Chapter1:
1.A patient is having adverse effects resulting from a medication. The nurse calls the primary
care provider to request a change in the medication order. The nurse is functioning as
a/an
A.educator.
B.advocate.
C.organizer.
D.counselor.
2.Nurses advocate for underserved populations to reduce health disparities. This promotes
A.autonomy.
B.altruism.
C.respect.
D.human dignity.
3.Nurses belong to the ANA as part of their
A.ongoing professional responsibility.
B.role as manager of care.
C.wellness promotion for patients.
D.cultural education activities.
4.The purpose of health assessment is to
A.obtain subjective and objective data.
B.intervene to correct difficulties.
C.outline appropriate care.
D.determine whether interventions are effective.
5.The nurse documents the following information in a patient’s chart: “Cough and deep
breathe every hour while awake.” This is an example of
A.evidence-based nursing.
B.priority setting.
C.comprehensive assessment.
D.nursing interventions.
6.The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse
assesses that the patient is concerned because his father died from lung cancer. Which
theory would the nurse most likely use when providing teaching to this patient?
A.Health belief model
B.Diagnostic reasoning model
C.Cultural competence model
D.Body systems model
7.Which of the following processes is the most important when providing nursing care to an
ill patient?
A.Writing outcomes
B.Performing a focused assessment
C.Collecting objective data
D.Using critical thinking
8.A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is
the nurse most likely to perform on admission?
A.Emergency
B.Focused
C.Comprehensive
D.Illness
9.Which of the following are components of a comprehensive health assessment?
A.Nursing diagnoses
B.Goals and outcomes
C.Collaborative problems
D.Examination of body systems
10.The nurse conducts the health history based on the patient’s responses to the medical
diagnosis. This type of framework is based on the
A.functional framework.
B.objective framework.
C.coordinator framework.
D.collaborative framework.
Key Points
•The role of the professional nurse is to promote health, prevent illness, treat human responses, and
advocate for patients.
•Nurses are providers, designers, managers, and coordinators of care as well as advocates and
educators.
•Nursing values include respect, unity, diversity, integrity, and excellence.
•Health can be conceptualized as a point between wellness and illness, as either a high or a low level
of health.
•Healthy People is a United States government initiative to focus on health promotion and risk
reduction strategies.
•The four main goals of nursing are to promote health; prevent illness; treat human responses to
health and illness; and advocate for individuals, families, and communities.
•Steps of the nursing process include assessing, diagnosing, setting goals and outcomes, planning,
intervening, and evaluating.
•Critical thinking is the key to resolving problems.
•Diagnostic reasoning is a process by which nurses use critical thinking to cluster the assessment
information and to draw inferences and propose diagnoses.
•Types of assessments are emergency, comprehensive, and focused assessments.
 Comprehensive physical exam includes all body system, heat to toe format
 Focused assessmen is based on health issues
•Subjective data are based on the patient’s experiences and perceptions.
•Objective data are measurable and usually collected as part of the physical assessment.
•Organizing frameworks for assessment include functional, head-to-toe, and body systems.
•Evidence-based nursing relies on research findings and high-grade scientific support.
Chapter 2:
1.A patient says that she is having throbbing pain that she rates as 6 on a 10-point scale. This
is referred to as
A.subjective primary data.
B.subjective secondary data.
C.objective primary data.
D.objective secondary data.
2.The nurse is gathering the health history data before performing the physical assessment.
This phase of the interview process is the
A.preinteraction phase.
B.beginning phase.
C.working phase.
D.closing phase.
3.The patient is crying after being given a diagnosis with a poor prognosis. The best
response from the nurse is
A.“Don’t cry. It will be OK.”
B.“My mother has the same thing.”
C.“I think that you should have surgery.”
D.“I’ll stay with you” (gets a tissue).
4.When gathering the family history, the nurse draws a genogram
A.using circles for males and squares for females.
B.putting the patient on the left to show birth order.
C.inserting lines between parents to show marriage.
D.listing health problems above the symbol for the patient.
5.The mother of an infant with severe asthma is extremely anxious. The nurse is treating the
patient in the emergency room. When collecting the history, the best response of the
nurse is
A.“You must be extremely worried.”
B.“I’d be in worse shape than you are if it were my baby.”
C.“Is there anyone here that you can talk to?”
D.“You seem worried, but I need to ask a few questions.”
