NCLEX Review Questions Intro to Professional Nursing Questions and Answers

NCLEX Review Questions Intro to Professional Nursing Questions and Answers In which of the following cases is the nursing process applicable? When nurses work with patients who are able to participate in their care When families are clearly supportive and wish to participate in care When patients are totally dependent on the nurse for care All of the above All of the above Which of the following statements concerning the nursing process is true? the nursing process is nurse-oriented the steps of the nursing process are separate entities the nursing process is nursing practice in action the nursing process comprises 4 steps to promote patient well-being The nursing process is nursing practice in action Data that can be observed by one person and verified by another person observing the same patient are known as: Subjective Objective Symptomatic Covert Objective Which of the following sources of patient data is usually the primary and best source? Patient Family Members Patient Records Other healthcare professionals Patient When a patient you are admitting asks you why you are doing a history and physical assessment since the doctor just completed one, your best reply is: "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." "It's hospital policy. I know it must be tiresome, but I will try to be quick!" "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care. This information will help me develop a plan of care for your unique needs." "We want to make sure that your responses are consistent and that all our data are accurate." "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." A patient complains of feeling nauseated after lunch. This is an example of what type of data? A) Subjective B) Objective C) Signs and Symptoms D) Overt Subjective Use Maslow's Hierarchy of human needs to prioritize the following patient problems from highest priority to lowest priority. A) Disturbed body image B) Ineffective airway clearance C) Spiritual distress D) Impaired social interaction Ineffective airway clearance, impaired social interaction, disturbed body image, spiritual distress Which of the following statements regarding nursing diagnoses is accurate? 1. Nursing diagnoses remain the same for as long as the disease is present 2. Nursing diagnoses are written to identify diseases 3. Nursing diagnoses are written to describe the primary course of disease treatment 4. Nursing diagnoses focus on identifying responses to health and illness Nursing diagnoses focus on identifying responses to health and illness Which of the following nursing diagnoses are written correctly? (Select ALL that apply) 1. possible chronic low self-esteem 2. risk for impaired skin integrity 3. deficient fluid volume related to abnormal fluid loss as evidenced by vomiting 4. impaired verbal communication related to tracheostomy 5. acute pain related to fractured femur as evidenced by grimacing when walking 3. deficient fluid volume related to abnormal fluid loss as evidenced by vomiting 4. impaired verbal communication related to tracheostomy 5. acute pain related to fractured femur as evidenced by grimacing when walking From which of the following are patient outcomes derived? 1. Problem statement of the nursing diagnosis 2. Etiology of the problem of the nursing diagnosis 3. Defining characteristics of the problem 4. Evaluative statement Problem statement of the nursing diagnosis Which of the following is a correctly written goal for a patient who is scheduled to ambulate following hip surgery? 1. Over the next 24 hours, the patient will walk the length of the hall assisted by the nurse 2. The nurse will help the patient walk the length of the hallway once a day 3. Offer to help the patient walk the length of the hallway each day 4. Patient will become mobile within 24 hours Over the next 24 hours, the patient will walk the length of the hall assisted by the nurse Mr. Conner is a 48 year old patient with a new colostomy. Which of the following patient goals for Mr. Conner is written correctly? 1. Explain to Mr. Conner the proper care of the stoma by 9/15/13. 2. Mr. Conner will know how to care for his stoma by 9/15/13. 3. Mr. Conner will demonstrate proper care of his stoma by 9/15/13. 4. Mr. Conner will be able to care for his stoma and cope with psychological loss by 9/15/13. Mr. Conner will demonstrate proper care of his stoma by 9/15/13. Which of the following nursing interventions is correctly written? (Choose ALL that apply) 1. The nurse will walk with patient to bathroom for toileting every 2 hours while patient is awake 2. The nurse will demonstrate how to count a radial pulse during each vital signs assessment 3. The nurse will manage the patient's pain -The nurse will walk with patient to bathroom for toileting every 2 hours while patient is awake -The nurse will demonstrate how to count a radial pulse during each vital signs assessment A nurse creates a weight loss plan of care with a patient. Her first goal is to lose 5 lbs in 1 month, but she loses only 1 lb. Which is the best nursing response? 1. Congratulate the patient and continue the plan of care. 2. Terminate the plan of care since it is not working. 3. Try giving the patient more time to reach the goal. 4. Modify the plan of care after discussing with the patient reasons for her partial success. Modify the plan of care after discussing with the patient reasons for her partial success. Which of the following is a correctly written evaluative statement? 1. Outcome not met. 2. 9/30/16- Patient reports no change in tobacco use. 3. Outcome not met. Patient reports no change in tobacco use. 4. 