Clinical Nursing Basics
Test Preparation
Course Introduction
Clinical Nursing Basics introduces students to the foundational principles and essential skills required for patient care in clinical settings. The course covers core topics such as patient assessment, vital sign measurement, infection control procedures, basic hygiene and comfort measures, medication administration, documentation, and communication within the healthcare team. Emphasis is placed on safe, ethical, and evidence-based nursing practices, as well as the development of professional attitudes and empathy toward patients. Through a combination of theoretical instruction and practical simulations, students gain competence and confidence to deliver quality nursing care in a variety of healthcare environments.
Recommended Textbook
Essentials for Nursing Practice 9th Edition by Potter FAAN
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40 Chapters
977 Verified Questions
977 Flashcards
Source URL: https://quizplus.com/study-set/2491 Page 2
Chapter 1: Professional Nursing
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12 Verified Questions
12 Flashcards
Source URL: https://quizplus.com/quiz/49521
Sample Questions
Q1) Which action of the nurse demonstrates coordination of care for the patient?
A) The nurse creates a warm,therapeutic relationship with the patient by actively listening to what the patient has to say.
B) The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair.
C) The nurse educates the patient about energy conservation techniques to increase activity tolerance.
D) The nurse uses clear and objective language when documenting assessment findings in the patient's medical record.
Answer: B
Q2) The nurse feels that an assigned duty is outside the scope of nursing practice.Which document is the best source to answer the nurse's concern?
A) ANA Code of Ethics
B) State Nurse Practice Act
C) QSEN Initiative Act
D) Nurse's Bill of Rights
Answer: B
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Chapter 2: Health and Wellness
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21 Verified Questions
21 Flashcards
Source URL: https://quizplus.com/quiz/49522
Sample Questions
Q1) Which is an example of an environmental risk factor?
A) The patient's drinking water contains high levels of lead.
B) The patient has a strong family history of autoimmune diseases.
C) The patient carefully follows a lactose-free,gluten-free diet.
D) The patient drinks one glass of red wine every night before bed.
Answer: A
Q2) Which statement by the nurse will help the patient progress to the preparation stage for smoking cessation?
A) "You will die of emphysema or lung cancer if you do not stop smoking."
B) "Research has shown that smoking causes emphysema and lung cancer."
C) "The physician will give you nicotine patches to help you start to quit smoking."
D) "You need to avoid people who smoke so you will not be tempted to start again."
Answer: C
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Chapter 3: The Health Care Delivery System
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) A single mother with three children uses the public health department services in the county to immunize her children.Which level of health care did the mother use?
A) Continuing care
B) Preventative care
C) Secondary acute care
D) Restorative care
Answer: B
Q2) Which information is included in the Minimum Data Set?
A) The patient has a history of gout and macular degeneration.
B) The average length of stay for pneumonia is 3 days in the hospital.
C) The hospital has a 14% nosocomial urinary tract infection rate.
D) Approximately 40% of American adults exercise at least 30 minutes daily.
Answer: A
Q3) Which patient will be treated in a Critical Access Hospital (CAH)?
A) The cancer patient who requires a bone marrow transplant
B) The victim of a serious car accident that occurred in a remote area
C) The pregnant patient whose baby will require neonatal intensive care
D) The patient who requires minimally invasive heart valve replacement
Answer: B
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Page 5
Chapter 4: Community-Based Nursing Practice
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12 Verified Questions
12 Flashcards
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Sample Questions
Q1) Which is the priority goal for a patient who is being abused by the spouse?
A) The patient's dignity will remain intact.
B) The patient will remain free from injury.
C) The patient will develop a sense of trust with the nurse.
D) The patient will be able to verbalize fears to the nurse.
Q2) Which is an appropriate goal within the scope of Healthy People 2020?
A) Uninsured patients will receive the same level of care as patients with private health insurance.
B) The patient will be able to transfer to the wheelchair with a gait belt and assistance of one person.
C) The patient's family will verbalize reduction of stressors when respite care is provided for the patient.
D) Family members are taught how to assist the patient with feeding and other activities of daily living.
Q3) Which is an example of an incidence rate?
A) The patient was able to ambulate 50 feet in 10 minutes.
B) 65% of the hospital's registered nurses are bachelor-prepared.
C) The hospital has a 12% ventilator-associated pneumonia rate.
