Exam 1 V2: PNR105 / PNR 105 (Latest Update 2025 / 2026) Pharmacology Exam Study| Questions and Verified Answers | 100% Correct | Grade A - Fortis

Exam 1 V2: PNR105 / PNR 105 (Latest Update 2025 / 2026) Pharmacology Exam Study| Questions and Verified Answers | 100% Correct | Grade A - Fortis Question: An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Passive prevention Answer: A - Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems from developing in the future. • Question: A nurse determines that a fracture bedpan should be used for the patient who: a. Has a spinal cord injury b. Is on bedrest c. Has dementia d. Is obese Answer: A - A fracture bedpan has a low back that promotes function of the patient's lower back while on the bedpan. The fracture pan has one flat end for ease of use with specific patient populations: i.e. hip fractures, hip replacements, or lower extremity fractures. • Question: Which intervention is an example of primary prevention? a. Administering digoxin (Lanoxicaps) to a patient with heart failure. b. Administering measles, mumps, and rubella immunization to an infant. c. Obtaining a Papanicolaou smear to screen for cervical cancer. d. Using occupational therapy to help a patient cope with arthritis. Answer: B - Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future. • Question: The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? a. Assessment b. Nursing diagnosis c. Planning d. Evaluation Answer: B - The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. • Question: Nurse Nikki is revising a client's care plan. During which step of the nursing process does such revision take place? a. Assessment b. Planning c. Implementation d. Evaluation Answer: D - During the evaluation step of the nursing process, the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. • Question: Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? a. Administer sleeping medication before bedtime. b. Ask the client each morning to describe the quantity of sleep during the previous night. c. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. d. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks. Answer: D - The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. • Question: A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as: a. Unbundling b. Overbilling c. Upcoding d. Misrepresentation Answer: C - Upcoding is the practice of using a CPT code that's reimbursed at a higher rate than the code for the service actually provided. • Question: A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: a. Encourage the client to ask questions about personal sexuality. b. Provide time for privacy. c. Provide support for the spouse or significant other. d. Suggest referral to a sex counselor or other appropriate professional. Answer: D - The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor. • Question: Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need? a. Security b. Elimination c. Safety d. Belonging Answer: B - According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. • Question: A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? a. Inadequate vitamin D intake. b. Inadequate protein intake. c. Inadequate massaging of the affected area. d. Low calcium level. B - A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. • Question: Which document addresses the client's right to information, informed consent, and treatment refusal? a. Standard of Nursing Practice b. Patient's Bill of Rights c. Nurse Practice Act d. Code for Nurses B • Question: Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? a. Semi-Fowler's b. Supine c. High-Fowler's d. Side-lying D - Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. • Question: The nurse in charge is caring for an Italian client. He's complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that: a. He may have a low threshold for pain. b. He was faking pain. c. Someone else gave him medication. d. The pain went away. A - People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up. • Question: Critical thinking and the nursing process have which of the following in common? Both: a. Are important to use in nursing practice. b. Use an ordered series of steps. c. Are patient-specific processes. d. Were developed specifically for nursing. A - Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. Neither is linear. • Question: In which step of the nursing process does the nurse analyze data and identify client problems? a. Assessment b. Diagnosis c. Planning outcomes d. Evaluation B - In the diagnosis phase, the nurse identifies the client's health status. • Question: In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? a. Assessment b. Diagnosis c. Planning outcomes d. Evaluation D - During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. • Question: What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: a. Identify personal biases that may affect his thinking and actions. b. Identify the most effective interventions for a patient. c. Communicate more efficiently with colleagues, patients, and families. d. Learn and remember new procedures and techniques. A - The most basic reason is that self-knowledge directly affects the nurse's thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affect all the other nursing actions, it is the most basic reason. • Question: The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negative about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient." This best illustrates: a. Theoretical knowledge b. Self-knowledge c. Using reliable resources d. Use of the nursing process B - Personal knowledge is self-understanding—awareness