Basic Nursing Care
Final Test Solutions
Course Introduction
Basic Nursing Care introduces students to the foundational principles and skills essential for providing quality care to patients across the lifespan. The course covers fundamental concepts such as hygiene, mobility, nutrition, patient safety, infection control, therapeutic communication, and basic assessment techniques. Emphasis is placed on developing clinical competence, understanding the role of the nurse within interdisciplinary healthcare teams, and adhering to ethical and legal standards. Through a combination of theoretical instruction and practical experiences, students learn to deliver compassionate, evidence-based care while promoting the dignity and well-being of patients in various healthcare settings.
Recommended Textbook
Fundamentals of Nursing Active Learning for Collaborative Practice 1st Edition by Yoost
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42 Chapters
1050 Verified Questions
1050 Flashcards
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Chapter 1: Nursing, Theory, and Professional Practice
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Sample Questions
Q1) The nurse is determining the patient care assignments for a nursing unit. Which of the following responsibilities may be delegated to the licensed practical nurse?
A) Initiating the nursing care plans
B) Formulating nursing diagnoses
C) Assessing a newly admitted patient
D) Administering oral medications
Answer: D
Q2) Which nurse established the American Red Cross during the Civil War?
A) Dorothea Dix
B) Linda Richards
C) Lena Higbee
D) Clara Barton
Answer: D
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Chapter 2: Values, Beliefs, and Caring
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Sample Questions
Q1) A patient with terminal cancer says to the nurse, "I just don't know if I should allow CPR in the event I quit breathing. What do you think?" Which statement by the nurse would be most beneficial to the patient?
A) "If it were me, I would want to live no matter what."
B) "Don't worry. You have plenty of time to decide that later on."
C) "It's totally up to you. Have you discussed this with your family?"
D) "Let's talk about what CPR means to you."
Answer: D
Q2) Patients who enter the health care system have two reasonable expectations. The first is not to be harmed, and the second is that the nurses providing care will be both competent and compassionate. Provision of care that is consistent and delivered in a predictable way can make the experience less intimidating for the patient. The nurse provides predictable care by:
A) Explaining what is going to take place beforehand.
B) Never making promises to patients.
C) Assuring the patient that his/her requests will get done eventually.
D) Protect the patient from knowing why things are happening.
Answer: A
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Chapter 3: Communication
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Sample Questions
Q1) The nurse is admitting a patient with a foul smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language?
A) Using hand gestures to enhance verbal communication
B) Standing at the end of the bed with arms crossed
C) Facial grimacing at the sight of the wound
D) Gentle touching of the patient's shoulder
Answer: D
Q2) A female patient is admitted to the emergency department after being raped by a neighbor. The patient refuses to discuss the circumstances surrounding the event with the sexual assault nurse examiner. This patient is most likely using the defense mechanism of:
A) suppression
B) sublimation
C) displacement
D) rationalization
Answer: A
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Chapter 4: Critical Thinking in Nursing
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Sample Questions
Q1) The nurse is planning care for a group of patients. Which of the following activities may be delegated to unlicensed assistive personnel?
A) Analysis of the patient's physical condition
B) Morning vital signs, height, and weight.
C) Evaluation of whether colostomy drainage is normal
D) Determining patient readiness for postsurgical learning
Q2) The nurse is caring for a patient who is suspected of having early stages of dementia. The nurse observes mild confusion, short-term memory loss, and restlessness. The nurse conducts a mini-mental status exam. The nurse is using which of the following components of critical thinking?
A) Validation
B) Interpretation
C) Intuition
D) Reasoning
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6
Chapter 5: Introduction to the Nursing Process
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Sample Questions
Q1) The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:
A) The framework that nurses used to provide care.
B) A complex process during which nurses think about their thinking.
C) The process that allows nurses to collect essential data.
D) Thinking like a nurse in developing plans of care.
Q2) The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The health history is conducted in which step of the nursing process?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation
Q3) The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:
A) assessment.
B) diagnosis.
