Health Assessment in Nursing Practice Questions
Course Introduction
Health Assessment in Nursing introduces students to the foundational skills and knowledge necessary for comprehensive patient assessment across the lifespan. This course emphasizes the systematic collection of health data through patient histories, physical examinations, and risk assessments, integrating both theoretical and practical components. Students learn to use evidence-based tools and techniques to assess physiological, psychological, sociocultural, and developmental factors influencing health. Emphasis is placed on effective communication, critical thinking, and clinical reasoning to interpret assessment findings and document them accurately, forming the basis for safe, effective, and individualized nursing care planning.
Recommended Textbook
Fundamentals of Nursing 9th Edition by Potter
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50 Chapters
1588 Verified Questions
1588 Flashcards
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Chapter 1: Nursing Today
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22 Verified Questions
22 Flashcards
Source URL: https://quizplus.com/quiz/2380
Sample Questions
Q1) Which nurse most likely kept records on sanitation techniques and the effects on health?
A) Florence Nightingale
B) Mary Nutting
C) Clara Barton
D) Lillian Wald
Answer: A
Q2) A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using?
A) Code of ethics
B) Standards of practice
C) Standards of professional performance
D) Quality and safety education for nurses
Answer: A
Q3) A nurse has compassion fatigue. What is the nurse experiencing?
A) Lateral violence and intrapersonal conflict
B) Burnout and secondary traumatic stress
C) Short-term grief and single stressor
D) Physical and mental exhaustion
Answer: B
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Chapter 2: The Health Care Delivery System
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient?
A) Capitation provides the hospital with a means of recovering variable charges.
B) The hospital will be paid for the full cost of the patient's hospitalization.
C) Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.
D) Medicare will pay the national average for the patient's condition.
Answer: C
Q2) A nurse is completing a minimum data set. Which area is the nurse working?
A) Nursing center
B) Psychiatric facility
C) Rehabilitation center
D) Adult day care center
Answer: A
Q3) Medicaid
A)Insurance for low-income families
B)Federal insurance for people aged 65 and older
C)Health maintenance focus to specific group of voluntarily enrolled people
D)Services at a discount for companies under contract
Answer: A
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Chapter 3: Community-Based Nursing Practice
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) A nurse is working as a public health nurse. What will be the nurse's primary focus?
A) The individual as one member of a group
B) Individuals and families
C) Needs of a population
D) Health promotion
Answer: C
Q2) A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.)
A) A 47-year-old immigrant who speaks only Spanish
B) A 35-year-old living in own home
C) A 22-year-old pregnant woman
D) A 40-year-old schizophrenic
E) A 15-year-old rape victim
Answer: A, D, E
Q3) Population
A)Education level
B)Housing
C)Government
Answer: A
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Page 5
Chapter 4: Theoretical Foundations of Nursing Practice
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21 Flashcards
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Sample Questions
Q1) A nurse is caring for pediatric patients and using the developmental theory to plan nursing care. What is the focus of this nurse's care?
A) Humans have an orderly, predictive process of growth and development.
B) Humans respond to threats by adapting with growth and development.
C) Humans respond with cognitive principles for growth and development.
D) Humans have psychosocial domains to growth and development.
Q2) A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice?
A) Nursing theory can direct how a nurse uses the nursing process.
B) Nursing theory requires the nursing process to develop knowledge.
C) Nursing theory with the nursing process has a minor role in professional nursing.
D) Nursing theory combined with the nursing process is specific to certain ill patients.
Q3) Which action indicates the nurse is using the nursing process in patient care?
A) Generates nursing knowledge for use in nursing practice.
B) Conceptualizes an aspect of nursing to predict nursing care.
C) Develops nursing care as a specific, distinct phenomenon.
D) Delivers nursing care using a systematic approach.
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6
Chapter 5: Evidence-Based Practice
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23 Flashcards
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Sample Questions
Q1) After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee's next step?
A) Evaluate the changes in 1 month.
B) Implement the changes as a pilot study.
C) Wait a month before implementing the changes.
D) Communicate to staff the results of this project.
Q2) Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.)
