Introduction to Nursing Pre-Test
Questions
Course Introduction
Introduction to Nursing offers students a foundational understanding of the nursing profession, including its history, core values, and evolving roles within healthcare systems. The course explores essential concepts such as patient-centered care, communication, ethical and legal considerations, and the use of evidence-based practice. Students will also examine various healthcare settings, interprofessional collaboration, and the importance of cultural competence. By the end of the course, students will have a broad perspective on the diverse responsibilities of nurses and the impact of nursing on patient outcomes and community health.
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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Sample Questions
Q1) The nurse is caring for a patient who suddenly becomes acutely short of breath.The nurse elevates the head of the patient's bed,checks the patient's pulse oximetry,and administers 2 L of oxygen before notifying the patient's physician.Which term best describes the actions of the nurse?
A) Accountability
B) Autonomy
C) Licensure
D) Certification
Answer: B
Q2) 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
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Chapter 2: Health and Wellness
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Sample Questions
Q1) Which assessment finding is a modifiable risk factor for disease?
A) The patient has a family history of breast cancer.
B) The patient smokes two packs of cigarettes every day.
C) The patient was born with a congenital heart defect.
D) The patient's childhood home contained high levels of radon.
Answer: B
Q2) Using the Health Promotion Model while rendering care enables a nurse to do which of the following:
A) Help the patient attain better health
B) Detect the presence of illness
C) Promote health behaviors in a patient
D) Assess a family's response to illness
E) Stimulate relational transcendence
Answer: A,C
Q3) Which action by the patient reflects a cultural influence on health practices?
A) The patient uses seaside purification rituals to ease arthritis pain.
B) The patient refuses to take blood pressure medicine due to the side effects.
C) The patient has annual mammograms to screen for breast cancer.
D) The patient avoids eating red meat due to a family history of heart disease.
Answer: A
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Chapter 3: The Health Care Delivery System
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Sample Questions
Q1) Which is an example of health care disparity?
A) The physician treats cardiac patients with insurance more aggressively than noninsured patients.
B) The patient takes longer to recover from surgery due to a history of aggressive rheumatoid arthritis.
C) The nurse prioritizes care so that additional time is spent with patients who require more intensive interventions.
D) The registered nurse is able perform more advanced interventions than the licensed practical nurse.
Answer: A
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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Page 5
Chapter 4: Community-Based Nursing Practice
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Sample Questions
Q1) 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.
Q2) The nurse identified the source of food poisoning as a local restaurant and ensured that no further patrons became ill.Which community health nursing role was demonstrated by these actions?
A) Caregiver
B) Educator
C) Epidemiologist
D) Case manager
Q3) 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
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Chapter 5: Legal Principles in Nursing
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Sample Questions
Q1) The nurse is at the shopping mall when the sales clerk collapses in cardiac arrest.The nurse assists the victim and performs CPR until the paramedics arrive.Which action by the nurse could lead to a malpractice suit even though the state has a Good Samaritan law?
A) The nurse went to visit the victim in the hospital the following day.
B) The nurse accepted a small gift from the store in appreciation for her help.
C) The nurse sent a bill to the victim to request payment for services rendered.
D) The nurse provided both chest compressions and rescue breathing for the victim.
Q2) The nurse is directed to take an unsafe patient assignment.What is the most appropriate first action of the nurse?
A) Contact the State Board of Nursing.
B) Contact the nursing supervisor on duty.
C) Contact the hospital administrator on call.
D) Refuse to accept the assignment and leave.
Q3) Which situation will enable a nurse to use restraints?
A) To punish a patient
B) To ensure staff convenience
C) To ensure the patient's safety
D) To retaliate against poor behavior
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Page 7
Chapter 6: Ethics
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Sample Questions
Q1) Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance?
A) Autonomy
B) Justice
C) Fidelity
D) Nonmaleficence
Q2) Which is the appropriate action for the nurse manager when a nurse refuses to assist with an abortion due to personal ethical beliefs?
A) Assign the nurse to care for other patients.
B) Counsel the nurse about professional responsibility.
C) Report the nurse's refusal to the State Board of Nursing.
D) Inform the nurse that the refusal will lead to termination.
Q3) Which ethical principle is violated when the patient is not told the truth about the medical diagnosis and therefore is not able to decide on the course of treatment?