C) outcome identification.
D) evaluation.
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Page 7
Chapter 6: Assessment
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Sample Questions
Q1) The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)
A) A 28-year old patient scheduled to be discharged home today
B) A 49-year-old patient with stable chronic lung disease
C) A 78-year-old patient with recent onset of rectal bleeding
D) A 35-year-old patient waiting for transfer to a rehabilitation center
E) A 40-year-old patient being admitted from the emergency department
Q2) During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which of the following frameworks would the nurse most likely choose to document this data?
A) Head-to-toe model
B) Gordon's Functional Health Patterns
C) Body systems model
D) Cephalic-caudal model
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Chapter 7: Nursing Diagnosis
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Sample Questions
Q1) The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of malnutrition. The patient is unable to walk because of his malnutrition, and he has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why he stopped getting up. When planning this patient's care, the nurse should:
A) develop multiple nursing diagnoses.
B) develop only one nursing diagnosis to aid in focusing.
C) focus on the physical issues facing this patient.
D) deal primarily with the patient's psychological needs.
Q2) North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every:
A) 2 years.
B) 3 years.
C) 4 years.
D) 5 years.
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Page 9
Chapter 8: Planning
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Sample Questions
Q1) Patients should be included in the planning process. Involving patients in planning their care helps them to: (Select all that apply.)
A) be aware of identified needs.
B) accept that not all goals are measurable.
C) embrace mutually agreed-on goals.
D) feel a sense of empowerment.
E) overcome unrealistic goals.
Q2) The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:
A) must be done at the end of every shift.
B) should be done at least every 24 hours.
C) depend on intervention and patient condition.
D) are always done at time of discharge.
Q3) The nurse knows that standardized care plans may be available and:
A) need to be individualized for each patient.
B) are implemented without adjustment.
C) remove the need for nurse involvement.
D) do not require the use of nursing diagnoses.
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Chapter 9: Implementation and Evaluation
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Sample Questions
Q1) The final phase of the nursing process is evaluation, which focuses on:
A) recording the care that was implemented.
B) medical and nursing goals for the welfare of the patient.
C) long-term goals only.
D) the patient responses to interventions and outcomes.
Q2) Of the following interventions, which are prevention oriented? (Select all that apply.)
A) Immunization programs
B) Cleansing an incision
C) Cardiac education related to risk factor modification
D) Placing infants prone when they sleep
E) Teaching patients to ask their physicians to wash their hands
F) None of the above
Q3) The registered nurse is providing an independent nursing intervention when:
A) administering oral medications.
B) administering oxygen.
C) providing emotional support.
D) administering intravenous medication.
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Chapter 10: Documentation, Electronic Health Records, and Reporting
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Sample Questions
Q1) A type of charting that records only abnormal or significant data is:
A) PIE.
B) SOAP.
C) narrative.
D) charting by exception.
Q2) The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
A) admission summary.
B) discharge summary.
C) flow sheet.
D) Kardex.
Q3) Expected nursing documentation includes: (Select all that apply.)
A) nursing assessment.
B) the care plan.
C) critique of the physician's care.
D) interventions.
E) patient responses to care.
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Chapter 11: Ethical and Legal Considerations
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Sample Questions
Q1) Who is ultimately responsible for explaining the content of the informed consent?
A) The registered nurse
B) The hospital social worker
C) Educated family members
D) The provider of the procedure
Q2) In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, nurses should: (Select all that apply.)
A) maintain confidentiality.
B) follow legal guidelines for sharing information.
C) block document once per shift.
D) change nursing procedures according to latest journal articles.
E) meet licensure and continuing education requirements.
Q3) Practicing nursing without a license is a:
A) misdemeanor.
B) statute.
C) felony.
D) tort.
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13
Chapter 12: Leadership and Management
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Sample Questions
Q1) For patient care to be completed in a safe and timely manner, it is sometimes necessary for the nurse to delegate tasks to other health care providers. The ANA describes delegation as:
A) a transfer of authority to a less-qualified individual.
