Nursing Process and Critical Thinking
Exam Solutions
Course Introduction
This course introduces students to the foundational concepts of the nursing process and the development of critical thinking skills in clinical practice. Emphasizing a systematic, evidence-based approach, students will learn to assess patient needs, formulate nursing diagnoses, plan and implement care strategies, and evaluate outcomes. Through case studies, simulations, and reflective practice, students will enhance their ability to apply critical thinking in decision making, prioritize patient care, and adapt interventions in diverse healthcare settings. The course prepares students to utilize the nursing process as a dynamic tool for problem-solving and delivering high-quality, patient-centered care.
Recommended Textbook
Essentials for Nursing Practice 9th Edition by Potter FAAN
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40 Chapters
977 Verified Questions
977 Flashcards
Source URL: https://quizplus.com/study-set/2491 Page 2
Chapter 1: Professional Nursing
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12 Verified Questions
12 Flashcards
Source URL: https://quizplus.com/quiz/49521
Sample Questions
Q1) Which program is appropriate for a nurse who wishes to become an expert in ostomy and wound care?
A) Specialty certification
B) Master of Science program
C) Doctoral degree program
D) Continuing education program
Answer: A
Q2) Which nursing actions incorporate informatics into nursing practice?
A) The nurse uses written materials to teach a patient who is hard of hearing.
B) The nurse uses an online database to learn more about the patient's disease.
C) The nurse uses a bar-code scanner to prevent medication administration errors.
D) The nurse teaches the patient's family how to perform range of motion.
E) The nurse checks the electronic record to review the patient's medical history. Answer: B,C,E
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Chapter 2: Health and Wellness
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21 Verified Questions
21 Flashcards
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Sample Questions
Q1) 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
Q2) Which statement by the patient indicates to the nurse that the patient is in the preparation stage of smoking cessation?
A) "I don't ever want to quit smoking."
B) "I hope to quit smoking sometime before I die."
C) "I am really working hard to stop smoking."
D) "I stocked up on nicotine patches and gum."
Answer: D
Q3) 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
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Page 4
Chapter 3: The Health Care Delivery System
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) Which is an example of 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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12 Verified Questions
12 Flashcards
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Sample Questions
Q1) Which is the highest priority problem for a homeless patient without family in December?
A) Risk for loneliness
B) Risk for hypothermia
C) Risk for social isolation
D) Risk for compromised human dignity
Q2) Which is the priority goal for a patient who is being abused by the spouse?
A) The patient's dignity will remain intact.
B) The patient will remain free from injury.
C) The patient will develop a sense of trust with the nurse.
D) The patient will be able to verbalize fears to the nurse.
Q3) 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.
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6
Chapter 5: Legal Principles in Nursing
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) Providing assistance to which victim would be covered under the state's Good Samaritan law?
A) The unit secretary at the hospital suffers an anaphylactic reaction after eating nuts as a morning snack.
B) A patient has a grand mal seizure in the hospital foyer when saying goodbye to his family.
C) A patient at the clinic where the nurse is working suffers a cardiac arrest after walking in the door.
D) Two people are badly hurt in a car accident on the nurse's way to work in the morning.
Q2) In which case might the patient be ordered by the court to receive treatment?
A) The patient has infectious TB and refuses to take the prescribed antibiotics.
B) The patient's mother refuses a vaccine for her child because he is allergic to it.
C) A Jehovah's Witness refuses a blood transfusion based on religious convictions.
D) A patient refuses treatment to slow the advancement of an inoperable brain tumor.
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Chapter 6: Ethics
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19 Verified Questions
19 Flashcards
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Sample Questions
Q1) Which ethical area is challenged when the nurse feels bound to refuse to assist with an abortion procedure?
A) Values
B) Culture
C) Confidentiality
D) Social networking
Q2) Which ethical principle is upheld when the registered nurse provides medical assistance to victims of an accident?
