nurse implement for the patient?
a.
Private room
b.
Private, negative-airflow room
c.
Mask worn by the staff when entering the room
d.
Mask worn by the staff and the patient when leaving the patient's room
2. A new patient is admitted to a medical unit with Clostridium difficile. Which type of
precautions or isolation does the nurse know is appropriate for this patient?
a.
Airborne precautions
b.
Droplet precautions
c.
Contact precautions
d.
Protective isolation
3. In which situations does the nurse wear clean gloves as part of standard precautions? (Select
all that apply.)
a.
In the care of a patient diagnosed with an infectious process
b.
When the patient is diaphoretic
c.
During perineal care of each individual under treatment in the facility
d.
In the presence of urine or stool
e.
When taking the patient's blood pressure
4. The nurse is providing patient education on infection prevention. Which definition of an
infection does the nurse use as a teaching point?
a.
An illness resulting from living in an unclean environment
b.
A result of lack of knowledge about food preparation
c.
A disease resulting from pathogens in or on the body
d.
An acute or chronic illness resulting from traumatic injury
5. The nurse is caring for a patient who had abdominal surgery and has developed an infection
in the wound while hospitalized. Which agent is most likely the cause of the infection?
a.
Virus
b.
Bacterium
c.
Fungus
d.
Spore
6. A nurse is preparing to change a sterile dressing and has donned a pair of sterile gloves. To
maintain surgical asepsis, what else must the nurse do?
a.
Keep the amount of splashes on the sterile field to a minimum.
b.
If a sneeze is imminent, cover the nose and mouth with a gloved hand.
c.
With a moist saline sponge, use the dominant hand to clean the wound and then apply a
dry dressing.
d.
Regard the outer 1 inch of the sterile field as contaminated.
7. What is the proper order of removal of soiled personal protective equipment when the nurse
leaves the patient's room?
a.
Gown, goggles, mask, gloves, and exit the room
b.
Gloves, wash hands, remove gown, mask, and wash hands
c.
Gloves, goggles, gown, mask, and wash hands
d.
Goggles, mask, gloves, gown, and wash hands
8. Of the following hospitalized patients, who is most at risk for acquiring a health care–
associated infection?
a.
A 60-year-old who smokes two packs of cigarettes per day
b.
A 40-year-old who has an indwelling urinary catheter in place
c.
A 65-year-old who is a vegetarian and slightly underweight
d.
A 60-year-old who has a white blood cell count of 6000
9. A patient develops food poisoning from contaminated food. What is the means of
transmission for the infectious organism?
a.
Direct contact
b.
Vector
c.
Vehicle
d.
Airborne
10. Of the following assessment findings, which signs indicate to a nurse that a patient has a
surgical site infection? (Select all that apply.)
a.
Redness or warmth at the affected site
b.
Purulent drainage at the incision site
c.
Tenderness and localized pain
d.
Wound with well-approximated edges
e.
White blood cell count 6500 cells/mm3
MULTIPLE CHOICE
1. A nurse is making a home visit to a family of five children. The youngest, aged 5, has a temperature
of 101.1°F, is lethargic, and has a poor appetite. This assessment leads you to suspect influenza. Which
instruction by the nurse is inconsistent with knowledge about influenza?
a. Keep children home from day care and school while symptoms are present.
b. Remind family that they only need to wash their hands if they are visibly dirty.
c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission.
d. Encourage the family to receive their annual influenza vaccine.
2. When caring for a patient with rubella, in addition to standard precautions, which precautions would
be used?
a. Droplet precautions
b. Airborne precautions
c. Contact precautions
d. Universal precautions
3. During normal patient care that does not soil hands, effective hand hygiene between patients requires:
a. at least a 20-second soap and water scrub.
b. at least a 23-minute scrub with antimicrobial soap.
c. use of an alcohol-based antiseptic hand sanitizer.
d. wearing a mask while scrubbing is occurring.