A) Gives complete information about the purpose
B) Allows free choice to participate or withdraw
C) Understands how confidentiality is maintained
D) Identifies risks and benefits of participation
E) Ensures that subjects complete the study
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Chapter 6: Health and Wellness
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Sample Questions
Q1) The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Risk factor prevention
Q2) The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using?
A) Health belief model
B) Holistic health model
C) Health promotion model
D) Maslow's hierarchy of needs
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Chapter 7: Caring in Nursing Practice
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20 Verified Questions
20 Flashcards
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Sample Questions
Q1) Which action indicates a nurse is using caring touch with a patient?
A) Inserts a catheter
B) Rubs a patient's back
C) Prevents a patient from falling
D) Administers an injection
Q2) Which actions by the nurse should be done in order to get to know the patient?
(Select all that apply.)
A) Avoid assumptions
B) Focus on the patient
C) Engage in a caring relationship
D) Form the relationship very quickly
E) Not address spiritual or higher needs
Q3) The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, the patient says, "I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family." What should the nurse do \(\bold{first}\)?
A) Assure the patient that everything will be all right.
B) Tell the patient that there is no need to worry.
C) Listen to the patient's concerns and fears.
D) Inform the patient a social worker is available.
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Chapter 8: Caring for the Cancer Survivor
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18 Flashcards
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Sample Questions
Q1) When planning for cancer survivor care needs, which information should the nurse consider?
A) Survivorship care plans are reviewed with the patient at home.
B) All health care agencies provide survivorship care plans.
C) Some survivors are discharged with no survivor plan.
D) The plan does not deal with future cancer screenings.
Q2) A breast cancer survivor has chemotherapy-related cognitive impairment. Which area should the nurse assess?
A) Pain
B) Grief
C) Nightmares
D) Short-term memory
Q3) The nurse is caring for a young woman with breast cancer. The stress between the woman and spouse is obvious, as is anxiety among the children. What is the nurse's best action in this situation?
A) Help find or develop an educational program for the patient and spouse.
B) Encourage the patient to agree with the spouse.
C) Support the spouse, and explain that the spouse knows what is best.
D) Take the children away and recommend foster care.
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Page 10
Chapter 9: Cultural Awareness
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using?
A) Document staff satisfaction.
B) Focus on the family.
C) Implement change on a grand scale.
D) Reduce disparities.
Q2) Cultural encounters
A)In-depth self-examination of one's own background
B)Ability to assess factors that influence treatment and care
C)Sufficient comparative understanding of diverse groups
D)Motivation and commitment to continue learning about cultures
E)Cross-cultural interaction that develops communication skills
Q3) A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
A) How should your sickness be treated?
B) What do you call your problem?
C) How does this illness work inside your body?
D) What do you fear most about your sickness?
E) What name does it have?
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11
Chapter 10: Caring for Families
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20 Flashcards
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Sample Questions
Q1) A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.)
A) Developmental
B) Interactive
C) Integrity
D) Coping
E) Life
Q2) The nurse is providing discharge teaching for an older-adult patient who will need tube feedings at home. The spouse is the only source of care and states "I will not be able to perform the feedings due to arthritis." Which action should the nurse take?
A) Obtain extra feeding supplies.
B) Arrange for home care.
C) Cancel the discharge.
D) Teach the spouse.
Q3) Who is the "peacekeeper" of the family?
A)Intimacy expression
B)Social support
C)Roles
D)Family nurturing
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Page 12
Chapter 11: Developmental Theories
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21 Flashcards
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Sample Questions
Q1) The nurse is teaching the parents of a 3-year-old child who is at risk for developmental delays. Which instruction will the nurse include in the teaching plan?
A) Insist that your child discuss various points of view.
B) Encourage play as your child is exploring the surroundings.
C) Discuss world events with your child to foster language development.
D) Actively encourage your child to read lengthy books to foster reading abilities.
Q2) A patient follows all the instructions a nurse provides because the patient wants to be perceived as a "good" patient. How should the nurse interpret this information according to moral development?
A) The patient is in postformal thought reasoning.
B) The patient is in postconventional reasoning.
C) The patient is in preconventional reasoning.
D) The patient is in conventional reasoning.