A) Veracity
B) Fidelity
C) Autonomy
D) Beneficence
Q3) Which ethical area is involved when the clinic releases genetic test results to the patient's employer without the patient's consent?
A) Veracity
B) Bioethics
C) Justice
D) Beneficence
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8
Chapter 7: Evidence-Based Practice
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20 Verified Questions
20 Flashcards
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Sample Questions
Q1) Which is an example of a PICO question?
A) How does the agency's monthly catheter-associated urinary tract infection rate compare with the national average?
B) Which types of topical antibiotic irrigation solutions may be used to reduce healing time for stage 4 decubitus pressure injuries?
C) Does oral care with chlorhexidine solution more effectively reduce the incidence of ventilator-associated pneumonia in intubated patients than saline solution?
D) Which emotions are commonly felt by patients upon learning that they were diagnosed with a terminal illness?
Q2) Which type of research study is most appropriate to determine if premedication with diphenhydramine is more effective than acetaminophen to reduce the incidence of aseptic meningitis after intravenous globulin infusion?
A) Randomized trial
B) Qualitative study
C) Historical review
D) Descriptive report
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Chapter 8: Critical Thinking
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) Which is the best tool that the nurse can use to make sense of the patient's multiple medical diagnoses,assessment findings,and medications?
A) Plan of care
B) Concept map
C) Reflective journal
D) Intellectual standards
Q2) Which patient's need constitutes the highest priority for the nurse?
A) The patient who is waiting for discharge teaching in order to go home
B) The constipated patient who has not had a bowel movement in 3 days
C) The patient with sudden onset of slurred speech and right-sided weakness
D) The patient who requires linen changes after being incontinent of urine and stool
Q3) The new nurse keeps a diary to record experiences,patient encounters,and feelings when beginning work in the nursing profession.Which critical thinking action is used by the nurse?
A) Professional standards
B) Nursing process
C) Concept mapping
D) Purposeful reflection
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Chapter 9: Nursing Process
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34 Verified Questions
34 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient with the nursing diagnosis ineffective airway clearance related to narrowed airways and thick sputum.Which is an appropriate goal for this patient?
A) "The patient will be resting comfortably by the morning."
B) "The patient's airway will remain clear throughout the night."
C) "The patient will not experience any feelings of shortness of breath or anxiety."
D) "The patient's respiratory rate and pulse will remain within normal limits."
Q2) The nurse is caring for a nonverbal patient who just had surgery.The nurse notes that the patient moans with position changes,the hands are clenched,and the skin is very sweaty.The nurse decides that the patient is in pain and decides to administer an analgesic.What is the correct term for this nursing action?
A) Setting priorities
B) Recognizing inconsistencies
C) Using empathy
D) Making inferences
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Chapter 10: Informatics and Documentation
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?
A) The laboratory technician did not know what he was doing and traumatized the patient's arm.
B) The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture.
C) The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.
D) The patient must have moved during the blood draw because there is a huge bruise on his left arm.
Q2) What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?
A) Withhold the medication until the physician signs the order.
B) Authorize the physician's order with the pharmacy.
C) Read back the order to the physician for confirmation.
D) Double-check the order with another registered nurse.
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Chapter 11: Communication
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) The nurse educates the patient about what to expect during insertion of a nasogastric tube.Which term best describes the nurse's communication role?
A) Channel
B) Receiver
C) Message
D) Sender
Q2) The nurse educates the patient about what to expect during suctioning of the tracheostomy tube.Which term best describes the patient's communication role?
A) Channel
B) Receiver
C) Message
D) Sender
Q3) A nurse is caring for a patient who cannot speak clearly.Which technique should the nurse use to enhance conversation with this patient?
A) Ask questions that require "yes" or "no" answers.
B) Avoid communication aids to prevent embarrassment.
C) Speak loudly and slowly to facilitate patient understanding.
D) Finish the patient's sentences when the patient is unable to.
