Fundamentals of Nursing NCLEX Practice Questions Quiz Set 5 | 75 Questions

Fundamentals of Nursing NCLEX Practice Questions Quiz Set 5 | 75 Questions 1. 1. Question Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: o A. Plan is developed for nursing care. o B. Physical assessment begins. o C. List of priorities is determined. o D. Review of the assessment is conducted with other team members. Incorrect Correct Answer: A. Plan is developed for nursing care. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. • Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. • Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. • Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment. 2. 2. Question Planning is a category of nursing behaviors in which: • A. The nurse determines the health care needed for the client. • B. The physician determines the plan of care for the client. • C. Client-centered goals and expected outcomes are established. • D. The client determines the care needed. Incorrect Correct Answer: C. Client-centered goals and expected outcomes are established. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. • Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. • Option B: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future. • Option D: Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Critical thinking skills will play a vital role as nurses develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. 3. 3. Question Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: • A. Physician • B. Non-Emergent, non-life-threatening needs • C. Future well-being. • D. Urgency of problems Incorrect Correct Answer: D. Urgency of problems Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If the client does not have any emergency signs, the health worker proceeds to assess the client for priority conditions. This should not take more than a few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked. • Option A: All clinical staff involved in the care of the sick should be prepared to carry out a rapid assessment to identify the few clients who are severely ill and require emergency treatment. • Option B: Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: those with EMERGENCY SIGNS who require immediate emergency treatment; those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay; and those who have no emergency or priority signs and are NON-URGENT cases. These clients can wait their turn in the queue for assessment and treatment. The majority of sick clients will be non-urgent and will not require emergency treatment. • Option C: Ideally, all clients should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the client will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined. 4. 4. Question A client-centered goal is a specific and measurable behavior or response that reflects a client’s: • A. Desire for specific health care interventions. • B. Highest possible level of wellness and independence in function. • C. Physician’s goal for the specific client. • D. Response when compared to another client with a similar problem. Incorrect Correct Answer: B. Highest possible level of wellness and independence in function. Client-centered practices facilitate the development of strong therapeutic relationships and enable care providers to understand how to maximize clients’ strengths and minimize challenges in achieving treatment and recovery goals. • Option A: Care providers negotiate between clients’ decisions and ongoing risk assessments. The care plan reflects safe practices and promotes interventions that minimize or reduce potential harms to the client. • Option C: Client-centred care empowers clients, promoting autonomy, rights, voice, and self-determination in the treatment planning and recovery process and supports care plans that are developed in collaboration with clients, and allows clients to express their self-identified needs and choices. • Option D: Client-centred care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities. Health care providers who take the time to get to know their clients can provide care that better addresses the needs of clients and improves their quality of care. 5. 5. Question For clients to participate in goal setting, they should be: • A. Alert and have some degree of independence. • B. Ambulatory and mobile. • C. Able to speak and write. • D. Able to read and write. Incorrect Correct Answer: A. Alert and have some degree of independence. Goal setting in nursing provides direction for planning nursing interventions and evaluating patient progress. The purpose of goal setting in nursing is to enable the patient and nurse to determine when the problem has been resolved and help motivate the patient and the nurse by providing a sense of achievement. • Option B: In light of the potential benefits of patient participation in goal setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the following are needed: (1) patient and therapist education regarding the potential advantages of participation, (2) the enhancement of patient readiness to assume greater responsibility in their care, and (3) the development of models for use in achieving patient participation. • Option C: Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities. In a study by Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them. • Option D: Patient participation in goal setting is emphasized in order to enhance patient management and the effectiveness of treatment. Participation should improve outcomes and could be used to identify benefits that may result from the treatment. These benefits include greater goal attainment, increased patient satisfaction, gains in function, better adherence to treatment regimens, decreased depression in patients, and reduced burnout rates among physical therapists. 6. 