B) the nurse transferring accountability to the delegate.
C) the transfer of tasks by the nurse while retaining accountability.
D) transferring responsibility for assessments and planning.
Q2) An effective manager must: (Select all that apply.)
A) understand the concepts of budgeting.
B) run a unit efficiently without regard to cost.
C) be able to staff the unit effectively.
D) be adept at information management.
E) achieve desired outcomes in any way possible.
Q3) The leadership theory that assumes that leaders are born with certain leadership skill that few people possess is known as:
A) trait theory.
B) behavioral theory.
C) situational theory.
D) transformational theory.
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Page 14
Chapter 13: Evidence-Based Practice and Nursing Research
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Sample Questions
Q1) If the nurse is trying to determine the best treatment or course of action and wants to incorporate the most reliable evidence into the decision, the nurse will use a filtered resource such as:
A) Cochrane Reviews.
B) UpToDate.
C) STAT!Ref.
D) MD Consult.
Q2) An institutional review board (IRB) is a review committee established to:
A) approve research involving animal subjects.
B) approve research that is not government funded.
C) function differently than scholarly journals do.
D) protect the rights of human research subjects.
Q3) The acronym PICO assists in remembering the steps to constructing a good research question. The "O" in the acronym stands for:
A) objectivity.
B) ordinal approach.
C) outcome.
D) observer.
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15
Chapter 14: Health Literacy and Patient Education
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Sample Questions
Q1) The nurse is preparing to discharge a patient home. In providing instruction about the patients medications, the nurse should state:
A) "Before taking Metoprolol, you need to take your BP and rate."
B) "MS should be taken only when needed for pain."
C) "Take 1 baby aspirin by mouth every morning."
D) "Take your water pill bid and you should be fine."
Q2) Which of the following patients would most likely need to have adjustments made to the education plan for discharge because of role function?
A) A 67-year-old married female who lives with her retired husband
B) A 32-year-old single mother of a toddler following hysterectomy.
C) A 13-year-old who lives at home with his parents after appendectomy
D) A 50-year-old married mother with 2 child in college and teenager at home
Q3) The nurse is preparing to teach a 5-year-old child postoperative care that will be anticipated after a tonsillectomy. The nurse should:
A) use pictures and simple words to describe care to the patient.
B) teach the parents alone to reduce fear in the patient.
C) exclude the parents to reduce parental anxiety.
D) use clear simple explanations to convey information.
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Chapter 15: Nursing Informatics
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22 Flashcards
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Sample Questions
Q1) The Computer Ethics Institute has developed guidelines for ethics in the development and use of computer technologies. These guidelines are called:
A) the Ten Commandments of Computer Ethics.
B) the eHealth Code of Ethics.
C) HIPAA guidelines.
D) the Internet Healthcare Coalition.
Q2) The nurse is providing care to a patient newly diagnosed with multiple sclerosis. The patient expresses the desire to communicate with other people living with the disorder. The nurse appropriately refers the patient to:
A) an e-mail list with the patient's contacts.
B) a social media blog.
C) a listserv concerning multiple sclerosis.
D) Facebook, Twitter, and LinkedIn.
Q3) Information technology (IT) can be used to increase patient safety. The nurse uses IT in this way by:
A) creating redundancy in orders making them safer.
B) removing the need for verification by the nurse.
C) analyzing errors to develop prevention strategies.
D) eliminating the need for bar codes in medication administration.
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Page 17
Chapter 16: Health and Wellness
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Sample Questions
Q1) The nurse is discussing immunizations for infants and children with new parents. The nurse should focus on:
A) providing scientific evidence to parents.
B) stressing that non-immunization is a crime.
C) acknowledging that immunizations are not needed.
D) informing the parents that they have no choice.
Q2) When caring for patients with chronic illness, the nurse needs to:
A) help the patient face the reality that he will not get better.
B) emphasize to the patient that the illness is not his fault.
C) emphasize improving quality of life through preventive behaviors.