6.The nurse asks, “What are the most important things to you in life?” to assess the
functional pattern related to
A.role.
B.self-perception.
C.coping.
D.values.
7.To assess self-perception, the nurse asks
A.“How would you describe yourself?”
B.“Are you having difficulty handling any family problems?”
C.“What gives you hope when times are troubled?”
D.“How do you usually deal with stress? Is it effective?”
8.The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home
maintenance, shopping, and cooking is assessing
A.whether the patient is a reliable historian.
B.functional health patterns.
C.ADLs. Activities of daily living
D.review of systems.
9.The nurse assessing an older adult focuses the health history on
A.previous pregnancies, obstetrical history, and psychosocial factors.
B.birth history, immunizations, and growth and development.
C.sensory deficits, illness history, and lifestyle factors.
D.religion, spirituality, culture, and values.
10.The nurse performs patient teaching after assessing that the nutritional history reveals
that the patient generally consumes a high-fat, high-calorie diet. This critical thinking
A.uses subjective data to analyze findings and intervene.
B.documents and communicates data using appropriate medical terminologies.
C.individualizes health assessment considering the age, gender, and culture of the patient.
D.uses assessment findings to identify medical and nursing diagnoses.
Chapter 3:
1.Which of the following interventions is most important to prevent nosocomial infections?
A.Proper glove use
B.Hand hygiene
C.Appropriate draping
D.Quiet environment
2.Standard precautions
A.are used on every patient because it is not always known whether a patient is infected.
B.state that hand gel is used for infection with Clostridium difficile.
C.include the use of gowns, gloves, and masks with all patients.
D.recognize that transmission-based precautions are common.
3.Latex allergies
A.always result in anaphylactic reactions and shock.
B.can be reduced by moisturizing the hands after washing.
C.cannot be caused by equipment such as a stethoscope.
D.are more common in nurses and in frequently hospitalized patients.
4.Which of the following is an appropriate use of gloves?
A.Gloves are worn during anticipated contact with intact skin.
B.Gloves are removed when going from clean to contaminated areas.
C.Gloves are worn during anticipated contact with body secretions.
D.Gloves are removed when assessing the back of an incontinent patient.
5.Which of the following is an example of inspection?
A.Heart rate and rhythm regular
B.Lungs clear
C.Abdomen tympanic
D.Skin pink
6.The patient is complaining of abdominal pain. What technique is used to form an overall
impression?
A.Auscultation
B.Light palpation
C.Direct percussion
D.Deep palpation
7.Tympany is a percussion sound commonly located in the
A.thorax.
B.upper arm.
C.abdomen.
D.lower leg.
8.Which organs or body areas does the nurse auscultate as part of the admitting assessment?
A.Heart, lungs, and abdomen
B.Kidneys, bladder, and ureters
C.Abdomen, flank, and groin
D.Neck, jaw, and clavicle
9.What technique facilitates accurate auscultation?
A.Earpieces of the stethoscope are positioned to point toward the back.
B.The tubing of the stethoscope is long and dark in color.
C.The chestpiece of the stethoscope is sealed against the skin.
D.The diaphragm of the stethoscope is used for low-frequency sounds.
10.When assessing a child, the nurse makes the following adaptation to the usual
techniques:
A.A pediatric stethoscope is used for better contact.
B.The child is seated away from the parent.
C.The room is full of toys for play.
D.The child is undressed, including the diaper.
Chapter 4:
1.Which of the following are advantages of the electronic medical record? Select all that
apply.
A.Nurses can enter data by checking boxes and adding free full text.
B.It is economical and easy to learn and implement.
C.It allows primary care providers to directly order into the computer.
D.It cannot be used as a legal document in case of a lawsuit.
2.Select all of the documentation errors that are potentially high risk.
A.Failure to document completely
B.Inadequate admission assessment
C.Charting in advance
D.Bunch charting at the end of shift
3.The purpose of auditing charting is to
A.enhance nurses’ learning and understanding of complex clinical situations.
B.identify staff members who document completely and counsel those who do not.
C.determine whether staff members are providing and documenting standards of care.
D.locate data in the chart the evening before a morning clinical visit.
4.Select all actions that are acceptable under the HIPAA Privacy Rule.
A.Communicate report with the next nurse during change of shift.
B.Communicate with the primary care provider about a patient’s change in assessment.
C.Consult in the hall with the instructor about the patient’s abnormal findings.