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Chapter 12: Conception Through Adolescence
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) 8 to 10 months
A)Can place objects into containers
B)Pulls a string to obtain an object
C)Can hold a baby bottle
D)Holds rattle for short periods
E)Uses pincer grasp well
Q2) A mother has delivered a healthy newborn. Which action is priority?
A) Encourage close physical contact as soon as possible after birth.
B) Isolate the newborn in the nursery during the first hour after delivery.
C) Never leave the newborn alone with the mother during the first 8 hours after delivery.
D) Do not allow the newborn to remain with parents until the second hour after delivery.
Q3) A nurse is teaching the parents of a school-aged child about accidents most common in this age group. Which topic should the nurse address?
A) Falls
B) Fires
C) Drownings
D) Poisonings
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14
Chapter 13: Young and Middle Adults
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP?
A) White males
B) Pregnant females
C) Middle-aged adults
D) Nonsubstance abusers
Q2) During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding?
A) Assess the patient as thoroughly as possible.
B) Explain to the patient that breast tenderness is normal at her age.
C) Tell the patient that redness is not a cause for concern and is quite common.
D) Inform her that redness is the precursor to normal unilateral breast enlargement.
Q3) A nurse is planning care for a 30 year old. Which goal is priority?
A) Refine self-perception.
B) Master career plans.
C) Examine life goals.
D) Achieve intimacy.
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15
Chapter 14: Older Adult
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns?
A) "I'll take my time getting up from the bed or chair."
B) "I should dim the lighting outside to decrease the glare in my eyes."
C) "I'll leave my throw rugs in place so that my feet won't touch the cold tile."
D) "I should wear my favorite smooth bottom socks to protect my feet when walking around."
Q2) A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient?
A) This is multiple side effects experienced when taking medications.
B) This is many adverse drug effects reported to the pharmacy.
C) This is the multiple risks of medication effects due to aging.
D) This is concurrent use of many medications.
Q3) A nurse is caring for an older adult. Which goal is \(\bold{priority}\)?
A) Adjusting to career
B) Adjusting to divorce
C) Adjusting to retirement
D) Adjusting to grandchildren
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Page 16
Chapter 15: Critical Thinking in Nursing Practice
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following?
A) Fairness
B) Intellectual standards
C) Independent reasoning
D) Institutional practice guidelines
Q2) Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions?
A) Drawing on past clinical experiences to formulate standardized care plans
B) Relying on recall of information from past lectures and textbooks
C) Depending on the charge nurse to determine priorities of care
D) Using the nursing process
Q3) A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?
A) Examine the meaning of data.
B) Support findings and conclusions.
C) Review the effectiveness of nursing actions.
D) Search for links between the data and the nurse's assumptions.
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Chapter 16: Nursing Assessment
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25 Flashcards
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Sample Questions
Q1) The nurse is gathering data on a patient. Which data will the nurse report as objective data?
A) States "doesn't feel good"
B) Reports a headache
C) Respirations 16
D) Nauseated
Q2) The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
A) Completes a comprehensive database
B) Identifies pertinent nursing diagnoses
C) Intervenes based on priorities of patient care
D) Determines whether outcomes have been achieved
Q3) The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
A) Gordon's Functional Health Patterns
B) Activity-exercise pattern assessment
C) General to specific assessment
D) Problem-oriented assessment
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Chapter 17: Nursing Diagnosis
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.
1) Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma
2) Writes a diagnostic label of impaired gas exchange
3) Organizes data into meaningful clusters
4) Interprets information from patient
5) Writes an etiology
A) 1, 3, 4, 2, 5
B) 1, 3, 4, 5, 2
C) 1, 4, 3, 5, 2
D) 1, 4, 3, 2, 5
Q2) Which question would be \(\bold{most}\) appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
A) "What types of foods do you think caused your upset stomach?"
B) "How many bowel movements a day have you had?"
C) "Are you able to get to the bathroom in time?"
D) "What medications are you currently taking?"
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Page 19
Chapter 18: Planning Nursing Care
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Sample Questions
Q1) Which action indicates the nurse is using a PICOT question to improve care for a patient?
A) Practices nursing based on the evidence presented in court
B) Implements interventions based on scientific research
C) Uses standardized care plans for all patients.