of one's beliefs, values, biases, and so on. That best describes the nurse's awareness that her bias can affect her patient care. Question: Which organization's standards require that all patients be assessed specifically for pain? a. American Nurses Association (ANA) b. State nurse practice acts c. National Council of State Boards of Nursing (NCSBN) d. The Joint Commission D - The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. The Joint Commission has developed assessment standards, including that all clients be assessed for pain. Question: Which of the following is an example of data that should be validated? a. The urinalysis report indicates there are white blood cells in the urine. b. The client states she feels feverish; you measure the oral temperature at 98°F. c. The client has clear breath sounds; you count a respiratory rate of 18. d. The chest x-ray report indicates the client has pneumonia in the right lower lobe. B - Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results. Question: Which of the following is an example of appropriate behavior when conducting a client interview? a. Recording all the information on the agency-approved form during the interview. b. Asking the client, "Why did you think it was necessary to seek health care at this time?" c. Using precise medical terminology when asking the client questions. d. Sitting, facing the client in a chair at the client's bedside, using active listening. D - Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient's problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician's interpersonal repertoire. Question: The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply. a. A body systems model b. A head-to-toe framework c. Maslow's hierarchy of needs d. Gordon's functional health patterns e. Adaptation Model of Nursing C, D Question: The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. a. Used a vague generality. b. Did not use the patient's exact words. c. Used a "waffle" word (e.g., appears). d. Recorded an inference rather than a cue. e. Did not record the patient's vital signs. A, C, D, E - The nurse recorded a vague generality: "he has had a good night." The nurse used the "waffle" word, "seems" worried instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: worried and had a good night. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale. Question: The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? a. Sitting upright. b. Lying flat on the back with knees flexed. c. Lying flat on the back with arms and legs fully extended. d. Side-lying with the knees flexed. A - If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. Question: The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? a. Sims' b. Supine c. Dorsal recumbent d. Semi-Fowler's A - Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery. Question: The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? a. Dorsal recumbent b. Semi-Fowler's c. Lithotomy d. Sims' B Question: Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? a. Providing a back massage. b. Feeding a client. c. Providing hair care. d. Providing oral hygiene. D Question: A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is: a. Fowler's position b. Side-lying c. Supine d. Trendelenburg B - An unconscious client is best placed on his side when doing oral care to prevent aspiration. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Question: A client is hospitalized for the first time, which of the following actions ensure the safety of the client? a. Keep unnecessary furniture out of the way. b. Keep the lights on at all times. c. Keep side rails up at all times. d. Keep all equipment out of view. C Question: A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse? a. Assessment b. Diagnosis c. Planning d. Implementation A Question: It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community a. Assessment b. Nursing Process c. Diagnosis d. Implementation B Question: Which of the following cluster of data belong to Maslow's hierarchy of needs a. Love and belonging b. Physiological needs c. Self actualization d. All of the above D Question: This is characterized by severe symptoms relatively of short duration. a. Chronic Illness b. Acute Illness c. Pain d. Syndrome B Question: Which of the following is the nurse's role in health promotion? a. Health risk appraisal b. Teach client to be effective health consumer c. Worksite wellness d. None of the above B Question: It is described as a collection of people who share some attributes of their lives. a. Family b. Illness c. Community d. Nursing C Question: Which of the following is the meaning of PRN? a. When advice b. Immediately c. When necessary d. Now. C Question: The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? a. Bathe the patient's entire body using 8 to 10 washcloths. b. Assist the patient to a chair and provide bathing supplies. c. Saturate a towel and blanket in a plastic bag, and then bathe the patient. d. Assist the patient to the bathtub and provide a bath chair. A Question: For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? a. Cover the mattress with a sheepskin. b. Keep the linens wrinkle free. c. Separate the skin folds with towels. d. Apply petrolatum barrier creams. C - Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Question: A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? a. Fever b. Intact skin c. Inflammation d. Lethargy B Question: A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? a. A clean gown and gloves must be worn when in contact with the client. b. Everyone who enters the room must wear a N-95 respirator