D) The patient's hemoglobin rate is 50% lower than the previous day.
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Page 6
Chapter 5: Legal Principles in Nursing
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) While at the grocery store,the nurse witnesses another shopper collapse near the checkout.The nurse performs CPR and the patient survives after being treated at the hospital.The patient later attempts to sue the nurse for malpractice because several ribs were broken as a result of chest compressions.Why will the patient's lawsuit be thrown out of court?
A) The patient should not have been at the grocery store with a history of heart disease.
B) The patient needed to disclose her history of heart disease to the nurse before she collapsed.
C) The patient's rib fractures occurred as a result of properly performed CPR by the nurse.
D) The nurse's personal liability insurance company decided to settle rather than face a jury.
Q2) The home care nurse suspects that the patient's bedsores are due to neglect from family caregivers.Which is the appropriate action of the nurse?
A) Inform the caregivers that their actions are illegal.
B) Report it to the proper legal authority immediately.
C) Call the agency's security department to handle the problem.
D) Prevent the caregivers from being responsible for the patient's care.
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Page 7
Chapter 6: Ethics
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19 Verified Questions
19 Flashcards
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Sample Questions
Q1) Which ethical principle is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure?
A) Autonomy
B) Justice
C) Fidelity
D) Nonmaleficence
Q2) Which ethical principle is upheld when the nurse refuses to administer a placebo pill to the patient?
A) Justice
B) Culture
C) Veracity
D) Competency
Q3) The nurse administers the wrong dose of medication and then blames the mistake on a co-worker.Which ethical principle is violated by the nurse?
A) Fidelity
B) Accountability
C) Confidentiality
D) Social networking
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Chapter 7: Evidence-Based Practice
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20 Verified Questions
20 Flashcards
Source URL: https://quizplus.com/quiz/49527
Sample Questions
Q1) A researcher tests a new fall prevention protocol on a nursing unit with patients who are at very low risk of falling.Which term describes the problem with this study?
A) This type of study is better suited for qualitative research.
B) The subjects are at risk of being harmed by participating in the study.
C) The study is biased because the subjects are already at low risk of falling.
D) The study results will be inaccurate due to placebo effects on the subjects.
Q2) Where is the best place for the nurse to obtain the latest information about prevention of catheter-associated urinary tract infections?
A) Online information
B) Peer-reviewed nursing journal
C) Latest edition of a nursing textbook
D) Most recent edition of a popular magazine
Q3) After careful research,the nursing staff have implemented a new fall prevention protocol on the unit.Which is the logical next step of the staff?
A) Review the available literature.
B) Encourage abstract thinking.
C) Measure the patient fall rate.
D) Execute the theoretical framework.
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9
Chapter 8: Critical Thinking
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) Which action by the nurse demonstrates the use of fairness for critical thinking?
A) Adherence to the six rights when administering medication to a patient
B) Clarification of an unusually high dosage medication with the prescriber
C) Effective pain management is provided for all patients regardless of background
D) Development of a personalized swallowing precautions protocol for the patient
Q2) The nurse readily accepts an opportunity to become certified in wound care and ostomy management.Which critical thinking concept is demonstrated by the nurse?
A) Maturity
B) Analyticity
C) Systematicity
D) Inquisitiveness
Q3) Which is the best tool that the nurse can use to make sense of the patient's multiple medical diagnoses,assessment findings,and medications?
A) Plan of care
B) Concept map
C) Reflective journal
D) Intellectual standards
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Chapter 9: Nursing Process
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) The nurse is caring for an unconscious patient.The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.What is the rationale for these actions?
A) The nurse is following the standing orders listed in the patient's medical record.
B) The nurse realizes the potential for bedsores and acts to prevent their development.
C) The nurse identifies the patient care areas in which additional assistance is required.
D) Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.
Q2) Every time the nurse asks the patient a question for the admission assessment,the patient's husband interrupts and answers the question for her.What is the best action of the nurse?
A) Enter the husband's responses into the patient's chart.
B) Request that the husband leave the room.
C) Complete the admission assessment after the husband has gone home.
D) Allow time for the patient to answer each question.
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11
Chapter 10: Informatics and Documentation
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?
A) "I am thankful that I won't have to keep changing my passwords all the time."
B) "I'll be able to see my son's medical record using my password and user ID."