9/30/16- Outcome not met. Patient reports no change in tobacco use. 4. 9/30/16- Outcome not met. Patient reports no change in tobacco use. The nurse notices a patient walking to the bathroom with facial grimacing. The nurse should assess the patient for: A) pain B) anxiety C) depression D) fluid volume defecit Pain Which of the following statements about the communication process is true? A) Communication is a reciprocal process in which both the sender and receiver of messages take turns participating. B) One-to-one communication occurs when 3 or more people are involved in the communication process. C) Nursing instructors and students seldom experience opportunities to communicate effectively. D) Communicating people receive and send messages through verbal and non-verbal means which occur simultaneously. Communicating people receive and send messages through verbal and non-verbal means which occur simultaneously. The nurse enters the room of a patient with cancer. The patient is crying and states "I feel so alone." Which is the most therapeutic response? A) The nurse stands at the patient's bedside and states "I understand how you feel, my mother said the same thing when she was ill." B) The nurse stands in the patient's room and asks "Why do you feel so alone? Your wife visits you every day." C) The nurse holds the patient's hand and asks "What makes you feel so alone?" The nurse holds the patient's hand and asks "What makes you feel so alone?" During an interaction with the family of a critically ill patient, the nurse uses the communication technique of silence. This technique assists the family to: A) communicate with the patient B) plan for discharge C) organize their thoughts D) decrease anxiety Organize their thoughts A 76 year old patient states "I've been having complications related to my diabetes." The nurse needs to direct the patient to gain more information. What is the most appropriate comment or question to elicit additional information? A) "Do you take 2 injections of insulin to decrease the complications?" B) "Most physicians recommend diet and exercise to regulate blood sugar." C) "Most complications of diabetes are related to neuropathy." D) "What specific complications have you experienced?" "What specific complications have you experienced?" Which of the following techniques would a nurse employ when using listening skills appropriately? A) the nurse would try to avoid body gestures when listening to the patient. B) the nurse would not allow conversation to lapse into periods of silence. C) the nurse would listen to themes in the patient's comments D) the nurse would stand close to the patient when communicating with him or her and maintain eye contact. The nurse would listen to themes in the patient's comments A 36 year old women who underwent a hysterectomy 4 days ago says to the nurse "I wonder if I'll still feel like a woman." Which of the following responses would most likely encourage the patient to expand on this and express her concerns in more specific terms? A) "When did you begin to wonder about this?" B) "Do you want more children?" C) "Feel like a woman..." D) Remaining silent "Feel like a woman..." Which of the following is an example of an open-ended question? A) Tell me what brought you to the hospital today. B) Which medication are you taking for your blood pressure? C) Did these symptoms begin before or after your blood transfusion? Tell me what brought you to the hospital today. Which of the following would most likely help nurses improve their communication with patients? (choose ALL that apply) A) The nurse should control the tone of his/ her voice so that it conveys the correct meaning. B) The nurse should remain focused on the topic at hand and not allow the patient to diverge to another topic. C) The nurse should make statements that are as simple as possible, gearing conversation to the patient's level. D) The nurse should fell free to use words that might have different interpretations when using the same language as the patient. E) The nurse should never admit a lack of knowledge to the patient to avoid undermining the patient's confidence. F) The nurse should take advantage of any available opportunities to communicate information to patients in routine caregiving situations. A) The nurse should control the tone of his/ her voice so that it conveys the correct meaning. C) The nurse should make statements that are as simple as possible, gearing conversation to the patient's level. F) The nurse should take advantage of any available opportunities to communicate information to patients in routine caregiving situations. Which of the following techniques are recommended to help improve listening skills? (choose ALL that apply) A) sit with the patient in a comfortable environment with arms and legs crossed in a relaxed position. B) always maintain eye-contact with the patient. C) use appropriate facial expression and body gestures to indicate that you are paying attention. D) think before responding to the patient, even if this creates a lull in the conversation. E) listen for themes in the patient's comments. C) use appropriate facial expression and body gestures to indicate that you are paying attention. D) think before responding to the patient, even if this creates a lull in the conversation. E) listen for themes in the patient's comments. A patient with newly diagnosed cancer is crying. The nurse replies "I am sure everything will be fine. You have nothing to worry about." This is an example of which block to effective communication? A) false reassurance B) giving advice C) being judgmental D) changing the subject False reassurance Your patient has