Question 1

The nurse giving a patient a back massage is performing an intervention considered to be a(n) _____ nursing action.

Accepted Answer

A)  dependent 
B)  independent 
C)  interdependent 
D)  semi-dependent 
A)  dependent 
B)  independent 
C)  interdependent 
D)  semi-dependent B

Question 2

Standards of care are set by: (Select all that apply.)

Accepted Answer

A)  the state's nurse practice act. 
B)  professional medical association standards. 
C)  the facility's policies and procedures. 
D)  the physician in charge of the patient's treatment. 
E)  the director of nurses and the agency administrator. 
A)  the state's nurse practice act. 
B)  professional medical association standards. 
C)  the facility's policies and procedures. 
D)  the physician in charge of the patient's treatment. 
E)  the director of nurses and the agency administrator. A, B, C

Question 3

During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

Accepted Answer

A)  position the patient to lie on his side, document it, and inform the head nurse. 
B)  position the patient on his side and encourage him to massage around the area. 
C)  report to the physician so that the nursing care plan can be revised. 
D)  tell the nursing assistant to change the patient's position every 2 hours. 
A)  position the patient to lie on his side, document it, and inform the head nurse. 
B)  position the patient on his side and encourage him to massage around the area. 
C)  report to the physician so that the nursing care plan can be revised. 
D)  tell the nursing assistant to change the patient's position every 2 hours. A

Question 4

The nurse is aware that one of the time-flexible tasks to be accomplished would be:

Accepted Answer

A)  administering daily insulin 30 minutes before breakfast. 
B)  taking the patient's vital signs once a day. 
C)  weighing the patient before breakfast. 
D)  monitoring a critical patient's vital signs every 15 minutes. 
A)  administering daily insulin 30 minutes before breakfast. 
B)  taking the patient's vital signs once a day. 
C)  weighing the patient before breakfast. 
D)  monitoring a critical patient's vital signs every 15 minutes.

Question 5

Before performing a catheterization, the inexperienced nurse should:

Accepted Answer

A)  close the door or curtains to provide the patient with privacy. 
B)  provide necessary teaching and explanation of the procedure to the patient. 
C)  observe rules of standard precautions to protect herself from exposure to blood or body fluids. 
D)  review the agency's procedure manual for the accepted way of performing the procedure. 
A)  close the door or curtains to provide the patient with privacy. 
B)  provide necessary teaching and explanation of the procedure to the patient. 
C)  observe rules of standard precautions to protect herself from exposure to blood or body fluids. 
D)  review the agency's procedure manual for the accepted way of performing the procedure.

Question 6

Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered:

Accepted Answer

A)  an independent nursing action. 
B)  the doctor's responsibility. 
C)  a dependent nursing action that requires the doctor's authorization. 
D)  an interdependent nursing action. 
A)  an independent nursing action. 
B)  the doctor's responsibility. 
C)  a dependent nursing action that requires the doctor's authorization. 
D)  an interdependent nursing action.

Question 7

An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of Risk for falls related to weakness would be:

Accepted Answer

A)  nurse will assist the patient to the bathroom every 2 hours. 
B)  patient will be free of injury from falls. 
C)  patient will call for assistance when ambulating for the next week. 
D)  nurse will keep room well lit 24 hours a day. 
A)  nurse will assist the patient to the bathroom every 2 hours. 
B)  patient will be free of injury from falls. 
C)  patient will call for assistance when ambulating for the next week. 
D)  nurse will keep room well lit 24 hours a day.

Question 8

Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially:

Accepted Answer

A)  question the rationale for the procedure. 
B)  perform a physical assessment of the patient. 
C)  check the agency manual for the procedure. 
D)  mentally review the procedure. 
A)  question the rationale for the procedure. 
B)  perform a physical assessment of the patient. 
C)  check the agency manual for the procedure. 
D)  mentally review the procedure.

