Health Assessment for Nurses Exam Bank
Course Introduction
Health Assessment for Nurses provides students with the foundational knowledge and practical skills required to conduct comprehensive health assessments across the lifespan. This course covers essential topics such as effective communication, health history taking, physical examination techniques, and the interpretation of findings. Students will learn to apply critical thinking in identifying normal and abnormal health indicators, document assessment outcomes accurately, and integrate cultural competence into patient care. The curriculum emphasizes the importance of a holistic and systematic approach, preparing nurses to prioritize patient needs and work collaboratively within interdisciplinary healthcare teams.
Recommended Textbook
Essentials for Nursing Practice 9th Edition by Potter FAAN
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40 Chapters
977 Verified Questions
977 Flashcards
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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 program is appropriate for a nurse who wishes to become an expert in ostomy and wound care?
A) Specialty certification
B) Master of Science program
C) Doctoral degree program
D) Continuing education program
Answer: A
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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Page 3
Chapter 2: Health and Wellness
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) Which action of the nurse demonstrates the concept of the Holistic Health Model?
A) The nurse incorporates the patient's religious restrictions,economic status and personal preferences when developing the nutrition plan.
B) The nurse has the patient demonstrate how to perform a sterile dressing change after teaching about the procedure.
C) The nurse consistently uses a 0-10 objective pain rating scale to achieve consistent pain management for the patient.
D) The nurse assists the patient to sit up slowly when getting out of bed to avoid fainting from orthostatic hypotension.
Answer: A
Q2) Which statement indicates the patient's perception of susceptibility to illness as described by the Health Belief Model?
A) "I am never going to get lung cancer so I refuse to stop smoking."
B) "Cancer is no big deal with all of the new treatments available now."
C) "I have been smoking for so many years that I will never be able to quit."
D) "I cannot afford the nicotine patches so I might as well keep on smoking."
Answer: A
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Page 4
Chapter 3: The Health Care Delivery System
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) Which is an example of a diagnosis-related group (DRG)?
A) Patients recovering from orthopedic surgery are placed on the same nursing unit.
B) Specialty hospitals are utilized to treat patients with life-threatening illnesses.
C) The speech therapist is consulted to see every patient admitted with dysphagia.
D) Hospitals will be paid $4500 to care for patients with uncomplicated pneumonia
Answer: D
Q2) Which type of health care agency is appropriate for a patient who sustained a back injury while at work?
A) Respite care center
B) Skilled nursing facility
C) Occupational health clinic
D) Outpatient surgical center
Answer: C
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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 highest priority problem for a homeless patient without family in December?
A) Risk for loneliness
B) Risk for hypothermia
C) Risk for social isolation
D) Risk for compromised human dignity
Q2) Which communication methods will the community nurse use when interacting with recent immigrants who do not speak English?
A) The nurse will obtain the assistance of a speech pathologist.
B) The nurse will speak in a louder tone of voice than usual.
C) The nurse will be sensitive to nonverbal communication cues.
D) The nurse will identify the preferred language for each family member.
E) The nurse will utilize an interpreter when explaining health care procedures.
Q3) Which problem is the highest priority for a family who has just moved to the United States and does not speak any English?
A) Risk for acute confusion
B) Disturbed energy field balance
C) Impaired verbal communication
D) Readiness for enhanced decision making
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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) What is the primary difference between negligence and malpractice?
A) Malpractice is intentional while negligence is unintended.
B) Malpractice is a felony while negligence is a misdemeanor.
C) Malpractice leads to more serious patient injury than negligence.
D) Malpractice is committed by a licensed professional while negligence is not.
Q2) Which patient scenario allows the physician to perform needed procedures without the need to obtain informed consent first?
A) An unconscious patient is brought into the ER after an auto accident.
B) The patient speaks only Russian and requires the services of a translator.
C) The patient is deaf and communicates through sign language or lip reading.
D) The patient is not an American citizen and does not have any health insurance.
Q3) The nurse is frustrated with an agitated patient and tells him "Now stay in that bed or I will make you stay there!" Which tort has the nurse just committed?
