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Final Practice Questions Key HA
Terms in this set (50)
1. A patient presents to the emergency department with chest tightness and shortness of breath. The nurse deems the situation nonemergent and proceeds to do what action first?
a. Complete a focused respiratory assessment
b. Gather a complete health history
c. Perform a full physical assessment
d. Ask their family member what happened leading to this event
1. A patient was recently admitted to your unit with pneumonia. Subjective data that led to this diagnosis includes (SATA):
a. Positive sputum culture
b. Shortness of breath
c. Oxygen saturation of 87%
d. Productive cough
e. Pain rating as an 8/10
1. On a pediatric unit, a nurse begins to gather a health history on a 10-year-old patient. Which action is most appropriate by the nurse?
a. Ask the parents what symptoms the child is having
b. Ask the parents to leave the room while she talks to the child
c. Ask the child how they are feeling
d. Ask the child to sit quietly while she talks to the patients
1. A nurse notices that a patient is having difficulty swallowing and coughs after each bite. What should the nurse do next?
a. Notify the physician and request a speech therapy consult
b. Document the findings and continue to monitor to patient
c. Raise the head of the bed while they eat or drink
d. Tell the patient they can no longer eat or drink for the time-being
1. The student nurse recognizes that which of the following factors can negatively influence an assessment (SATA):
b. Developing a trusting relationship
c. Language barriers
d. Previous healthcare experiences
e. Anxiety disorder
1. The dayshift nurse notices their patient is quiet and withdrawn for the second day in a row. How should the nurse document this in their chart?
a. "Patient has shown signs of depression for 2 consecutive days"
b. "Patient refuses to participate in care"
c. "Patient may benefit from a psychiatric consult"
d. "Patient has been quiet and withdrawn for 2 consecutive days"
1. During a health history, the patient tells the nurse their pain has lasted "for several days now". What is the best response by the nurse?
a. "Thank you, I will document that in your chart."
b. "Do you mind if I ask some questions about your pain?"
c. "Do you know why you are having this pain?"
d. "You should have reported this pain when it first started."
1. Medical diagnoses differ from nursing diagnoses in that:
a. Medical diagnoses deal with actual problems; nursing diagnoses deal with patient risks
b. Medical diagnoses deal with disease processes; nursing diagnoses deal with patient responses to illness
c. Medical diagnoses are constantly changing; nursing diagnoses are concrete throughout admission
d. Medical diagnoses are ongoing; nursing diagnoses are terminated with discharge
1. "PC: Aspiration related to impaired swallowing" is an example of a:
a. Nursing diagnosis
b. Medical diagnosis
c. Collaborative problem
d. Health problem
1. A patient with a long history of hypertension has a blood pressure reading of 152/95. Based on this and his health history, the nurse knows:
a. He is in hypertensive crisis
b. He is not taking his blood pressure medication
c. This finding is normal based on his standard
d. He would benefit from smoking cessation resources
1. The student nurse knows that nursing diagnosis can apply to both actual and potential patient problems. An example of a nursing diagnosis that reflects a potential problem would be:
a. Imbalanced nutrition: more than body requirements
b. Impaired skin integrity
c. Readiness for enhanced learning
d. Risk for injury
1. What are the components of a nursing diagnosis? (SATA)
d. Defining characteristics
1. Consider the following nursing diagnosis: "Bathing self-care deficit related to fear of falling in the tub as evidenced by strong body odor and unclean hair". What part of this diagnosis is considered the etiology?
a. Bathing self-care deficit
b. Related to fear of falling in the tub
c. As evidenced by unclean hair
d. As evidenced by strong body odor
1. A patient has recently had a double mastectomy. The nurse knows that which nursing diagnosis will likely be included in her care plan:
a. Ineffective coping
b. Disturbed body image
c. Risk for injury
d. Impaired gas exchange
1. Which of the following is a priority nursing diagnosis for a patient with epilepsy?
a. Knowledge deficit
b. Chronic pain
c. Risk for aspiration
1. Out of the following diagnoses, which is least likely to be included in a care plan?
a. Mild anxiety related to impending surgery
b. Constipation related to opioid analgesic use
c. Fluid volume deficit related to impaired swallowing
d. Ineffective airway clearance related to history of smoking
1. A student nurse writes a practice nursing diagnosis as follows: "Need to stop smoking related to respiratory difficulties as evidenced by patient's frequently reported shortness of breath". What feedback would the instructor give?