6. Question The nurse writes an expected outcome statement in measurable terms. An example is: • A. Client will have less pain. • B. Client will be pain-free. • C. Client will report pain acuity less than 4 on a scale of 0-10. • D. Client will take pain medication every 4 hours around the clock. Incorrect Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-10. When developing goals for patients, the nurse needs to look at several factors. Think back to the SMART goal criteria. In order to be specific, nurses focus on questions like ‘What is the problem? What is the response desired?’ To make it measurable, ‘How will the client look or behave if the healthy response is achieved? What can I see, hear, measure, observe?’ • Option A: One way to help nurses remember how to write goals is to make sure they are SMART. SMART goals are Specific, Measurable, Action-Oriented, Realistic, and Timely. ‘Specific’ refers to who, what, when, where, and why. ‘Measurable’ means that you can actually measure and evaluate the progress of that goal in a concrete way. ‘Action-oriented’ means there are actions that can be taken to reach the goal. ‘Realistic’ includes the ability to work on the goal, having the resources, attitudes, abilities, and skills to reach this goal, and how realistic it is to come to fruition. Finally, ‘Timely’ means that there is an end time frame or date at which the goal is going to be evaluated. • Option B: Goal setting occurs in the third phase of the process, planning. Is the goal for nursing care to heal patients? To help them get better? To help them get well? While these are certainly at the forefront of nurses’ minds, how do you evaluate these statements? What if the definition of wellness is different from one person to another? This is why nursing goal statements that are patient-centered and measurable are so important. • Option D: Considering action-oriented, ‘Are there steps and nursing interventions needed to reach that goal? Is this a realistic outcome for the patient? Have we considered all of the factors involved, including the client’s capabilities and limitations? Does the patient have what he or she needs to reach that goal?’ And finally, ‘Is it timely? When do we expect the goal to be reached?’ 7. 7. Question As goals, outcomes, and interventions are developed, the nurse must: • A. Be in charge of all care and planning for the client. • B. Be aware of and committed to accepted standards of practice from nursing and other disciples. • C. Not change the plan of care for the client. • D. Be in control of all interventions for the client. Incorrect Correct Answer: B. Be aware of and committed to accepted standards of practice from nursing and other disciples. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. • Option A: Patients’ participation in decision-making in health care and treatment is not a new area, but currently it has become a political necessity in many countries and health care systems around the world. Emphasizing the importance of participation in the decision-making process motivates the service provider and the health care team to promote participation of patients in treatment decision-making. • Option C: A review of some literature reveals that participation of patients in health care has been associated with improved treatment outcomes. Moreover, this participation causes improved control of diabetes, better physical functioning in rheumatic diseases, enhanced patients’ compliance with secondary preventive actions, and improvement in health of patients with myocardial infarction. • Option D: With enhanced patient participation, and considering patients as equal partners in healthcare decision making patients are encouraged to actively participate in their own treatment process and follow their treatment plan and thus a better health maintenance service would be provided. 8. 8. Question When establishing realistic goals, the nurse: • A. Bases the goals on the nurse’s personal knowledge. • B. Knows the resources of the health care facility, family, and the client. • C. Must have a client who is physically and emotionally stable. • D. Must have the client’s cooperation. Incorrect Correct Answer: B. Knows the resources of the health care facility, family, and the client. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment. • Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. • Option C: The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition. • Option D: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future. 9. 9. Question To initiate an intervention the nurse must be competent in three areas, which include: • A. Knowledge, function, and specific skills. • B. Experience, advanced education, and skills. • C. Skills, finances, and leadership. • D. Leadership, autonomy, and skills. Incorrect Correct Answer: A. Knowledge, function, and specific skills Critical thinking and reflection are essential skills because they can enhance nurses’ ability to solve problems and make sound decisions. Critical thinking skills enable nurses to identify multiple possibilities in clinical situations and alternatives to interventions; weigh the consequences of alternate actions; and determine the right judgment and decisions. To provide safe and effective care to the clients, nurses must integrate knowledge, skills, and attitudes to make sound judgment and decisions. • Option B: Due to the increasing internal and external expectations of higher quality nursing, it is no longer acceptable for nurses to deliver nursing care only on experience and textbook knowledge. Clinical nurses are expected to systematically gather the best research evidence, draw from nursing experience, and consider patient’s preferences when they are making professional decisions • Option C: Some research findings showed that changing the attitude and enhancing the knowledge of nurses are the first step in EBP. McCleary and Brown conducted a study on 528 graduate nurses working in educational pediatric hospitals of Canada and reported that the nurses’ knowledge of EBP and their positive attitude towards it will contribute to its implementation in the healthcare system. • Option D: Melnyk et al. stated that acquiring knowledge about research methods and having the skill to evaluate research reports critically may enable overcoming the obstacles hindering the application of research findings and thus will lead to improvement of healthcare quality. Hence, the EBP attitude, knowledge, and skills of nurses are so important. 