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13
Chapter 12: Patient Education
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23 Verified Questions
23 Flashcards
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Sample Questions
Q1) A nurse prepares to teach the patient about strategies to minimize feelings of powerlessness.Which techniques will the nurse implement that are the best for this type of learning?
A) Lecture
B) Practice
C) Discussion
D) Role play
E) Return demonstration
Q2) Which is the first action of the nurse when teaching the patient how to perform colostomy care?
A) Determine the patient's educational background and learning abilities.
B) Identify a responsible family member to reinforce colostomy care teaching.
C) Have the patient watch a video that demonstrates how to perform colostomy care.
D) Assess the patient's level of comfort with looking at and caring for the colostomy.
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14
Chapter 13: Managing Patient Care
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21 Verified Questions
21 Flashcards
Source URL: https://quizplus.com/quiz/49533
Sample Questions
Q1) A nurse must give feedback to a nursing assistant that did not take vital signs.How will the nurse give feedback?
A) "Did you miss the class about how to take vital signs?"
B) "I refuse to work with you again if you cannot do your job."
C) "The patient's vital signs were not taken.What happened?"
D) "I cannot trust you to complete tasks that you are assigned."
Q2) A registered nurse works as a case manager on an orthopedic unit.What primary role is fulfilled by the nurse?
A) Coordinating care for patients following joint replacement surgery
B) Obtaining insurance preauthorization for joint replacement surgeries
C) Providing bedside care to patients who have had joint replacement surgery
D) Tracking infection rates and outcomes for patients after joint replacement surgery
Q3) Which leadership skills will the nursing student use when caring for patients?
A) Priority setting
B) Time management
C) Case management
D) Careful delegation
E) Team communication
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15
Chapter 14: Infection Prevention and Control
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24 Verified Questions
24 Flashcards
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Sample Questions
Q1) Which item of protective apparel is removed first when the nurse leaves the room of the patient with Clostridium difficile?
A) Gown
B) Mask
C) Gloves
D) Eyewear
Q2) The nurse maintains a sterile field when inserting a urinary catheter into the patient's bladder.Which term best describes the infection control practice of the nurse?
A) Pathogenesis
B) Bacteriostasis
C) Medical asepsis
D) Surgical asepsis
Q3) Which action demonstrates disinfection?
A) Washing the hands with warm water and antimicrobial liquid soap
B) Cleaning the patient's mouth with a swab soaked in chlorhexidine solution
C) Cleaning the stethoscope with isopropyl alcohol after each use with patients
D) Using an alcohol-based hand sanitizer after performing physical assessments
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16
Chapter 15: Vital Signs
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50 Verified Questions
50 Flashcards
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Sample Questions
Q1) The patient's blood pressure is 152/92 but the primary health care provider does not diagnose the patient with hypertension.What is the rationale for this decision?
A) The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension.
B) The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension.
C) The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made.
D) The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment.
Q2) The nurse is shown the mercury thermometer which was used to take the patient's temperature before coming to the hospital.What is the appropriate statement of the nurse?
A) "Mercury thermometers are more accurate than electronic ones."
B) "Hospitals use mercury thermometers for patients with very high fevers"
C) "Electronic thermometers are much safer than mercury thermometers"
D) "Mercury thermometers can be used to take rectal or oral temperatures"
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Chapter 16: Health Assessment and Physical Examination
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42 Verified Questions
42 Flashcards
Source URL: https://quizplus.com/quiz/49536
Sample Questions
Q1) Which question will the nurse ask the patient to assess abstract thinking ability?
A) "Can you tell me the color of the blanket on your bed?"
B) "Can you tell me what you ate for breakfast this morning?"
C) "Can you tell me about what it was like to grow up in your neighborhood?"
D) "What do I mean when I say that something costs an arm and a leg?"
Q2) Which factor in the female patient's history places her at higher risk for the development of breast cancer?
A) The patient's first period started at age 10.
B) The patient has three children under the age of 12.
C) The patient used condoms exclusively for contraception.
D) The patient's breasts are tender before each period.