A) Assault
B) Battery
C) Incursion
D) Onslaught
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Chapter 6: Ethics
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19 Verified Questions
19 Flashcards
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Sample Questions
Q1) The patient's family members disagree about which treatment is most appropriate for the terminally ill comatose patient.Which nursing intervention is most appropriate for this situation?
A) The nurse will provide statistical information about the patient's odds of survival.
B) The nurse will promote effective communication between the family members.
C) The nurse will ask the family members to leave medical decisions to the physician.
D) The nurse will wait until the patient is able to make the decisions about treatment.
Q2) A patient with a rare neurological disease is misdiagnosed by the physician and told that the symptoms are psychosomatic.The patient's sense of self is shattered after being told "You are a waste of a hospital bed." Which ethical theory is violated in this situation?
A) Liberty
B) Fidelity
C) Ethics of care
D) Confidentiality
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8
Chapter 7: Evidence-Based Practice
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20 Verified Questions
20 Flashcards
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Sample Questions
Q1) A new central line care protocol to prevent site infection is instituted after it has been shown to be significantly more effective than previous approaches.Which term best describes this action?
A) Inductive reasoning
B) Qualitative research
C) Evidence-based practice
D) Process measurement
Q2) Which is an example of a sentinel event?
A) The patient suffers a fatal air embolism after a central line is removed incorrectly.
B) The nurse identifies a patient's urinary tract infection before symptoms develop.
C) The unit's urinary tract infection rate is 5% lower than the national average.
D) The pilot study indicates potential effectiveness of a new oral care protocol.
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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 statement is true about critical thinking?
A) It is the same thing as the nursing process.
B) It is moving from writing a plan of care to thinking.
C) It is a haphazard method of providing nursing care.
D) It is a continuous process characterized by open-mindedness.
Q2) The nurse asks another nurse for assistance when trying to determine the best way to manage a postoperative patient's pain.Which critical thinking attitude is demonstrated by the nurse?
A) Humility
B) Confidence
C) Risk taking
D) Fairness
Q3) Which action by the nurse best demonstrates independent thinking?
A) Removing and carefully cleaning the patient's dentures every night
B) Initiating swallow precautions when the patient shows signs of aspiration
C) Teaching the diabetic patient how to self-administer insulin injections
D) Actively listening to the patient when recording the patient's health history
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Chapter 9: Nursing Process
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) A nurse is delegating care of patients to the certified nursing assistant (CNA)and a licensed practical nurse (LPN).Which task assignment indicates that the nurse needs additional education about delegation?
A) The LPN is assigned to change a sterile dressing.
B) The CNA is assigned to provide skin care.
C) The CNA is assigned to insert an indwelling urinary catheter.
D) The LPN is assigned to administer a soapsuds enema.
Q2) The nurse is caring for a patient who has just arrived at the hospital with chest pain.Which is the most important question for the nurse to ask the patient?
A) "Did your family doctor tell you to come to the hospital?"
B) "When did your chest pain begin?"
C) "Do you have a family history of heart disease?"
D) "Did someone come to the hospital with you?"
Q3) Which nursing diagnosis is the highest priority for a patient with multiple sclerosis?
A) Chronic sorrow related to loss of independence
B) Disturbed sensory perception related to nerve cell damage
C) Risk for powerlessness related to impaired fine- and gross-motor skills
D) Risk for falls related to impaired mobility and sensation
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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) The patient was not able to continue along the migraine headache critical pathway after suffering a stroke.Which terminology describes this deviation from the prescribed pathway?
A) Negative variance
B) Noncompliance with the treatment plan
C) Risk-prone health behavior
D) Care plan intolerance
Q2) The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician.How will the nurse correct this error?
A) Black out the error with a thick marker and enter the correct information.
B) Use correction tape to write over the incorrect information.
C) Draw one line through the error,make the correction and initial it.
D) Shred the forms with the incorrect information and write on new ones.
Q3) What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care?
A) Cost of care per patient day
B) Number of registered nurses
C) Absence of sentinel events
D) Documentation audits
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Chapter 11: Communication
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) Which is the most appropriate nursing diagnosis to use for a patient with expressive aphasia following a stroke?
A) Impaired verbal communication related to inability to speak and reply
B) Readiness for enhanced comfort related to drooling and facial droop
C) Deficient diversional activity related to lack of stimuli in hospital room
D) Noncompliance related to inability to verbally answer questions
Q2) Which action by the nurse demonstrates appropriate timing for effective communication?