10. 10. Question Collaborative interventions are therapies that require: • A. Physician and nurse interventions. • B. Nurse and client interventions. • C. Client and Physician intervention. • D. Multiple health care professionals. Incorrect Correct Answer: D. Multiple health care professionals. Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint. • Option A: Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. • Option B: Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgment and skills. Includes ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals. • Option C: Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step. 11. 11. Question Well formulated, client-centered goals should: • A. Meet immediate client needs. • B. Include preventative health care. • C. Include rehabilitation needs. • D. All of the above. Incorrect Correct Answer: D. All of the above. The process of client-centered goal planning encourages members of the multi-professional team to work in partnership with the client, his or her family, and each other, united by the aim of helping the client to achieve his or her desired outcome. Goals enable clients, their carers or partners, and the multidisciplinary team to focus on strengths rather than problems. They also enable the team to gauge where the client and family are in their ‘thinking’ (Davis and O’Connor, 1999). • Option A: Once set, goals provide a central focus for all therapeutic activity, enabling clients to move away from a period of dependency to a level of achievement and/or adjustment to their situation. • Option B: Goal planning is part of the overall care plan in which the client’s own values, beliefs, and aspirations are recognized and valued, and form the central focus of the rehabilitation process. • Option C: Goals for rehabilitation can be divided into two groups: short-term and long-term. Short-term goals can act as stepping stones to achieving longer-term targets. A short-term goal for this client might be to be able to clean her teeth. 12. 12. Question The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): • A. Nursing diagnosis • B. Short-term goal • C. Long-term goal • D. Expected outcome Incorrect Correct Answer: B. Short-term goal Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair, and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth. • Option A: Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. NANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. • Option C: Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. Long-term goal indicates an objective to be completed over a longer period, usually over weeks or months. • Option D: Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably. 13. 13. Question The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at the incision site; and the client remains afebrile. These statements are examples of: • A. Nursing interventions • B. Short-term goals • C. Long-term goals • D. Expected outcomes Incorrect Correct Answer: D. Expected outcomes Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably. • Option A: Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. • Option B: Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair, and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth. • Option C: Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. Long-term goal indicates an objective to be completed over a longer period, usually over weeks or months. 14. 14. Question The planning step of the nursing process includes which of the following activities? • A. Assessing and diagnosing. • B. Evaluating goal achievement. • C. Performing nursing actions and documenting them. • D. Setting goals and selecting interventions. Incorrect Correct Answer: D. Setting goals and selecting interventions. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. • Option A: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. • Option B: This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. • Option C: Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards. 15. 15. Question The nursing care plan is: • A. A written guideline for implementation and evaluation. • B. A documentation of client care. • C. A projection of potential alterations in client behaviors. • D. A tool to set goals and project outcomes. Incorrect Correct Answer: A. A written guideline for implementation and evaluation. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. • Option B: Documentation is any written or electronically generated information about a client that describes the status, care or services provided to that client. Through documentation, you communicate observations, decisions, actions, and outcomes of these actions for clients, demonstrating the nursing process. • Option C: Behavioral tools are psychological instruments that are used for understanding and interpreting human behavior. Such tools have found many applications in corporate and educational sectors, considering their exploratory and insightful nature. • Option D: A SMART goal is one that is specific, measurable, attainable, relevant and time-bound. The SMART criteria help to incorporate guidance and realistic direction in goal setting, which increases motivation and leads to better results in achieving lasting change. 16. 16. Question After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: • A. Encourage the client to implement guided imagery when pain begins. • B. Determine the effect of pain intensity on client function. • C. Administer analgesic 30 minutes before physical therapy treatment. • D. Pain intensity reported as a 3 or less during hospital stay. Incorrect Correct Answer: D. Pain intensity reported as a 3 or less during hospital stay. This is measurable and objective. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement. • Option A: This is an example of nursing intervention. Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. • Option B: Evaluating is a planned, ongoing, purposeful activity in which the client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan (NCP). • Option C: This is an example of nursing intervention. Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. 17. 17. Question When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: • A. Apply a cold pack to the tibia. • B. Elevate the leg 5 inches above the heart. • C. Perform a range of motion to right leg every 4 hours. • D. Administer aspirin 325 mg every 4 hours as needed. Incorrect Correct Answer: B. Elevate the leg 5 inches above the heart. This does not require a physician’s order. Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgment and skills. Includes ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals. • Option A: This intervention requires a doctor’s order. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions. • Option C: C is not appropriate for a fractured tibia. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present. • Option D: Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. 18. 18. Question Which of the following nursing interventions are written correctly? • A. Apply continuous passive motion machines during the day. • B. Perform neurovascular checks. • C. Elevate head of bed 30 degrees before meals. • D. Change dressing once a shift. Incorrect Correct Answer: C. Elevate head of bed 30 degrees before meals. It is specific in what to do and when. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. • Option A: This intervention does not specify the location of the application. Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them. The nurse uses his or her knowledge, experience, and critical-thinking skills to decide which interventions will help the patient the most. • Option B: It was not stated in this intervention when the neurovascular check should be performed. Nurses must use their knowledge, experience, resources, research of evidence-based practice, the counsel of others, and critical-thinking skills to decide which nursing interventions would best benefit a specific patient. • Option D: Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.” 19. 19. Question A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: • A. Notifying the physician. • B. Calling the wound care nurse. • C. Changing the wound care treatment. • D. Consulting with another nurse. Incorrect Correct Answer: B. Calling the wound care nurse. Calling the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. As the largest health care workforce, nurses apply their knowledge, skills, and experience to care for the various and changing needs of patients. A large part of the demands of patient care is centered on the work of nurses. • Option A: Option A may be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Interprofessional and interprofessional collaboration, through multidisciplinary teams, is important in the right work environments. Skills for teamwork are considered nontechnical and include leadership, mutual performance monitoring, adaptability, and flexibility. • Option C: Option C is possible unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. Clinicians working in teams will make fewer errors when they work well together, use well-planned and standardized processes, know team members and their own responsibilities, and constantly monitor team members’ performance to prevent errors before they could cause harm. • Option D: Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan. Understanding the complexity of the work environment and engaging in strategies to improve its effects is paramount to higher-quality, safer care. 20. 20. Question When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: • A. Length of time the current treatment has been in place. • B. The spouse’s reaction to the client’s dressing change. • C. Client’s concern about the current treatment. • D. Physician’s reluctance to change the current treatment plan. Incorrect Correct Answer: A. Length of time the current treatment has been in place. This gives the consulting nurse facts that will influence a new plan. Other choices are subjective and emotional issues and conclusions about the current treatment plan may cause bias in the decision of a new treatment plan by the nurse consultant. In general, it is important to create a supportive environment with open and honest communication, focusing on the achievements and not on negative aspects. • Option B: Navigating the new system is very challenging and it is important for the clients to have a person to whom they could always turn with questions and concerns. It could not necessarily be a formal caseworker, but rather any clinician who had a trusting relationship and was helpful and willing to guide the client. • Option C: Education and information for both the patient and the family were mentioned by all the participants in a study as the main strategies to help them develop a clear understanding of their condition and prognosis. • Option D: Several successful strategies to improve client-centered care have been introduced in different hospitals: writing a family note (a summary that is given to the family) at the family meeting, appointing a contact person/therapy leader for each client, improving continuity and coordination of care through interdisciplinary collaborations, having the same staff working with the client, and providing written materials. 21. 