developed a low-grade fever and states that she has felt very tired lately. This phase of an infection is known as the: A) incubation period B) prodromal stage C) full stage of illness D) convalescent period Prodromal stage Your patient has developed a low-grade fever and states that she has felt very tired lately. The patient is (MOST or LEAST) contagious at this time? Prodromal stage Which hospitalized patient is most at risk for developing a healthcare-associated infection? A) Mr. Y, a 60 year old patient who smokes 2 packs/day of cigarettes B) Mrs. J., a 40 year old patient with a normal WBC count C) Mr. L., a 65 year old patient with an indwelling urinary catheter D) Mrs. M., a 60 year old patient who is a vegetarian and slightly underweight Mr. L., a 65 year old patient with an indwelling urinary catheter A patient develops a urinary tract infection after an indwelling catheter has been inserted. This would be considered: A) a viral infection B) a chronic infection C) an iatrogenic infection D) an opportunistic infection An iatrogenic infection What one activity is most important in preventing infection when providing patient care? A) wearing gloves whenever touching the patient B) following proper procedures for sterile dressing changes C) asking family members to leave the room during care D) performing hand hygiene before and after care Performing hand hygiene before and after care The nurse has just finished administering oral medications to Mr. J and needs to assist Mr. R to the restroom. The nurses hands are not visibly contaminated. What would be most appropriate for the nurse to do? A) 15 sec. handwashing with soap and water B) 23 min. scrub with antimicrobial soap and water C) use of alcohol-based hand gel D) no hand hygiene Use of alcohol-based hand gel Standard precautions recommendations apply to: A) only patients with diagnosed infections B) only blood C) all blood and body fluids including sweat D) all patients All patients Mrs. Teal is to have an indwelling urinary catheter inserted. Which of the following would be the precaution taken during this procedure? A) surgical asepsis technique B) medical asepsis technique C) droplet precautions D) contact precautions Surgical asepsis technique The nurse is performing a sterile wound dressing. Maintaining surgical asepsis requires the nurse to (select ALL that apply): A) keep splashes on the sterile field to a minimum B) keep hands above waist at all times C) consider the outer 1 inch of the sterile field to be contaminated D) raise working surface to waist height E) cover mouth with hand when sneezing to prevent transmission of infection F) ensure that sterile field is placed behind the nurse B) keep hands above waist at all times C) consider the outer 1 inch of the sterile field to be contaminated D) raise working surface to waist height Specialty knowledge, experience, and clinical judgment which results in recognition in a specific practice area based on specific criteria established by a non-governmental association is called: A) Accreditation B) Licensure C) Certification D) Board approval Certification Which of the following nursing degrees prepares a nurse for advanced practice as a clinical specialist or nurse practitioner? A) Diploma B) BSN C) MSN D) PhD MSN A professional nurse committed to the principle of autonomy would be careful to: 1. Provide the information and support a patient needed to make decisions to advance his/her own interests 2. Treat each patient fairly, trying to give everyone his or her due 3. Keep any promises made to a patient or another professional caregiver 4. Avoid causing harm to the patient Provide the information and support a patient needed to make decisions to advance his/her own interests Nurse advocates often are conflicted about respecting a patient's right to be self-determining, while at the same time wanting to do everything in their power to promote the patient's best interests. Which is the best general guideline for situations like this? 1. Patient rules! "It's my life!" 2. Nurse rules! "It may be your life, but in this instance you don't know enough to make the right choice!" 3. When in conflict, weigh the benefits and risks of following each option and then choose wisely. When in conflict, weigh the benefits and risks of following each option and then choose wisely. A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accord with which ethical principle? 1. Autonomy 2. Beneficence 3. Justice 4. Fidelity 5. Nonmaleficence Nonmaleficence A friend asks you about the Bill of Rights for Nurses. What can you tell her that accurately reflects the concerns of the drafters of these rights? 1. The Bill of Rights was drafted by nurses who care more about themselves than their patients. 2. The Bill of Rights was drafted by union nurses who are always looking for a reason to strike. 3. The Bill of Rights was drafted to empower nurses and to improve conditions in the workplace. The Bill of Rights was drafted to empower nurses and to improve conditions in the workplace. Janie wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. She believes his dying is being prolonged painfully. She is troubled when the patient's doctor tells her that she'll be fired if she raises questions about his care or calls the consult. This is an example of: 1. Ethical uncertainty 2. Ethical distress 3. Ethical dilemma Ethical distress What type of authority regulates the practice of nursing? 