51 notecards = 13 pages (4 cards per page)
Which would represent an attainable goal for an obese client who works at a fast food restaurant wanting to lose weight?
A. Quit working
B. Workout 3 hours a day
C. Get a gym membership
D. List affordable but healthy meal options
Rationale: According to our page 2343 of our text client goals should be realistic and attainable for client. Quitting his/her job would likely be unrealistic and likely not beneficial for the goal of losing weight. Working out 3 hours a day is far above what most associations recommend and for most working individuals unrealistic. Getting a gym membership might be beneficial, but this might be difficult for someone with a low income. The only one that qualifies as realistic and attainable is D. Listing affordable but healthy meal options is the only option that meats the realistic and attainable requirement for writing a goal.
Which patient would you visit first?
A. Patient with broken finger
B. Patient with head injury who just stopped breathing
C. Patient needing oral care
D. Patient pressing call bell for the 8th time in the last hour for ice chips
Rationale: According to pg 2366 high priority patients are those with life-threatening problems. The only patient with a life-threatening problem above is the patient with a head injury who just stopped breathing. This patient is showing signs of ineffective breathing pattern, which could lead to death without intervention.
Nurse is going to enter room of patient with MRSA, what is the nurse’s first priority?
a. Don PPE
b. Ensure the rooms thermostat is set to 70 degrees Fahrenheit
c. Perform hand hygiene
d. Check if room is a droplet precaution and eye protection is needed.
Rationale: “The most effective preventative measure against spreading infections in the hospital setting is consistent and appropriate hand hygiene.” (Nursing, 2015)
Nursing: a concept-based approach to learning. (2nd ed., Vol. 1, page 958). (2015). Pearson.
Four patients arrive at the emergency room, which patient should be seen first?
a. A 16 year-old female complaining of severe abdominal cramping.
b. A six year-old boy who’s wheezing and his oxygen saturation is 75%
c. A 42 year-old male a temperature of 101 *F who is coughing
d. A 30 year-old female with a gunshot wound in her right shoulder.
Rationale: “Inadequate levels of oxygenation can affect the acid-base balance. Decreased levels of oxygen can lead to a condition known as respiratory acidosis.” (Nursing, 2015)
Nursing: a concept-based approach to learning. (2nd ed., Vol. 2, page 2702). (2015). Pearson.
An elder client comes into the emergency department with symptoms of a cough and fever. Nurse Jackie obtains his vitals, listens to his lung and heart sounds, and asks client to rate his pain on a scale of 0-10. Which step in the clinical decision making process is nurse Jackie making?
A patent walks into his Doctors appointment and is complaining of shortness of breath. The nurse looks through the patient’s documentation and notices the patient has a diagnosis of COPD. What would the priority nursing diagnosis be?
A. Risk for acid base imbalance
B. Risk for bleeding
C. Impaired skin integrity
D. Risk for infection
A patient has chronic kidney failure and is being admitted with pulmonary edema. Which is a priority nursing intervention?
a) Teach importance of dialysis appointments
b) Monitor serum potassium levels
c) Assess lung sounds and oxygen saturation level
d) Promote independence in activities of daily living
Which patient needs immediate nursing intervention? The patient who:
a) has epigastric pain after eating.
b) has a rigid, board-like abdomen.
c) has ribbon-like stools.
d) complains of anorexia and periumbilical pain.
In the emergency room there is Patient a, patient b, patient c, and patient d. Which
would the nurse’s highest priority?
A) Patient with peripheral edema and numbness in lower extremities
B) Patient 2 days postoperative complaining of pain at incision site, 5 out of 10
C) Patient with COPD complaining of SOB with pulse oximetry of 87%
D) Patient with superficial abrasion to left arm in stable condition
Patient is exhibiting signs of allergic reaction. Which manifestation would the nurse treat first?