C) "I won't have to worry about reading the doctor's messy handwriting anymore."
D) "It will take me so much less time than writing everything out on paper."
Q2) Which patient situations require the completion of an incident report?
A) A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy.
B) A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold.
C) A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist.
D) The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward.
E) The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.
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Page 12
Chapter 11: Communication
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25 Verified Questions
25 Flashcards
Source URL: https://quizplus.com/quiz/49531
Sample Questions
Q1) Which action by the nurse will help to reduce the fears of a hospitalized young child?
A) Stand over the bed when talking to the patient.
B) Sit in a chair next to the bed when talking to the patient.
C) Maintain constant eye contact with the patient at all times.
D) Stay within 12 inches of the patient when talking to the patient.
Q2) Which action communicates to the patient that the nurse wants to leave the patient's room to care for other patients?
A) Sitting in a chair next to the patient's bed
B) Making sure the door is completely shut for privacy
C) Repeatedly checking the clock to see what time it is
D) Holding the patient's hand when the patient starts to cry
Q3) A nurse gives a hand-off report to the oncoming staff nurse.Which type of communication does this illustrate?
A) Gossip
B) Courtesy
C) Validation
D) Intrapersonal
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Chapter 12: Patient Education
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) Which teaching approach is demonstrated when the nurse provides guidance while the patient performs the sterile dressing change?
A) Telling
B) Entrusting
C) Reinforcing
D) Participating
Q2) Which type of reinforcement is used when the nurse gives a sticker to a pediatric patient every time the incentive spirometer is used?
A) Social
B) Material
C) Activity
D) Negative
Q3) Which is the best method to begin teaching the adult patient how to self-administer tube feeding through a new gastrostomy tube?
A) Analogies
B) Detachment
C) Role play
D) Demonstration
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14
Chapter 13: Managing Patient Care
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) Which action by the nurse best demonstrates the concept of right supervision?
A) The nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient's weight.
B) The nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch.
C) The nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task.
D) The nurse confirms that the patient's urine output is entered into the medical record by the nursing assistant by the end of the shift.
Q2) A nurse is using SBAR.Which information will the nurse report for the "B"?
A) The patient has a fractured right leg with a cast that was applied 2 days ago.
B) The patient's toes are cool and pale and the patient reports that the foot feels numb.
C) The patient is reporting severe pain 1 hour after pain medication was given.
D) The nurse requests that the primary health care provider examines the patient.
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Chapter 14: Infection Prevention and Control
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient with the nursing diagnosis risk for latex allergy response related to multiple food allergies.Which is the priority intervention of the nurse?
A) Recommend that the patient wear a medical alert bracelet at home.
B) Ensure that a medical plan is in place if an allergic response occurs.
C) Lightly powder inside of the gloves before putting them on the hands.
D) Provide written information about latex allergy prevention to the patient.
Q2) The nurse maintains a sterile field when inserting a urinary catheter into the patient's bladder.Which term best describes the infection control practice of the nurse?
A) Pathogenesis
B) Bacteriostasis
C) Medical asepsis
D) Surgical asepsis
Q3) Which mode of transmission is demonstrated when the nurse spreads an infection with the hands after neglecting to perform hand hygiene?
A) Direct
B) Automatic
C) Spontaneous
D) Uninterrupted
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Chapter 15: Vital Signs
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50 Verified Questions
50 Flashcards
Source URL: https://quizplus.com/quiz/49535
Sample Questions
Q1) The nurse is caring for a patient with a temperature of 100.3° F.Why will the nurse refrain from administering an antipyretic at this time?
A) A temperature of 100.3° F is within the normal range for the patient.
B) The patient's shivering will lower the temperature more quickly than an antipyretic.
C) Antipyretics should not be administered until the temperature is at over 104° F.
D) The patient is diaphoretic after the temperature was 101.3° F 1 hour ago.
Q2) The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly.Which is the appropriate action of the nurse?
A) Obtain a soft cloth cover for the stethoscope tubing.
B) Clean the stethoscope tubing throughout each shift with isopropyl alcohol.
C) Send the entire stethoscope to central supply for disinfection.
D) Clean the stethoscope tubing weekly with a solution of mild dish soap.
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17
Chapter 16: Health Assessment and Physical Examination
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42 Verified Questions
42 Flashcards
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Sample Questions
Q1) The patient presents with fever for the last few days,sore throat,and enlarged lymph nodes under the jaw.What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes?