D) Plans care based on tradition
Q2) A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
A) Risk for impaired skin integrity
B) Risk for infection
C) Spiritual distress
D) Reflex urinary incontinence
Q3) The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
A) Dependent
B) Independent
C) Interdependent
D) Physician-initiated
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Page 20
Chapter 19: Implementing Nursing Care
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Sample Questions
Q1) A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
A) Equipment
B) Safe environment
C) Confidence
D) Assistive personnel
E) Creativity
Q2) The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
A) Administer the acetaminophen.
B) Notify the health care provider to obtain a verbal order.
C) Direct the nursing assistive personnel to give the acetaminophen.
D) Perform a pain assessment only after administering the acetaminophen.
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Chapter 20: Evaluation
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Sample Questions
Q1) The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?
A) Wait and change the dressing at 1800 as ordered.
B) Revise the plan of care and change the dressing now.
C) Reassess the dressing and the wound in 2 hours.
D) Discontinue the plan of care for wound care.
Q2) The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
A) Ask the nursing assistive personnel if the wound looks better.
B) Document the progress of wound healing as "better" in the chart.
C) Measure the wound and observe for redness, swelling, or drainage.
D) Leave the dressing off the wound for easier access and more frequent assessments.
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Chapter 21: Managing Patient Care
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Sample Questions
Q1) A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms for equipment and supplies. Which type of skill does the nurse need?
A) Interpersonal communication
B) Clinical decision making
C) Organizational
D) Evaluation
Q2) High priority
A)Patient that needs to be turned to prevent pneumonia
B)Patient with acute asthma attack
C)Patient who will be discharged in 2 days who needs teaching
Q3) A nurse is prioritizing care for four patients. Which patient should the nurse see first?
A) A patient needing teaching about medications
B) A patient with a healed abdominal incision
C) A patient with a slight temperature
D) A patient with difficulty breathing
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23
Chapter 22: Ethics and Values
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Sample Questions
Q1) The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient?
A) Consequentialism
B) Autonomy
C) Fidelity
D) Justice
Q2) The nurse is caring for a dying patient. Which intervention is considered futile?
A) Giving pain medication for pain
B) Providing oral care every 5 hours
C) Administering the influenza vaccine
D) Supporting lower extremities with pillows
Q3) A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using?
A) Deontology
B) Ethics of care
C) Utilitarianism
D) Feminist ethics
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24
Chapter 23: Legal Implications in Nursing Practice
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Sample Questions
Q1) Abandonment
A)Nurse posts about patient's loud and unruly family members.
B)Nurse immediately applies restraints to make patient stay in bed.
C)Nurse leaves bed in high position, causing patient to fall and break hip.
D)Nurse states that she will wrap a bandage over patient's mouth if he won't be quiet.
E)Nurse applies abdominal bandage after refusal.
F)Nurse gets angry at patient and nurse leaves the hospital.
Q2) A home health nurse notices that a patient's preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to the home and talks with the patient, but the situation continues. Which immediate action by the nurse is mandated by law?
A) Contact the appropriate community child protection facility.
B) Tell the parents that the authorities will be contacted shortly.
C) Take pictures of the children to support the overt child abuse.
D) Discuss with both parents about the safety needs of their children.
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Chapter 24: Communication
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Sample Questions
Q1) A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive?
A) "I think you've had a hard day."
B) "I feel uncomfortable hearing that statement."
C) "I don't think you should say things like that. It is not right."
D) "I have been checking on you regularly. How can you say that?"
Q2) A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R?
A) Relax
B) Respect
C) Reminisce
D) Reassure
Q3) A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR?
A) Having chest pain
B) Pulse rate of 108
C) History of angina
D) Oxygen is needed
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Page 26
Chapter 25: Patient Education
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Sample Questions
Q1) A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback?
A) The nurse
B) The patient
C) The nurse teaching about healthy food choices
D) The patient stating that eating yogurt is better than eating cake
Q2) A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn?
A) "What do you want to know about strokes?"
B) "Please read this handout and tell me what it means."
C) "Do you feel strong enough to perform the tasks I will teach you?"
D) "On a scale from 1 to 10, tell me where you rank your desire to learn."
Q3) A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage?