A) The nurse sits in a chair next to the patient's bed to maintain eye contact.
B) The nurse waits to begin teaching until the patient's nausea has subsided.
C) The nurse speaks slowly and loudly for a patient who is hard of hearing.
D) The nurse maintains privacy during all conversations with the patient.
Q3) A nurse enters a patient's room and sees the patient grimacing with each movement.When the nurse asks how the patient is feeling,the patient states "I feel fine." Which finding will the nurse classify as nonverbal communication?
A) The patient states "I feel fine."
B) The nurse asks how the patient is feeling.
C) The patient grimaces with each movement.
D) The nurse is present at the patient's bedside.
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Page 13
Chapter 12: Patient Education
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) Which patient learning goal is measurable?
A) The patient will understand the importance of daily iron supplements.
B) The patient will be able to learn sufficient information to be discharged.
C) The patient will feel comforted by the nurses' presence during anxious periods.
D) The patient will verbalize responsibility for obtaining daily weights each morning.
Q2) Which nursing diagnosis indicates that the patient will have difficulty learning how to perform sterile dressing changes at home?
A) Deficient knowledge related to diabetic wound management
B) Stress overload related to ongoing emotional abuse and bullying
C) Readiness for enhanced knowledge related to diabetes management
D) Impaired physical mobility related to need to use a cane for ambulation
Q3) Which is the highest priority concern for the nurse who is educating the homeless patient about medications,appointments,and therapies for management of diabetes?
A) Motivation
B) Health literacy
C) Developmental stage
D) Psychomotor learning
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Chapter 13: Managing Patient Care
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) Which is the highest priority nursing intervention for a patient with the nursing diagnosis risk for suicide related to recent suicide attempt and desire to die?
A) Assist the patient to identify sources of support in the community.
B) Assess the patient's readiness to sign a pledge to do no self-harm.
C) Question the patient's family members about previous suicide attempts.
D) Remove dangerous items such as scissors from the patient's environment.
Q2) Which leadership skills will the nursing student use when caring for patients?
A) Priority setting
B) Time management
C) Case management
D) Careful delegation
E) Team communication
Q3) Which approaches will the nurse use in order to effectively participate in interprofessional collaboration?
A) Utilize a top-down communication strategy.
B) Work to maintain a climate of mutual respect.
C) Support a team approach to the maintenance of health.
D) Use role-specific knowledge to address health care needs.
E) Apply relationship-building values and principles of team dynamics.
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Page 15
Chapter 14: Infection Prevention and Control
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) Which action of the nurse demonstrates the use of standard precautions?
A) The nurse uses gloves when performing oral care for the patient.
B) The nurse puts on a surgical mask before entering the patient's room.
C) The patient is placed in a private room with negative-pressure airflow.
D) The nurse uses sterile gloves when emptying the patient's urinary catheter bag.
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 is a semicritical item that requires disinfection?
A) Nail file
B) Safety pin
C) Emesis basin
D) Laryngoscope
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16
Chapter 15: Vital Signs
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) The nurse notes that the patient's temperature varies significantly throughout the day and night.Which are possible reasons for this variation?
A) The patient's diagnosis of pneumonia
B) The patient's gluten-free,low sodium diet
C) The patient's history of hypertension
D) The patient's frequent trips outside to smoke
E) The patient's allergies to penicillin and shellfish
Q2) Which patient should have the temperature taken orally rather than using a tympanic thermometer?
A) An unconscious,intubated patient
B) A patient with bilateral middle ear infections
C) A patient with gastroenteritis who is vomiting
D) An agitated patient who cannot follow directions
Q3) The nurse is caring for a patient who lost consciousness and collapsed.Which site will be used to determine if the patient has a pulse?
A) Apical artery
B) Radial artery
C) Carotid artery
D) Brachial artery
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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 is brought in after collapsing outside on a very hot day.Which assessment finding will the nurse expect to note during physical examination of the patient?
A) Pallor of the patient's extremities
B) Cyanosis of the patient's nail beds and lips
C) Dry mucus membranes and poor skin turgor
D) Lower extremity edema and a generalized itchy rash
Q2) Which assessment finding is expected for a patient presenting with a middle ear infection?