D) acknowledge the limitations placed on the patient by his suffering.
Q3) The nurse is assessing a patient's environment and its impact on outdoor activity and notes that the child rarely plays outside. Which is true regarding the indoor environment?
A) Indoor environments protect the patient from toxics chemicals.
B) Indoor activity is sometimes a result of unsafe outdoor conditions.
C) Indoor activity decreases the risk of respiratory illness.
D) Indoor lifestyles reduce the risk for sedentary behaviors.
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Chapter 17: Human Development: Conception through Adolescence
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Q1) A nurse is conducting a preschool screening in the community. Which child would the nurse refer for further assessment?
A) A 4-year-old who throws a ball over-handed but better under-handed.
B) A 4-year-old who can skip across the room after being shown how.
C) A 5-year-old who is able to ride a bicycle with training wheels.
D) A 5-year-old who is unable to ride a tricycle without falling.
Q2) To help a hospitalized infant master the tasks in Erikson's stage of Trust versus Mistrust, which action by the nurse is best?
A) Provide calming music during quiet time so the infant can sleep
B) Give the family food vouchers for the hospital cafeteria
C) Arrange to have a cot or small bed placed in the infant's room
D) Do not allow unlicensed assistive personnel to care for the infant
Q3) A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best?
A) Document the findings and continue the assessment.
B) Refer the child and parent to a pediatric neurologist.
C) Assess the child for other age-appropriate behaviors.
D) Assess the child for signs of child abuse or neglect.
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Chapter 18: Human Development Young Adult to Older Adult
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Sample Questions
Q1) A nurse working with a middle-aged adult is concerned that the adult is not meeting developmental tasks associated with Erikson's theory. What question by the nurse is most appropriate?
A) Are there community organizations you would like to volunteer with?
B) Do your children come to see you on a regular basis?
C) Do you get at least 30 minutes of exercise most days of the week?
D) How do you feel about reading for a leisure time activity?
Q2) A nurse who uses Havighurst's theory of development is assessing a young adult. What question does the nurse ask to provide the most relevant information about this person's successful negotiation of this developmental stage?
A) "Do you find yourself doing familiar tasks in new ways to accomplish them?"
B) "Please count backwards from 100 by 7s, such as 100, 93, and so on."
C) "What occupation have you chosen for your life's work?"
D) "Do you still have a good relationship with your parents and siblings?"
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Chapter 19: Vital Signs
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Sample Questions
Q1) A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
A) Instruct the patient not to get up without help.
B) Document the findings and continue to monitor.
C) Reassure the patient that these findings are normal.
D) Reassess the blood pressures in 1 hour.
Q2) A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
A) 28
B) 42
C) 58
D) 66
Q3) A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
A) Document the findings.
B) Notify the provider.
C) Compare with prior readings.
D) Retake the vital signs.
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21
Chapter 20: Health History and Physical Assessment
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Q1) The nurse examining a patient's skin correlates which conditions with which underlying pathology? (Select all that apply.)
A) Albinism: Full-thickness burns
B) Peripheral cyanosis: poor circulation
C) Purpura: clotting disorders
D) Jaundice: liver disease
E) Vitiligo: skin infestation
Q2) A nurse is conducting a physical examination using palpation. Which assessments might the nurse note? (Select all that apply.)
A) Rebound tenderness: tenderness long after palpation
B) Crepitation: crackling or rubbing
C) Guarding: holding the nurse's hands away from the body
D) Turgor: tension caused by fluid content
E) Consistency: organ location and size
Q3) The nurse is assessing a patient's cranial nerve III. What technique is best?
A) Have patient identify a common scent with closed eyes.
B) Shine a light into the patient's eyes to assess pupil response.
C) Have the patient read a newspaper or use the Snellen chart.
D) Assess if patient can hear both spoken and whispered words.
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Page 22
Chapter 21: Ethnicity and Cultural Assessment
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Q1) A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best?
A) Work with the patient to allow the shaman to perform the ritual.