a. This is an accurate diagnosis
b. Nursing diagnoses should not be statements of patient needs
c. Smoking is not a nursing problem
d. Signs and symptoms should not be included in a nursing diagnosis
1. How do goals differ from outcomes?
a. The terms are interchangeable
b. A goal is what is wanted, an outcome is the result achieved
c. Goals are not included in the care plan
d. Goals are always changing; outcomes remain the same
1. Planning for discharge begins:
a. Immediately upon admission
b. After the health history is gathered
c. After the health history and physical assessment are completed
d. The day the patient is expected to leave
1. Based on Maslow's Hierarchy of Needs, list the following problems in order from highest priority to lowest priority: 1) Situational low self-esteem, 2) Impaired social interaction, 3) Impaired gas exchange, 4) Risk for falls
a. 1, 3, 4, 2
b. 4, 3, 1, 2
c. 3, 4, 2, 1
d. 3, 4, 1, 2
1. SMART is an acronym for writing effective goals and outcomes. What does the M stand for?
1. When creating a care plan for a patient, the nurse knows that:
a. They are the expert, and should independently make the decisions
b. Interventions are planned based on the physician's orders
c. The patient must be involved in all aspects of care planning
d. All problems are collaborative, and nurses never act autonomously
1. Which of the following is the best example of a nurse-initiated intervention:
a. Repositioning a patient every 2 hours after noticing a red spot on their coccyx
b. Increasing a patient's fluid rate per the physician's orders
c. Consult physical therapy to help a patient ambulate after surgery
d. Administer prescribed pain medication when a patient reports pain
1. A nurse preceptor has a student nurse with her during morning rounds. The nurse introduces the student, but the student makes no conversation with the patient. After this interaction, the nurse tells the student:
a. "Please try to interact more with the patients"
b. "Are you shy when it comes to meeting new patients?"
c. "It is important to develop a trusting relationship with your patient so they are comfortable"
"I know you are new to patient care, but the patient is relying on you to take care of them
1. What is one way that patients can be involved and kept up to date on their care plan?
a. Asking the physician to round more often
b. Having the nursing assistant explain the plan for the day
c. Assessing the patient every 4 hours
d. Writing information on their whiteboard
1. A patient's wife is visiting him in the hospital when the nurse gets an order to remove his Foley catheter. What is the best action by the nurse?
a. Politely ask the family to leave the room during the procedure
b. Ask the patient if they'd like privacy during the procedure
c. Go in and complete the procedure
1. Time management is crucial in nursing care, especially when understaffing is an issue. How can nurses manage their time more effectively when caring for patients?
a. Cluster care wherever possible
b. Complete all charting before visiting the patients again
c. Set a time limit for completing tasks for each patient
d. Delegate assessment and education to a UAP
1. During a clinical rotation, one of the nurses on the unit asks a student nurse to administer medications to one of her patients. The student nurse has practiced passing medications in simulation, but not yet in a clinical setting. How should she proceed?
a. Ask her instructor to help and observe her passing the medications
b. Tell the nurse she is not allowed to pass medications
c. Agree to the nurse's request and prepare the patient's medications
d. Ask another student nurse to help her give the medications
1. Factors that may impede the patient's compliance to their care plan include (SATA):
a. Having a family support system
b. Lack of understanding
c. Financial troubles
d. Readiness for change
e. Limited access to healthcare clinics
1. A nurse enters a patient's room to hang their ordered bag of antibiotics. The patient starts to get upset and tells the nurse that the medication makes her nauseous and she does not want it until her husband gets there. How should the nurse proceed?
a. Insist that she must get her antibiotics now because the doctor ordered it
b. Call the patient's husband and ask the physician how long you can wait to administer the med
c. Ask the patient to remain calm and assure her you will not give the med
d. Tell the patient you will try giving the med orally instead of IV to prevent the nausea
1. A nurse and her patient come up with an expected outcome that the patient, who smokes 2 packs a day, will stop smoking by the end of the year. Three months later, the patient comes back to the clinic in October and tells the nurse his support group really helps, and he is down to 3 cigarettes per day. Based on this the nurse decides to:
a. Terminate the care plan because his expected outcome was met
b. Modify the care plan and offer the patient more smoking cessation resources
c. Continue the care plan to offer the patient more time to meet the outcome
d. Suggest the patient attend his support group once a week instead of twice
1. A pediatric patient with asthma is admitted for respiratory distress and a low oxygen saturation of 86%. One of the expected outcomes for this patient is that they will maintain an oxygen saturation above 92% for the remainder of the shift. At the end of the shift, the nurse is taking vital signs and notes that the patient's oxygen saturation is 90%. How should the nurse document the evaluative statement?