A) The right tympanic membrane is pink and bulging.
B) The patient becomes dizzy when sitting upright.
C) The pinna is red,swollen,and tender to palpation.
D) The eardrum is a translucent pearly gray color.
Q3) The patient has been smoking 2 packs of cigarettes for the last 15 years.How will the nurse chart the patient's tobacco use history in pack-years?
A) 7.5 pack-years
B) 17 pack-years
C) 30 pack-years
D) 35 pack-years
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Page 18
Chapter 17: Administering Medications
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48 Verified Questions
48 Flashcards
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Sample Questions
Q1) Which of the following patients is most at risk for liver damage after taking acetaminophen regularly for arthritis pain?
A) Patient with a history of alcohol abuse and hepatitis C
B) Patient with type 2 diabetes and end-stage renal disease
C) Patient with prostate enlargement and urinary frequency
D) Patient with COPD and a 20 pack-year history of smoking
Q2) The patient's medication order is for transdermal fentanyl.How will the nurse administer this medication?
A) Apply the medication patch to a clean,dry intact area of skin.
B) Inject the medication into the soft tissue behind the patient's arm.
C) Carefully place the medication between the patient's cheek and teeth.
D) Have the patient swallow the medication with a small sip of water.
Q3) Order: Enalaprilat 1.25 mg IV push
Enalaprilat injection
For IV use only
2.5 mg per 2 mL
The agency's safe IV push infusion rate for Enalaprilat is 625 mcg over 5 minutes. How many minutes will it take to safely administer the dose? _____ minutes
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Page 19
Chapter 18: Fluid, Electrolyte, and Acid-Base Balances
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38 Verified Questions
38 Flashcards
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Sample Questions
Q1) The patient is scheduled for hip replacement surgery and significant blood loss is expected.What is the best possible action of the patient to reduce the risk of transfusion complications?
A) Arrange for an autologous blood donation.
B) Take an iron supplement daily prior to the surgery.
C) Expect transfusions will come from a directed donor.
D) Request that donated blood be screened twice by the blood bank.
Q2) The patient is receiving an intravenous infusion of 40 mEq of potassium chloride in a 1000 mL solution of 0.9% saline.The patient states that the area around the IV site burns.What intervention does the nurse perform first?
A) Notify the physician.
B) Stop the IV infusion.
C) Document the finding.
D) Increase the IV drip rate.
Q3) Order: 500 mL D W to infuse at 100 mL/hour
IV tubing: 10 drops/mL
The IV bag was hung at 12:00 noon. What time will the IV bag be completed? _____
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Chapter 19: Complementary and Alternative Therapies
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) The patient reports taking valerian root capsules regularly.What is the patient's rationale for taking the supplement?
A) Relief of constipation
B) Relief of nausea and vomiting
C) Relief of arthritis pain
D) Inability to fall asleep at night
Q2) Which assessment finding indicates to the nurse that the patient has begun to master the cognitive skill of receptivity?
A) The patient readily accepts feedback from the nurse about how to perform dressing changes.
B) The patient calmly accepts the physician's recommendation for surgery without a request for a second opinion.
C) The patient chooses not to inform family members about the complications and risks of upcoming surgery.
D) The patient uses guided imagery techniques to minimize anxiety and push negative thoughts out of the mind.
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21
Chapter 20: Caring in Nursing Practice
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Sample Questions
Q1) The nurse respects the patient's cultural standard to have the father of the baby wait outside the delivery room when the baby is born.Which caring behavior is demonstrated by the nurse?
A) Meeting basic human needs
B) Appreciating unique meanings
C) Offering attentive reassurance
D) Providing an encouraging manner
Q2) Which action by the nurse demonstrates attentive reassurance?
A) The nurse provides gentle oral care to a patient with a nasogastric tube.
B) The nurse spends time with the patient to provide empathy and inspire hope.
C) The nurse assesses the patient for cultural influences that affect body image.
D) The nurse encourages the patient to wear hearing aids to facilitate communication.
Q3) Which statement is part of Leininger's Transcultural View of Caring?
A) Caring and curing are basically synonymous.
B) Caring acts are independent of patient values.
C) Care uses a standardized approach for all patients.
