1. A nurse is administering influenza immunizations at a local clinic. What level of disease
prevention is the nurse demonstrating?
Primary
2. An elderly client has impaired sensation in her lower extremities. What educational statement
would be necessary to reduce her risk of injury?
Always test the temperature of the bath before stepping in
3. A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which
information should be provided to the NAP delegated to take her temperature? (Select all that
apply.)
The patient's age.
The type of temperature required.
The patient's diagnosis.
The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
4. Which of the following situations may affect a patient's vital signs? (Select all that apply.)
Time of day.
Occupation.
Moving from lying to standing position.
Pain rated as a 7 on 0-10 pain scale.
Isolation precautions.
5. You are supposed to take your patient's vital signs preoperatively and record them on the
patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital
signs preoperatively? (Select all that apply.)
To see if the patient is "feeling funny."
To provide a set of vital signs to use for comparison during and after surgery.
To make sure the patient is not experiencing any complications such as a high fever that may
contraindicate surgery or require intervention at this time.
To provide the patient with reassurance that he or she is being cared for by a competent staff
6. A nurse is caring for a patient in the ICU who is being moni- tored for a possible cerebral
aneurysm following a loss of consciousness in the emergency room. The nurse anticipates
preparing the patient for ordered diagnostic tests. This nurse's knowledge of the diagnostic
procedures for this condition reflects which aspect of nursing?
a. The art of nursing
b. The science of nursing
The science of nursing is the knowledge base for care that is provided. In contrast, the skilled
application of that knowledge is the art of nursing. Providing holistic care to patients based on
the science of nursing is considered the art of nursing
c. The caring aspect of nursing
d. The holistic approach to nursing
7. In early civilizations, the theory of animism attempted to explain the mysterious changes
occurring in bodily functions. Which statement describes a component of the development of
nursing that occurred in this era?
a. Women who committed crimes were recruited into nursing the sick in lieu of serving jail
sentences.
b. Nurses identified the personal needs of the patient and their role in meeting those needs.
c. Women called deaconesses made the first visits to the sick and male religious orders cared for
the sick and buried the dead.
d. The nurse was the mother who cared for her family during sickness by using herbal remedies
8. World War II had a tremendous effect on the nursing profession. Which development occurred
during this period?
a. The role of the nurse was broadened.
b. There was a decreased emphasis on education.
c. Nursing was practiced mainly in hospital settings.
d. There was an overabundance of nurses.
9. Which phrase describes the purpose of the ANA's Nursing's Social Policy Statement? Select
all that apply.
a. To describe the nurse as a dependent caregiver
b. To provide standards for nursing educational programs
c. To define the scope of nursing practice
d. To establish a knowledge base for nursing practice
e. To describe nursing's social responsibility
f. To regulate nursing research
10. One of the four broad aims of nursing practice is to restore health. Which examples of
nursing interventions reflect this goal? (Select all that apply).
a. A nurse counsels adolescents in a drug rehabilitation
program.
b. A nurse performs range-of-motion exercises for a patient on bedrest.
c. A nurse shows a diabetic patient how to inject insulin.
d. A nurse recommends a yoga class for a busy executive.
e. A nurse provides hospice care for a patient with end-stage cancer.
f. A nurse teaches a nutrition class at a local high school
11. Nursing is recognized increasingly as a profession based on which defining criteria? (Select
all that apply).
a. Well defined body of general knowledge
b. Interventions dependent upon the medical practice
c. Recognized authority by a professional group
d. Regulation by the medical industry
e. Code of ethic
f. Ongoing research
12. A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing
is necessary to practice at this level?
a. LPN
b. ADN
c. BSN
d. MSN
13. Nurse practice acts are established in each state of the United States to regulate nursing
practice. What is a common element of every state practice act?
a. Defining the legal scope of nursing practice
b. Providing continuing education programs
c. Determining the content covered in the NCLEX
examination
d. Creating institutional policies for health care practices
14. The National Advisory Council on Nurse Education and Practice identifies critical challenges
to nursing practice in the 21st century. What is a current health care trend contributing to these
challenges?
a. Decreased numbers of hospitalized patients
b. Older and more acutely ill patients
c. Decreasing health care costs due to managed care
d. Slowed advances in medical knowledge and technology
15. When you ask an experienced nurse why it is necessary to change the patient's bed every day,
the nurse says, "I guess we have just always done it that way." This answer is an example of
what type of knowledge?
a. Instinctive knowledge
b. Scientific knowledge
c. Authoritative knowledge
d. Traditional knowledge
16. Which nursing actions reflect the use of philosophy as a knowledge base when delivering
evidence-based care to patients? (Select all that apply).
a. A nurse interviews and examines a new patient
diagnosed with prehypertension to formulate a
care plan.
b. A nurse draws from personal experiences of being a
patient to establish a therapeutic relationship with a
patient.
c. A nurse searches the Internet to find the latest treatments for type 2 diabetes.
d. A nurse uses spiritual training to draw strength when counseling a patient who is in hospice
for an inoperable brain tumor.
e. A nurse follows the protocol for assessing postoperative patients in the ICU.
f. A nursing student studies anatomy and physiology of the body systems to understand the
disease states of assigned patients.