Question 9

The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of a:

Accepted Answer

A)  45-year-old white male patient with uncontrolled diabetes. 
B)  50-year-old Hispanic man with a broken leg. 
C)  55-year-old Japanese man with irritable bowel syndrome. 
D)  60-year-old Muslim woman with pneumonia. 
A)  45-year-old white male patient with uncontrolled diabetes. 
B)  50-year-old Hispanic man with a broken leg. 
C)  55-year-old Japanese man with irritable bowel syndrome. 
D)  60-year-old Muslim woman with pneumonia.

Question 10

The nurse explains that a multidisciplinary step-by-step approach to patient care is:

Accepted Answer

A)  documented in the nursing care plan in the patient's chart. 
B)  not used often since managed care became part of health care. 
C)  referred to as a clinical pathway and is used instead of a nursing care plan. 
D)  more expensive than the traditional separation of health care services. 
A)  documented in the nursing care plan in the patient's chart. 
B)  not used often since managed care became part of health care. 
C)  referred to as a clinical pathway and is used instead of a nursing care plan. 
D)  more expensive than the traditional separation of health care services.

Question 11

Nurses design interventions that are appropriate for a patient that are:

Accepted Answer

A)  based on the physician's orders and the medical diagnosis. 
B)  expected to help the patient meet the goals most quickly. 
C)  used to evaluate whether the nursing care plan should be revised. 
D)  based on cost-effectiveness and staff availability. 
A)  based on the physician's orders and the medical diagnosis. 
B)  expected to help the patient meet the goals most quickly. 
C)  used to evaluate whether the nursing care plan should be revised. 
D)  based on cost-effectiveness and staff availability.

Question 12

The nurse is aware that the nursing audit is a valuable process used to:

Accepted Answer

A)  determine whether a particular patient received the care indicated in the nursing care plan. 
B)  evaluate whether nursing care for a group of patients meets the standards of care in that facility. 
C)  determine the cost of nursing care in the hospital in order to set rates for daily care. 
D)  identify careless or negligent nursing care to protect the facility from lawsuits. 
A)  determine whether a particular patient received the care indicated in the nursing care plan. 
B)  evaluate whether nursing care for a group of patients meets the standards of care in that facility. 
C)  determine the cost of nursing care in the hospital in order to set rates for daily care. 
D)  identify careless or negligent nursing care to protect the facility from lawsuits.

Question 13

At the 7:00 AM change-of-shift report, the nurse receives the report that patient A had a sleepless night related to pain and just fell asleep after an increased pain medication administration one-half hour ago. Patient B, who is scheduled for surgery at 8:30 AM, is also sleeping. How would an organized nurse plan the early morning activities?

Accepted Answer

A)  Wake patient A for breakfast. 
B)  Perform time-flexible tasks that can be done while both patients sleep. 
C)  Prep patient B now; allow patient A to sleep. 
D)  Assign a nursing assistant to wake and help feed patient A. 
A)  Wake patient A for breakfast. 
B)  Perform time-flexible tasks that can be done while both patients sleep. 
C)  Prep patient B now; allow patient A to sleep. 
D)  Assign a nursing assistant to wake and help feed patient A.

Question 14

The nurse is assessing a patient who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero-sanguineous drainage. The nurse should initially:

Accepted Answer

A)  perform a sterile dressing change. 
B)  document and report the wet dressing to the charge nurse. 
C)  reinforce the wet dressing and document. 
D)  place a towel on the bed and turn the patient to the operated side. 
A)  perform a sterile dressing change. 
B)  document and report the wet dressing to the charge nurse. 
C)  reinforce the wet dressing and document. 
D)  place a towel on the bed and turn the patient to the operated side.

Question 15

The nurse compares actual nursing outcomes to the expected nursing outcomes in order to:

Accepted Answer

A)  prepare the patient to be discharged from the facility. 
B)  determine if the patient's health problems have been treated. 
C)  calculate charges for nursing services during the patient's hospital stay. 
D)  determine if progress is made or to determine if revisions are needed. 
A)  prepare the patient to be discharged from the facility. 
B)  determine if the patient's health problems have been treated. 
C)  calculate charges for nursing services during the patient's hospital stay. 
D)  determine if progress is made or to determine if revisions are needed.