D) Care is tailored to meet the needs of the individual patient.
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Chapter 21: Cultural Awareness
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11 Flashcards
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Sample Questions
Q1) Which action of the nurse demonstrates culturally competent care?
A) Helping a Hindu patient to eat meatloaf and gravy for dinner
B) Cutting up ham and vegetables for an orthodox Jewish patient
C) Bringing a grieving Mormon family a tray of coffee and snacks
D) Adding fruit to a Buddhist patient's bowl of oatmeal for breakfast
Q2) A Muslim patient has requested to have only female nursing staff provide personal care.Which is the appropriate response of the nurse?
A) "I know that it may be difficult to understand but both male and female nurses are employed at this hospital."
B) "I will make sure that the charge nurse is notified about your request so that it can be accommodated."
C) "It will be difficult for people like you to adjust to our ways,but there are limitations for all of us."
D) "You may be perceived as a 'difficult patient' if you insist on limiting which nurses can take care of you."
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Chapter 22: Spiritual Health
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Sample Questions
Q1) The nurse is caring for a patient who expresses anger about being abandoned and unloved by God since becoming ill.Which nursing diagnosis is appropriate for this patient?
A) Spiritual distress related to perceived alienation from God
B) Risk for loneliness related to social and physical isolation
C) Acute confusion related to hallucinations and misperceptions
D) Impaired memory related to inability to remember familiar prayers
Q2) The nurse feels a deep sense of altruism and wonderment after successfully resuscitating a young athlete who suddenly collapsed in cardiac arrest.Which term best describes the sensation experienced by the nurse?
A) Holy conviction
B) Spiritual distress
C) Divine expectation
D) Self-transcendence
Q3) Which action by the nurse is appropriate for a family with a terminally ill newborn?
A) Call the rabbi to come to the bedside.
B) Arrange for the infant to be baptized immediately.
C) Call the hospital chaplain to pray with the family.
D) Ask the family how their spiritual needs can be supported.
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Page 24
Chapter 23: Growth and Development
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Sample Questions
Q1) The nurse is caring for an adolescent with a BMI of 22 and the nursing diagnosis imbalanced nutrition,more than body requirements related to caloric intake greater than metabolic needs.Which nursing interventions will the nurse use to help the adolescent achieve a balanced diet?
A) Use sugary treats as a reward for getting good grades in school.
B) Encourage the adolescent to gradually increase physical activity.
C) Recommend intake of at least 2 to 3 L of water each day.
D) Remind the adolescent of how body image affects relationships.
E) Encourage the adolescent to eat breakfast every day before school.
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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Sample Questions
Q1) The nurse is caring for an adolescent patient who dips snuff because all of his friends do it.Which self-concept need led the patient to do this?
A) Body image
B) Sexual identity
C) Cultural identity
D) Role performance
Q2) The nurse is caring for a patient who has lost all sexual desire due to severe chronic illness.Which term will the nurse use to chart this assessment finding?
A) Fluid
B) Queer
C) Binary
D) Aromantic
Q3) The nurse is caring for an adolescent who feels overweight with a BMI of 16.Which nursing diagnosis is most appropriate for this patient?
A) Risk-prone health behavior related to inadequate self-efficacy
B) Noncompliance related to failure to adhere to healthy dietary plan
C) Disturbed body image related to distorted view of ideal body weight
D) Self-mutilation related to depersonalization and self-destructive behaviors
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Chapter 25: Family Dynamics
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Sample Questions
Q1) Which outcome is most important for the family with the nursing diagnosis interrupted family processes related to terminally ill father?
A) Family members will verbalize their feelings when sharing the evening meal.
B) Family members will feel fulfilled when meeting the dying wishes of the father.
C) Family members will cooperate to support the father's needs during his last days.
D) Family members will find spiritual meaning and peace through the dying process.
Q2) Which is an example of a skip generation family?
A) A military family moves frequently from state to state due to deployments.
B) A couple provides foster care for infants while their mothers are incarcerated.
C) A divorced mother moves far away from the child's father to prevent visitation.
D) Grandparents raise the grandchildren after their parents are jailed for drug abuse.
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Chapter 26: Stress and Coping
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Sample Questions
Q1) Which position is best suited for a nurse who preferred to study until the early hours of the morning during nursing school?