A) "Enlarged lymph nodes are associated with hypertensive heart disease."
B) "You probably have a blockage in the thoracic lymph duct."
C) "You should probably see an oncologist to rule out lymphedema."
D) "They are most likely enlarged as a result of the throat infection."
Q2) The nurse hears a distinctive swooshing sound with each heartbeat when auscultating the patient's heart sounds.What is the cause of this assessment finding?
A) The mitral valve is leaking and some blood leaks backward with each heartbeat.
B) The nurse's stethoscope is not placed firmly enough against the patient's skin.
C) The patient's tricuspid valve was replaced with a mechanical prosthetic valve.
D) The patient is having short runs of premature supraventricular contractions.
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18
Chapter 17: Administering Medications
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48 Verified Questions
48 Flashcards
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Sample Questions
Q1) Which is an IV bolus order?
A) 1 L 0.9% normal saline IV infuse over 4 hours
B) Primaxin 750 mg IVPB infuse over 30 minutes Q 12 hours
C) Naloxone 300 mcg IV push over 2 minutes STAT
D) 0.9% normal saline IV infusion at 125 mL/hour
Q2) The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.The patient soon starts having difficulty breathing and his blood pressure drops.What is the correct analysis of the patient's condition?
A) The patient is having a mild reaction that can be treated easily with an antihistamine.
B) The patient is experiencing a moderate allergic reaction and should improve shortly. C) These symptoms are probably due to food poisoning because very few patients have true allergic responses.
D) The patient is having an anaphylactic reaction and emergency interventions should be started.
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19
Chapter 18: Fluid, Electrolyte, and Acid-Base Balances
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38 Verified Questions
38 Flashcards
Source URL: https://quizplus.com/quiz/49538
Sample Questions
Q1) The nurse is caring for a patient with a poorly controlled hypoparathyroid condition.Which is the highest priority nursing diagnosis for this patient?
A) Risk for injury/fracture related to bone fragility
B) Disturbed energy field related to chronic illness
C) Deficient knowledge related to importance of exercise
D) Disturbed body image related to hormonal changes
Q2) The patient reports muscle weakness after taking prescribed furosemide daily.Which laboratory finding will the nurse expect to see in the patient's chart?
A) Chloride 84 mEq/L
B) Sodium 124 mEq/L
C) Calcium 12.6 mg/dL
D) Potassium 2.8 mEq/L
Q3) The nurse is caring for a patient with a sodium level of 156 mEq/L due to diabetes insipidus.Which is the highest priority nursing diagnosis for this patient?
A) Activity intolerance related to fatigue from chronic illness
B) Imbalanced nutrition related to excessive carbohydrate intake
C) Excess fluid volume related to increased isotonic fluid retention
D) Risk for ineffective airway clearance related to secretions during seizure
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20
Chapter 19: Complementary and Alternative Therapies
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) Which assessment findings indicate to the nurse that the patient is experiencing a stress response?
A) The patient's pupils are dilated.
B) The patient's blood sugar is 36 mg/dL.
C) The patient's blood pressure is 104/56.
D) The patient's pulse is 132 beats/minute.
E) The patient is unable to sleep at night.
Q2) Which patient would be a candidate for animal-assisted therapy?
A) An elderly patient with Clostridium difficile diarrhea
B) A patient who has just undergone bone marrow transplantation
C) A young patient with an acute asthma exacerbation and dyspnea
D) A forgetful,irritable patient with a history of Alzheimer's disease
Q3) Which nursing diagnosis is a priority for a patient using tai chi to relieve arthritis pain?
A) Risk for falls
B) Sleep deprivation
C) Risk for contamination
D) Ineffective individual coping
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Chapter 20: Caring in Nursing Practice
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) The nurse helps the patient set small,achievable goals and celebrates with the patient when the goals are met.Which caring behavior is demonstrated by the nurse?
A) Human respect
B) Encouraging manner
C) Healing environment
D) Affiliation needs
Q2) The nurse ensures that the patient's room is cool,quiet,and dark so that the patient can rest and sleep.Which caring behavior is demonstrated by the nurse?
A) Fulfilling affiliation needs
B) Providing a sense of presence
C) Creating a healing environment
D) Demonstrating an encouraging manner
Q3) Which statement about caring for patients is true?