21. Question The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: • A. Implement the specialist’s recommendations. • B. Report the recommendations to the primary physician. • C. Clarify the suggestions with the client and family members. • D. Discuss and review advised strategies with CNS. Incorrect Correct Answer: D. Discuss and review advised strategies with CNS. The primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. Effective clinical practice thus involves many instances where critical information must be accurately communicated. Team collaboration is essential. • Option A: Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving, and making decisions to formulate and carry out plans for patient care • Option B: This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. Collaboration between physicians, nurses, and other health care professionals increases team members’ awareness of each others’ type of knowledge and skills, leading to continued improvement in decision making. • Option C: The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family. A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction. 22. 22. Question After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. View Answers: • Ineffective tissue perfusion. • Ineffective airway clearance • Anticipated grieving • Constipation Incorrect The correct order is shown above. Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018). • Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production. • Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death. • Constipation occurs when bowel movements become less frequent than normal. It is accompanied by a difficult or incomplete passage of stool. Though common, constipation may also be a complex problem. Chronic constipation can result in the development of hemorrhoids; diverticulosis; straining at stool, and perforation of the colon. • Grieving is an individual’s normal response to a loss that may be perceived or actual. Assessment is necessary in order to identify potential problems that may have led to grief and also name any event that may happen during nursing care. 23. 23. Question The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? • A. A client’s family attending a diabetic teaching session. • B. Canceling physical therapy sessions on the weekend. • C. Normal VS and absence of wound infection in a post-op client. • D. A client demonstrating accurate medication administration following teaching. Incorrect Correct Answer: B. Canceling physical therapy sessions on the weekend. Variance analysis is the identification of patient or family needs that are not anticipated and the actions related to these needs in a system of managed care. There are four kinds of origin for the variance: patient-family origin, system-institutional origin; community origin, and clinician origin. • Option A: Critical pathways are care plans that detail the essential steps inpatient care with a view to describing the expected progress of the patient. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education. • Option C: Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient’s recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit. • Option D: Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilized as a process of quality control and to improve patient outcomes. 24. 24. Question The RN has received her client assignment for the day shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? • A. A client who is ambulatory. • B. A client, who has a fever, is diaphoretic and restless. • C. A client scheduled for OT at 1300. • D. A client who just had an appendectomy and has just received pain medication. Incorrect Correct Answer: B. A client, who has a fever, is diaphoretic and restless. This client’s needs are a priority. Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical careers to direct patient care and determine priorities. • Option A: An ambulatory client would not be a priority. However, a thorough assessment should still be done to make sure that the client does not have any underlying diseases. In unfamiliar situations, patient prioritization should be approached as a structured process, highlighting risk factors that may contribute to a decline in the patient’s condition and potential interventions that can reduce the risk of adverse outcomes (Jessee, 2019). • Option C: The client does not have any emergent concerns based on the stem. Seasoned nurses are able to pull from their depth of knowledge and experience that allows them to act deductively and intuitively when prioritizing patient care. • Option D: The client has already received pain medication, therefore she is not a priority. For expert nurses, the ability to prioritize based on these processes is predominately intuitive, and tasks are completed in a prioritized manner without much conscious thought. 25. 25. Question Which of the following statements about the nursing process is most accurate? • A. The nursing process is a four-step procedure for identifying and resolving patient problems. • B. Beginning in Florence Nightingale’s days, nursing students learned and practiced the nursing process. • C. Use of the nursing process is optional for nurses since there are many ways to accomplish the work of nursing. • D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept. Incorrect Correct Answer: D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept. The nursing process is a systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health it- is the essential core of nursing practice to deliver holistic, patient-focused care. Nursing process provides an organizing framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care.” • Option A: The nursing process is a five-step process. The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. • Option B: The term nursing process was first used by Hall in 1955. In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. • Option C: Nursing process is not optional since standards demand the use of it. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care. As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future. 26. 