A) Full-time 8-hour day/evening rotation
B) Part-time 12-hour day/night rotation position
C) Full-time 12-hour night position
D) Full-time 8-hour day position
Q2) The patient develops an inability to swallow after many years of emotional abuse.The physicians can find no medical reason for the patient's dysphagia.Which ego-defense mechanism is used by the patient?
A) Displacement
B) Dissociation
C) Compensation
D) Conversion
Q3) Which situation demonstrates an allostatic stress load?
A) The nursing student uses meditation to cope with mild test anxiety.
B) The patient develops anaphylactic shock after being stung by a bee.
C) The nurse develops hypertension after working too many double shifts.
D) The patient's heart rate returns to normal after a painful procedure is completed.
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Chapter 27: Loss and Grief
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Sample Questions
Q1) Which nursing diagnosis is most appropriate for a patient who is having difficulty with accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse?
A) Ineffective denial related to threat of unpleasant reality of lung cancer
B) Noncompliance related to failure to adhere to prescribed treatment plan
C) Effective therapeutic regimen management related to illness symptom reduction
D) Readiness for enhanced decision making related to realignment of personal values
Q2) Which action by the patient demonstrates reminiscence of a lost parent?
A) The patient obtains a copy of the parent's will and inventories all assets.
B) The patient returns to school to start a new career in business administration.
C) The patient sues the hospital for malpractice after reviewing the medical record.
D) The patient creates a scrapbook to remember special times spent with the parent.
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Chapter 28: Exercise and Activity
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Q1) Which action by the nurse demonstrates correct technique for repositioning the patient in bed?
A) The nurse's knees are kept stiff to enhance lifting strength potential.
B) The nurse's abdominal muscles are relaxed to prevent back injury.
C) The nurse's pelvis is tucked inward to maintain balance during the procedure.
D) The nurse's torso twists with the patient to facilitate upper extremity muscle use.
Q2) How does the nurse maintain a low center of gravity while transferring the patient from the bed to the chair?
A) The nurse ties the gait belt loosely around the patient's waist.
B) The nurse stands with the knees slightly bent and legs spread apart.
C) The nurse bends at the waist when setting the patient's feet on the floor.
D) The nurse leans backward slightly when helping the patient to stand.
Q3) Which exercise program should be avoided by a patient with osteoporosis?
A) Yoga
B) Tai chi
C) Tennis
D) Water aerobics
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Chapter 29: Immobility
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Q1) The nurse suspects that the postoperative patient has developed a deep vein thrombosis.Which is the priority action of the nurse?
A) Obtain an order for STAT bleeding time,D-dimer,and platelet count.
B) Elevate the patient's leg and assess for chest pain or shortness of breath.
C) Apply a mobile compression device (MCD)to the patient's affected leg.
D) Use a Doppler machine to confirm the presence of bilateral pedal pulses.
Q2) The nurse is caring for a pregnant mother of two small children who is on bed rest for several months until the baby is born.Which outcome is most appropriate to address the diagnosis of compromised family coping related to mother's prolonged bed rest?
A) The family will verbalize need for support and identify available resources.
B) The family will discuss alternatives to bed rest with the health care provider.
C) The mother will verbalize need for bed rest to minimize risk of premature birth.
D) The mother will report increased psychological comfort with each passing week.
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Chapter 30: Safety
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Q1) 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
Q2) Which is the appropriate intervention for a patient with the nursing diagnosis wandering related to disorientation,memory loss,and urge incontinence?
A) Raise three of the four side rails on the patient's bed.
B) Assign the patient to a room close to the nursing station.
C) Remind the patient to always ask for help before getting up.
D) Place a bed alarm to notify staff when the patient is getting up.
Q3) The patient is aggressively attempting to pull out IV lines and hurt staff members.Which is the first action of the nurse?
A) Conduct a thorough mental status assessment.
B) Contact the health care provider to obtain an order for restraints.
C) Place the patient in soft restraints to prevent injury.
D) Document the patient's actions in the medical record.
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32
Chapter 31: Hygiene
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Q1) 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.
Q2) Which is the priority nursing intervention for a patient with confusion and the diagnosis impaired dentition related to inability to perform oral care?