Q3) Which technique will the nurse use to facilitate the history and physical examination of a small child?
A) Examine the child's hands and feet before listening to breath sounds.
B) Direct assessment questions to the child to avoid unwanted parental influence.
C) Gently palpate the child's abdomen before auscultating for bowel sounds.
D) Call the parents by their first names to establish a more trusting bond.
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Chapter 17: Administering Medications
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48 Verified Questions
48 Flashcards
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Sample Questions
Q1) The patient develops constipation after taking the daily iron supplement that was prescribed by the physician.Which term accurately describes the patient's reaction to the supplement?
A) Therapeutic effect
B) Adverse reaction
C) Side effect
D) Toxicity
Q2) A patient is to receive insulin aspart and insulin detemir.How will the nurse draw up the insulins for administration?
A) Mix the detemir and aspart in the same syringe,drawing up the aspart first.
B) Mix the detemir and aspart in the same syringe,drawing up the detemir first.
C) Administer the two insulins using different syringes and different sites of the body.
D) Roll the bottles between the palms of the hands before drawing up the insulins.
Q3) Which pain medication may be administered to the patient as needed?
A) Ketorolac 10 mg IV Q 4 hours prn
B) Fentanyl transdermal patch 25 mcg Q 3 days
C) Acetaminophen with oxycodone 10 mg/325 mg PO Q 6 hours
D) Morphine-extended release 60 mg PO Q 12 hours
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19
Chapter 18: Fluid, Electrolyte, and Acid-Base Balances
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38 Verified Questions
38 Flashcards
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Sample Questions
Q1) The patient is scheduled for hip replacement surgery and significant blood loss is expected.What is the best possible action of the patient to reduce the risk of transfusion complications?
A) Arrange for an autologous blood donation.
B) Take an iron supplement daily prior to the surgery.
C) Expect transfusions will come from a directed donor.
D) Request that donated blood be screened twice by the blood bank.
Q2) Approximately 30 minutes into the transfusion of this blood product,the patient becomes short of breath with wheezing,low BP,and hives.Which medication must be administered to the patient immediately?
A) 500 mL 0.9 NS IV fluid bolus
B) Epinephrine 0.4 mg IM
C) Diphenhydramine 50 mg IV
D) Methylprednisolone 40 mg IV
Q3) Order: 500 mL D W to infuse at 100 mL/hour
IV tubing: 10 drops/mL
The IV bag was hung at 12:00 noon. What time will the IV bag be completed? _____
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Page 20
Chapter 19: Complementary and Alternative Therapies
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15 Verified Questions
15 Flashcards
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Sample Questions
Q1) Which is an example of allopathic treatment?
A) Prescription of antibiotic medication for a bacterial infection
B) Use of tai chi exercises to relieve chronic back pain
C) Manipulation of the spine to relieve migraine headaches
D) Burning dried herbs to relieve chronic abdominal pain and diarrhea
Q2) Which assessment finding indicates to the nurse that the patient has begun to master the cognitive skill of receptivity?
A) The patient readily accepts feedback from the nurse about how to perform dressing changes.
B) The patient calmly accepts the physician's recommendation for surgery without a request for a second opinion.
C) The patient chooses not to inform family members about the complications and risks of upcoming surgery.
D) The patient uses guided imagery techniques to minimize anxiety and push negative thoughts out of the mind.
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21
Chapter 20: Caring in Nursing Practice
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Sample Questions
Q1) The nurse helps the patient set small,achievable goals and celebrates with the patient when the goals are met.Which caring behavior is demonstrated by the nurse?
A) Human respect
B) Encouraging manner
C) Healing environment
D) Affiliation needs
Q2) Which statement about caring for patients is true?
A) Basically all patients are the same.
B) Each patient has a unique background.
C) Caring for patients requires very little experience.
D) Standard solutions exist for most patient's health care problems.
Q3) Which statement is part of Leininger's Transcultural View of Caring?