26. Question What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment? • A. A cotton ball • B. A penlight • C. An ophthalmoscope • D. A tongue depressor and flashlight Incorrect Correct Answer: D. A tongue depressor and flashlight Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated. The 9th (glossopharyngeal) and 10th (vagus) cranial nerves are usually evaluated together. Whether the palate elevates symmetrically when the patient says “ah” is noted. If one side is paretic, the uvula is lifted away from the paretic side. A tongue blade can be used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is observed; bilateral absence of the gag reflex is common among healthy people and may not be significant. • Option A: For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against the lower or lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the angle of the jaw should be examined; sparing of this area (innervated by spinal root C2) suggests a trigeminal deficit. A weak blink due to facial weakness (eg, 7th cranial nerve paralysis) should be distinguished from depressed or absent corneal sensation, which is common in contact lens wearers. A patient with facial weakness feels the cotton wisp normally on both sides, even though blink is decreased. • Option B: A penlight provides a source of light and has become the most common used tool to assess pupil diameter. Asymmetry of pupil constriction in response to light means one pupil constricts and the other remains dilated or constricts more slowly. It may indicate dynamic anisocoria or a Marcus Gunn pupil, a relative afferent pupillary defect (RAPD), or temporal lobe herniation in the brain. • Option C: The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. Ophthalmoscopy (examination of the posterior segment of the eye) can be done directly by using a handheld ophthalmoscope or with a handheld lens in conjunction with the slit lamp biomicroscope. 27. 27. Question Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain? • A. Offering the client pamphlets on support groups for brain cancer. • B. Asking the client if there is anything he or his family needs. • C. Reminding the client that advances in technology are occurring every day. • D. Providing accurate information about the disease and treatment options. Incorrect Correct Answer: D. Providing accurate information about the disease and treatment options. Providing information for the client is the best technique for a new diagnosis. Every clinician at one time or another faces these important questions. In the treatment of terminally ill patients, the health professional needs many skills: the ability to deliver bad news, the knowledge to provide appropriate optimal end-of-life care, and the compassion to allow a person to retain his or her dignity. • Option A: Cassem, in the Massachusetts General Hospital Handbook of General Hospital Psychiatry, recommends relaying negative information to patients through a brief, rehearsed initial statement that succinctly communicates the news and clearly indicates that the treatment team is committed to the ongoing care and support of the patient. • Option B: In considering the emotional state of a person with terminal illness, it is often helpful to consider the effects of the family members on the patient and vice versa. By observing the interactions of a patient with family, the consultant can become aware of long-standing grudges or new difficulties in communication that can make the process of coming to closure at the end of a life more difficult. • Option C: In most cases, patients who are told their diagnosis in an up-front, clear manner have better emotional adjustments to their situation than those who are not told about their condition. By providing direct, clear information in a compassionate manner, and by making clear to the patient that everything possible will be done to provide medical and emotional support, physicians can elicit trust and reduce anxiety. 28. 28. Question An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic? • A. Administer insulin. • B. Administer oxygen. • C. Feed the infant glucose water (10%). • D. Place the infant in a warmer. Incorrect Correct Answer: C. Feed the infant glucose water (10%) After birth, the infant of a diabetic mother is often hypoglycemic. Treatment will depend on the baby’s gestational age and overall health. Treatment includes giving the baby a fast-acting source of glucose. This may be as simple as a glucose and water mixture or formula as an early feeding. Or the baby may need glucose given through an IV. The baby’s blood glucose levels are checked after treatment to see if the hypoglycemia occurs again. • Option A: Second-line therapies for the treatment of persistent hypoglycemia include the use of corticosteroids or glucagon, not insulin. Glucagon is a hormone that stimulates endogenous glucose production via glycogenolysis and gluconeogenesis; thus its effectiveness depends on the infant having adequate glycogen stores. It is most useful in term infants and infants of diabetic mothers. Glucagon dosing is as a 30 mcg/kg bolus or 300 mcg/kg per minute continuous infusion. • Option B: Oxygen is not administered to hypoglycemic neonates. Early initiation of breastfeeding is crucial for all infants. For asymptomatic infants at risk of neonatal hypoglycemia, the AAP recommends initiating feeds within the first hour of life and performing initial glucose screening 30 minutes after the first feed. The AAP recommends goal blood glucose levels equal to or greater than 45 mg/dL prior to routine feedings, and intervention for blood glucose <40 mg/dL in the first 4 hours of life and <45 mg/dL at 4 to 24 hours of life. • Option D: Placing the infant in a warmer does not manage the hypoglycemia. In infants of diabetic mothers, lower glucose infusions rates of 3 to 5 mg/kg/minute may be used to minimize pancreatic stimulation and endogenous insulin secretion. Infants requiring higher rates of intravenous dextrose (>12 to 16 mg/kg/minute) or for more than 5 days are more likely to have a persistent cause of hypoglycemia. 29. 