A) Swollen tongue obstructing patient’s airway
B) Raised red hives on patient’s limbs
C) Increased level of anxiety
D) Pain level 4 out of 10
Mr. Smith has type 1 diabetes mellitus. He knows that when he shows
signs of hypoglycemia he should immediately:
B. Consume 15 grams of rapid acting sugar followed by the 15/15 rule
C. Perform a brief, quick 15 minute exercise to raise blood glucose
D. Inject Lantus and Humulin R together for faster homeostasis
The answer is B. The patient should immediately consume 15 grams of rapid acting glucose such as glucose tablets, half cup of fruit juice, skim milk, hard candies, marshmallow, sugar, or honey. If after 15 minutes later and blood glucose is still low the individual should consume 15 more grams of carbohydrates. This can continue till blood glucose returns to normal. Also, Lantus should never be mixed with any other insulin. Plus insulin will only cause blood sugar to go lower.
Signs and symptoms are linked to the etiology by the phrase:
C. Primary & secondary
D. As evidenced by
The answer is D as these are physiological responses to an illness or imbalance and seen by the nurse.
Which of the following should the nurse delegate to the licensed
practical nurse (LPN)? Select all that apply.
Answers - A, B, D, E
Four patients all require the attention of the nurse. Who should the
nurse see first?
Answer - C
A nurse enters the room of a patient with COPD. The nurse quickly assesses that the patient is short of breath, she also assesses that the patient’s O2 sat is at 85%. Immediately, the nurse assists the patient to a sitting position on the side of the bed and instructs him to lean over the bedside table. She also instructs him to take slow, deep breaths in through his nose and out through pursed lips. Which part of the nursing process is being demonstrated?
Answer: D Rationale: The nurse acts within her scope of practice to implement leaning over the bedside table and teach pursed lip breathing as a strategy to overcome the COPD patient’s ineffective breathing pattern. The nurse does not plan by making a broadly stated goal. Evaluation of the success of the nursing interventions would be the next step (after implementation) that the nurse would take. The nurse does not present a diagnosis for the patient.
Which nursing diagnosis takes highest priority for client with hypothyroidism?
a.Risk for imbalanced nutrition: Less than body requirements related to TH excess
b.Disturbed body image related to weight loss
c. Risk for imbalanced nutrition: More than body requirements related to TH deficiency
d. Risk for heat intolerance
Answer: C Rationale: All of the other options are related to hyperthyroidism, so by process of elimination, the answer is C.
An RN is caring for 4 clients. Which client should be seen
Answer is A. The client with the fever is not in danger with a temperature of 101° F. A blood glucose of 220 mg/dl is high, but again it is not a high priority problem. A child reporting an abdominal pain level of 7 is concerning, but with no other indication of a serious problem this ailment is not of critical urgency. A breathing rate of 32 while resting takes priority over the others as it is a compromise of the ABC’s of patient care, and could possibly worsen to become life-threatening.
A patient was admitted to the hospital with cirrhosis and has developed ascites and edema. What is the priority nursing intervention for this patient?
a. Inform the patient of the effects alcohol has on the liver
b. Restrict the patient’s sodium intake
c. Balance fluid volume, assess and measure the ascites
d. Call the physician
Answer is C. Restricting the patient’s sodium could make the ascites and edema worse. Calling the physician at this point is unwarranted. Informing the patient of the effects of alcohol will not improve the patient’s condition. Balancing the patient’s fluid volume will begin to reduce the ascites and edema, and assessing and measuring the ascites will give the nurse a base reading to gauge the effectiveness of treatment as time progresses.
Which of the following characteristics is not a common attitude of
Answer B Adaptability, which is a characteristic of verbal communication. Spoken messages must be altered in response to behavioral cues from the patient. (Page 2317, Table 36-1)
A nurse is caring for 9 year old Amber who has ineffective
respirations following abdominal surgery. Amber's doctor ordered the
patient to use an incentive spirometer. Amber is frightened by the
equipment and tires quickly during the treatment. The nurse offers
Amber a bottle of bubbles knowing that her respiratory effort in
blowing bubbles will promote alveolar expansion and suggests she blow
bubbles between incentive spirometry treatment. In what way is the
nurse applying her critical thinking skills?