A) Caring and curing are basically synonymous.
B) Caring acts are independent of patient values.
C) Care uses a standardized approach for all patients.
D) Care is tailored to meet the needs of the individual patient.
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22
Chapter 21: Cultural Awareness
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11 Flashcards
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Sample Questions
Q1) The nurse has just completed discharge teaching about self-injection of insulin to a patient who speaks little English.How can the nurse best determine that the teaching has been successful?
A) Ask the patient if there are any questions about the procedure.
B) Provide written instructions in the patient's preferred language.
C) Have the patient watch a video about how to self-inject insulin.
D) Watch the patient self-administer the next scheduled dose of insulin.
Q2) Which patient populations are at risk for being marginalized?
A) Recent immigrants to the United States
B) Individuals with type AB positive blood
C) Professionals with a master's or doctoral degree
D) Individuals who speak at least three different languages
E) Individuals who have undergone sexual reassignment surgery
Q3) Which assessment findings are social determinants of health?
A) Living in a house containing lead paint
B) Genetic predisposition to spinal osteoarthritis
C) Growing up in a neighborhood without grocery stores
D) Annual income 125% above the federal poverty level
E) Completed high school and 1 year of community college
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Page 23
Chapter 22: Spiritual Health
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11 Flashcards
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Sample Questions
Q1) 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.
Q2) A patient who survived a near-death experience tells the nurse about feeling a deep sense of peace,light,and unconditional love while watching the health care providers perform resuscitation procedures.Which is the best response of the nurse?
A) "Your experiences were probably due to side effects of the medications."
B) "I will ask the doctor for a psychiatric evaluation since you are hallucinating."
C) "It sounds like you are fearful of suffering associated with the dying process."
D) "Your experience is similar to others who have survived near-death experiences."
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Chapter 23: Growth and Development
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24 Verified Questions
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Sample Questions
Q1) The nurse is caring for a middle-aged adult who verbalizes a desire to start jogging and has a goal to run a half marathon.Which is the most appropriate action of the nurse?
A) Tell the patient that exercising during middle age could lead to injury.
B) Recommend that the patient have a complete physical examination first.
C) Inform the patient that it is unwise to take up new sports during middle age.
D) Explain that the disability from normal aging prevents taking up new sports.
Q2) Which is the highest priority nursing diagnosis for a toddler who is at the autonomy versus doubt stage of development?
A) Toileting self-care deficit related to readiness for transition from diapers
B) Impaired verbal communication related to stage of cognitive development
C) Readiness for enhanced sleep related to desire to sleep in a big kids' bed
D) Risk for poisoning related to unawareness of environmental risks within reach
Q3) Which are expected physical assessments finding for a middle-aged adult?
A) Difficulty hearing female voices
B) Diminished breath sounds bilaterally
C) Gradual loss of senses of taste and smell
D) Need for reading glasses to see small print
E) Decreased ability to solve practical problems
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Page 25
Chapter 24: Self-Concept and Sexuality
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16 Flashcards
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Sample Questions
Q1) 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.
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) The nurse is caring for an adult patient who must quit working due to complications from hypertension.Which self-concept is likely to be put at risk for this patient?
A) Identity
B) Self-esteem
C) Body image
D) Role performance
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26
Chapter 25: Family Dynamics
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21 Flashcards
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Sample Questions
Q1) Which questions should the nurse ask to assess family patterns?
A) "How does your family cope?"
B) "How does your family make day-to-day decisions?"
C) "Which family members work outside the home?"
D) "Does your family have any goals for childrearing?"
E) "How does your family divide household cleaning chores?"
Q2) Which is an example of a skip generation family?
A) A military family moves frequently from state to state due to deployments.
B) A couple provides foster care for infants while their mothers are incarcerated.
C) A divorced mother moves far away from the child's father to prevent visitation.
D) Grandparents raise the grandchildren after their parents are jailed for drug abuse.
Q3) Which is the appropriate action of the nurse when the patient's daughter offers to assist with the morning bath?