29. Question What question would be most important to ask a male client who is in for a digital rectal examination? • A. “Have you noticed a change in the force of the urinary system?” • B. “Have you noticed a change in tolerance of certain foods in your diet?” • C. “Do you notice polyuria in the AM?” • D. “Do you notice any burning with urination or any odor to the urine?” Incorrect Correct Answer: A. “Have you noticed a change in the force of the urinary system?” This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy. The goals of the evaluation of such men are to identify the patient’s voiding or, more appropriately, urinary tract problems, both symptomatic and physiologic; to establish the etiologic role of BPH in these problems. • Option B: Food intolerances are more common in those with digestive system disorders, such as irritable bowel syndrome (IBS). According to the IBS network, most people with IBS have food intolerances. The symptoms of food intolerances can also mimic the symptoms of chronic digestive conditions, such as IBS. However, certain patterns in the symptoms can help a doctor distinguish between the two. • Option C: History can often distinguish polyuria from frequency, but rarely a 24-hour urine collection may be needed. Polyuria caused by solute diuresis is suggested by a history of diabetes mellitus. Abrupt onset of polyuria at a precise time suggests central diabetes insipidus, as does preference for extremely cold or iced water. • Option D: Dysuria is a symptom of pain and/or burning, stinging, or itching of the urethra or urethral meatus with urination. It is one of the most common symptoms experienced by most people at least once over their lifetimes. Primarily, causes of dysuria can be divided broadly into two categories, infectious and non-infectious. 30. 30. Question The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to: • A. Turn off the infusion. • B. Turn the client to the left. • C. Change the fluid to Ringer’s Lactate. • D. Increase mainline IV rate. Incorrect Correct Answer: A. Turn off the infusion Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration. When late decelerations are observed, the nurse should attempt to increase the oxygen delivery to the fetus by turning the mother on her left side and/or administering oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped. • Option B: Variable decelerations are marked by a sharp decrease (“V” shape) in FHR that does not correlate to contractions. Umbilical cord compression is usually the cause of variable decelerations. Repositioning of the mother can relieve this compression if it is minor. • Option C: Late decelerations are shown by the FHR gradually decreasing around the peak of the contraction and gradually increasing when the contraction is over. These decelerations will also have a “U” shape but will not mirror the contractions. The most common cause of late decelerations is uteroplacental insufficiency (insufficient oxygen exchange between the placenta and the fetus). • Option D: Increasing the main IV line would not manage the decelerations. While caring for a patient in labor, one of the important nursing duties is monitoring the variability of the fetal heart rate (FHR) and monitoring the FHR response during contractions. Variability in the FHR during labor is a sign of fetal well-being or fetal activity or both. The expected variability usually includes slight accelerations and decelerations. 31. 31. Question Which nursing approach would be most appropriate to use while administering an oral medication to a 4-month-old? • A. Place medication in 45cc of formula. • B. Place medication in an empty nipple. • C. Place medication in a full bottle of formula. • D. Place in supine position. Administer medication using a plastic syringe. Incorrect Correct Answer: B. Place medication in an empty nipple. This is a convenient method for administering medications to an infant. Draw up the correct amount of medicine into an oral syringe (a syringe without a needle) or an empty nipple. Let the infant suck the medicine out of the syringe or empty nipple. When giving medicine to an infant, use his natural reflexes (such as sucking) whenever possible. • Option A: Avoid mixing medicine with foods the child must have. The child may begin to dislike the foods he needs. Mix the medicine with a small amount (1 to 2 teaspoons) of applesauce or pears and give it with a spoon. This is a good way to give pills that have been crushed well. (To crush a pill, place it between two spoons and press the spoons together). • Option C: Some medicines can be put in a small amount of juice or sugar water. Follow the instructions from the doctor, nurse, or pharmacist. Do not put medicine in a full bottle or cup in case the infant does not drink very much. • Option D: Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration. Hold the infant in a nearly upright position. If the infant struggles, gently hold one arm and place his other arm around the waist. Hold the baby close to the body. 32. 32. Question Which nursing intervention would be a priority during the care of a 2-month-old after surgery? • A. Minimize stimuli for the infant. • B. Restrain all extremities. • C. Encourage stroking of the infant. • D. Demonstrate to the mother how she can assist with her infant’s care. Incorrect Correct Answer: C. Encourage stroking of the infant. Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive. Most babies with FTT do not have a specific underlying disease or medical condition to account for their growth failure. This is referred to as Non-organic FTT. Up to 80% of all children with FTT have Non-organic type FTT. Non-organic FTT most commonly occurs when there is inadequate food intake or there is a lack of environmental stimuli. • Option A: Provide sensory stimulation. Attempt to cuddle the child and talk to him or her in a warm, soothing tone and allow for play activities appropriate for the child’s age. Feed the child slowly and carefully in a quiet environment; during feeding, the child might be closely snuggled and gently rocked; it may be necessary to feed the child every 2 to 3 hours initially. • Option B: Do not restrain the child. Burp the child frequently during and at the end of each feeding, and then place him or her on the side with the head slightly elevated or held in a chest-to-chest position. • Option D: If a family caregiver is present, encourage him or her to become involved in the child’s feedings. While caring for the child, point out to the caregiver the child’s development and responsiveness, noting and praising any positive parenting behaviors the caregiver displays. 