A) Assess the patient's preferred methods for oral hygiene.
B) Brush the patient's teeth twice daily with a soft toothbrush.
C) Use foam swab sticks to clean the oral cavity every morning.
D) Encourage the patient to chew sugarless gum during the day.
Q3) Which assessment finding leads the nurse to question the physician's order for irrigation of the patient's ear?
A) The patient has some short soft hairs present on the pinna.
B) A large amount of cerumen is noted in the patient's ear canal.
C) The patient has ear pain with purulent drainage in the ear canal.
D) The patient's tympanic membrane is a translucent pearl-gray color.
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Page 33
Chapter 32: Oxygenation
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Q1) Which assessment finding explains the patient's tachycardia?
A) The patient drinks at least eight cans of diet cola every day.
B) The patient takes digoxin 0.125 mg PO daily.
C) The patient has a history of untreated hypothyroid disease.
D) The patient takes metoprolol 50 mg PO daily.
Q2) Which assessment findings indicate that the patient is at risk for developing ventricular fibrillation?
A) Serum potassium level 7.6 mEq/L
B) Long history of coronary artery disease
C) Impaired conduction through the SA node
D) Recent incidents of ventricular tachycardia
E) Vagal stimulation from removal of fecal impaction
Q3) The nurse has orders to titrate the patient's oxygen to maintain a pulse oximetry level greater than 94%.The patient's pulse oximetry will not rise above 90% despite use of a nonrebreather mask.Which is the appropriate action of the nurse?
A) Insert an oral airway and apply a full face oxygen mask.
B) Call respiratory therapy to consider BiPAP support for the patient.
C) Remove the nonrebreather mask and replace it with a Venturi mask.
D) Place an oxygen nasal cannula underneath the patient's nonrebreather mask.
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Page 34
Chapter 33: Sleep
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Sample Questions
Q1) Which is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking zolpidem?
A) Risk for falls related to ambulating to kitchen while asleep
B) Wandering related to cognitive impairment from sleeping aid
C) Powerlessness related to inability to keep from eating during sleep
D) Risk for imbalanced nutrition: more than body requirements related to sleep eating
Q2) Which nighttime activity will keep the patient from being able to fall asleep easily?
A) Doing crossword puzzles on a tablet computer
B) Turning down the temperature in the bedroom
C) Listening to recordings of soothing classical music
D) Always going to bed at approximately the same time
Q3) Which outcome is most appropriate for the patient with the nursing diagnosis insomnia related to night shift work?
A) The patient will rotate day/night work shifts frequently.
B) The patient will obtain at least 48 hours of sleep per week.
C) The patient will use caffeine sparingly to wake up before shifts.
D) The patient will use bright lights to stay awake through the night.
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Chapter 34: Pain Management
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Q1) Which medication order will provide the most consistent control of the patient's chronic pain?
A) Fentanyl transdermal patch 25 mcg
B) Hydromorphone 0.5 mg IV
C) Fentanyl oral lozenge 200 mcg
D) Morphine sulfate liquid 10 mg
Q2) A patient has a morphine sulfate patient-controlled analgesia (PCA)to control postoperative pain.When the nurse enters the room,the patient complains of pain.The nurse's first response is which of the following?
A) Ask the patient to rate the pain on a 0-to-10 scale.
B) Check the patency of the patient's intravenous line.
C) Call the physician or health care provider immediately.
D) Speak to the patient in a calming tone to reduce anxiety.
Q3) 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
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Page 36
Chapter 35: Nutrition
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Q1) Which intervention is most effective for measuring the patient's fluid balance over time?
A) Measure daily intake and output.
B) Figure the patient's body mass index.
C) Record daily weights before breakfast.
D) Calculate the patient's ideal body weight.
Q2) Which soup is appropriate for a patient who follows a vegan diet?
A) Cream of broccoli and cheddar cheese soup
B) Moroccan carrot,apple,and cauliflower soup
C) Minestrone soup with lamb,vegetables,and pasta
D) Egg drop soup with chow mein noodles and scallions
Q3) Which food item contains the most calories?
A) 1 g of cane sugar
B) 1 g of lean meat
C) 1 g of butter
D) 1 g of banana
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Chapter 36: Urinary Elimination
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Q1) Which assessment finding needs to be communicated promptly to the patient's health care provider?