A) Accept the daughter's offer if the patient agrees.
B) Accept the daughter's offer and encourage her to assist.
C) Politely decline the daughter's offer of assistance.
D) Decline the daughter's offer as it will not be needed.
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Chapter 26: Stress and Coping
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20 Flashcards
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Sample Questions
Q1) The patient is overwhelmed by the stresses of being a spouse,new parent,and full-time employee.The nurse encourages the patient to use a housekeeper,babysitter,friends,or relatives to help reduce personal responsibilities and obligations.Which stress-relieving technique was recommended for the patient?
A) Assertiveness training
B) Engaging support systems
C) Mindfulness stress reduction
D) Progressive muscle relaxation
Q2) The patient is frustrated after being treated poorly by providers due to lack of health insurance.Which type of factor is causing the stress for the patient?
A) Rational
B) Situational
C) Maturational
D) Sociocultural
Q3) Which intervention is appropriate for the nurse to reduce compassion fatigue?
A) Increase nursing responsibilities at work.
B) Hang out with co-workers when not at work.
C) Strengthen relationships outside of the hospital.
D) Take control over new areas at work to reduce stress.
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Page 28
Chapter 27: Loss and Grief
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Sample Questions
Q1) The patient is on a ventilator and has a heartbeat,but is brain dead.What should the nurse do?
A) Explain that as long as the heart is beating,the patient is still alive.
B) Provide a private area for the family to discuss organ donation options.
C) Inform the family that the organs will be harvested when he is off the ventilator.
D) Stress the importance of leaving the patient on the ventilator to harvest the corneas.
Q2) 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.
Q3) Which of the following is true for a patient to receive home hospice care?
A) Caregiver support is available during normal business hours.
B) A primary caregiver must be living in the home with the patient.
C) If the patient goes to the hospital,all prehospital orders are canceled.
D) In the hospital,the home hospice care person must provide personal care.
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29
Chapter 28: Exercise and Activity
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Sample Questions
Q1) 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.
Q2) Which action by the nurse demonstrates correct technique for repositioning the patient in bed?
A) The nurse's knees are kept stiff to enhance lifting strength potential.
B) The nurse's abdominal muscles are relaxed to prevent back injury.
C) The nurse's pelvis is tucked inward to maintain balance during the procedure.
D) The nurse's torso twists with the patient to facilitate upper extremity muscle use.
Q3) 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.
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Chapter 29: Immobility
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Sample Questions
Q1) Which scale is used to assess the patient's risk for development of pressure injury?
A) Baker
B) Morse
C) Braden
D) Hendrich
Q2) Which is the appropriate intervention for the patient with the diagnosis powerlessness related to pain and weakness after right hip fracture?
A) Place the patient's personal items within view on the left side of the bed.
B) Encourage the patient to participate in self-care and recreational activities.
C) Assess the patient's sleep patterns and potential for obstructive sleep apnea.
D) Reposition the patient and pad bony prominences to prevent skin breakdown.
Q3) Which intervention will help prevent the development of footdrop for a comatose patient?
A) Place high-top tennis shoes on the patient's feet.
B) Place pillows under the legs to keep the heels off the mattress.
C) Apply sequential compression devices to the patient's feet.
D) Assist the patient to a lateral position whenever possible.
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Chapter 30: Safety
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Sample Questions
Q1) Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time?
A) Sleep deprivation related to noisy dormitory environment
B) Risk-prone health behavior related to weekend binge drinking
C) Relocation stress syndrome related to moving away from home
D) Risk for loneliness related to being away from family and old friends
Q2) Which assessment finding leads the nurse to add risk for poisoning to the patient's care plan?
A) The patient takes alprazolam 0.25 mg every 8 hours.
B) The patient rinses with a fluoride mouthwash after brushing the teeth.
C) The patient takes acetaminophen 1000 mg every 4 hours around the clock.
D) The patient frequently uses an alcohol-based sanitizer for hand hygiene.