a. Outcome Met
b. Outcome Partially Met
c. Outcome Not Met
d. Outcome Discontinued
1. In a care plan, the nurse writes the following expected outcome: "Patient will demonstrate correct use of their insulin pen before discharge". This is an example of what type of outcome:
1. When should expected outcomes be evaluated?
a. The day the patient will be discharged
b. When the outcome or time-limit has been met
c. When the patient returns for their follow-up appointment
d. By the end of the day when they are created
1. A nurse is assisting a postop patient in ambulating down the length of the hallway when she begins to complain of dizziness. The nurse returns the patient to her room and takes what action next?
a. Investigates further into the incident to determine if it was a one-time problem
b. Tell the patient that they will try again in a couple minutes when she is feeling better
c. Request a consult from physical therapy to evaluate her ambulation
d. Call the physician and request an antihistamine to relieve the dizziness
1. Evaluation of an environment and how well it provides necessary resources and protocols is known as:
a. Quality by inspection
b. Quality by opportunity
c. Process evaluation
d. Structure evaluation
1. A nurse witnesses a coworker enter an isolation patient's room without a gown or gloves. What is the best action by the nurse?
a. Confront the coworker and address it in a professional manner
b. Immediately notify your charge nurse and infection control
c. Tell another nurse about what you saw and ask their advice
d. Ignore the incident, as the coworker probably made a one-time mistake
1. According to HIPPA, what patient information is confidential? (SATA)
a. Name, birthday, social security #
b. Current medical diagnosis
c. Past medical history
d. Lab results
1. A student nurse asks her instructor what the punishment is for breaking HIPPA laws. The instructor responds by saying:
a. Expulsion from school
b. Up to $250,000 in fines
c. Jail time up to 10 years
d. All of the above
1. A nurse is on the phone with the doctor who prescribes the patient a new medication and orders a straight catheterization. How does the nurse end the phone call?
a. By thanking the doctor for his time
b. By repeating back all orders that were given before hanging up
c. By asking the doctor to put the orders in the computer as soon as possible
d. By writing down the orders on paper before hanging up
1. A physician leaves a written order for the nurse that says "Give patient X 10mg metoprolol QD". The nurse cannot tell if the order says "QD" or "QID", so what is her best action?
a. Call the physician to clarify
b. Go with her best judgment of what it says
c. Ask another nurse what they think it says
d. Ask the patient how much they take at home
1. Two nurses go into a patient's room to give a bedside report. The patient asks why they come in to talk about her. What is their best response?
a. "This is how we tell the oncoming nurse what is going on with you"
b. "It gives you a chance to meet the new nurse, ask any questions, and be involved in your care"
c. "The oncoming nurse has to assess you"
d. "We do this when there are new nurses who are unfamiliar with the patient rooms"
1. A mother of a 1-year-old boy is concerned because her child has a fever and diaper rash. She sets up a video chat meeting with their pediatrician who prescribes Tylenol and an antibiotic ointment. This interaction is an example of:
1. An informatics nurse on a telemetry unit recognizes the need for a more organized admission form. She works with the nursing staff to design a new form. Based on the phases of the system development lifecycle, what would be the next step in implementing this new form?
a. Activating the new form in the EHR so the nurses can now use it
b. Discussing the purpose of the new form with the unit staff
c. Conducting unit testing to identify any errors in the form
d. Training the staff by having them complete an online module about the form
1. A new graduate nurse expresses interest in informatics to the informatics nurse specialist on the unit. She asks how she can also become an INS. What is the best response by the INS?
a. "You can receive training on the unit after a year of experience"
b. "You should look into some graduate programs for informatics"
c. "You can't become an INS until you get more experience with technology"
d. "You just graduated, so you shouldn't think about that so soon"
1. Which of the following statements is true regarding telehealth?
a. It provides a new way to deliver existing healthcare services
b. Telehealth is only used to provide clinical services
c. Nutritional tracking is an example of telemedicine
d. Telehealth is mainly geared towards younger generations
1. While giving a patient a bed bath, the nurse encourages the patient to do as much of the bathing for themselves as possible. Which nursing theorist promoted this self-care approach to nursing care?
a. Florence Nightingale
b. Sister Callista Roy
c. Dorothea Orem
d. Jean Watson
1. A nurse on an oncology unit at a children's hospital is conducting a study examine how mothers with critically ill children cope. This is an example of which research method:
b. Grounded theory
1. A student nurse comes up with the following PICO question: "Among pregnant women, do home births result in more complications compared to hospital births?". Which part of this question represents the "O" in PICO:
b. Hospital births
c. Pregnant women
d. Home births
1. A nursing supervisor would like to conduct research on preventing catheter-associated urinary tract infections (CAUTIs). What would be the first step in conducting this research:
a. Review the statistics on CAUTIs on the unit
b. Appraise existing evidence on CAUTIs
c. Discuss current CAUTI prevention practices with the staff
d. Ask the question of how CAUTIs can better be prevented
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