A) Basically all patients are the same.
B) Each patient has a unique background.
C) Caring for patients requires very little experience.
D) Standard solutions exist for most patient's health care problems.
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22
Chapter 21: Cultural Awareness
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11 Verified Questions
11 Flashcards
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Sample Questions
Q1) Which technique is most appropriate when performing a physical assessment for a male Muslim patient?
A) Use short,simple sentences and complete the physical assessment as quickly as possible.
B) Have a male nurse perform the assessment and expose only the body part being examined.
C) Stand close to the patient,speak clearly,and be careful not to exaggerate lip movements or facial expressions.
D) Use therapeutic touch to reassure the patient and convey the nurse's sense of concern.
Q2) The emergency room staff insists that a female Muslim patient disrobe completely and put on a hospital gown before being treated by the physician.Which nursing diagnosis is most applicable in this situation?
A) Risk for compromised human dignity related to cultural attire requirements
B) Ineffective role performance related to inadequate direction and preparation
C) Noncompliance related to expected behavior of patients in the emergency room
D) Impaired environmental interpretation syndrome related to busy emergency room
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23
Chapter 22: Spiritual Health
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11 Flashcards
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Sample Questions
Q1) A patient refuses to remove a religious headscarf when being bathed.Which is appropriate action of the nurse?
A) Remove the headscarf because its presence hinders hygiene.
B) Respect the patient's wishes and work around the headscarf.
C) Explain to the patient that the headscarf has no real spiritual value.
D) Identify the refusal to remove the headscarf as a sign of spiritual distress.
Q2) Which nursing interventions are appropriate for a terminally ill patient who is a devout Jew?
A) Arrange for a minister to provide the sacrament of anointing of the sick.
B) Facilitate bedside Sabbath services for the patient and the family members.
C) Allow the patient's family to maintain a vigil throughout the day and night.
D) Provide snacks and meals for the patient and family only from sunset until dawn.
E) Respect the decision of the patient and family not to put the patient on life support.
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Chapter 23: Growth and Development
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24 Flashcards
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Sample Questions
Q1) The nurse is caring for an elderly patient with the nursing diagnosis loneliness related to recent loss of spouse and limited contact with significant others.Which stage of Maslow's hierarchy of needs is addressed with this diagnosis?
A) Belonging
B) Self-esteem
C) Self-actualization
D) Safety and security
Q2) Which abilities are required for moral development of the child?
A) Accept social responsibility.
B) Perform repetitive motion responses.
C) Respect the integrity and rights of others.
D) Integrate principles of justice and fairness.
E) Use symbols and objects for abstract thinking.
Q3) Which is an example of a primary sexual characteristic?
A) Enlarged larynx and deeper voice
B) Enlargement of female breast tissue
C) Growth of hair on the face and chest
D) Development of the penis and testicles
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Chapter 24: Self-Concept and Sexuality
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16 Flashcards
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Sample Questions
Q1) Which is the priority intervention for an elderly patient with the nursing diagnosis ineffective sexuality pattern related to vaginal dryness?
A) Help the patient to communicate the need for privacy for sexual activity.
B) Encourage the patient to utilize a water-based vaginal lubricant for comfort.
C) Let the patient know that vaginal dryness is a normal finding in older women.
D) Instruct the patient to void immediately after intercourse to prevent irritation.
Q2) The patient tells the nurse that the spouse is only interested in sexual activity when inflicting physical pain on the patient.Which is the priority nursing diagnosis for the patient?
A) Activity intolerance related to inability to fulfill spouse's sexual needs
B) Ineffective sexuality pattern related to differing sexual activity expectations
C) Risk for injury related to physical abuse from spouse during sexual activity
D) Risk for compromised human dignity related to spouse's demeaning actions
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Chapter 25: Family Dynamics
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21 Flashcards
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Sample Questions
Q1) Which nursing diagnosis is most appropriate for an adult patient who is raising young children while caring for elderly parents?
A) Risk for unilateral neglect related to inability to care for both generations
B) Ineffective protection related to inability to constantly supervise elderly parents
C) Risk for caregiver role strain related to responsibilities for parents and children
D) Readiness for enhanced parenting related to realistic expectations of development
Q2) Which assessments are appropriate when caring for a stroke patient living with a spouse and two children using the family as context?