17. A nurse is using general systems theory to describe the role of nursing to provide health
promotion and patient teaching. Which statements reflect key points of this theory? (Select all
that apply).
a. A system is a set of individual elements that rarely interact with each other.
b. The whole system is always greater than its parts.
c. Boundaries separate systems from each other and their environments.
d. A change in one subsystem will not affect other
subsystems.
e. To survive, open systems maintain balance through
feedback.
f. A closed system allows input from and to the environment.
18. A charge nurse meets with staff to outline a plan to provide transcultural nursing care for
patients in their health care facility. Which theorist promoted this type of caring as the central
theme of nursing care, knowledge, and practice?
a. Madeline Leininger
b. Jean Watson
c. Dorothy E. Johnson
d. Betty Newman
19. A student nurse interacting with patients on a cardiac unit recognizes the four concepts in
nursing theory that determine nursing practice. Of these four, which is most important?
a. Person
b. Environment
c. Health
d. Nursing
20. A nurse manager schedules a clinic for the staff to address common nursing interventions
used in the facility and to explore how they can be performed more efficiently and effectively.
What is the term for this type of theory affecting change in clinical nursing practice?
a. Prescriptive theory
b. Descriptive theory
c. Developmental theory
d. General systems theory
21. A nurse is formulating a clinical question in PICO format. What does the letter P represent?
a. Comparison to another similar treatment
b. Clearly defined, focused literature review
c. Specific identification of the desired outcome
d. Explicit descriptions of the population of interest
The P in the PICO format represents an explicit description of the patient population of interest.
The I represents the intervention, C represents the comparison, and O stands for the outcomes
22. A nurse provides care based on Maslow's hierarchy of basic human needs. For which nursing
activities is this approach useful?
a. Making accurate nursing diagnoses
b. Establishing priorities of care
(Maslow's hierarchy of basic human needs is useful for establishing priorities of care.)
c. Communicating concerns more concisely
d. Integrating science into nursing care
23. The nurse is prioritizing nursing care for a patient in a long-term care facility. Which
examples of nursing interventions help meet physiologic needs? Select all that apply.
a. Preventing falls in the facility
b. Changing a patient's oxygen tank
c. Providing materials for a patient who likes to draw
d. Helping a patient eat his dinner
e. Facilitating a visit from a spouse
f. Referring a patient to a cancer support group.
Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity,
and rest—must be met at least minimally to maintain life. Providing food and oxygen are
examples of interventions to meet these needs. Preventing falls helps meet safety and security
needs, providing art supplies may help meet self-actualization needs, facilitating visits from
loved ones helps meet self-esteem needs, and referring a patient to a support group helps meet
love and belonging needs.
24.The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques
when handling patients. Which of Maslow's basic human needs is being met by this nurse?
a. Physiologic
b. Safety and security
c. Self-esteem
d. Love and belonging
25. The nurse caring for patients in a long-term care facility knows that the highest level on
Maslow's hierarchy of needs is self-actualization needs. Which statements accurately describe
the achievement of self-actualization? (Select all that apply.)
a. Humans are born with a fully developed sense of self-actualization.
b. Self-actualization needs are met by depending on others for help.
c. The self-actualization process continues throughout life.
d. Loneliness and isolation occur when self-actualization needs are unmet.
e. A person achieves self-actualization by focusing on problems outside self.
f. Self-actualization needs may be met by creatively solving
problems.
26. A nurse works with families in crisis at a community mental health care facility. What is the
best broad definition of a family?
a. A father, a mother, and children
b. A group whose members are biologically related
c. A unit that includes aunts, uncles, and cousins
d. A group of people who live together and depend on each other for support
27. A nurse performs an assessment of a family consisting of a single mother, a grandmother,
and two children. Which inter- view questions directed to the single mother could the nurse use
to assess the affective and coping family function? (Select all that apply).
a. Who is the person you depend on for emotional support?
b. Who is the breadwinner in your family?
c. Do you plan on having any more children?
d. Who keeps your family together in times of stress?
e. What family traditions do you pass on to your children?
f. Do you live in an environment that you consider safe?
28. The clinical nurse educator at a long-term care facility is responsible for organizing and
carrying out staff education sessions. Which of the following topics for the all-staff education is
most likely to benefit the greatest number of residents?
