NURS 1871 EXAM 1 QUESTIONS WITH ACCURATE
ANSWERS
A critical care nurse is using a new research-based intervention to correctly
position her ventilated patients to reduce pneumonia caused by accumulated
respiratory secretions. This is an example of which Quality and Safety in the
Education of Nurses (QSEN) competency?
1. Patient-centered care
2. Evidence-based practice
3. Teamwork and collaboration
4. Quality improvement 2
A new nurse is going to help a patient walk down the corridor and sit in a chair.
The patient has an eye patch over the left eye and poor vision in the right eye.
What is the correct order of steps to help the patient safely walk down the hall
and sit in the chair?
1. Tell patient when you are approaching the chair.
2. Walk at a relaxed pace.
3. Guide patient's hand to nurse's arm, resting just above the elbow.
4. Position yourself one-half step in front of patient.
5. Position patient's hand on back of chair. 3, 4, 2, 1, 5
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient
has labored breathing, a respiratory rate of 28 per minute, and lung sounds with
bilateral wheezing. The nurse makes the patient comfortable and starts an
ordered intravenous infusion to administer medication that will relax the patient's
airways. The patient tells the nurse after the first medication infusion, "I feel as if I
can breathe better." The nurse auscultates the patient's lungs and notes
,decreased wheezing with a respiratory rate of 22 per minute. Which of the
following is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds 2, 3, 5
A nurse asks how a patient's condition from a serious infection changed since
yesterday while receiving a hand-off report. The 280nurse leaving the shift reports
the patient has two priority nursing diagnoses—fluid imbalance and fever. The
receiving nurse begins to provide care by measuring the patient's body
temperature, inspecting the condition of the skin, reviewing the intake and
output record, and checking the summary notes describing the patient's progress
since the day before. The nurse asks a technician to measure intake and output
during the shift. What critical thinking indicators reflect the nurse's ability to
perform evaluation? (Select all that apply.)
1. Checking the summary notes
2. Asking the leaving RN about the patient's condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient's goals
5. Reflecting on patient's progress 1, 2, 4, 5
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is
partially immobilized because of a stroke. The nurse turns the patient and finds
that the skin over the sacrum is very red and the patient does not feel sensation
in the area. The patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity.
Which of the following outcomes is appropriate for the patient?
,1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient's ability to turn self in bed improves.
4. Erythema of skin will be mild to none within 48 hours. 4
A nurse completes the following steps during her shift of care. Which are the
steps of nursing assessment? (Select all that apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse working the next
scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a
pattern of mobility alteration
5. Conducting an interview of a family caregiver 1, 2, 4, 5
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The
woman is married and lives in a condo with her husband. She reports having
frequent voiding and pain when she passes urine. The nurse asks whether she has
to go to the bathroom at night, and the patient responds, "Yes, usually twice or
more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and
reports having difficulty cleansing herself after voiding or passing stool. Which of
the following demonstrate assessment findings that cluster to indicate the
nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
, 5. Episode of diarrhea 2, 4
A nurse enters a patient's room and begins a conversation. During this time the
nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to
also evaluate the patient's expectations of care. Which of the following is
appropriate for evaluating a patient's expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, "Did you believe that you received the information you needed
to follow your diet?"
4. The nurse states, "Tell me four different foods included in your diet." 3
A nurse enters the hospital room of a patient who had a total knee replacement
the day before. Which of the following pose potential safety risks? (Select all that
apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The overbed table with the patient's glasses is positioned against the wall
opposite the end of the bed. 3, 4, 5
A nurse has been caring for a patient over 2 consecutive days. During that time
the patient had an intravenous (IV) catheter in the right forearm. At the end of
shift on the second day the nurse inspects the catheter site, observes for redness,
and asks whether the patient feels tenderness when the site is palpated. The
nurse reviews the medical record from 24 hours ago and finds the catheter site
ANSWERS
A critical care nurse is using a new research-based intervention to correctly
position her ventilated patients to reduce pneumonia caused by accumulated
respiratory secretions. This is an example of which Quality and Safety in the
Education of Nurses (QSEN) competency?
1. Patient-centered care
2. Evidence-based practice
3. Teamwork and collaboration
4. Quality improvement 2
A new nurse is going to help a patient walk down the corridor and sit in a chair.
The patient has an eye patch over the left eye and poor vision in the right eye.
What is the correct order of steps to help the patient safely walk down the hall
and sit in the chair?
1. Tell patient when you are approaching the chair.
2. Walk at a relaxed pace.
3. Guide patient's hand to nurse's arm, resting just above the elbow.
4. Position yourself one-half step in front of patient.
5. Position patient's hand on back of chair. 3, 4, 2, 1, 5
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient
has labored breathing, a respiratory rate of 28 per minute, and lung sounds with
bilateral wheezing. The nurse makes the patient comfortable and starts an
ordered intravenous infusion to administer medication that will relax the patient's
airways. The patient tells the nurse after the first medication infusion, "I feel as if I
can breathe better." The nurse auscultates the patient's lungs and notes
,decreased wheezing with a respiratory rate of 22 per minute. Which of the
following is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds 2, 3, 5
A nurse asks how a patient's condition from a serious infection changed since
yesterday while receiving a hand-off report. The 280nurse leaving the shift reports
the patient has two priority nursing diagnoses—fluid imbalance and fever. The
receiving nurse begins to provide care by measuring the patient's body
temperature, inspecting the condition of the skin, reviewing the intake and
output record, and checking the summary notes describing the patient's progress
since the day before. The nurse asks a technician to measure intake and output
during the shift. What critical thinking indicators reflect the nurse's ability to
perform evaluation? (Select all that apply.)
1. Checking the summary notes
2. Asking the leaving RN about the patient's condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient's goals
5. Reflecting on patient's progress 1, 2, 4, 5
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is
partially immobilized because of a stroke. The nurse turns the patient and finds
that the skin over the sacrum is very red and the patient does not feel sensation
in the area. The patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity.
Which of the following outcomes is appropriate for the patient?
,1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient's ability to turn self in bed improves.
4. Erythema of skin will be mild to none within 48 hours. 4
A nurse completes the following steps during her shift of care. Which are the
steps of nursing assessment? (Select all that apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse working the next
scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a
pattern of mobility alteration
5. Conducting an interview of a family caregiver 1, 2, 4, 5
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The
woman is married and lives in a condo with her husband. She reports having
frequent voiding and pain when she passes urine. The nurse asks whether she has
to go to the bathroom at night, and the patient responds, "Yes, usually twice or
more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and
reports having difficulty cleansing herself after voiding or passing stool. Which of
the following demonstrate assessment findings that cluster to indicate the
nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
, 5. Episode of diarrhea 2, 4
A nurse enters a patient's room and begins a conversation. During this time the
nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to
also evaluate the patient's expectations of care. Which of the following is
appropriate for evaluating a patient's expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, "Did you believe that you received the information you needed
to follow your diet?"
4. The nurse states, "Tell me four different foods included in your diet." 3
A nurse enters the hospital room of a patient who had a total knee replacement
the day before. Which of the following pose potential safety risks? (Select all that
apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The overbed table with the patient's glasses is positioned against the wall
opposite the end of the bed. 3, 4, 5
A nurse has been caring for a patient over 2 consecutive days. During that time
the patient had an intravenous (IV) catheter in the right forearm. At the end of
shift on the second day the nurse inspects the catheter site, observes for redness,
and asks whether the patient feels tenderness when the site is palpated. The
nurse reviews the medical record from 24 hours ago and finds the catheter site