B) Investigate whether the ritual will harm the patient.
C) Check to see if the ritual breaks laws or policies.
D) Offer to call the hospital chaplain instead.
Q2) A patient from an unfamiliar culture appears disinterested when the physician is telling her about options for treatment of a new diagnosis. After the physician leaves, the nurse attempts to talk to the patient and notices the same behavior. What action by the nurse is best?
A) Give the patient the information in writing to read later.
B) Ask the patient about the meaning of the patient's behavior.
C) Investigate nonverbal communication patterns of this group.
D) Leave the patient alone to come to terms with the diagnosis.
Q3) What does the nursing student learn about race?
A) It is biologically based.
B) It is a social construct.
C) It is chosen by the person.
D) It helps establish superiority.
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Page 23
Chapter 22: Spiritual Health
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Q1) The nurse who is aware of spirituality practices of major religions knows that which religions view health and illness as a process of balance or imbalance? (Select all that apply.)
A) Catholicism
B) Native American
C) Hinduism
D) Greek Orthodox
E) Buddhism
Q2) The nurse is caring for four patients. Which one should the nurse assess for spirituality needs as a priority?
A) New mother, older child at home
B) Faces terminal diagnosis
C) Needs to change medications
D) Pleasant but quiet
Q3) Which actions by a nurse constitute spiritual care? (Select all that apply.)
A) Baptizing a critically ill child per the parent's request.
B) Leaving the room, giving the patient and family privacy for prayer.
C) Considering developmental stage when planning care.
D) Notifying the hospital chaplain of a patient's request.
E) Praying with patients and families when requested.
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Chapter 23: Public Health, Community Base, and Home Health Care
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Q1) The home health care nurse educates patients on which goals of hospice care? (Select all that apply.)
A) Relieve suffering
B) Support the patient and family
C) Provide grief support
D) Keep patients out of the hospital
E) Lower medical expenses
Q2) A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role strain?
A) Family eats dinner together every night.
B) Family uses respite care one night a week.
C) Family investigates research trials for patient.
D) Family verbalizes exhaustion from caregiving.
Q3) When planning interventions for a community, what action by the nurse is best?
A) Involve community leaders in planning.
B) Create a plan of action addressing priorities.
C) Determine what resources are available.
D) Attempt to find funding for the plan.
Page 25
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Chapter 24: Human Sexuality
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Q1) A nurse in the emergency department wants to screen a patient for domestic violence, but the woman's partner won't leave. What action by the nurse is best?
A) Ask the questions anyway.
B) Tell the partner to leave.
C) Go with the patient to the bathroom.
D) Skip the abuse assessment.
Q2) A patient has been diagnosed with a sexually transmitted disease (STD) and the patient's partner is angry, saying, "She must have cheated on me." What response by the nurse is most appropriate?
A) "This infection may have been present for a long time."
B) "You need to be tested for this disease too."
C) "Yes, you're right; if you don't have the STD, she cheated."
D) "Now, now, getting angry will not help anything."
Q3) An emergency department (ED) manager wants to improve care for victims of sexual assault. What action by the manager is best?
A) Designate a private area of the ED for examinations.
B) Establish a SART team for the department.
C) Ask nurses to volunteer to be advocates for these patients.
D) Have victims examined immediately, rather than waiting their turn.
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Page 26
Chapter 25: Safety
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Q1) Many health care facilities use the fire emergency response defined by the acronym:
A) RACE.
B) PASS.
C) PACE.
D) QSEN.
Q2) The nurse is ambulating her patient back from the bath when the patient begins to have a seizure. Which of the following actions should the nurse do first?
A) Lower the patient to the floor if standing.
B) Move sharp or hard objects away from the patient.
C) Turn the patient to his/her side to prevent aspiration.
D) Attempt to place a tongue blade to prevent choking.
Q3) The nurse displays an understanding of high-risk populations for MRSA when identifying which group as the lowest risk?