A) Autonomy
B) Justice
C) Fidelity
D) Nonmaleficence
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8
Chapter 7: Evidence-Based Practice
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Sample Questions
Q1) After the implementation of a new protocol,the nursing unit had a central line site infection rate of 3%.This rate is well below the agency's expected standard of 5%.Which term best describes this evaluation?
A) Research bias
B) Control group
C) Benchmarking
D) Descriptive research
Q2) After careful research,the nursing staff have implemented a new fall prevention protocol on the unit.Which is the logical next step of the staff?
A) Review the available literature.
B) Encourage abstract thinking.
C) Measure the patient fall rate.
D) Execute the theoretical framework.
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9
Chapter 8: Critical Thinking
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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) The nurse becomes very skilled at feeding patients with dysphagia after working on a rehabilitation unit for many years.Which component of critical thinking allows the nurse to function at this high level of practice?
A) Integrity
B) Experience
C) Risk taking
D) Responsibility
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Page 10
Chapter 9: Nursing Process
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Sample Questions
Q1) Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient?
A) Calculating the patient's fluid intake and output at the end of every shift
B) Encouraging fluid and fiber intake to prevent constipation from pain medications
C) Administering a mild stool softener daily to prevent constipation
D) Assessing the patient's abdomen for distention,bowel sounds,and passage of flatus
E) Reinserting of the patient's urinary catheter for retention of greater than 500 mL of urine
Q2) The nurse is preparing to insert an indwelling urinary catheter into the patient.Where will the nurse check to ensure that the packaging is sterile,intact,and not past the expiration date?
A) In the clean utility room immediately after removing the package from the shelf
B) At the patient's bedside after verifying the patient's name and birthdate
C) At the nurses' station after verifying the physician's order for the procedure
D) At the patient's bedside after performing careful perineal care for the patient
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11
Chapter 10: Informatics and Documentation
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Sample Questions
Q1) The nurse is entering a note in the patient's medical record using the SOAP format.Which statement belongs in the Assessment section?
A) The patient stated "I started feeling short of breath after smelling strong perfume."
B) The patient is using accessory muscles and has wheezes in all lung fields.
C) Ineffective airway clearance related to exposure to environmental allergen.
D) Monitor pulse oximetry and administer nebulized bronchodilators.
Q2) The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient's chart demonstrates that the teaching was successful?
A) The patient correctly self-administered his next scheduled dose of insulin.
B) The patient denied having any questions or concerns about the procedure.
C) Additional written instructions about how to perform the injection was provided.
D) The patient identified the steps and equipment used for the injection.
Q3) Which is the primary purpose of a patient's medical record?
A) To invoice the nursing services for hospital reimbursement
B) To protect the patient in case of a malpractice suit
C) To facilitate professional communication and safe health care
D) To contribute to a worldwide databank for trends in health care
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12
Chapter 11: Communication
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Sample
Questions
Q1) The patient reports using history of ibuprofen for arthritis pain after telling the nurse about a severe allergy to NSAID medications.The nurse asks the patient to further explain the allergy and use of ibuprofen.Which action is demonstrated by the nurse?
A) Focusing
B) Clarifying
C) Summarizing
D) Sharing observations
Q2) When the nurse takes the patient's hand,the patient quickly pulls it back.How will the nurse interpret this patient's behavior?
A) The patient is unable to express feelings.
B) The patient is uncomfortable with being touched.
C) The patient has impaired social skills with others.
D) The patient has difficulty with nonverbal communication.
Q3) Which behavior best demonstrates active listening by the nurse?
A) Keeping arms crossed
B) Sitting facing the patient
C) Standing facing the patient
D) Leaning away from the patient
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13
Chapter 12: Patient Education
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Sample Questions
Q1) The nurse is caring for a patient who had a stroke because of lack of understanding about how to take the prescribed blood pressure medication.Which is the priority nursing diagnosis for this patient?
A) Noncompliance related to patient's refusal to follow the prescribed treatment regimen
B) Ineffective therapeutic regimen management related to lack of understanding about prescribed medications
C) Ineffective health maintenance related to lack of expressed interest in taking prescribed medications correctly
D) Readiness for enhanced decision making related to desire to choose the course of action that best meets health needs
Q2) The nurse educator uses manikins to teach patients how to correctly perform CPR on a victim of cardiac arrest.Which teaching technique is used by the nurse?