Question 16

The purpose of the evaluation step of the nursing process is to: (Select all that apply.)

Accepted Answer

A)  determine if outcomes have been reached and the goals are met. 
B)  compare actual outcomes with expected outcomes. 
C)  identify inefficient care given by assigned staff. 
D)  confirm that nursing interventions are effective. 
E)  ensure that the facility has not put itself at risk for litigation. 
A)  determine if outcomes have been reached and the goals are met. 
B)  compare actual outcomes with expected outcomes. 
C)  identify inefficient care given by assigned staff. 
D)  confirm that nursing interventions are effective. 
E)  ensure that the facility has not put itself at risk for litigation.

Question 17

The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should:

Accepted Answer

A)  inactivate the nursing diagnosis from the care plan. 
B)  notify the physician that the patient can now feed himself. 
C)  document the ability to self-feed and mark the nursing diagnosis as resolved. 
D)  inform the RN to document the self-feeding and to cancel the nursing diagnosis. 
A)  inactivate the nursing diagnosis from the care plan. 
B)  notify the physician that the patient can now feed himself. 
C)  document the ability to self-feed and mark the nursing diagnosis as resolved. 
D)  inform the RN to document the self-feeding and to cancel the nursing diagnosis.

Question 18

The agency-wide process that takes into consideration nursing audits and compliance to standards of every department is the _____________.

Accepted Answer

Outcome Based Quality Improvement
OBQI
T

Question 19

The nurse coming on duty has received a report that an IV of 1000 ml of 5% glucose in 0.9% normal saline is running at a rate of 50 ml an hour to be followed by another 1000 ml to be run at the same rate. The reporting nurse states that the second IV should be hung at 9:00 AM. The prudent nurse should: (Select all that apply.)

Accepted Answer

A)  hang the next 1000 ml when the first is finished. 
B)  check to label on the present IV. 
C)  confirm the flow rate. 
D)  check the order for the IVs. 
E)  speed up the flow so that the IV will be completed by 9:00 AM. 
A)  hang the next 1000 ml when the first is finished. 
B)  check to label on the present IV. 
C)  confirm the flow rate. 
D)  check the order for the IVs. 
E)  speed up the flow so that the IV will be completed by 9:00 AM.

Question 20

The nurse documents interventions periodically during the shift in nurses' notes primarily to:

Accepted Answer

A)  validate the number of non-licensed personnel who interact with the patient. 
B)  indicate that the nursing care plan has been implemented. 
C)  briefly summarize activities during the shift. 
D)  confirm that the nursing diagnoses in the care plan are appropriate. 
A)  validate the number of non-licensed personnel who interact with the patient. 
B)  indicate that the nursing care plan has been implemented. 
C)  briefly summarize activities during the shift. 
D)  confirm that the nursing diagnoses in the care plan are appropriate.

Exam 6: Implementation and Evaluation

The nurse giving a patient a back massage is performing an intervention considered to be a(n) _____ nursing action.

Standards of care are set by: (Select all that apply.)

During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

The nurse is aware that one of the time-flexible tasks to be accomplished would be:

Before performing a catheterization, the inexperienced nurse should:

Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered:

An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of Risk for falls related to weakness would be:

Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially:

The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of a:

The nurse explains that a multidisciplinary step-by-step approach to patient care is:

Nurses design interventions that are appropriate for a patient that are:

The nurse is aware that the nursing audit is a valuable process used to:

The nurse is assessing a patient who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero-sanguineous drainage. The nurse should initially:

The nurse compares actual nursing outcomes to the expected nursing outcomes in order to:

The purpose of the evaluation step of the nursing process is to: (Select all that apply.)

The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should:

The agency-wide process that takes into consideration nursing audits and compliance to standards of every department is the _____________.

The nurse documents interventions periodically during the shift in nurses' notes primarily to:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Documentation of Nursing Care

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Lifting, Moving, and Positioning Patients

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

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