A) Assess the stroke patient for self-care abilities.
B) Assess the ability of the spouse and two children to help feed and bathe the patient.
C) Assess communication processes among family members.
D) Assess the spouse's ability to emotionally comfort the patient.
E) Assess how the spouse is dealing with parenting issues of the two children.
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Chapter 26: Stress and Coping
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20 Flashcards
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Sample Questions
Q1) A young child begins wetting the bed again after the parents bring home a new baby sister.Which ego-defense mechanism is used by the child?
A) Regression
B) Conversion
C) Identification
D) Compensation
Q2) The patient is frustrated after being treated poorly by providers due to lack of health insurance.Which type of factor is causing the stress for the patient?
A) Rational
B) Situational
C) Maturational
D) Sociocultural
Q3) The young child cries and tries to run away when after being told that a flu shot is to be administered.Which term best describes the psychological reaction of the child?
A) Primary appraisal
B) Ineffective denial
C) Adventitious crisis
D) Developmental crisis
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28
Chapter 27: Loss and Grief
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Sample Questions
Q1) A nurse is caring for a patient who is depressed because her children have gone away to college.Which type of loss is experienced by the patient?
A) Perceived
B) Situational
C) Conditional
D) Maturational
Q2) The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss.Which stage of grief is currently being experienced by the patient?
A) Anger
B) Denial
C) Bargaining
D) Acceptance
E) Depression
Q3) Which of the following is true for a patient to receive home hospice care?
A) Caregiver support is available during normal business hours.
B) A primary caregiver must be living in the home with the patient.
C) If the patient goes to the hospital,all prehospital orders are canceled.
D) In the hospital,the home hospice care person must provide personal care.
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Page 29
Chapter 28: Exercise and Activity
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Q1) Which assessment finding is expected for a patient who suffered a left-sided thrombotic stroke?
A) Bilateral footdrop
B) Fine tremors of the hands
C) Curvature of the lumbar spine
D) Weakness of the right arm and leg
Q2) Which action is appropriate for transferring a hemiplegic patient from the bed to the wheelchair?
A) The nurse ensures that the wheelchair brakes are locked before helping the patient to stand.
B) The patient's arms are placed around the nurse's neck before the patient is helped to stand.
C) The nurse secures the gait belt under the patient's arms and uses it to lift the patient to a standing position.
D) The nurse's legs are kept straight and close together to avoid tripping the patient during the transfer.
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Chapter 29: Immobility
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Sample Questions
Q1) Which are the appropriate interventions for the patient with the diagnosis impaired bed mobility related to hemiplegia after stroke?
A) Assist the patient to reposition in the bed at least every 3 hours.
B) Maintain the patient's bed in high Fowler's position whenever possible.
C) Instruct the patient how to use the over-bed trapeze to reposition self in bed.
D) Utilize a sliding sheet to minimize skin trauma during repositioning of the patient.
E) Position the patient's affected limbs in neutral alignment between ranges of motion.
Q2) A patient had surgery two days ago.Which intervention will be included in the plan of care for this patient wearing compression stockings?
A) The patient's stockings should be removed at night for washing.
B) Slippers should not be applied over the stockings for ambulation.
C) Regular size stockings are for females and large size are for males.
D) Make sure that the patient's toes are not sticking out of the stockings.
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Chapter 30: Safety
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Q1) The nurse is caring for a patient who has ongoing headaches,nausea,dizziness,and fatigue since the weather turned cold and snowy.Which assessment question is most important to ask the patient?
A) "Has your furnace been inspected lately?"
B) "Have you checked your roof for any leaks?"
C) "When was the last time your house was painted?"
D) "When did you change your smoke detector batteries?"
Q2) Into which seating position will the nurse teach a family to place their 18-month-old toddler in the family car?
A) Front seat facing backward
B) Rear seat facing backward
C) Front seat facing forward
D) Rear seat facing forward
Q3) Which nursing diagnosis is the highest priority for a sexually active adolescent?
A) Risk for infection related to participation in unprotected sexual activity
B) Disturbed body image related to depersonalization and fear of rejection
C) Spiritual distress related to inability to integrate sexuality with church teaching
D) Risk for compromised human dignity related to loss of respect from peer group
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32
Chapter 31: Hygiene
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Q1) Which is the highest priority nursing diagnosis for a patient who is frequently incontinent of stool and urine?