A) Analogy
B) Role play
C) Simulation
D) Enunciation
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Chapter 13: Managing Patient Care
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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) A nurse is using SBAR.Which information will the nurse report for the "B"?
A) The patient has a fractured right leg with a cast that was applied 2 days ago.
B) The patient's toes are cool and pale and the patient reports that the foot feels numb.
C) The patient is reporting severe pain 1 hour after pain medication was given.
D) The nurse requests that the primary health care provider examines the patient.
Q3) Which action by the nurse demonstrates the concept of nurse autonomy?
A) The nurse braids the patient's long hair to prevent tangles.
B) The nurse directs the nursing assistant to obtain the patient's weight.
C) The nurse counts the patient's pulse before administering digoxin.
D) The nurse checks the policy manual before changing the central line dressing.
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Chapter 14: Infection Prevention and Control
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Sample Questions
Q1) Which mode of transmission is demonstrated when the nurse spreads an infection with the hands after neglecting to perform hand hygiene?
A) Direct
B) Automatic
C) Spontaneous
D) Uninterrupted
Q2) Which action by the nurse demonstrates correct hand-hygiene practice?
A) Letting hand sanitizer dry for a full minute before applying gloves
B) Keeping hands and wrists above the level of the elbows while washing
C) Scrubbing hands and nails for at least 15 seconds using plenty of soap
D) Making sure that the water is hot before wetting the hands and wrists
Q3) Which action of the nurse will minimize the onset and spread of infection?
A) Insert indwelling urinary catheters to prevent incontinence.
B) Use aseptic technique when providing mouth care to the patient.
C) Keep the patient's mucus membranes dry to prevent maceration.
D) Use masks and gowns sparingly to reduce the patient's sense of isolation.
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Chapter 15: Vital Signs
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Sample Questions
Q1) The nurse applies a cooling blanket to a patient with a dangerously high fever.Which is the most accurate method to monitor the patient's temperature?
A) Taping a digital thermometer probe to the skin of the patient's axilla to download the temperature readings directly to the patient's chart
B) Checking the patient's oral temperature every 15 minutes while the cooling blanket is in place until the patient is afebrile
C) Applying a temperature-sensitive patch to the patient's forehead to monitor the temperature of the patient's skin surface
D) Inserting a small rectal thermometer probe for continuous core temperature measurement
Q2) Which technique will provide the most accurate measurement of the patient's core temperature?
A) Orally
B) Rectally
C) Axillary
D) Forehead
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Chapter 16: Health Assessment and Physical Examination
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Sample Questions
Q1) Which assessment finding will the nurse expect to note during physical examination of the patient with a cast on the lower left leg?
A) The patient's left foot has a musty,fetid smell
B) The patient's left foot has 3+ pitting edema and pallor.
C) The temperature of the left foot is the same as the right foot.
D) The patient's left foot is cool with thin,shiny skin.
Q2) The patient has red,itchy eyes with thick yellow drainage.What will the nurse plan to do as a result of this assessment finding?
A) Apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient.
B) Assess the patient's visual fields and compare results from each of the patient's eyes.
C) Ask the patient about any history of hyperthyroid disease,hypertension,or Addison's disease.
D) Instruct the patient not to pluck or wax the eyebrows until the eye infection symptoms have resolved completely.
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18
Chapter 17: Administering Medications
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Sample Questions
Q1) The nurse notes that the patient is to receive diprivan to treat the patient's vaginal yeast infection.What is the appropriate action of the nurse?
A) Immediately contact the prescriber to clarify the order.
B) Check with the pharmacy to confirm that the order was received.
C) Ensure that the order appears on the patient's medication sheet.
D) Confirm that the dosage is appropriate for the patient's body weight.
Q2) The nurse is to administer acetaminophen to an unconscious patient.Which medication formulations may safely be administered to the patient?
A) Acetaminophen tablet
B) Acetaminophen elixir
C) Acetaminophen IV
D) Acetaminophen suppository
E) Acetaminophen suspension
Q3) Which medication is to be administered immediately to the patient?