A) Encourage independent learning.
B) Develop a problem-solving scenario.
C) Wrap a bandage around a stuffed animal's ear.
D) Use discussion throughout the teaching session.
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Chapter 26: Documentation and Informatics
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Sample Questions
Q1) A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?
A) A verbal report
B) An electronic record entry
C) A referral
D) An acuity rating
Q2) A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?
A) Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
B) Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints.
C) Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
D) Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.
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Chapter 27: Patient Safety and Quality
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Sample Questions
Q1) The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?
A) Risk for falls
B) Deficient knowledge
C) Risk for suffocation
D) Impaired physical mobility
Q2) The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
A) "The number for poison control is 800-222-1222."
B) "Never induce vomiting if my grandchild drinks bleach."
C) "I should call 911 if my grandchild loses consciousness."
D) "If my grandchild eats a plant, I should provide syrup of ipecac."
Q3) Which activity will cause the nurse to monitor for equipment-related accidents?
A) Uses a patient-controlled analgesic pump
B) Uses a computer-based documentation record
C) Uses a measuring device that measures urine
D) Uses a manual medication-dispensing device
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Page 29
Chapter 28: Immobility
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Sample Questions
Q1) A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
A) Patient is lying on side.
B) Patient is lying on back.
C) Patient is lying semiprone.
D) Patient is lying on abdomen.
Q2) The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling?
A) Use at least three people.
B) Have the patient reach for the opposite side rail when turning.
C) Move the top part of the patient's torso and then the bottom part.
D) Do not use pillows after turning.
Q3) Which goal is \(\bold{most}\) appropriate for a patient who has had a total hip replacement?
A) The patient will ambulate briskly on the treadmill by the time of discharge.
B) The patient will walk 100 feet using a walker by the time of discharge.
C) The nurse will assist the patient to ambulate in the hall 2 times a day.
D) The patient will ambulate by the time of discharge.
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Chapter 29: Infection Prevention and Control
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Q1) A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority?
A) "When was the last time you visited your primary health care provider?"
B) "Has this condition affected your eating habits in any way?"
C) "What medications are you currently taking?"
D) "Are you able to sleep at night?"
Q2) The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition?
A) "An infectious disease like pneumonia may not pose a risk to others."
B) "We need to isolate the patient in a private negative-pressure room."
C) "Clinical signs and symptoms are not present in pneumonia."
D) "The patient will not be able to return home."
Q3) Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response?
A) Vigorous range-of-motion exercises
B) Turn, cough, and deep breathe
C) Orient to date, time, and place
D) Rest, ice, and elevation
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Chapter 30: Vital Signs
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Sample Questions
Q1) The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
A) Non-Hispanic Caucasians
B) European Americans
C) African-Americans
D) Asian Americans
Q2) The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
A) 30 to 60
B) 22 to 28
C) 16 to 20
D) 10 to 15
Q3) Heatstroke
A)Patient's temperature is 113° F (45° C) with hot, dry skin.
B)Patient's blood pressure sitting is 130/60 and 110/40 standing.
C)Patient's pulse is 110 beats/min.
D)Patient's temperature is 93.2° F (34° C).
E)Patient's blood pressure went from 126/76 to 90/50.
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Page 32
Chapter 31: Health Assessment and Physical Examination
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Sample Questions
Q1) The nurse is preparing for a rectal examination of a nonambulatory male patient. In which position will the nurse place the patient?
A) Sims'
B) Knee-chest
C) Dorsal recumbent
D) Forward bending with flexed hips
Q2) The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal?
A) Pulse strength 3
B) 1+ pitting edema
C) Constricting pupils when directly illuminated
D) Hyperactive bowel sounds in all four quadrants
Q3) The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation?
A) Uses deep palpation posteriorly.
B) Lightly palpates each abdominal quadrant.
C) Percusses posteriorly the costovertebral angle at the scapular line.
D) Inspects abdomen for abnormal movement or shadows using indirect lighting.
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33
Chapter 32: Medication Administration
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Sample Questions
Q1) A nurse is administering oral medications to patients. Which action will the nurse take?
A) Remove the medication from the wrapper, and place it in a cup labeled with the patient's information.