A) Risk for impaired skin integrity related to exposure to urine and stool
B) Powerlessness related to inability to control release of bowel and bladder
C) Readiness for enhanced comfort related to expressed desire to smell fresh
D) Social isolation related to unpleasant odor from stool and urine
Q2) How can the nurse best respect the patient's cultural preferences for hygiene?
A) Shave the patient's facial hair every morning after the bath.
B) Add scented bath oils to the water before bathing the patient.
C) Ensure that a staff member of the same sex bathes the patient.
D) Accommodate the patient's wish to wash before morning prayers.
Q3) The nurse is caring for a bedridden patient with long straight hair.Which is the appropriate intervention to prevent the hair from becoming matted?
A) Apply no-tangle conditioner to the hair.
B) Cut the matted hair.
C) Braid the patient's hair into several pigtails.
D) Wash the patient's hair daily with baby shampoo.
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Page 33
Chapter 32: Oxygenation
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Q1) Which assessment findings indicate to the nurse that the patient is hypoxic?
A) Heart rate is 55 beats/minute and irregular.
B) Urine output is 300 mL over the last 8 hours.
C) The patient is drowsy and difficult to arouse.
D) Hands and feet are pale and cool to the touch.
E) Abdomen is soft with bowel sounds × 4 quadrants.
Q2) Which respiratory problem is experienced by premature infants due to lack of surfactant in their lungs?
A) The alveoli shrivel and are unable to exchange oxygen for carbon dioxide.
B) Weakness of the respiratory muscles limits airflow in and out of the lungs.
C) Swelling of abdominal organs limits expansion and contraction of the diaphragm.
D) Insufficient hemoglobin impairs delivery of oxygen to tissues throughout the body.
Q3) The nurse assesses distended neck veins in a patient sitting in a chair to eat.Which is the priority intervention of the nurse?
A) Document the observation in the chart.
B) Assess the patient's deep tendon reflexes.
C) Measure urine specific gravity and volume.
D) Check the patient's pulse and blood pressure.
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34
Chapter 33: Sleep
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Q1) Which assessment is most important to determine if a patient is receiving sufficient sleep?
A) Sleep-wake pattern
B) Frequency of nocturia
C) Hours of sleep each night
D) Whether the patient feels rested
Q2) Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?
A) Risk for impaired skin integrity related to tight-fitting mask on face
B) Impaired bed mobility related to presence of CPAP mask on face
C) Health-seeking behaviors related to expressed desire for better sleep
D) Risk for powerlessness related to inability to breathe regularly during sleep
Q3) Why is it important for a postoperative patient to get enough sleep after being discharged from the hospital?
A) Sleep restores biological processes.
B) Sleep stimulates appetite on waking.
C) Sleep causes a mental and physiological calm.
D) Sleep produces dreams that decrease epinephrine.
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Chapter 34: Pain Management
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Q1) Which medication order will provide the most immediate relief of the patient's acute pain?
A) Morphine sulfate 5 mg PO
B) Hydromorphone 0.5 mg IV
C) Buprenorphine transdermal patch 10 mg
D) Oxymorphone 30 mg extended release
Q2) Which nonpharmacological pain-relief technique is appropriate for a confused,nonverbal patient?
A) Tai chi
B) Biofeedback
C) Massage therapy
D) Guided imagery
Q3) The nurse observes a postoperative patient trying to take a friend's oxycodone pain pills in addition to the pain medication administered by the nurse.Which is the priority nursing diagnosis for this patient?
A) Risk for poisoning
B) Situational low self-esteem
C) Ineffective impulse control
D) Readiness for enhanced comfort
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Page 36
Chapter 35: Nutrition
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Q1) Which is the best reason why a gastrostomy tube is ordered rather than parenteral nutrition for a patient with dysphagia?
A) Parenteral nutrition can only be administered to the patient in the hospital.
B) The gastrostomy tube provides more nutrition and protects intestinal function.
C) Parenteral nutrition is significantly more expensive than gastrostomy feedings.
D) The gastrostomy tube allows for administration of medications as well as nutrition.
Q2) Which is the appropriate intervention for a patient with the nursing diagnosis feeding self-care deficit related to neuromuscular hand and arm weakness?
A) Provide meticulous oral hygiene before and after meals.