D.Describe patient assessment findings to a colleague in the cafeteria.
5.The proper technique for correcting written documentation is to
A.use correction fluid and write over the error.
B.completely black out the error with a black marker.
C.write over the error in darker ink.
D.draw a line through the error and write the date, time, reason for error, and your initials.
6.All formats of progress notes
A.use the nursing process in some form to show nursing thinking.
B.identify the patient outcomes or goals to evaluate.
C.include head-to-toe assessment data for completeness.
D.have a section for evaluation of care so that nurses may revise interventions.
7.Strategies for effective handoffs during change-of-shift report are to
A.tape-record the report for efficiency.
B.vary the format to individualize to the patient.
C.allow an opportunity to ask and answer questions.
D.put report in writing so that the next shift care provider can get right to work.
8.In the SBAR reporting format, which of the following would be an example of data found in
the assessment?
A.Mrs. Kelly’s diagnosis is Stage II breast cancer.
B.Mr. Imami’s lung sounds are decreased.
C.Ms. Choi needs to have a social work consult.
D.Mr. Jones was admitted at 10:30 this morning.
9.Nursing assessment of trends in an unconscious patient’s neurological status over time is
best recorded on
A.an admission assessment
B.a PO
C.a progress note
D.a focused assessment flow sheet
10.Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. His hand is
pale, cool, and swollen. His pain medication is ineffective, and he is at risk for impaired
circulation. What action will the nurse take first?
A.Reassess the pain in 30 minutes and contact the provider if unresolved.
B.Give additional pain medication and reassess the pain in 30 minutes.
C.Document the abnormal findings and give an extra dose of pain medication now.
D.Contact the primary care provider and document the findings now.
Chapter 5:
1.The nurse assesses the following vital signs in a 78-year-old man: temperature 36.6°C,
temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use
of accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal?
A.Pulse
B.BP
C.Respirations
D.Temperature
2.The best way to assess a client’s respiration rate is by:
A.Place a hand over the client’s chest and count for 30 seconds
B.Observe and count respirations for 30 seconds and multiply by two without mentioning that you
are observing the respirations.
C.Ask the client to breath normally for one minute.
D.If respirations are irregular have the client rest for 10 minutes and then recount.
3.The patient’s radial pulse is weak and thready. The next action of the nurse is to
A.transfer the patient to a critical care unit.
B.notify the primary care provider.
C.compare findings with previous findings and opposite extremity.
D.assess vital signs every 15 minutes.
4.Which of the following patients should not have a temperature measured orally?
A.An 84-year-old woman with diarrhea
B.A 30-year-old patient with an earache
C.A 45-year-old man with chest pain
D.A 62-year-old woman who has had oral surgery
5.The nurse notes an irregular radial pulse in a patient. Further evaluation includes
assessing
A.for a pulse deficit.
B.the carotid pulse.
C.for diminished peripheral circulation.
D.the brachial pulse.
6.Which actions will result in an inaccurate BP reading? Select all that apply.
A.Obtaining a BP immediately after the patient has entered the room
B.Using a BP cuff with a bladder length which is 80% of the arm circumference
C.Asking the patient to hold out his or her arm above heart level
D.Pumping the cuff 10 mm Hg above the palpated systolic BP
7.Adult patients may have variations in pulse rates with
A.respirations.
B.food intake.
C.heat.
D.exercise.
8.An unconscious 22-year-old man arrives at the hospital after experimenting with
hallucinogenic substances. His vital signs are temperature 37.2°C, orally; pulse 142
beats/min; respirations 20 breaths/min; BP 100/64 mm Hg. The patient is experiencing
A.tachycardia.
B.eupnea.
C.auscultatory gap.
D.asystole.
9.An auscultatory gap is defined as
A.a drop in the SBP of 15 mm Hg or more with position change.
B.a period of silence heard between Korotkoff sounds.
C.the difference between the apical and radial pulse.
D.SBP minus the DBP.
10.Which of the following findings during the general survey may indicate a change in
mental status? Select all that apply.
A.Disheveled appearance
B.Rapid speech
C.Lethargy
D.Asymmetrical movements
Chapter 6:
1.The patient has pain of a short duration with an identifiable cause. This is referred to as
A.acute pain.
B.chronic pain.
C.neuropathic pain.
D.complex pain.
2.To identify the location of pain, the nurse asks the patient
A.how long he or she has had the pain.