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 is the priority nursing intervention for a patient with confusion and the diagnosis impaired dentition related to inability to perform oral care?
A) Assess the patient's preferred methods for oral hygiene.
B) Brush the patient's teeth twice daily with a soft toothbrush.
C) Use foam swab sticks to clean the oral cavity every morning.
D) Encourage the patient to chew sugarless gum during the day.
Q2) 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
Q3) The nurse is caring for a bedridden patient with long straight hair.Which is the appropriate intervention to prevent the hair from becoming matted?
A) Apply no-tangle conditioner to the hair.
B) Cut the matted hair.
C) Braid the patient's hair into several pigtails.
D) Wash the patient's hair daily with baby shampoo.
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Page 33
Chapter 32: Oxygenation
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Sample Questions
Q1) The nurse is caring for a dying patient in hospice.The patient's respirations are slow and uneven with deep breaths and long periods of apnea.Which term best describes this breathing pattern?
A) Rhonchal bradypnea
B) Forrest-Shiley breaths
C) Kussmaul's respirations
D) Cheyne-Stokes breathing
Q2) The nurse is caring for a patient who has pneumonia and chronic bronchitis.The patient is very congested,coughing up copious amounts of thick green sputum.Which breath sounds will the nurse expect to hear?
A) Fine crackles
B) Coarse rhonchi
C) Diminished bases
D) Scattered wheezes
Q3) Which assessment findings indicate to the nurse that the patient is hypoxic?
A) Heart rate is 55 beats/minute and irregular.
B) Urine output is 300 mL over the last 8 hours.
C) The patient is drowsy and difficult to arouse.
D) Hands and feet are pale and cool to the touch.
E) Abdomen is soft with bowel sounds × 4 quadrants.
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Chapter 33: Sleep
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Sample Questions
Q1) Which is the priority nursing diagnosis for an adolescent who gets up at 5:00 a.m.every morning for school and studies until midnight every night?
A) Fatigue related to insufficient rest and stress of academic demands
B) Risk for injury related to inattention and excessive daytime sleepiness
C) Deficient diversional activity related to lack of time for recreation and leisure
D) Impaired social interaction related to time required to study and maintain grades
Q2) A nurse is caring for a patient who suffers from a sleep pattern disturbance.To promote adequate sleep,what are the most appropriate nursing interventions?
A) Provide personal hygiene before bedtime.
B) Straighten and change any soiled bed linens.
C) Assist the patient to use the toilet before bed.
D) Administer sleep aids every night at the same time.
E) Synchronize the schedule for medications and vital signs.
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Chapter 34: Pain Management
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Q1) The patient expresses frustration about not being able to function as the family breadwinner any longer due to chronic severe pain.Which psychosocial nursing diagnosis is most appropriate for this patient's concern?
A) Risk for loneliness related to need for prescription pain medications
B) Interrupted family processes related to changes in assigned roles
C) Disturbed sensory perception related to insufficient environmental stimuli
D) Moral distress related to time constraints for ethical decision making
Q2) Which medication order will provide the most immediate relief of the patient's acute pain?
A) Morphine sulfate 5 mg PO
B) Hydromorphone 0.5 mg IV
C) Buprenorphine transdermal patch 10 mg
D) Oxymorphone 30 mg extended release
Q3) Which is an example of nociceptive pain?
A) Neuropathy due to uncontrolled diabetes
B) Phantom pain after amputation of a limb
C) Pain from rheumatoid arthritis joint damage
D) Chronic nerve pain after shingles infection
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Chapter 35: Nutrition
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Q1) Which action of the patient will facilitate aspiration of food and fluids into the airway?
A) The patient avoids talking when eating or swallowing.
B) The patient tilts the head backward when swallowing.
C) The patient thickens liquids to the consistency of honey.
D) The patient clears the throat after every few bites of food.
Q2) Which food item contains the most calories?