mask. c. All linen and trash must be marked as contaminated and send to biohazard waste. d. Place the client in a room with a client with an upper respiratory infection. A Question: A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: a. Admitted with unstable diabetes mellitus. b. Who underwent surgical repair of a perforated bowel. c. With a stage 3 sacral pressure ulcer. d. Admitted with a urinary tract infection. A - The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Question: The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: a. Transient flora from the skin b. Resident flora from the skin c. All microorganisms from the skin d. Media for bacterial growth A Question: Which of the following incidents requires the nurse to complete an occurrence report? a. Medication given 30 minutes after scheduled dose time. b. Patient's dentures lost after transfer. c. Worn electrical cord discovered on an IV infusion pump. d. Prescription without the route of administration. B - A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. Question: The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: a Separates the health record according to discipline. b. Organizes documentation around the patient's problems. c. Highlights the patient's concerns, problems, and strengths. d. Is designed to streamline documentation. A - In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. Question: When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? a. NA b. NDA c. NKA d. NPO C Question: The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: a. Are comprehensive charting forms that integrate assessments and nursing actions. b. Contain only graphic information, such as I&O, vital signs, and medication administration. c. Are used to record routine aspects of care; they do not contain assessment data. d. Contain vital data collected upon admission, which can be compared with newly collected data. A Question: At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? a. Complete an occurrence report before leaving. b. Do nothing; the next nurse will document it was done. c. Write the note of the dressing change into an earlier note. d. Make a late entry as an addition to the narrative notes. D Question: Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? a. It includes organizational reports of unusual occurrences that are not part of the client's record. b. This type of system consists of combined documentation and daily care plans. c. It improves interdisciplinary collaboration that improves efficiency in procedures. d. This type of system tracks medication administration and usage over 24 hours. C Question: In the United States, the first programs for training nurses were affiliated with: a. The military b. General hospitals c. Civil service d. Religious orders D Question: What are the 5 moments of hand hygiene? 1. Before touching a patient. 2. Before clean/aseptic procedure. 3. After fluid body exposure. 4. After touching a patient. 5. After touching patient surroundings. Question: Which of the following is/are an example(s) of a health restoration activity? Select all that apply. a. Administering an antibiotic every day. b. Teaching the importance of handwashing. c. Assessing a client's surgical incision. d. Advising a woman to get an annual mammogram after age 50 years. e. Attending rehabilitation of a fractured arm. A, C, E - Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client's surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness. Question: Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? a. Established standards of care b. Professional organizations c. Practice supported by scientific research d. Activities determined by a scope of practice C - A profession must have knowledge that is based on technical and scientific knowledge. Question: Which of the following is/are an example(s) of theoretical knowledge? Select all that apply. a. Antibiotics are ineffective in treating viral infections. b. When you take a patient's blood pressure, the patient's arm should be at heart level. c. In Maslow's framework, physical needs are most basic. d. When drawing medication out of a vial, inject air into the vial first. e. Let the patient dangle his feet first before assisting him to stand or transfer. A, C - Theoretical knowledge consists of research findings, facts (e.g., "Antibiotics are ineffective . . ." is a fact), principles, and theories (e.g., "In Maslow's framework . . ." is a statement from a theory). Instructions for taking blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it. Question: Back Care is best described as: a. Caring for the back by means of massage. b. Washing of the back. c. Application of cold compress at the back. d. Application of hot compress at the back. A Question: It refers to the preparation of the bed with a new set of linens a. Bed bath b. Bed making c. Bed shampoo d. Bed lining B Question: Which of the following is the most important purpose of handwashing? a. To promote hand circulation. b. To prevent the transfer of microorganisms. c. To avoid touching the client with a dirty hand. d. To provide comfort. B Question: What should be done in order to prevent contaminating the environment in bed making? a. Avoid fanning soiled linens b. Strip all linens at the same time c. Finished both sides at the time d. Embrace soiled linen A Question: The most important purpose of cleansing bed bath is: a. To cleanse, refresh and give comfort to the client who must remain in bed. b. To expose the necessary parts of the body. c. To develop skills in bed bath. d. To check the body temperature of the client in bed. A Question: Which of the following patients is at greatest risk for developing pressure ulcers? a. An alert, chronic arthritic patient treated with steroids and aspirin. b. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home. c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula. d. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. B - Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Question: A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate? a. Encourage the patient to walk in the hall alone. b. Discourage the patient from walking in the hall for a few more days. c. Accompany the patient for his walk. d. Consult a physical therapist before allowing the patient to ambulate. C Question: Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be: a. “Don’t worry. It’s only temporary” b. “Why are you crying? I didn’t get to the bad news yet” c. “Your hair is really pretty” d. “I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy” D Question: Which of the following nursing interventions promotes patient safety? a. Assess the patient's ability to ambulate and transfer from a bed to a chair. b. Demonstrate the signal system to the patient. c. Check to see that the patient is wearing his identification band. d. All of the above. D Question: Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions? a. Side rails are ineffective. b. Side rails should not be used. c. Side rails are a deterrent that prevent a patient from falling out of bed. d. Side rails are a reminder to a patient not to get out of bed. D - Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. Question: Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Host b. Reservoir c. Mode of transmission d. Portal of entry D Question: Which of the following will probably result in a break in sterile technique for respiratory isolation? a. Opening the patient's window to the outside environment. b. Turning on the patient's room ventilator. c. Opening the door of the patient's room leading into the hospital corridor. d. Failing to wear gloves when administering a bed bath. C - Opening the patient's window is acceptable because the room needs to be well-ventilated. A private room with appropriate air handling and ventilation is particularly important for reducing the risk of transmission of microorganisms from a source patient to susceptible patients and other persons in hospitals when the microorganism is spread by airborne transmission. Question: Which of the following patients is at greater risk for contracting an infection? a. A postoperative patient who has undergone orthopedic surgery. b. A patient receiving broad-spectrum antibiotics. c. A patient with leukopenia. d. A newly diagnosed diabetic patient. C Question: Effective handwashing requires the use of: a. Soap or detergent to promote emulsification. b. Hot water to destroy bacteria. c. A disinfectant to increase surface tension. d. All of the above. A - Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Question: After routine patient contact, handwashing should last at least: a. 30 seconds b. 1 minute c. 2 minutes d. 3 minutes A Question: Sterile technique is used whenever: a. Strict isolation is required b. Terminal disinfection is performed c. Invasive procedures are performed d. Protective isolation is necessary C Question: A natural body defense that plays an active role in preventing infection is: a. Yawning b. Body hair c. Hiccupping d. Rapid eye movements B Question: When removing a contaminated gown, the nurse should be careful that the first thing she touches is the: a. Waist tie and necktie at the back of the gown b. Waist tie in front of the gown c. Cuffs of the gown d. Inside of the gown A Question: All of the following measures are recommended to prevent pressure ulcers except: a. Massaging the reddened area with lotion. b. Using a water or air mattress. c. Adhering to a schedule for positioning and turning. d. Providing meticulous skin care. A Question: A clinical nurse specialist is a nurse who has: a. Been certified by the National League for Nursing. b. Received credentials from the American Nurses' Association. c. Graduated from an associate degree program and is a registered professional nurse. d. Completed a master's degree in the prescribed clinical area and is a registered professional nurse. D Question: In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain? a. Assessment b. Analysis c. Planning d. Evaluation D Question: Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: a. Plan is developed for nursing care. b. Physical assessment begins. c. List of priorities is determined. d. Review of the assessment is conducted with other team members. A 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. C 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 D 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. B 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. A 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. C - 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?' 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. B - Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. 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. B - 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. 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. A 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. D 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. D 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 B 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 D 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. D 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. A 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. D 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. B - 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. 