B) Place all of the patient's medications in the same cup, except medications with assessments.
C) Crush enteric-coated medication, and place it in a medication cup with water.
D) Measure liquid medication by bringing liquid medication cup to eye level.
Q2) A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose?
A) 1
B) 2
C) 3
D) 4
Q3) A patient is taking 1 tablet of hydrocodone bitartrate 5 mg and acetaminophen 500 mg (Vicodin) every 4 hours. The patient is also taking 2 tablets of acetaminophen (Tylenol) 325 mg every 12 hours. How many grams of acetaminophen is the patient taking daily? Record your answer using one decimal place. ______ g
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Page 34
Chapter 33: Complementary and Alternative Therapies
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Sample Questions
Q1) A nurse is using the holistic approach to care. Which goal is the priority?
A) Integrate spiritual treatments.
B) Join physical care with a vegan diet.
C) Incorporate the mind-body-spirit connection.
D) Use complementary and alternative therapies.
Q2) A nurse is using caring-healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using?
A) Holistic nursing
B) Integrative nursing
C) Interprofessional nursing
D) Complementary and alternative nursing
Q3) Ginger
A)Elevated cholesterol levels
B)Nausea and vomiting
C)Benign prostatic hyperplasia
D)Skin inflammation
E)Mild anxiety
F)Unsafe and should not be used
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Chapter 34: Self-Concept
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Q1) A nurse is developing a drinking prevention presentation for adolescents. Which areas should the nurse include in the teaching session?
A) Stressful life events and scholarships
B) Very high self-esteem and work failure
C) Health problems and avoidance of conflict
D) Stress management and improving self-esteem
Q2) Low self-esteem
A)I am ugly with all these burn scars.
B)I am one with the universe.
C)I am good for nothing.
D)I am a good mother.
Q3) The nurse in an addictions clinic is working with a patient on priority setting before the patient's discharge from residential treatment. Which goal is a priority at this time?
A) Identifying local self-help groups before being discharged from the program
B) Stating a plan to never be tempted by illicit substances after discharge
C) Staying away from all triggers that cause substance abuse
D) Recognizing personal areas of weakness to grow stronger
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Chapter 35: Sexuality
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Sample Questions
Q1) A nurse is caring for a patient with dyspareunia. In which order will the nurse provide care, starting with the first step?
1) Determine which signs and symptoms of dyspareunia the patient has.
2) Mutually decide upon goals and objectives for dyspareunia.
3) Ask the patient if the dyspareunia is improving.
4) Develop a nursing diagnosis for the patient.
5) Use resources to help resolve the problem.
A) 5, 3, 1, 4, 2
B) 1, 4, 2, 5, 3
C) 3, 1, 4, 2, 5
D) 4, 2, 5, 3, 1
Q2) A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up?
A) "I have lost 12 pounds on this diet."
B) "I use the diaphragm to prevent pregnancy."
C) "I use a contraceptive cream with my diaphragm."
D) "I know this provides a barrier over the cervical opening."
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Chapter 36: Spiritual Health
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Sample Questions
Q1) The nurse is admitting a patient to the hospital. The patient is a very spiritual person but does not practice any specific religion. How will the nurse interpret this finding?
A) This indicates a strong religious affiliation.
B) This statement is contradictory.
C) This statement is reasonable.
D) This indicates a lack of hope.
Q2) The nurse is caring for a patient with a chronic illness who is having conflicts with beliefs. Which health care team member will the nurse ask to see this patient?
A) The clergy
B) A psychiatrist
C) A social worker
D) An occupational therapist
Q3) Islam
A)Nature controls life and health.
B)Organ transplantation or donation is not considered.
C)Observance of the Sabbath is important.
D)Past sins cause illness.
E)Nonhuman spirits invading the body cause illness.
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38
Chapter 37: The Experience of Loss, Death, and Grief
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Sample Questions
Q1) A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene?
A) Elevating head of bed
B) Making the patient eat
C) Giving mouth care every 2 to 4 hours
D) Keeping skin clean, dry, and moisturized
Q2) A patient has had two family members die during the past 2 days. Which coping strategy is \(\bold{most}\) appropriate for the nurse to suggest to the patient?