B) Consult a speech-language pathologist for swallow precautions.
C) Provide the patient with a pleasant,quiet environment for meals.
D) Teach the patient how to use adaptive utensils to facilitate independence.
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Chapter 36: Urinary Elimination
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Q1) The nurse is caring for an older adult patient who has a constant urge to void due to a bladder infection.Which are the appropriate nursing diagnoses for this patient?
A) Sleep deprivation related to frequent need to use the toilet during the night
B) Risk for falls related to getting up frequently to use the bathroom at night
C) Impaired urinary elimination: frequency related to urinary tract inflammation
D) Risk for infection related to bacterial invasion of urinary tract
E) Risk for urge urinary incontinence related to urinary tract inflammation
Q2) The nurse is caring for an incontinent male patient with a large sacral pressure injury.Which is the safest intervention that will maintain skin integrity and facilitate healing of the ulcer?
A) Obtain a surgical consult for placement of a suprapubic urinary catheter.
B) Apply a condom catheter attached to a bedside urinary drainage bag.
C) Insert an indwelling urinary catheter attached to a small volume drainage bag.
D) Perform intermittent straight catheterization of the patient every 4 to 6 hours.
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Chapter 37: Bowel Elimination
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Sample Questions
Q1) Which assessment finding leads the nurse to conclude that digital disimpaction of stool is unsafe for the patient?
A) The patient has a large mass of hard,dry stool in the rectum.
B) The patient has not had a bowel movement for the last 6 days.
C) The patient's pulse is 50 beats/minute due to a history of heart block.
D) The patient has taken senna every morning for the last 3 days.
Q2) Which medication does the nurse identify as most likely to cause a patient's constipation?
A) Ferrous sulfate 325 mg PO BID
B) Cefaclor 500 mg PO TID
C) Warfarin 5 mg PO daily
D) Prednisone 10 mg PO daily
Q3) The nurse is caring for a patient with painful hemorrhoids.Which is the appropriate recommendation of the nurse to prevent their recurrence?
A) Stool softener daily at bedtime
B) Low-carbohydrate ketogenic diet
C) Periodic bowel cleansing programs
D) High-fiber diet with plenty of liquids
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Chapter 38: Skin Integrity and Wound Care
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Q1) The patient's wound has thick creamy yellow drainage present on the dressing.How will the nurse document this finding?
A) Serous drainage
B) Purulent drainage
C) Sanguineous drainage
D) Serosanguineous drainage
Q2) Which intervention will the nurse use for an abscessed leg wound?
A) Warm water sitz baths
B) Cold moist compresses
C) Warm moist compresses
D) Epsom salt solution soaks
Q3) The nurse is caring for a patient with a puncture wound.How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?
A) 1 year
B) 3 years
C) 5 years
D) 10 years
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Chapter 39: Sensory Alterations
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Q1) Which medications can lead to development of tinnitus?
A) Furosemide
B) Vancomycin
C) Insulin glulisine
D) Docusate sodium
E) Naproxen sodium
Q2) Although the patient can see movement in the periphery,the patient can no longer see to read books or do crossword puzzles.Which is the most likely cause of the patient's vision loss?
A) Cataracts
B) Glaucoma
C) Diabetic retinopathy
D) Macular degeneration
Q3) Which nursing diagnosis is most appropriate for a patient with xerostomia?
A) Total urinary incontinence related to inability to feel urge to urinate
B) Bathing self-care deficit related to inability to perceive left-sided body parts
C) Impaired oral mucus membranes related to decreased salivation and dry mouth
D) Disturbed sensory perception related to feeling of electric pain in feet and hands
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Chapter 40: Surgical Patient
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Q1) Which is the most appropriate outcome for the postoperative patient with the nursing diagnosis ineffective breathing pattern related to side effects of pain medication?
A) The patient will correctly demonstrate how to use pursed-lip breathing.
B) The patient will report the ability to breathe comfortably without anxiety.
C) The patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute.
D) The patient will rest comfortably and rate pain no higher than 4 on 0-to-10 scale.
Q2) Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in the operating room?
A) Powerlessness related to unconscious state from general anesthesia
B) Hypothermia related to cool ambient temperature in the operating room
C) Risk for impaired oral mucus membranes related to prolonged NPO status
D) Risk for caregiver role strain related to lengthy waiting period for family members
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