A) Postvoid residual of 15 mL of urine.
B) Leakage of small amounts of urine when coughing.
C) Urine output of 160 mL over the last 8 hours.
D) Patient's report of an urge to void during palpation of the bladder.
Q2) The patient's urinalysis indicates increased specific gravity of the urine.Which finding does the nurse anticipate will be found upon assessment?
A) The patient uses supplemental oxygen due to COPD.
B) The patient is thirsty with dry oral mucus membranes.
C) The patient has a history of benign prostatic enlargement.
D) The patient just completed antibiotics for a bladder infection.
Q3) Which assessment finding leads the nurse to question an order for an abdominal flat plate test?
A) The patient is very claustrophobic.
B) The patient is 8 weeks pregnant.
C) The patient has a history of renal failure.
D) The patient is allergic to iodine and shrimp.
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Chapter 37: Bowel Elimination
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Q1) The nurse is caring for a patient who relies on laxatives to ensure daily bowel movements.Which is the appropriate nursing diagnosis for this patient?
A) Risk for constipation related to irregular bowel elimination patterns
B) Perceived constipation related to expectation of daily bowel movements
C) Toileting self-care deficit related to inability to set regular defecation regimen
D) Powerlessness related to inability to have daily bowel movements without laxatives
Q2) Which patient does the nurse identify that would benefit from a nasogastric tube to low intermittent suction?
A) A patient who is vomiting due to a complete large bowel obstruction
B) A patient with constipation who has not had a bowel movement in 6 days
C) A patient with constant diarrhea due to side effects of antibiotic therapy
D) A patient with extensive skin irritation due to a leaking colostomy appliance
Q3) Which patient would benefit from a sitz bath?
A) A patient who has not had a bowel movement for the last 4 days
B) A patient with painful,swollen hemorrhoids after vaginal childbirth
C) A patient with perineal skin breakdown due to continuous oozing of stool
D) A patient who is having difficulty adhering the ostomy appliance to the skin
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Chapter 38: Skin Integrity and Wound Care
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Q1) The patient has a large red,blistered area on the left hip.Which pressure injury stage will be recorded in the patient's chart?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Q2) The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?
A) Reactive hyperemia
B) Secondary erythema
C) Blanchable hyperemia
D) Nonblanchable erythema
Q3) The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?
A) Hemostasis phase
B) Proliferative phase
C) Inflammation phase
D) Remodeling phase
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Chapter 39: Sensory Alterations
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Q1) The nurse is caring for a patient with the nursing diagnosis of disturbed sensory perception related to loud,bright hospital environment.Which is the priority intervention for the patient's care plan?
A) Maintain eye contact with the patient and avoid chewing gum.
B) Ask the patient to repeat information back to ensure understanding.
C) Repeatedly orient the patient to time,place,and the hospital room surroundings.
D) Shut the patient's door and avoid turning on the bright overhead lights in the room.
Q2) Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?
A) The patient must hold on to the railing when ambulating in the hallway.
B) The patient must add extra seasoning to food in order for it to have any flavor.
C) The patient did not smell smoke even though the smoke detector was alarming.
D) The patient suffered a first-degree burn when a heating pad was left on too long.
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Chapter 40: Surgical Patient
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Sample Questions
Q1) Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter?
A) The patient does not wish to get out of bed and ambulate to the toilet.
B) The patient just underwent radical prostatectomy surgery 2 days ago.
C) The drainage bag contains 300 mL of clear yellow urine from the last 4 hours.
D) The patient is to be discharged home after a final assessment by the surgeon.
Q2) Which surgical procedure may be performed using conscious sedation?
A) Knee-replacement surgery
B) Coronary artery bypass surgery
C) Cataract removal with lens implant
D) Modified radical mastectomy surgery
Q3) The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse?
A) Assist the patient to sit up in the chair and ambulate in the hallway.
B) Watch the patient use the incentive spirometer and ensure hourly usage.
C) Teach the patient to splint the incision when coughing to minimize pain.
D) Dim the lights,provide warm blankets,and maintain a quiet environment.
E) Maintain patient privacy and use therapeutic touch as desired by the patient.
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