Correct answer: c, pg. 2318, creativity means finding unique solutions to unique problems when traditional interventions are not effective.
A pediatric nurse is coming on shift, which patient should be assessed first?
A distressed five year old boy
A nine year old with a broken leg who rates their pain at a 6 out 10
A four year old patient with observed retractions
A two year old patient anticipating discharge
Rationale: Correct answer is C. The priority patient would be the one showing signs of respiratory distress. Accessory muscle use in pediatric patients is a sign of respiratory distress.
A 23-year-old female patient who is two hours post caesarian section is reporting her pain as an 8 out 10 on the pain scale. What is the priority intervention?
a. Call the physician
Ask the patient to describe their pain
Administer PRN pain medication
Reposition the patient
Answer C. Rationale: The patient’s pain is the priority. There is already a standing order for the medication so calling the physician is unnecessary and asking them to describe the pain is not the priority. Repositioning the patient may help but administering their medication is more important.
A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?
Encourage ambulation and administer bronchodilators and steroids as ordered.
Position in high Fowler's position and administer bronchodilators as ordered.
Position in Fowler’s position, initiate oxygen, and administer bronchodilators as ordered.
Place in supine position, initiate oxygen, and administer bronchodilators as ordered.
The nurse is caring for four patients. After reviewing the results of their arterial blood gases, which patient would require priority intervention?
A. pH 7.35, PaCO2 40, HCO3 24
B. pH 7.25, PaCO2 35, HCO3 18
C. pH 7.42, PaCO2 40, HCO3 22
D. pH 7.45, PaCO2 45, HCO3 28
The nurse is preparing for the suctioning of the airway of a client who has an endotracheal tube. In order of priority, which actions should the nurse take in order to perform this sterile procedure?
1.Hyperoxygenate the client before and after each time the airway is entered for suctioning and wait 1 minute before suctioning again.
2. Apply sterile gloves and with the non-dominant hand attach the suction catheter to the suctioning tube.
3. Place the client in semi-Fowler position to promote deep breathing, maximum lung expansion, and productive coughing.
4. Turn on suction, and set the pressure between 80 mmHg -120 mmHg.
5. Insert catheter until resistance is met, and then apply intermittent suction and slowly withdraw the catheter.
Answer: 3,4,2,1,5 Rationale?
Question 1: A patient requests that a nurse who was working on a
previous shift not beallowed to provide the patient's care again. What
is the most appropriate action by thenurse?
2. Document the issue on an incident report
3. Address patient's concern with the charge nurse.
4. Explain to the patient that the nurse was just having a bad day.
Answer is 3. Rationale: A personality conflict may need to be
addressed, but may not
A client with bulimia nervosa tells the nurse that they do not agree
with theirparents on anything. Which is the best method to address
this problem the next time thefamily comes for a meeting?
.2. Establish an internal locus of control.
3. Construct a multi-generational genogram.
4. Discuss age-specific developmental problems.
Answer is 1. Rationale: The nurse should teach the family conflict
resolution skills to
A charge nurse notices that some of the nurses on the floor have been
struggling toget along. What are some measures she can take to reduce
future conflict between thenurses? Select all that apply:
b Acknowledge the nurses' accomplishments
c.Encourage frequent and open feedback
dReduce her own stress
Answer: a, b, c, d Rationale: One of the main causes of conflict in
the workplace is role boundaries, so it is
Martha is a young Unit Manager of the Pediatric Ward. Most of her
staff nurses aresenior to her, very articulate, confident and
sometimes aggressive. Martha feelsuncomfortable believing that she is
the scapegoat of everything that goes wrong in herdepartment. Which of
the following is the best action that she must take?