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. B - 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. 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. A 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. B 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. D 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. D - 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. 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. C Question: While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? a. "That's OK, it's alright to skip your medication now and then." b. "I will have to call your doctor and report this." c. "Is there a reason why you don't want to take your medicine?" d. "Do you understand the consequences of refusing your prescribed treatment?" C - When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects. Question: A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? a. Explain to the client that the dentures must come out as they may get lost or broken in the operating room. b. Ask the client if there are second thoughts about having the procedure. c. Notify the anesthesia department and the surgeon of the client's refusal. d. Ask the client if the preference would be to remove the dentures in the operating room receiving area. D - Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept. Question: A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? a. “Good morning. Do you remember where you are?” b. “Hello. My name is Elaine Jones and I am your nurse for today.” c. “How are you today? Remember, you’re in the hospital.” d. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.” D Question: Mrs. Kennedy had a CVA (cerebrovascular accident) and has a severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects the correct use of the cane? a. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg. b. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg. c. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward then moves her left leg forward. d. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward. A - When Mrs. Kennedy. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. Question: An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility? a. Stiffness of the right ankle joint. b. Soreness of the gums. c. Short-term memory loss. d. Decreased appetite. A Question: During the nursing assessment, which data represent information concerning health beliefs? a. Family role and relationship patterns. b. Educational level and financial status. c. Promotive, preventive, and restorative health practices. d. Use of prescribed and over-the-counter medications. C Question: Nurse Patrick is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history? a. The chief complaint b. Past health status c. History immunizations d. Location of an advance directive D Question: Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves? a. Breast b. Integumentary c. Ophthalmic d. Oral D Question: Which assessment data should the nurse include when obtaining a review of body systems? a. Brief statement about what brought the client to the health care provider. b. Client complaints of chest pain, dyspnea, or abdominal pain. c. Information about the client's sexual performance and preference. d. The client's name, address, age, and phone number. B Question: Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview? a. "What brought you to the clinic today?" b. "Would you describe your overall health as good?" c. "Do you understand what is happening?" d. "Is there anything else you would like to tell me?" D - By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. Question: A nurse is caring for a client with severe burns of the face and head. The nurse will place the client in which position? a. Trendelenburg. b. Head of bed elevated. c. Supine position. d. Prone position. B - For clients with burns on the face and head, the best position is to elevate the head of the bed to reduce the occurance of facial edema. Question: A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time? a. Tell me about these medicines and how often you are using them. b. I advise you to refrain from taking those medicines from the tribal healer. c. Could these medicines cause your headaches? d. Maybe you should increase the frequency of the healer's medicines. A Question: The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to: A. Pick any physician and insurance company despite one's income. B. Receive free medical benefits as needed within the county of residence. C. Have equal access to all health care regardless of race and religion. D. Have basic care with a sliding scale payment plan from all healthcare facilities. C Question: Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to: a. Include care that is culturally congruent with the staff from predetermined criteria. b. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices. c. Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care. d. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices. D Question: Which factor is least significant during assessment when gathering information about cultural practices? a. Language, timing b. Touch, eye contact c. Biocultural needs d. Pain perception, management expectations C - Cultural practices do not influence biocultural needs because they are inborn risks that are related to a biological need and not a learned cultural belief or practice. Question: What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should: a. Allow the family to provide care during the hospital stay so no rituals or customs are broken. b. Identify how these cultural variables affect the health problem. c. Speak slowly and show pictures to make sure the client always understands. d. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital. B - Without assessment and identification of the cultural needs, the nurse cannot begin to understand how these might influence the health problem or health care management. Question: Which activity would not be expected by the nurse to meet the cultural needs of the client? a. Promote and support attitudes, behaviors, knowledge, and skills to respectfully meet the client's cultural needs despite the nurse's own beliefs and practices. b. Ensure that the interpreter understands not only the language of the client but feelings and attitudes behind cultural practices to make sure an ethical balance can be achieved. c. Develop structure and process for meeting cultural needs on a regular basis and means to avoid overlooking these needs with clients. d. Expect the family to keep an interpreter present at all times to assist in meeting the communication needs all day and night while hospitalized. D Question: Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: a. American Nurses Association's (ANA's) Code of Ethics b. Nurse Practice Act (NPA) written by state legislation c. Standards of care from experts in the practice field d. Good Samaritan laws for civil guidelines A Question: When the nurse described the client as "that nasty old man in room 201," the nurse is exhibiting which ethical dilemma? a. Gender bias and ageism b. HIPAA violation c. Beneficence d. Code of ethics violation A Question: Nurses are bound by a variety of laws. Which description of a type of law is correct? a. Statutory law is created by an elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA). b. Regulatory law includes prevention of harm for the public and punishment for those laws that are broken. c. Common law protects the rights of the individual within society for fair and equal treatment. d. Criminal law creates boards that pass rules and regulations to control society. A Question: Besides the Joint Commission on Accreditation of Healthcare Organizations (JACHO), which governing agency regulates hospitals to allow continued safe services to be provided, funding to be received from the government, and penalties if guidelines are not followed? a. Board of Nursing Examiners (BNE) b. Nurse Practice Act (NPA) c. American Nurses Association (ANA) d. Americans With Disabilities Act (ADA) D Question: When a client is confused, left alone with the side rails down, and the bed in a high position, the client falls and breaks a hip. What law has been broken? a. Assault b. Battery c. Negligence d. Civil tort C Question: When signing a form as a witness, your signature shows that the client: a. Is fully informed and is aware of all consequences. b. Was awake and fully alert and not medicated with narcotics. c. Was free to sign without pressure. d. Has signed that form and the witness saw it being done. D Question: When providing care to clients with varied cultural backgrounds, it is imperative for the nurse to recognize that: a. Cultural considerations must be put aside if basic needs are in jeopardy. b. Generalizations about the behavior of a particular group may be inaccurate. c. Current health standards should determine the acceptability of cultural practices. d. Similar reactions to stress will occur when individuals have the same cultural background. B Question: To respect a client's personal space and territoriality, the nurse: a. Avoids the use of touch. b. Explains nursing care and procedures. c. Keeps the curtains pulled around the client's bed. d. Stands 8 feet away from the bed, if possible. B - The patients reported that requesting permission to manipulate their body, to examine them, or to perform other care/procedures shows consideration and attention on the part of the professional, which makes the patient feel valued and in control of the situation. This approach may minimize the effects of the invasion and the feeling of being seen as an object. Question: To be effective in meeting various ethnic needs, the nurse should: A. Treat all clients alike. B. Be aware of the client's cultural differences. C. Act as if he or she is comfortable with the client's behavior. D. Avoid asking questions about the client's cultural background. B Question: The most important factor in providing nursing care to clients in a specific ethnic group is: a. Communication b. Time orientation c. Biological variation d. Environmental control A Question: The scope of nursing practice is legally defined by: a. State nurses practice acts b. Professional nursing organizations c. Hospital policy and procedure manuals d. Physicians in the employing institutions A Question: A student nurse who is employed as a nursing assistant may perform any functions that: a. Have been learned about in school. b. Are expected of a nurse at that level. c. Are identified in the position's job description. d. Require technical rather than professional skill. B Question: The nurse puts a restraint jacket on a client without the client's permission and without the physician's order. The nurse may be guilty of: a. Assault b. Battery c. Invasion of privacy d. Neglect B Question: Cultural awareness is an in-depth self-examination of one's: a. Background, recognizing biases and prejudices. b. Social, cultural, and biophysical factors. c. Engagement in cross-cultural interactions. d. Motivation and commitment to caring. A