A) Prison inmates
B) College dorm residents
C) Team athletes
D) Food service workers
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Chapter 26: Asepsis and Infection Control
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Q1) The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.)
A) Decreased cough reflex
B) Decreased lung elasticity
C) Increased activity of the cilia
D) Abnormal swallowing reflex
E) Increased sputum production
Q2) The nurse anticipates correctly that what type of medication would be ordered to treat athlete's foot?
A) Antiviral
B) Antibiotic
C) Antihelminth
D) Antifungal
Q3) The patient is on protective precautions. Which is true regarding these precautions? (Select all that apply.)
A) A positive-pressure room with a HEPA filtration system is required.
B) Special respirator masks should be available and one size fits all.
C) No live plants are allowed in the room.
D) The patient may eat any foods desired.
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Page 28
Chapter 27: Hygiene and Personal Care
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Q1) The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:
A) ineffective health maintenance.
B) readiness for enhanced self-care.
C) hygiene self-care deficit.
D) disturbed body image.
Q2) The nurse is demonstrating cultural sensitivity in performing perineal care when he/she does the following: (Select all that apply.)
A) The male nurse delegates perineal care of a female patient to the female UAP.
B) The male nurse asks a female patient if she would prefer a female to perform care.
C) The nurse approaches the care in a sensitive, professional manner.
D) The nurse assesses cultural preferences of the patient prior to care.
Q3) The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action?
A) Refuse to shave the patient because he is on an anticoagulant.
B) Shave as usual with a safety razor.
C) Offer to wax rather than shave the patient.
D) Use an electric razor.
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Chapter 28: Activity, Immobility, and Safe Movement
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Q1) An appropriate goal for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity is:
A) the patient will ambulate twice a day.
B) the patient will eat 50% of meals.
C) the patient will have no further skin breakdown.
D) the patient will interact with others.
Q2) The nurse appropriately delegates care to the UAP when she:
A) instructs the UAP to assess the patient's skin during a bath.
B) instructs the UAP to reposition the patient using the trapeze.
C) instructs the UAP to assess the patient's ability to perform range-of-motion exercises.
D) instructs the UAP to notify the health care provider of any changes.
Q3) The nurse knows the knee-high SCD sleeves are correctly placed on the patient when the following conditions are met: (Select all that apply.)
A) Both sleeves are connected to the SCD device.
B) Two fingers fit inside when the SCDs are inflated.
C) There are no kinks in the tubing.
D) The ankle pressure is 55 to 65 mm Hg.
E) The cooling control is on.
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Chapter 29: Skin Integrity and Wound Care
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Q1) The nurse knows the following wound would be classified as a closed wound:
A) A large bruise on the side of the face
B) A surgical incision that is sutured closed
C) A puncture wound that is healing
D) An abrasion on the leg
Q2) The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do?
A) Cover the wound with a sterile gauze pad.
B) Cover the wound with a transparent dressing.
C) Put pressure on the wound with a sterile gauze pad.
D) Cover the wound with gauze soaked with normal saline.
Q3) The nurse knows to irrigate a deep wound with:
A) A 5-mL syringe.
B) A 10-mL syringe.
C) A 3-mL syringe.
D) A 30-mL syringe.
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Chapter 30: Nutrition
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Q1) The nurse is providing dietary education to her patient to help him include more complex carbohydrates in his diet. Which of the following would be beneficial to include? (Select all that apply.)
A) Green beans
B) Bananas
C) Beans
D) Potatoes
Q2) The nurse is concerned about aspiration precautions when feeding her patient who has recently suffered a stroke. Which of the following procedures that the nurse performs would demonstrate a need for further education?
A) The nurse uses thickened liquids.
B) The nurse puts the bed at 30 degrees.
C) The nurse encourages slow eating.
D) The nurse has the patient alternate between food and sips of fluid.
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Chapter 31: Cognitive and Sensory Alterations
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Q1) The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?
A) "I should make sure the passageways are wide."
B) "I should remove all the throw rugs."
C) "I should keep the lights dim."