A) Acetaminophen 325 mg PO prn
B) Insulin aspart 12 units subQ AC
C) Metronidazole 500 mg PO BID
D) Nitroglycerin 0.4 mg sublingual STAT
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19
Chapter 18: Fluid, Electrolyte, and Acid-Base Balances
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Sample Questions
Q1) Which intake and output measurement can the nurse delegate to the nursing assistant?
A) Oral fluid intake
B) Nasogastric tube intake
C) Wound drainage output
D) Intravenous fluid intake
Q2) The patient reports muscle weakness after taking prescribed furosemide daily.Which laboratory finding will the nurse expect to see in the patient's chart?
A) Chloride 84 mEq/L
B) Sodium 124 mEq/L
C) Calcium 12.6 mg/dL
D) Potassium 2.8 mEq/L
Q3) The patient receives an infusion of albumin to pull water from the tissues into the bloodstream.Which process is demonstrated by this treatment?
A) Diffusion
B) Osmosis
C) Filtration
D) Clarification
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Chapter 19: Complementary and Alternative Therapies
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Sample Questions
Q1) Which nursing diagnosis is a priority for a patient using tai chi to relieve arthritis pain?
A) Risk for falls
B) Sleep deprivation
C) Risk for contamination
D) Ineffective individual coping
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) Which activity best demonstrates the caring role of a nurse?
A) Assessing the patient's entire health history
B) Administering antibiotic medications on time
C) Inserting a urinary catheter using aseptic technique
D) Maintaining privacy when conversing with the patient
Q2) 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.
Q3) The nurse teaches the patient's family members how to assist with colostomy care.Which caring behavior is demonstrated by the nurse?
A) Providing presence
B) Meeting affiliation needs
C) Meeting basic human needs
D) Appreciating unique meanings
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Chapter 21: Cultural Awareness
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Sample Questions
Q1) Which intervention is most appropriate for the patient with the nursing diagnosis Noncompliance related to the patient's preference for cultural therapies rather than prescription medications?
A) Create a clearly written medication schedule and instruction list with dosages and side effects.
B) Describe the negative health outcomes that will be experienced if the cultural therapies are continued.
C) Attempt to coordinate the patient's cultural therapies with the prescribed treatments.
D) Inform the patient that the hospital will not be able to continue providing care if the noncompliant behavior continues.
Q2) 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
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Chapter 22: Spiritual Health
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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) 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.
Q3) A patient refuses to remove a religious headscarf when being bathed.Which is appropriate action of the nurse?
A) Remove the headscarf because its presence hinders hygiene.
B) Respect the patient's wishes and work around the headscarf.
C) Explain to the patient that the headscarf has no real spiritual value.
D) Identify the refusal to remove the headscarf as a sign of spiritual distress.
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Chapter 23: Growth and Development
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Sample Questions
Q1) Which technique is best to calm a preschooler's fears before auscultating bowel sounds?
A) Reassure the child that listening to bowel sounds will not hurt in the least.
B) Allow the child to use the stethoscope to listen to a teddy bear's abdomen.
C) Explain how a stethoscope is used to listen to the functioning of the bowel.
D) Seat the child in the parent's lap and have the parent hold the child's hands.
Q2) The adolescent with a BMI of 18.5 feels overweight after seeing excessively slender actresses on TV and in the movies.Which nursing diagnosis is appropriate for this adolescent?
A) Decisional conflict related to how much weight should be lost to look pretty
B) Defensive coping related to denial of imbalanced weight to height proportion
C) Powerlessness related to perception that weight loss is needed to gain friends
D) Disturbed body image related to cultural perception of ideal body proportions
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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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 patient tells the nurse that the spouse is only interested in sexual activity when inflicting physical pain on the patient.Which is the priority nursing diagnosis for the patient?
A) Activity intolerance related to inability to fulfill spouse's sexual needs
B) Ineffective sexuality pattern related to differing sexual activity expectations
C) Risk for injury related to physical abuse from spouse during sexual activity
D) Risk for compromised human dignity related to spouse's demeaning actions
Q3) Which sexual education concept is appropriate for a 3-year-old child?
A) Little boys have a penis while little girls do not.
B) Sometimes white liquid comes out of the penis.
C) The penis gets bigger when it is ready to make a baby.