33. 33. Question While performing a physical examination on a newborn, which assessment should be reported to the physician? • A. Head circumference of 40 cm. • B. Chest circumference of 32 cm. • C. Acrocyanosis and edema of the scalp. • D. Heart rate of 160 and respirations of 40. Incorrect Correct Answer: A. Head circumference of 40 cm Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure. A newborn’s head is usually about 2 cm larger than the chest size. Between 6 months and 2 years, both measurements are about equal. After 2 years, the chest size becomes larger than the head. • Option B: The body of a normal newborn is essentially cylindrical; head circumference slightly exceeds that of the chest. For a term baby, the average circumference of the head is 33–35 cm (13–14 inches), and the average circumference of the chest is 30–33 cm (12–13 inches). • Option C: Peripheral cyanosis (acrocyanosis) involves the hands, feet, and circumoral area. It is evident in most infants at birth and for a short time thereafter. If limited to the extremities in an otherwise normal infant, it is due to venous stasis and is innocuous. Localized cyanosis may occur in presenting parts, particularly in association with abnormal presentations. • Option D: Heart rates normally fluctuate between 120 and 160 beats per minute. In agitated states, a rate of 200 beats per minute may occur transiently. The heart rate of premature infants is usually between 130 and 170 beats per minute, and during occasional episodes of bradycardia, it may slow to 70 beats per minute or less. Normal neonates breathe at rates that vary between 40 and 60 respirations per minute. Rapid rates are likely to be present for the first few hours after birth. 34. 34. Question Which action by the mother of a preschooler would indicate a disturbed family interaction? • A. Tells her child that if he does not sit down and shut up she will leave him there. • B. Explains that the injection will burn like a bee sting. • C. Tells her child that the injection can be given while he’s in her lap. • D. Reassures the child that it is acceptable to cry. Incorrect Correct Answer: A. Tells her child that if he does not sit down and shut up she will leave him there. Threatening a child with abandonment will destroy the child’s trust in his family. Children growing up in such families are likely to develop low self-esteem and feel that their needs are not important or perhaps should not be taken seriously by others. As a result, they may form unsatisfying relationships as adults. • Option B: It can help to describe the need for injections and blood testing in kid terms. For example, the nurse might explain that the shots and blood tests help keep the child feeling good throughout the day — and that not getting them could mean having to stay home from school or miss fun activities because of health problems. • Option C: Having both parents (or one parent plus another caregiver) involved in the management process will help keep treatment consistent and also provide support as the nurse deals with struggles over shots and blood tests. • Option D: If the child argues or cries, the parents might be tempted to skip an injection or test just this once. Nurses shouldn’t negotiate blood tests or shots. They’re necessary and not optional. The first time you’re talked out of one, you’ll set a precedent that that child won’t forget. 35. 35. Question During the history, which information from a 21-year-old client would indicate a risk for development of testicular cancer? • A. Genital Herpes • B. Hydrocele • C. Measles • D. Undescended testicle Incorrect Correct Answer: D. Undescended testicle Undescended testicles make the client at high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors. The risk of testicular cancer might be a little higher for men whose testicles stayed in the abdomen as opposed to one that has descended at least partway. If cancer does develop, it’s usually in the undescended testicle, but about 1 out of 4 cases occur in the normally descended testicle. • Option A: While HPV infections are very common, cancer caused by HPV is not. Most people infected with HPV will not develop cancer-related to the infection. However, some people with long-lasting infections of high-risk types of HPV, are at risk of developing cancer. • Option B: Hydroceles generally don’t pose any threat to the testicles. They’re usually painless and disappear without treatment. However, if the patient has scrotal swelling, he should see his doctor rule out other causes that are more harmful such as testicular cancer. • Option C: Measles has a low death rate in healthy children and adults, and most people who contract the measles virus recover fully. The risk of complications is higher in the following groups: children under 5 years old. adults over 20 years old. 36. 36. Question While caring for a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which of the following assessments is appropriate for the nurse to perform? • A. Measure the length of the mass. • B. Auscultate the mass. • C. Percuss the mass. • D. Palpate the mass. Incorrect Correct Answer: B. Auscultate the mass. Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. Occasionally, an overlying mass (pancreas or stomach) may be mistaken for an AAA. An abdominal bruit is nonspecific for an unruptured aneurysm, but the presence of an abdominal bruit or the lateral propagation of the aortic pulse wave can offer subtle clues and maybe more frequently found than a pulsatile mass. • Option A: In one study, 38% of AAA cases were detected on the basis of physical examination findings, whereas 62% were detected incidentally on radiologic studies obtained for other reasons. Femoral/popliteal pulses and pedal (dorsalis pedis or