D) "I can use a cane to feel for objects in front of me."
Q2) An appropriate goal for a patient with a diagnosis of social isolation is:
A) the patient will participate in cognitive exercises.
B) the patient will interact with other residents during activities.
C) the patient will communicate basic needs through use of photos.
D) the patient will remain within the unit while in long-term care.
Q3) The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
A) Use simple phrases.
B) Speak loudly.
C) Use yes/no questions.
D) Use a picture board.
E) Be patient and unrushed.
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33
Chapter 32: Stress and Coping
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Q1) The nurse knows that certain personality factors have been shown to buffer the impact of stress. These factors are: (Select all that apply.)
A) resilience.
B) sense of coherence.
C) gender.
D) hardiness.
E) coping style.
Q2) The nurse knows that the coping strategies that are more frequently seen in older adults are: (Select all that apply.)
A) anger.
B) withdrawal.
C) information gathering.
D) avoidance.
E) problem focused.
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Chapter 33: Sleep
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Q1) The nurse is providing discharge education for a patient with narcolepsy. The following statement by the patient indicates a need for further education:
A) "Daytime naps are helpful."
B) "Taking the medication will cure it."
C) "High protein meals are helpful."
D) "I should avoid alcohol."
Q2) The nurse knows that cataplexy includes:
A) an uncontrolled desire to sleep.
B) falling asleep for several minutes.
C) loss of voluntary muscle tone.
D) a sleep cycle that begins with NREM.
Q3) Which of the following is inappropriate to delegate to the unlicensed assistive personnel (UAP)?
A) Providing oral care
B) Evaluating sleep patterns
C) Providing bedtime routines
D) Documenting sleep hours
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Chapter 34: Diagnostic Testing
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Q1) The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient's chart?
A) C-reactive protein (CRP) 6.5 mg/dL
B) Serum creatinine 0.8 mg/dL
C) Serum bilirubin 0.5 mg/dL
D) Prothrombin time (PT) 11.5 sec
Q2) The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required?
A) "I will keep the urine container on ice to keep it chilled until I bring it to the lab."
B) "I will start the test over if I forget and urinate into the toilet during the testing time."
C) "I will start the test tomorrow after I urinate first thing in the morning."
D) "I will drink extra fluids so that the lab will have an extra large specimen to test."
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36
Chapter 35: Medication Administration
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Q1) The nurse is caring for a patient with multiple chronic illnesses who is having difficulty remembering to take all of her many medications at the correct times. Which is the appropriate nursing diagnosis for this patient?
A) Activity intolerance related to inability to take medications on time
B) Ineffective therapeutic regimen management related to complexity of medication schedule
C) Risk for aspiration related to need to swallow many pills during day
D) Acute confusion related to inability to figure out medication dose times
Q2) During discharge teaching, the nurse is to give the patient a signed, dated, and timed prescription from the physician for medications to be taken at home. Which prescription drug order needs to be corrected before it is given to the patient?
A) Warfarin (Coumadin) 5 mg PO daily before dinner
B) Methotrexate (Trexall) 8 tablets PO once weekly on Saturdays
C) Levothyroxine (Synthroid) 137 mcg PO daily before breakfast
D) Zolpidem (Ambien) 5 mg PO at bedtime as needed for sleep
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Chapter 36: Pain Management
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Questions
Q1) The nurse is caring for a patient who has been taking ibuprofen (Advil, Motrin) 800 mg TID for the last several months to relieve arthritis pain in her knees. Which assessment finding must be reported to the physician promptly?
A) The patient has abdominal pain and pale skin.
B) The patient has constipation and takes stool softeners daily.
C) The patient enjoys a glass of wine every Friday and Saturday evening.
D) The patient has gained 15 lb in the last 3 months.
Q2) Which patient is best suited for PCA analgesia?
A) A patient who is confused after a head injury
B) A patient recovering from total hysterectomy surgery
C) A patient who has severe psychogenic pain
D) A patient with arthritis who is unable to push the nurse call button
Q3) Which assessment question helps the nurse determine the character of the patient's pain?
