Question 1

The nurse correctly identifies which referral as an inappropriate nursing referral?

Accepted Answer

A)   Music therapist
B)   Community agencies
C)   Adaptive care services
D)   Dermatologist D

Question 2

The registered nurse is providing an independent nursing intervention when completing which action?

Accepted Answer

A)   Administering oral medications
B)   Administering oxygen
C)   Providing emotional support
D)   Administering intravenous medication C

Question 3

When the nurse is supportive and works of behalf of patients, this role is identified by which term?

Accepted Answer

A)   Advocate
B)   Primary care provider
C)   Collaborator
D)   Delegator A

Question 4

The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2 hours. When the nurse administers this medication, which concept is being provided?

Accepted Answer

A)   Independent nursing intervention
B)   Dependent nursing intervention
C)   Referral
D)   Indirect care procedure

Question 5

The nurse recognizes which topic is appropriate teaching content for the patient who is returning from surgery?

Accepted Answer

A)   Signs and symptoms of infection
B)   Use of patient-controlled analgesia
C)   Activity limitations upon discharge
D)   Physical therapy

Question 6

The nurse is providing care for a patient of the Jehovah's Witness faith. Based on the nurse's knowledge of the patient's religious beliefs, the nurse would question which order?

Accepted Answer

A)   Obtain vital signs every shift.
B)   Regular diet as tolerated.
C)   Activity as tolerated.
D)   Infuse 1 unit packed red blood cells.

Question 7

The nurse identifies which action as a direct-care intervention?

Accepted Answer

A)   Administration of an injection
B)   Making the change-of-shift report
C)   Collaborating with members of the health care team
D)   Ensuring availability of needed equipment

Question 8

The nurse is caring for a patient who is blind. When reviewing the care plan, the nurse would modify which goal?

Accepted Answer

A)   The patient will report any drainage from the wound with a foul odor to the primary care provider after discharge.
B)   The patient will agree to report pain promptly while hospitalized.
C)   The patient will obtain no injuries while in the hospital.
D)   The patient will report any purulent wound drainage to the primary care provider after discharge.

Question 9

The nurse is learning to identify readiness to learn in patients. Which patient would the nurse identify correctly as ready to learn?

Accepted Answer

A)   The patient requesting pain medication for treatment of severe discomfort
B)   The patient reporting nausea and vomiting
C)   The patient who was just told the diagnosis of cancer of the pancreas
D)   The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days

Question 10

The nurse manager is creating the patient assignment for today. She has five registered nurses (RNs), two licensed practical nurses (LPNs), and five nurse technicians (NAs) scheduled. When making the assignment, the nurse manager needs to remember which fact of delegation?

Accepted Answer

A)   RNs are responsible for all care delegated to unlicensed nursing personnel.
B)   Delegation is considered direct intervention for patient care.
C)   LPNs operate independently and may delegate patient care.
D)   Nursing practice is clearly delineated and is standard across the country.

Question 11

The nurse understands that the five rights of delegation include which components?

Accepted Answer

A)   Right patient
B)   Right time
C)   Right person
D)   Right supervision
E)   Right task

Question 12

The male nurse is caring for a female patient who needs a complete bed bath. The patient requests that a female nurse bathe her. The male nurse recognizes this request as an example of what type of diversity?

Accepted Answer

A)   Gender diversity involving generational norms.
B)   Life span diversity
C)   Disability diversity
D)   Morphology diversity

Question 13

When the nurse realizes that the patient's short-term goals have not been met, the nurse should carry out which task?

Accepted Answer

A)   Revise or adapt the plan of care.
B)   Assume that the patient did not want to achieve his goals.
C)   Understand that a plan of care is almost never changed.
D)   Reassess plans of care only after major patient-nurse interactions.

Question 14

The nurse identifies change-of-shift report, collaboration with other health care members, and ensuring availability of needed equipment are examples of which term?

Accepted Answer

A)   Indirect care
B)   Direct care
C)   Referrals
D)   Delegation

Question 15

The nurse asks the patient for permission to involve the patient's family members in the teaching plan for the patient. Which response is the best rationale to support this involvement?

Accepted Answer

A)   Involving the family empowers the patients and their support system.
B)   Teaching family members decreases the number of questions they may ask.
C)   Educated family members ensure the patient will comply with the treatment plan.
D)   The family members may be interested in the information.

Question 16

The nurse recognizes which task that cannot be delegated?

Accepted Answer

A)   Obtaining vital signs
B)   Assessing lung sounds
C)   Bathing a patient
D)   Ambulating a patient

Question 17

The nurse is preparing to administer medications to a patient. When the patient reports new shortness of breath, which action by the nurse is most appropriate?

Accepted Answer

A)   Provide the patient with oxygen since it does not require a provider order.
B)   Complete at least three checks to ensure that the proper medication is given.
C)   Check the provider orders for all forms of prescription medications.
D)   Document that the 6 rights of medication administration were followed.

Question 18

When implementing research-based interventions, the nurse realizes which concept?

Accepted Answer

A)   Implementing evidence-based care is unique to the nursing profession.
B)   Evidence-based practice is based entirely in nursing research.
C)   Evidence-based care is focused on practices and not outcomes.
D)   Nurses must read recent literature and remain current in practice.

Question 19

The nurse understands which essential fact regarding documentation?

Accepted Answer

A)   It should be completed accurately and in a timely manner.
B)   It should not be computerized (EHR)  because of disclosure risks.
C)   It is not a legal document although they can be helpful in lawsuits.
D)   It cannot be used in determining billing and reimbursement issues.

Question 20

After completing a patient's initial assessment and developing a plan of care, what action by the nurse is most appropriate?

Accepted Answer

A)   Continuously reassess the patient.
B)   Restrict changes to the care interventions.
C)   Reassess the patient at the start of each shift.
D)   Evaluate patient goal attainment at intervals.

Exam 9: Implementation and Evaluation