- Education nurses on how to prevent falls
29. The student nurse knows mobility contributes to positive outcomes throughout the body.
What is a positive effect of mobility on the respiratory system?
prevention of respiratory secretions from pooling
30. Identify the statement that is not therapeutic communication?
The nurse educates the client by stating "what you did was wrong. You shouldn't do that"
31. When caring for a client who is visually impaired, the nurse will do which of the following?
Explain the reason for touching the client before doing so
32. A nurse is planning care for a 17-year-old following a motor vehicle accident. Which of
Erickson's developmental stages should the nurse keep in mind in the planning?
Identity vs. Role Confusion
33. A nurse is admitting a client to a geriatric medicine unit following the client's recent
diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce
the client's chance of experiencing a fall while on the unit?
orient the client to the room and environment thoroughly upon admission
34. The student nurse knows lack of mobility contributes to negative outcomes throughout the
body. What is a negative effect of immobility on the cardiovascular system?
Thrombus Formation
35. A charge nurse is implementing the ISBARR communication tool for nurses and physicians.
How can the nurse help to reduce resistance to this change?
explain the change by listing advantages to nurses, physicians and patients
36. A nursing student is conducting a literature review to find evidence-based practice (EBP)
standards for the nursing care of clients diagnosed with diabetes. The student nurse knows that
the first step in this process is to locate reputable sources of information. Which sources below
would not be appropriate for the nursing student to use for the literature review?
Medline: an online database of health care related journals
Diabetes Care: a peer reviewed journal published by the American Diabetes Association
Cumulative Index to Nursing and Allied Health Literature
37. A child is admitted to the emergency department with a fractured arm. During the admission
interview, the nurse should implement what communication technique to elicit the most
information from the parents?
Clarifying questions
38. The student nurse knows lack of mobility contributes to negative outcomes throughout the
body. What is a negative effect of immobility on the musculoskeletal system?
Contracture
39.All individuals, according to Maslow's Hierarchy of Needs, have which of the following?
Basic human needs
40. What charting entry would be the most defensible in court?
The client has 3 + edema to left lower medial ankle
41. A nursing instructor has assigned a student to care for a client of Asian descent. The
instructor reminds the student that personal space considerations vary among cultures. What
personal space preferences are important for the student to consider when caring for this client?
They tend to prefer some distance between themselves and others
42. Examples of evidence-based practice (EBP) include which of the following? (Select all that
apply)
-Catheter associated urinary tract infectious practice alert
-prevention of pressure ulcers
-pain assessment - fifth vital sign
43. Barriers to evidence-based practice (EBP) include which of the following?
an organizational culture that does not support change
44. What is the primary purpose of an incident report?
Quality Improvement
45. The World Health Organization (WHO) defines health as which of the following?
A state of complete physical, mental, and social well-being, and not merely the absence of
disease or infirmity
46. A nurse has completed an informed consent form with a client. The client then states, "I have
changed my mind and do not want to have the procedure done." What action should the nurse
take?
notify the surgeon that the client wishes to withdraw informed consent from procedure
47. What drawbacks does charting by exception (CBE) have?
Vulnerability to legal liability since the nurse's safe, routine care is not recorded
48. What is one of the most significant trends in health care today?
shift from hospitals to community-based care
49. When assessing a client's blood pressure manually, the nurse can use which arteries? (Select
all that apply).
-Brachial
-Radial
-Popliteal
50. When a labor and delivery nurse tells a coworker that an Asian client probably did not want
any pain medication because "Asian women typically are stoic," the nurse is expressing what?
Stereotype
51. The documentations states, "patient is highly satisfied with her spiritual wellness." What
supporting documentation supports the highest spiritual wellness?
Having peace and harmony with your values and actions
52. Before developing a procedure, a nurse reviews all current research-based literature on
insertion of a nasogastric tube. What type of nursing will be practiced based on this review?
EBP
53. A nurse is documenting care given to a client with a new right leg amputation. The nurse
accidentally documents a dressing change was performed on the left leg. What would be the best
action to correct this error?
Draw a single line through the entry, write mistaken entry, and initial it
54. Nurses are responsible for making sure their educational background and clinical experience
are adequate to fulfill the nursing responsibilities delineated by the job description. What is one
way to violate this responsibility?
Accepting assignments that the nurse feels are unsafe
55. A nurse is collecting data from a client who has required strict bedrest for 1 week. What
should the nurse identify as an indication that the client is ready to ambulate?
Performs active ROM exercises of all extremities
56. When evaluating a resident for transition from a long-term care facility to a home
environment, what may the nurse ask the resident to perform?
ADL’s
57. A group of nurses are planning to investigate the effectiveness of turning immobilized stroke
clients' more frequently in order to prevent skin breakdown. The team has begun by formulating
a PICO question. Which of the following will the "O" in the team's PICO question refer to?
Preventing skin breakdown
58. Nurses provide many interventions to prevent falls in health care settings. What would be an
appropriate intervention to prevent falls?
lock wheels on beds and wheelchairs