A) "What does the pain feel like, i.e. stabbing, burning or throbbing?"
B) "When did the pain first start?"
C) "What interventions make the pain better?"
D) "Is there any pattern to when the pain occurs?"
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Chapter 37: Perioperative Nursing Care
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Q1) The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?
A) A patient who is waiting for discharge teaching before going home
B) A patient who needs to be ambulated for the first time postoperatively
C) A patient who has not voided since the catheter was removed 8 hours ago
D) A patient who requires a daily dressing change to the surgical incision
Q2) The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?
A) Patient will deny numbness or tingling in extremities after surgical procedure.
B) Patient will maintain urine output of at least 30 mL/hour during and after surgery.
C) Patient will maintain elastic skin turgor as well as moist tongue and mucus membranes.
D) Patient will have no emesis and deny nausea following arousal from general anesthesia.
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Chapter 38: Oxygenation and Tissue Perfusion
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Q1) The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.)
A) Increase the patient's oxygen to 4 L/min via nasal cannula.
B) Suction the patient's airway using sterile technique.
C) Maintain eye contact and provide calm reassurance.
D) Turn the patient onto the side for postural drainage.
E) Administer the ordered nebulized bronchodilator.
F) Elevate the head of the patient's bed to fully upright.
Q2) The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?
A) "Do you have a headache or any dizziness?"
B) "Do you have any chest pain or shortness of breath?"
C) "When did you first notice the swelling and redness in your leg?"
D) "Do you have any cramping or muscle spasms in your leg?"
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Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
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Q1) The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient's collapse?
A) Orthostatic hypotension
B) Circulatory overload
C) Hemolytic reaction
D) Catheter embolism
Q2) The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCOS1U1B12S1U1B0 32 mm Hg, HCOS1U1B13S1U1B0 42 mEq/L, PaOS1U1B12S1U1B0 90 mm Hg.
Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?
A) Gastroenteritis with severe nausea, vomiting, and diarrhea
B) Widespread tissue ischemia caused by cardiogenic shock
C) Respiratory failure caused by pneumonia with pleural effusions
D) Hyperventilation after a panic attack
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Chapter 40: Bowel Elimination
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Q1) The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse?
A) Assist the patient to ambulate in the hall.
B) Insert a rectal tube to remove retained flatus.
C) Administer an enema to stimulate peristalsis.
D) Encourage oral intake of fluids and high-fiber foods.
Q2) The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement?
A) Glass of warmed prune juice
B) Loperamide (Imodium)
C) Oral fiber supplement
D) An oil retention enema
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Chapter 41: Urinary Elimination
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Q1) The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient?
A) Alteration in comfort r/t continual urge to urinate
B) Overflow urinary incontinence r/t over-distention of the bladder
C) Urinary retention r/t obstruction of urinary bladder outlet
D) Toileting self-care deficit r/t inability to pass urine into the toilet
Q2) The nurse is caring for a patient with the nursing diagnosis of Urge urinary incontinence related to urinary tract infection. Which statement is appropriate for the "as evidenced by" portion of the patient's diagnosis?
A) Sudden leakage of urine when patient is unable to get to the toilet in time.
B) Continuous urine flow from the bladder regardless of attempts to use the toilet
C) Leakage of urine from the bladder when the patient coughs, sneezes, or laughs
D) Leakage of urine because the patient is unable to indicate need to use the toilet
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43
Chapter 42: Death and Loss
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Q1) The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse?
A) "The insurance company will not pay for chemotherapy at this stage."
B) "The focus right now needs to be on keeping your loved one comfortable."
C) "I will call the physician and let him know that you would like to restart chemotherapy."
D) "The patient needs to get stronger first before chemotherapy can be administered."
Q2) The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. Which term best describes the activity of the patient's children?
A) Anticipatory grieving
B) Bereavement
C) Caregiver role strain
D) Death anxiety
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