4. A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The
priority Nursing diagnosis for this patient is:
a. Impaired Nutritional Intake related to immobility
b. Impaired Mobility related to pain and discomfort.
c. Chronic Pain related to overweight.
d. Risk for Infection related to altered skin integrity.
5. Of the following patients, which patient is at a higher risk of infection?
a. 27 year old who is an athlete
b. 60 year old with arthritis
c. 12 year old with a broken leg
d. 36 year old with HIV
MULTIPLE RESPONSE
1. The nurse is caring for a patient who has of methicillin-resistant Staphylococcus aureus (MRSA).
Which of the following infection-control practices should the nurse implement for this patient? (Select
all that apply.)
a. Wear a protective gown when entering the patient’s room.
b. Don a particulate respirator mask when administering medication.
c. Ensure that all staff serving the patient’s meal trays don gloves prior to delivery.
d. Instruct all visitors to wear a surgical mask when entering the room.
e. Use sterile gloves when performing dressing changes.
f. Use a face shield before irrigating the patient’s wounds.
2. The student nurse learns that the components of the chain of infection include which of the following?
(Select all that apply.)
a. Infectious agent
b. Mode of transmission
c. Portal of entry
d. Reservoir
e. Vehicle of movement
Chapter 27: Hygiene and Personal Care
Review Questions
1. An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails.
The patient's toenails are long and thick. What is the next step the nurse should take?
a.
Soak the patient's feet, and trim her toenails using clippers.
b.
Delegate foot care of this patient to the unlicensed assistive personnel (UAP).
c.
Assess the patient's self-care abilities.
d.
Ask the primary care provider (PCP) for a referral to a podiatrist.
2. An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis
of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and
has a foul body odor. Asking which hygiene-related assessment question is a priority for the
nurse?
a.
“Do you have friends or family nearby?”
b.
“Can you raise your arms up to brush your teeth?”
c.
“Do you become short of breath during your shower?”
d.
“Are you able to get in and out of your bed at home?”
3. Which action by a female patient lets the nurse know the patient has understood perineal care
teaching?
a.
The patient washes her perineum with a circular motion beginning at the urinary meatus.
b.
The patient washes her perineum from front to back using a clean washcloth.
c.
The patient washes her perineum from back to front with long, firm strokes.
d.
The patient washes her perineum lightly to prevent tissue damage.
4. What should the nurse do before leaving a patient's room after giving a complete bed bath?
a.
Place the call light within reach so the patient can call for help if needed, and leave the
bed as it was during the bath.
b.
Lower the bed to its lowest position, raise all four side rails so that the patient does not
fall out of bed, and place the call light within reach.
c.
Lower the bed to its lowest position, raise the top two side rails to assist the patient in
turning and positioning, and place the call light within reach.
d.
Leave the bed in a position that is comfortable for the caregiver because more care will
be needed, raise the top two side rails, and place the call light within reach.
5. Which actions by the nurse concerning oral care for an unconscious patient are considered
safe? (Select all that apply.)
a.
Performing oral care with the patient in a supine position
b.
Performing oral care with the patient turned to the side
c.
Installing suction equipment at the bedside
d.
Providing oral care every 2 hours
e.
Using a hard-bristle toothbrush
6. Which safety precaution is a priority for the nurse when bathing a patient with peripheral
neuropathy?
a.
Keeping the top two side rails up during the bath
b.
Checking the bath water temperature before the bath
c.
Encouraging independence with perineal care during the bath
d.
Facilitating range-of-motion exercises and dangling before the bath
7. Which nursing diagnosis is a priority for a patient who needs assistance with activities of
daily living?
a.
Self-Care Deficit
b.
Lack of Knowledge
c.
Activity Intolerance
d.
Able to Perform Self-Care
8. Which statements are true regarding back massage? (Select all that apply.)
a.
Only a licensed massage therapist can perform back massage.
b.
Back massage may stimulate the deep muscles.
c.
Massage provides relaxation and comfort.
d.