B.to rate the intensity of the pain on a scale from 0 to 10.
C.to point to the painful area.
D.to describe the quality of pain.
3.A patient says that his pain worsens with weight-bearing activity. The nurse would
consider this
A.an alleviating factor.
B.a functional pain goal.
C.a quality/description.
D.an aggravating factor.
4.Which of the following tools would a nurse use to perform a multidimensional pain
assessment?
A.Visual analogue scale
B.Brief Pain Inventory
C.Numeric pain intensity
D.Verbal descriptor
5.Then nurse is most likely to assess pain using the McGill Pain Questionnaire to collect
which data?
A.Verbal description
B.Alleviating factors
C.Functional status goal
D.Pain goal
6.Which of the following indicators would be most likely to signify to the nurse that a patient
is having pain?
A.Falling asleep
B.Rubbing a body part
C.Relaxed body position
D.Facial droop
7.A patient reports pain, depression, and insomnia. The nurse observes a masklike facial
expression and frequent position changes. Which of the following is the nurse most
likely to use to describe the patient’s findings?
A.Acute pain
B.Chronic pain
C.Neuropathic pain
D.Chronic regional pain syndrome
8.With which of the following types of patients is the nurse most likely to use the FACES pain
scale?
A.Children
B.Patients with dementia
C.Older adults
D.Unconscious patients
9.Which of the following is the rationale for the nurse to reassess the patient’s pain after
treatment?
A.To pinpoint the pain’s location
B.To measure the pain’s duration
C.To establish the efficacy of medication
D.To make changes to the patient’s pain goal
10.Which of the following is a barrier to pain assessment?
A.The nurse believes that patients suffer if undermedicated.
B.The nurse focuses on pain relief as a primary end to the assessment process.
C.The nurse chooses treatment that will positively affect the patient’s care.
D.The nurse has difficulty accepting the patient’s self-report as valid.
Chapter 7:
1.The patient has serum values that are abnormal for sodium and potassium. The nurse
recognizes that these values are important to maintain in normal range for proper
A.tissue oxygenation.
B.tensile strength in the hair.
C.oil production in the skin.
D.fluid and electrolyte function.
2.Primary nutrients essential for optimal body function include
A.carbohydrates, proteins, and fats.
B.folate, vitamin B12, and iron.
C.vitamins A, D, E, and K.
D.iron, zinc, and calcium.
3.Which of the following are nutritional cardiac risk factors? Select all that apply.
A.Waist circumference of >40 in. in men
B.Waist circumference of >35 in. in women
C.A waist-to-hip ratio less than or equal to 1.0
D.Significant unintentional weight loss of 10% or more in 180 days
4.A woman who is pregnant is being screened for adequate intake of calcium and vitamin D.
Which of the following tools is most appropriate for the nurse to administer?
A.24-hour recall
B.3-day diet history
C.Food frequency questionnaire
D.Comprehensive nutrition assessment
5.Which of the following is the healthiest eating plan? Select all that apply.
A.excludes lean meats, poultry, and fish
B.allows for moderate intake of salt and sugars
C.with non or low-fat milk and dairy products
D.emphasizes fruits, vegetables, and whole grains
6.A patient has a BMI of 14. Which nursing intervention is indicated?
A.Provide additional high protein and calorie shakes.
B.Reduce total fat and calorie intake.
C.Increase the intake of green leafy vegetables.
D.Eat complete meals twice a day.
7.The nurse is caring for a patient with a BMI of 33. Which nursing diagnosis is most
appropriate?
A.Imbalanced nutrition: less than body requirements
B.Imbalanced nutrition: more than body requirements
C.Fluid volume excess
D.Fluid volume deficit
8.From the given list, select the older adult at greatest risk for malnutrition.
A.A 67-year-old married man with poor dentition
B.A 73-year-old woman in a nursing home
C.An 80-year-old widow who lives alone
D.A 78-year-old widower who receives food from Meals on Wheels
9.A patient is admitted to the hospital with multiple trauma from an automobile accident 5
days ago. Which of the following is the best indicator of current nutritional status?
A.Transferrin
B.Total protein
C.Albumin
D.Prealbumin
10.Which of the following patients is at highest risk for complications related to folate
deficiency?
A.A 3-year-old boy who is developmentally delayed
B.A 15-year-old girl who just started her menses
C.A 24-year-old woman who is attempting pregnancy
D.An 82-year-old man living in a nursing home