D) The penis goes into the woman's body to make a baby.
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26
Chapter 25: Family Dynamics
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Q1) Which assessments are appropriate when caring for a stroke patient living with a spouse and two children using the family as context?
A) Assess the stroke patient for self-care abilities.
B) Assess the ability of the spouse and two children to help feed and bathe the patient.
C) Assess communication processes among family members.
D) Assess the spouse's ability to emotionally comfort the patient.
E) Assess how the spouse is dealing with parenting issues of the two children.
Q2) Which interventions are appropriate for the nursing diagnosis risk for caregiver role strain related to inadequate support for caregiver?
A) Monitor the caregiver for signs of physical and/or emotional fatigue.
B) Observe both the patient and caregiver for any signs of neglect or abuse.
C) Encourage placement of the patient in a residential skilled nursing facility.
D) Help the caregiver to schedule time to meet needs for rest and personal care.
E) Identify resources for the caregiver in the family,church,and local community.
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Chapter 26: Stress and Coping
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Sample Questions
Q1) A patient telephones a crisis intervention hotline.The nurse assigned to this center assesses that the patient is experiencing a crisis.What is the most appropriate action for the nurse to take?
A) Define the problem at hand and ensure that the patient is safe.
B) Take control of the situation and tell the patient what needs to be done.
C) Ask the patient how he would like to handle the crisis and follow through.
D) Ask the patient to list all of his problems and prioritize which to deal with first.
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
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Chapter 27: Loss and Grief
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Sample Questions
Q1) Which of the following is true for a patient to receive home hospice care?
A) Caregiver support is available during normal business hours.
B) A primary caregiver must be living in the home with the patient.
C) If the patient goes to the hospital,all prehospital orders are canceled.
D) In the hospital,the home hospice care person must provide personal care.
Q2) The patient leaves behind nightly dinners with the family,babysitting assistance from friends,and the warmth of the local church community when moving across the country.Which type of loss was experienced by the patient?
A) Conditional
B) Perceived
C) Situational
D) Maturational
Q3) The nurse is caring for a patient who has just passed away.Which is the priority action of the nurse?
A) Ask the family to leave the room so that postmortem care can be provided.
B) Have the patient's family members sign consent forms for organ donation.
C) Remove all drainage tubes and IV lines in case an autopsy is to be performed.
D) Provide postmortem care in a manner consistent with religious or cultural beliefs.
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Chapter 28: Exercise and Activity
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Q1) Which assessment finding is expected for a patient who suffered a left-sided thrombotic stroke?
A) Bilateral footdrop
B) Fine tremors of the hands
C) Curvature of the lumbar spine
D) Weakness of the right arm and leg
Q2) Which action by the nurse demonstrates correct use of a gait belt?
A) The patient holds on to the gait belt during transfer to the chair.
B) The gait belt is used to lift the patient whose legs are too weak to stand.
C) The gait belt is tied loosely around the patient's waist just above the hips.
D) The nurse follows behind the patient holding onto the gait belt during ambulation.
Q3) Which is the safest method for a patient with a left leg injury to navigate up a set of stairs?
A) Sit down on the stairs and use the right leg to lift the body up each step.
B) Use a gait belt,the left handrail,and a crutch under the right arm.
C) Securely place both crutches on the next step and swing the body upward.
D) Bend the knee of the right leg when lifting the left leg up to the next step.
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Chapter 29: Immobility
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Q1) Which position should be avoided for a patient who is unconscious?
A) Semi-Fowler's
B) Sims'
C) Supine
D) Lateral
Q2) Which outcome is appropriate for the patient with the nursing diagnosis ineffective protection related to use of anticoagulant medications?
A) The patient will remain free of signs or symptoms of infection.
B) The patient will have a soft formed stool at least every other day.
C) The patient will verbalize precautions to take in order to prevent bleeding.
D) The patient will have clear lung sounds bilaterally and no sign of cyanosis.
Q3) Which is the best position for a patient who is acutely short of breath?
A) Lateral
B) Prone
C) High-Fowler's
D) Sims'
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Chapter 30: Safety
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Q1) Which nursing diagnosis is the highest priority for a sexually active adolescent?