1. International standards and codes 2. Federal guidelines and regulations 3. State nurse practice acts 4. Institutional policies State nurse practice acts If you harm a patient by administering an incorrect medication ordered by a physician, which of the following is true? A) You are not responsible since you were merely following the doctor's orders. B) Only you are responsible since you actually administered the medication. C) Only the physician is responsible since he/she actually ordered the medication. D) Both you and the physician are responsible for your respective actions. Both you and the physician are responsible for your respective actions A fellow student asks you about your legal liability when you do your clinical practice. Which of the following are true? (Select ALL that apply) A) Student nurses are responsible for their own acts of negligence if these result in patient injury. B) Student nurses are held to the same standards of care as a registered nurse C) Nursing instructors may share a student's responsibility for damages in the event of patient injury if the instructor failed to provide reasonable and prudent clinical supervision A) Student nurses are responsible for their own acts of negligence if these result in patient injury. B) Student nurses are held to the same standards of care as a registered nurse C) Nursing instructors may share a student's responsibility for damages in the event of patient injury if the instructor failed to provide reasonable and prudent clinical supervision What must be established to prove that malpractice or negligence has occurred? A) A physician involved in the patient's care called a nurse's actions negligence and said the patient could be saved B) The fact that the patient should not have died C) The nurse intended to harm the patient and was willfully negligent D) The nurse had a duty to perform a certain nursing action, but failed to do so resulting in patient injury. The nurse had a duty to perform a certain nursing action, but failed to do so resulting in patient injury. An infection is a disease state that results from the presence of what_______ in or on the body Pathogen What is the single most effective way to break the infection cycle? Hand Hygiene/Washing Which stage of infection is a person most infectious? Prodromal In addition to standard precautions, the nurse would initiate droplet precautions for which patient? • Select all that apply: • A patient with rubella • A patient with diphtheria • A patient with varicella • A patient with MRSA • A patient with the flu • A patient with rubella • A patient with diphtheria • A patient with the flu Mrs. Smith was admitted to your floor for hip replacement surgery. Prior to surgery she had an indwelling Foley catheter inserted into her bladder. After her surgery she was professing nicely. However, 48 hours after surgery she developed a fever, chills and general lethargy. Test were done and Mrs. Smith developed a urinary tract infection. The urinary tract infection is an example of what type of infection? • Hospital-Acquired infection: • Iatrogenic (caused by treatment done in hospital) • Nosocomial (acquired during hospitalization) Performing a physical examination and interviewing the patient are activities that nurse would conduct during which phase of the nursing process? Assessment The patient states "I have been under a lot of stress at work recently." What time of assessment data is this? Subjective The nurse will turn the patient in bed every 2 hours" is an example of what part of a nursing care plan? Nursing order (intervention) The following nursing diagnosis is correctly written-true or false? If false, identify the problem. TRUE: Acute pain related to abdominal incision The following patient goal is written correctly-true or false? If false identify the problem: FALSE: The patient will identify 3 stress relieving techniques. Problem: needs a time frame A nurse does not knowingly administer an overdose of a medication to her patient because of her need to "do no harm." What ethical principle is she following? Non-Maleficence (do no harm) A patient is scheduled for an appendectomy. The physician explains the procedure, risks and benefits. The patient is asked to sign a form called an: Informed consent What educational preparation would be expected of a nurse educator who is independently conducting a research study to examine the effects of alcohol on the sexual behaviors of college freshman PhD A nurse working on a post-surgical unit notices the urinary infection rates are very high in his patients. He explores the literature to determine the best practices related to indwelling catheter removal to decreased urinary infections. This is an example of: Evidence-Based practice A nurse is assigned to care for a 62-year-old Asian women who does not speak English. Her husband is at the beside at all times. What is the best way for the nurse to communicate with this patient? Professional translator What type of question can the nurse ask to encourage the patient to share freely, allowing the nurse to get a lot of information from the patient? Open-ended question The nurse is caring of a patient in a wheelchair. Name one thing the nurse should do when communicating with this patient? Sit (at eye level), talk directly to patient, treat as adult, ask about disability, etc. What is wrong with the following conversation? • Patient: "I don't know what to do. I'm so scared I'm going to die. My mother had cancer and she died 3 months after getting... • Nurse: "Don't worry that was a long time ago" False reassurance The nurse is caring for a patient with an endotracheal tube who is awake, but unable to speak. Identify two strategies the nurse can use to communicate with this patient and/or to assist the patient in communicating. Eye blinks, communication boards, sign language, pictures, flashcards, eye blinks, & hand squeezes