B. Disregard what she feels and continue to work independently
C. Seek help from the Director of Nursing
D. Quit her job and look for another employment
Answer: A. Rationale: This question is involving a problem solving approach,addressing the root cause of the situation.
Three nurses where put in charge of creating a plan of action that
should befollowed when it comes to treating pressure ulcers on
patients that have been immobile.The nurses have met 3 times
previously to discuss the plan of action and have alreadyselected
roles when it comes to the plan of action and collaboration between
the nurseshas already begin. What stage of group process are the
nurses currently in?
Answer: C. Rationale: In norming the group is able to effectively
Samantha is a nurse on the telemetry floor. She is having an argument
with anotherstaff member and states, “I have patients to attend to and
do not have time to talk aboutthis. I will talk to you later,” as she
walks away. What type of response was displayed bynurse?
Answer: D. Avoiding conflict is generally not advised. However, in
some cases if used
The patient complains of mouth pain when eating. Which member of
thehealth care team should the nurse consult?
c.) Physical therapist
d.) Spouse/family member
Answer: b. Rationale: A dietician often has special knowledge about
the diets required
A patients’ case has been determined to be one that is commonly of
b.) Chief Financial Officer (CFO)
c.) Nursing case manager
d.) Charge nurse
Answer: c. Rationale: To initiate case management, specific client diagnoses thatrepresent high-volume, high-cost, and high-risk cases are selected. (Pearson: 2015, p.2383)
An older client is admitted to the cardiac floor after suffering a
b) “I’ll be sure to write that down.”
c) “You should talk to your physician about this.”
d) “Is your family aware of how you feel?”
Rationale: Answer is A. An advance directive is a legal document that
will ensure the
A fellow nurse on your unit was injured four months ago in a car
accident. Her left leg
b) Recommend the nurse take sick leave until her rehab is more complete.
c) Transfer the nurse to a surgical unit.
d) Discuss options with the charge nurse.
Rationale: Answer A. Reasonable accommodations should be made for the
65 year old patient suffering from COPD is admitted to the hospital
for anexacerbation. The nurse needs to create a nursing care plan with
an inter-professionalcollaboration interventions. Who is the priority
professional to contact?
B. Respiratory Therapist
D. Certified Nursing Assistant
Answer: B. Rationale: An inter-personal collaboration would include
anyone other than
The nurse is assessing a 4 year old patent with petechiae to his neck
and multiplecircular first degree burns to the right upper and lower
arm. She suspects possibly childabuse. Who is the nurses’ priority
point of contact?
B. Family member
D. Social Worker
Answer: D. Rationale: When child abuse is suspected by the nurse,
they should never
A nurse witnesses a mental health worker kissing a patient in the
patient’s room.The patient tells the nurse, “Please don’t tell anyone
about this. It just happened. I careso much about him, but we have
agreed not to date until I’m discharged.” Which of the
Answer: B. Rationale: Even if a patient consents or initiates the
sexual conduct, it isstill sexual misconduct. Due to the power dynamic
between a patient and a nurse, andespecially with patients with mental
illness, there cannot be true consent because the
A nurse is providing discharge instructions to a Chinese patient. The
patient isturned away from the nurse and does not make eye contact.
Which of the following ismost appropriate? Select all that
B. Come back at a later time when the patient is more interested
C. Continue with the discharge instructions
D. Position yourself to be in front of the patient at all times
E. Take the cue from the patient and do not continue to try to make eye contact
Answers: C, E. Rationale: Many Chinese, due to a difference in
culture, show respect
A charge nurse observes that a staff nurse is not able to meet client
needs in areasonable time frame, does not problem-solve situations,
and does not prioritizenursing care. The charge nurse has the
b) Ask other staff members to help the staff nurse get the work done
c) Provide support and identify the underlying cause of the staff nurse's problem
d) Report the staff nurse to the supervisor so that something is
done to resolve the
Answer C. Option C empowers the charge nurse to assist the staff nurse while trying toidentify and reduce the behaviors that make it difficult for the staff nurse to function.Options A, B, and D are punitive actions, shift the burden to other workers, and do notsolve the problem.