A) Risk for infection related to participation in unprotected sexual activity
B) Disturbed body image related to depersonalization and fear of rejection
C) Spiritual distress related to inability to integrate sexuality with church teaching
D) Risk for compromised human dignity related to loss of respect from peer group
Q2) Which is the appropriate disposal method for used insulin syringes at home?
A) Engage the safety cap over the needle and place it in the recycle bin.
B) Remove the needle from the syringe and then flush it down the toilet.
C) Place the used syringes in a sharps container that is mailed back for destruction.
D) Place the used needles in a plastic can that is placed in the center of the trash bin.
Q3) Which assessment finding leads the nurse to add ineffective protection to the patient's care plan?
A) The patient follows a gluten-free,low-sodium,antiinflammatory diet.
B) The patient has not received immunizations against influenza or pneumonia.
C) The patient recently divorced after being in an unhappy marriage for 4 years.
D) The patient takes levothyroxine daily to treat hypothyroid disease.
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32
Chapter 31: Hygiene
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Q1) Which bath time assessment of the diabetic patient is most important?
A) Presence of fingernail clubbing
B) Presence of any petechiae or bruises
C) Presence of abdominal rebound tenderness
D) Presence of pedal pulses and intact sensation
Q2) Which assessment finding leads the nurse to lightly wash the patient's legs rather than using long,firm strokes?
A) The patient's platelet count was 40,000/mm<sup>3</sup> this morning.
B) The patient is taking ciprofloxacin for a bladder infection.
C) The patient is taking levothyroxine for hypothyroidism.
D) The patient's urinalysis was positive for protein and white blood cells.
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 is expected for a patient with impaired lung compliance?
A) The patient's respirations are very deep and rapid.
B) The patient reports sharp left-sided rib and chest pain.
C) The patient struggles to take a deep breath and exhale.
D) The patient's breathing pattern is irregular with periods of apnea.
Q2) Which assessment finding indicates that the patient is experiencing hypercapnia during sleep?
A) The patient sleeps in the lateral position with at least two pillows.
B) The patient wakes up feeling hung over after consuming no alcohol.
C) The patient has difficulty falling asleep and wakes up early each morning.
D) The patient works the night shift and is unable to sleep well during the day.
Q3) The patient's tuberculosis test appears red and flat after the injection 48 hours ago.Which is the appropriate action of the nurse?
A) Repeat the tuberculosis test because the results are inconclusive.
B) Measure the reddened area in millimeters and document the result.
C) Document the results as a negative reaction to the tuberculosis test.
D) Contact the state health department about the patient's positive test.
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Page 34
Chapter 33: Sleep
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Q1) Why is it important for a postoperative patient to get enough sleep after being discharged from the hospital?
A) Sleep restores biological processes.
B) Sleep stimulates appetite on waking.
C) Sleep causes a mental and physiological calm.
D) Sleep produces dreams that decrease epinephrine.
Q2) 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
Q3) A new mother is exhausted because her 4-week-old infant is unable to sleep through the night.Which is the best recommendation of the nurse?
A) "Try to sleep when your baby is sleeping."
B) "Try keeping the room warm during the night."
C) "Try not to let your baby nap during the day."
D) "Try laying the baby on his stomach at night."
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Chapter 34: Pain Management
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Q1) Which is the appropriate goal for a nonverbal,confused patient with the nursing diagnosis chronic pain related to widespread tissue damage?
A) The patient's pain will be reduced to a minimal level.
B) The nurse will assess the patient's pain every 2 hours.
C) The patient will not demonstrate moaning or grimacing.
D) The patient will use a 0-to-10 pain scale to identify pain levels.
Q2) Which nonpharmacological pain-relief technique is appropriate for a confused,nonverbal patient?
A) Tai chi
B) Biofeedback
C) Massage therapy
D) Guided imagery
Q3) Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)?
A) "Wait until the pain becomes severe before pushing the PCA button."
B) "The PCA will deliver medication through the IV until the pain is all gone."
C) "You or a designated family member are the only one who gets to push the PCA button-nobody else may do so."
D) "The PCA will give additional pain medication whenever the button is pushed."
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Page 36
Chapter 35: Nutrition
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Q1) 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
Q2) Which nursing diagnosis is the highest priority for a patient who had the large intestine removed?