A) Writing in a journal
B) Drinking alcohol to go to sleep
C) Exercising vigorously rather than sleeping
D) Avoiding talking with friends and family members
Q3) A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient's family. What is the primary rationale for the nurse's action?
A) The nurse is not as knowledgeable as the coordinator.
B) The nurse is uncomfortable asking the family.
C) The nurse does not want to upset the family.
D) The nurse is following a federal law.
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Chapter 38: Stress and Coping
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Sample Questions
Q1) A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing?
A) Ego defense model
B) Immunity model
C) Neuman Systems Model
D) Pender's Health Promotion Model
Q2) A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse?
A) "Let's call 911 because this freshman student is suicidal."
B) "Give the freshman student this list of university and community resources."
C) "I recommend that you help the freshman student start packing bags to go home."
D) "You must make an appointment for the freshman student to obtain medications."
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Chapter 39: Activity and Exercise
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Sample Questions
Q1) The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. What is the rationale for the nurse's action?
A) Narrows the nurse's base of support.
B) Allows the nurse to bring feet closer together.
C) Prevents a shift in the nurse's base of support.
D) Shifts the nurse's center of gravity farther away from the base of support.
Q2) The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What will the nurse do?
A) Place a horseshoe-shaped base on the opposite side from the chair.
B) Remove straps before lowering the patient to the chair.
C) Hook longer straps to the bottom of the sling.
D) Attach short straps to the bottom of the sling.
Q3) The nurse is caring for a patient with inner ear problems. Which goal is the priority?
A) Maintain balance.
B) Maintain proprioception.
C) Maintain muscle strength.
D) Maintain body alignment.
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Chapter 40: Hygiene
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Sample Questions
Q1) The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do?
A) Rinse thoroughly.
B) Allow the skin to air-dry.
C) Do not use a bath towel.
D) Dry the skin with a towel.
Q2) Which patients will the nurse determine are in need of perineal care? (Select all that apply.)
A) A patient with rectal and genital surgical dressings
B) A patient with urinary and fecal incontinence
C) A circumcised male who is ambulatory
D) A patient who has an indwelling catheter
E) A bariatric patient
Q3) A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?
A) A patient who is afebrile
B) A patient who is diaphoretic
C) A patient with strong pedal pulses
D) A patient with adequate skin turgor
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Page 42
Chapter 41: Oxygenation
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Sample Questions
Q1) The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse \(\bold{most}\) likely expect?
A) Increased preload
B) Increased heart rate
C) Decreased afterload
D) Decreased tissue perfusion
Q2) The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
A) Elevated blood pressure
B) Increased pulse rate
C) Restlessness
D) Cyanosis
Q3) A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest?
A) A cup of nonfat yogurt with granola and a handful of dried apricots
B) Whole wheat toast with butter and a side of bacon
C) A bowl of cereal with whole milk and a banana
D) Omelet with sausage, cheese, and onions
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Chapter 42: Fluid, Electrolyte, and Acid-Base Balance
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Sample Questions
Q1) A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?
A) Preps skin with povidone-iodine solution.
B) Suggests the femoral vein for insertion site.
C) Applies double gloving without hand hygiene.
D) Uses chlorhexidine skin antisepsis prior to insertion.
Q2) A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?
A) Blood pressure 110/60
B) Temperature 101.3° F
C) Poor skin turgor and pallor
D) Heart rate of 100 beats/min
Q3) The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern?
A) Sodium of 145 mEq/L
B) Calcium of 15.5 mg/dL
C) Potassium of 3.5 mEq/L
D) Chloride of 100 mEq/L
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Page 44
Chapter 43: Sleep
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Sample Questions
Q1) The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?
A) "I can't wait to get the baby home to play with the brothers and sisters."
B) "I will ask my mom to come after the first week, when the baby is more alert."
C) "I can get the baby on a sleeping schedule the first week while my mom is here."
D) "I won't be able to nap during the day because the baby will be awake."
Q2) The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding?
A) The patient misses family and is lonely.
B) The patient was waiting to talk with the nurse.
C) The patient has been kept up with the noise on the unit.
D) The patient's sleep-wake cycle preference is late evening.