The nurse manager is planning to implement a change in the nursing
unit from teamnursing to primary nursing. The nurse anticipates that
there will be resistance to thechange during the change process. The
primary technique that the nurse would use inimplementing this change
is which of the following?
c) Use coercion to implement the change
d) Manipulate the participants in the change process
Answer A. The primary technique that can used to handle resistance to
Nurse Ariel has just come onto shift and is greeted by an angry
patient, whocomplains of pain that has not been tended to. Nurse
Aurora, who she is relieving,
A. Interpersonal conflict
B. Covert conflict
C. Intrapersonal conflict
D. Overt conflict
Answer: B, Covert conflict. Rationale: Covert conflict is not
discussed openly and may
A 79-year old female presents to the ER in myocardial infarction. The
A. Improving the coordination of patient care
B. Discharging the client quickly
C. Increasing referrals to local organizations
D. Evaluate outcomes of patient care
Answers: A, D Rationale: One of the primary goals of case management
is to improve
a client has just undergone hip surgery and needs to start post
B. Physical therapist-
C. Occupational therapist-
Rationale: B. The physical therapist works with patients on gross motor movement aftersurgery
which of the following is the best example of a covert conflict?
A. A patient refuses to take blood pressure medication in front of the nurse.
B. Nurse refuses to provide care to a patient that was reacting to
care with sexual
C. Physician yells at nurse for calling them in the middle of the night.
D. Day shift nurses commenting to the patients about the lack of
quality care provided
Rationale: D. Covert behavior is lack of open feedback; the nurses in option D are notopenly communicating their issues with the night shift nurses.
A 52 year-old male patient becomes verbally abusive when denied
another dose of painmedication because it was too soon. How should the
nurse handle this situation?
2. Take away his call bell
3. Explain to the patient why he cannot receive medication at this
time and then
4. Call the healthcare provider
Answer 3. Rationale: By calmly explaining to the patient why they
cannot have more
A 4 year-old patient has multiple wounds at different stages of
healing and all ofunknown origin. As the nurse you suspect your
patient is being abused, how do youproceed?
2. Deny the parents access to the child
3. Report your findings to child protective services and to the hospital social worker
4. Dismiss the findings as just accidents
Answer 3. Rationale: Any suspicion of abuse should be reported. It is
not the nurse’s job
Reducing your stress, allocating resources fairly, defining and
reminding roles for allteam members are all ways to provide:
b. Conflict Resolution
c. Implementing the nursing process
d.Assessment, diagnosis, provide, implement, and evaluate.
*B. these are all ways to provide conflict resolution. By addressing
A charge nurse observes that a staff nurse is not able to meet
client's needs in areasonable time frame, does not problem solve the
situation, and does not prioritizenursing care. The charge nurse has a
b. Asks other staff members to complete tasks.
c. Provide support and identify the underlying cause of the staff nurses problem
d. Report staff nurse to supervisor so that action is taking to resolve the issue.
*C is the answer. This allows the charge nurse to assist and help the staff nurse whiletrying to identify and resolve the behaviors that make it difficult for the staff nurse tocomplete her assignments.
What would be important environmental assessments for the home care
nurse toexplore with a client who is being discharged home?
C is Correct. Explanation: Safety and access in the client’s home are
An adolescent admitted to the adolescent unit with pain caused by
sickle cell crisis.
C. case worker
A is Correct. Explanation: Children and adolescents hospitalized with sickle cell crisisare commonly in excruciating pain. Therefore, the pediatric pain specialist should beconsulted first to help relieve the adolescent's pain. The adolescent also requireshydration with I.V. fluids, but consulting a nutritionist isn't important at this time. Bed restis commonly ordered to minimize energy expenditure and oxygen demand; therefore,consulting a physical therapist isn't necessary at this time. It isn't necessary to consultthe case manager first; pain relief is most important at this time.