A) Risk for deficient fluid volume related to excessive fluid loss in stool
B) Risk for compromised human dignity related to stigma from ileostomy
C) Bathing/hygiene self-care deficit related to presence of ileostomy bag
D) Social isolation related to perceived offensive odor from ileostomy bag
Q3) Which is the highest priority nursing diagnosis for a patient with dysphagia following a stroke?
A) Risk for aspiration related to inability to ingest food and fluids safely
B) Feeding self-care deficit related to neuromuscular impairment and weakness
C) Risk for constipation related to intake of low-fiber foods and thickened liquids
D) Imbalanced nutrition: less than body requirements related to swallowing difficulty
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Page 37
Chapter 36: Urinary Elimination
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Q1) 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.
Q2) Which assessment finding supports the nursing diagnosis overflow urinary incontinence related to urethral obstruction?
A) Advanced dementia prevents the patient from indicating need to urinate
B) Postvoid residual of 900 mL after incontinence of small amounts of urine
C) Leakage of urine around the urostomy appliance leading to skin irritation
D) Incontinence of large amounts of urine every time the patient coughs or sneezes
Q3) The nurse is caring for a patient who feels the urge to urinate but is unable to void.Which is the appropriate action of the nurse?
A) Scan the patient's bladder to see how much urine is present.
B) Obtain a urine sample for urinalysis,culture,and sensitivity.
C) Perform a focused physical assessment of the patient's perineum.
D) Help the patient to utilize absorbent undergarments for protection.
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38
Chapter 37: Bowel Elimination
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Q1) The nurse is caring for a patient with painful hemorrhoids.Which is the appropriate recommendation of the nurse to prevent their recurrence?
A) Stool softener daily at bedtime
B) Low-carbohydrate ketogenic diet
C) Periodic bowel cleansing programs
D) High-fiber diet with plenty of liquids
Q2) 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
Q3) Which assessment finding by the nurse indicates that the patient's colonoscopy preparation is complete?
A) The patient has stopped vomiting.
B) The patient's stool is watery clear yellow.
C) The patient had a large soft formed stool.
D) The patient's abdomen is softly distended.
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Chapter 38: Skin Integrity and Wound Care
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Q1) Which patient would benefit from soaking in a sitz bath?
A) A patient with an abscessed tooth
B) A patient with a fractured right arm
C) A patient with painful back muscle spasms
D) A patient who just had hemorrhoid surgery
Q2) On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?
A) Mobility
B) Nutrition
C) Infection
D) Activity
E) Friction
Q3) The nurse is caring for a patient with a necrotic wound.Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?
A) Transparent film
B) Hydrogel dressing
C) Dry nonstick gauze
D) Hydrocolloid dressing
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Page 40
Chapter 39: Sensory Alterations
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Q1) Which is the most appropriate goal for a patient with the nursing diagnosis risk for loneliness related to loss of spouse and admission to long-term nursing facility?
A) The patient will use effective coping strategies to prevent self-harm.
B) The patient will participate in at least one group activity every week.
C) The patient will assist staff with activities of daily living every morning.
D) The patient will express the desire to achieve increased levels of comfort.
Q2) Which complication may develop as a result of frequent middle ear infections as a child?
A) Meniere's disease
B) Serous otitis media
C) Hearing impairment
D) Impaction of cerumen
Q3) A nurse is caring for a patient who signs and lip reads.When communicating,the most appropriate nursing action is to do which of the following?
A) Rely on friends or family members to interpret for the patient.
B) Sit facing the patient when speaking and ensure there is adequate light.
C) Repeat the entire conversation if it is not clearly understood the first time.
D) Speak louder and more distinctly than normal with exaggerated lip movements.
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Chapter 40: Surgical Patient
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Q1) Which type of anesthesia will the patient receive during surgery on the cervical spine?
A) Local
B) Spinal
C) General
D) Epidural
Q2) The nurse is caring for a patient undergoing a surgical procedure that will take 7 to 8 hours to complete.Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization?
A) The patient's skin will be assessed prior to surgery to identify areas at risk.
B) The patient's privacy and dignity will be maintained throughout the procedure.
C) The patient's bony prominences will be padded with pressure-reducing cushions.
D) The patient's skin will be free of redness or breakdown when surgery is complete.
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