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Chapter 44: Pain Management
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Sample Questions
Q1) A nurse is caring for a group of patients. Which patient will the nurse see first?
A) A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg
B) A patient lying very still in bed who reports no pain but is pale with warm, dry skin
C) A patient with severe pain who is nauseated and feels like he or she is about to vomit
D) A patient writhing and moaning from abdominal pain after abdominal surgery
Q2) A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time?
A) Superficial pain
B) Idiopathic pain
C) Chronic pain
D) Visceral pain
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46
Chapter 45: Nutrition
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Sample Questions
Q1) A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include?
A) Have values for protein, vitamins, and minerals
B) Are based on percentages of fat, cholesterol, and fiber
C) Have replaced recommended daily allowances (RDAs)
D) Are used to develop diets for chronic illnesses requiring 1800 cal/day
Q2) A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?
A) Custard
B) Frozen yogurt
C) Pureed vegetables
D) Mashed potatoes and gravy
Q3) The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
A) 10-mL Luer-Lok syringe
B) Asepto syringe
C) Sterile gloves
D) Double gloves
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Chapter 46: Urinary Elimination
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Sample Questions
Q1) To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?
A) Cleanse the urethral meatus from the area of most contamination to least.
B) Initiate the first part of the urine stream directly into the collection cup.
C) Drink fluids 5 minutes before collecting the urine specimen.
D) Hold the labia apart while voiding into the specimen cup.
Q2) A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?
A) Protein level of 2 mg/100 mL
B) Urine output of 80 mL/hr
C) Specific gravity of 1.036
D) pH of 6.4
Q3) A nurse is caring for a male patient with urinary retention. Which action should the nurse take \(\bold{first}\)?
A) Limit fluid intake.
B) Insert a urinary catheter.
C) Assist to a standing position.
D) Ask for a diuretic medication.
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Chapter 47: Bowel Elimination
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Q1) The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
A) Ultrasound
B) Barium enema
C) Endoscopy
D) Anorectal manometry
Q2) The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation?
A) The patient reports eliminating a soft, formed stool.
B) The patient has quit taking opioid pain medication.
C) The patient's lower left quadrant is tender to the touch.
D) The nurse hears bowel sounds in all four quadrants.
Q3) A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool?
A) Bright red blood
B) Dark black blood
C) Microscopic
D) Mucoid
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Chapter 48: Skin Integrity and Wound Care
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Q1) The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?
A) Turn on the television.
B) Explain the procedure.
C) Tell the patient "Close your eyes."
D) Ask the family to leave the room.
Q2) The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?
A) Monitor vital signs every 15 minutes.
B) Check pulses in the right foot.
C) Keep the leg dependent.
D) Apply ice.
Q3) The nurse is caring for a group of patients. Which patient will the nurse see \(\bold{first}\)?
A) A patient with a Stage IV pressure ulcer
B) A patient with a Braden Scale score of 18
C) A patient with appendicitis using a heating pad
D) A patient with an incision that is approximated
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Chapter 49: Sensory Alterations
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Sample Questions
Q1) A nurse is working to prevent blindness. Which preventive action is a \(\bold{priority}\)?
A) Screen young adults early for visual impairments.
B) Include rubella and syphilis screening in the preconception care plan.
C) Instruct parents to report reduced eye contact from their child immediately.
D) Administer eye prophylactic antibiotics to newborns within 24 hours after birth.
Q2) The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?
A) Asks the nurse to test the temperature of the water before entering the bath.
B) Places colored stickers on faucet handles to indicate temperature.
C) Replaces all lace-up shoes with Velcro straps for ease.
D) Uses a heating pad on a low setting to keep warm.
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Chapter 50: Care of Surgical Patients
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Sample Questions
Q1) The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be \(\bold{most}\) important to include in this patient's preparation?
A) Place the patient in a clean surgical gown.
B) Ask the patient to remove all hairpins and cosmetics.
C) Ascertain that the surgical site has been correctly marked.
D) Determine where the family will be located during the procedure.
Q2) During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate \(\bold{next}\)?
A) A delay in or cancellation of surgery
B) Questions regarding components of the coffee
C) Additional questions about why the patient had coffee
D) Instructions to determine what education was provided in the preoperative visit
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