Tapotement stimulates the skin.
e.
A massage may promote sleep.
9. A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement
is true about this shampoo?
a.
It can be used only on patients with the ability to stand in the shower.
b.
It can cause central nervous system side effects, including dizziness.
c.
It is used by pregnant women and young children.
d.
It is safe for patients with seizures or epilepsy.
10. Which statement indicates an understanding by the unlicensed assistive personnel of eye care
during a patient's bath using washcloths and a bath basin?
a.
“The eyes are washed with soap and water from the inner canthus to the outer canthus.”
b.
“The eyes should always be washed using sterile normal saline and a gauze sponge.”
c.
“The eyes are washed from the outer canthus to the inner canthus using water only.”
d.
“The eyes are washed with water using a clean part of the washcloth for each eye.”
MULTIPLE CHOICE
1. Which area of the body is most likely to be excoriated?
a. Elbows
b. Facial skin
c. Cervical spine
d. Perineum
2. Which nursing action is necessary for patient safety during a bed bath?
a. All four side rails are always kept in the raised position during the bath.
b. The bed is always in the low and locked position while bathing the patient.
c. The top side rail is raised opposite the side where the nurse is standing.
d. The bed is always kept in a flat position with a pillow under the patient’s head.
3. Which statement accurately describes proper technique for performing male perineal care? The nurse:
a. washes the patient from the back of the perineum toward the penis.
b. washes with a circular motion starting with the urinary meatus.
c. places the patient in the prone position with supporting pillows.
d. places the patient in the dorsal recumbent position.
4. The nurse has delegated care of a patient’s dentures to unlicensed assistive personnel. Which
statement by the assistive personnel indicates a good understanding of denture care?
a. “It is not necessary to use a toothbrush in the patient’s mouth since the patient does not have teeth.”
b. “I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside
table.”
c. “I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste.”
d. “I will soak the dentures in the sink and then place them in a denture cup labeled with the patient’s
name.”
5. Which assessment finding by the nurse indicates a complication from oxygen via nasal cannula?
a. Dry nasal passages
b. Inability to speak clearly
c. Increased nasal drainage
d. Skin breakdown on the chin
6. Which statement is most accurate about hearing aid and ear care for hospitalized patients who are
hard of hearing?
a. Hard of hearing patients should wear hearing aids at all times while hospitalized.
b. Hearing aids should be cleansed daily with soap and water before reinsertion.
c. Cerumen is removed with a cotton-tipped applicator before inserting hearing aids.
d. Hearing aids are cleansed with a dry cloth and stored in a labeled container.
7. Which procedure is correct when making an occupied bed?
a. The bed is left in the low and locked position for patient safety.
b. The bed is made starting at the head and working toward the feet.
c. Soiled linen is loosened on one side of the bed and rolled under the patient.
d. Making an occupied bed cannot be delegated to unlicensed assistive personnel.
8. Which statement by a patient with the Nursing diagnosis of Self-Care Deficit would indicate
attainment of the goal: Patient will actively participate in bathing within 24 hours after surgery?
a. “I need help with my bath.”
b. “I was able to wash my own feet today.”
c. “I am going to need assistance at home.”
d. “Could you help me brush my teeth this morning?”
MULTIPLE RESPONSE
1. Which statements are correct concerning bathing a hospitalized patient? (Select all that apply.)
a. A complete bed bath is for patients who are bedridden.
b. All hospitalized patients need a complete bed bath.
c. Bathing removes dead skin, bacteria, and body fluids.
d. Male personnel must always perform male perineal care.
e. Keeping skin clean and dry helps prevent breakdown.
2. Which hygienic care instructions by the nurse would be given to a patient who is being discharged on
an anticoagulant? (Select all that apply.)
a. Use an electric razor for shaving.
b. Brush teeth with a soft toothbrush.
c. Trim beard with double blade safety razor.
d. Use caution when trimming nails with clippers.
e. Deeply massage unused muscles while bathing.