A) 1 g of cane sugar
B) 1 g of lean meat
C) 1 g of butter
D) 1 g of banana
Q3) Which menu item should be removed from the tray of a patient on a full liquid diet?
A) Cup of chicken bouillon
B) Cup of tomato cream soup
C) Cup of orange frozen yogurt
D) Cup of strawberry applesauce
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Chapter 36: Urinary Elimination
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Q1) The family requests insertion of a Foley catheter to address the elderly patient's frequent episodes of incontinence.Which is the best action of the nurse?
A) Obtain an order for an indwelling urinary catheter.
B) Teach family to perform intermittent straight catheterization.
C) Utilize disposable absorbent undergarments for the patient.
D) Implement a bladder training program to promote continence.
Q2) 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.
Q3) Which teaching will the nurse provide to the patient before having an intravenous pyelogram (IVP)?
A) Drink water and do not void so the bladder will be full during the test.
B) An urge to void may be felt as the endoscope passes through the urethra.
C) The urine may have an orange or pink for a day or two following the test.
D) Drink plenty of water afterward to prevent kidney damage from the contrast dye.
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Chapter 37: Bowel Elimination
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Q1) The nurse is caring for a patient with diarrhea caused by Clostridium difficile infection.Which are the priority interventions of the nurse?
A) Perform hand hygiene with soap and water.
B) Increase the patient's dietary intake of fiber.
C) Maintain strict contact isolation precautions.
D) Accurate calculation of patient's intake and output.
E) Liberally apply skin barrier cream to the perineal area.
Q2) Which assessment finding leads the nurse to conclude that digital disimpaction of stool is unsafe for the patient?
A) The patient has a large mass of hard,dry stool in the rectum.
B) The patient has not had a bowel movement for the last 6 days.
C) The patient's pulse is 50 beats/minute due to a history of heart block.
D) The patient has taken senna every morning for the last 3 days.
Q3) Which patient does the nurse identify that would benefit from a nasogastric tube to low intermittent suction?
A) A patient who is vomiting due to a complete large bowel obstruction
B) A patient with constipation who has not had a bowel movement in 6 days
C) A patient with constant diarrhea due to side effects of antibiotic therapy
D) A patient with extensive skin irritation due to a leaking colostomy appliance
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Page 39
Chapter 38: Skin Integrity and Wound Care
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Sample Questions
Q1) 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
Q2) Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery?
A) Mental status and orientation
B) Hourly fluid intake and output
C) Lung sounds and pulse oximetry
D) Presence of peripheral pedal pulses
Q3) Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?
A) Serum total protein level of 4.6 g/dL
B) Braden Scale score of 22
C) Cetirizine 5 mg PO daily
D) Fasting serum glucose level 84 mg/dL
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Chapter 39: Sensory Alterations
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Q1) The nurse is caring for a patient who has a severe right-sided stroke with left-sided hemiplegia.The patient uses the right extremities well but does not realize that the left arm and leg even exist.Which is the most appropriate nursing diagnosis for this patient?
A) Deficient knowledge related to presence of paralyzed left arm and leg
B) Unilateral neglect related to brain tissue damage after right-sided stroke
C) Ineffective denial related to inability to accept paralysis of left arm and leg
D) Noncompliance related to inability to follow directions to use left arm and leg
Q2) The nurse is caring for a patient with the nursing diagnosis of disturbed sensory perception related to loud,bright hospital environment.Which is the priority intervention for the patient's care plan?
A) Maintain eye contact with the patient and avoid chewing gum.
B) Ask the patient to repeat information back to ensure understanding.
C) Repeatedly orient the patient to time,place,and the hospital room surroundings.
D) Shut the patient's door and avoid turning on the bright overhead lights in the room.
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Chapter 40: Surgical Patient
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Sample Questions
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 postanesthesia care unit nurse receives a patient from the operating room.Which assessment will the nurse perform first?
A) Foley catheter and surgical fluid intake
B) Intravenous lines for patency or redness
C) Airway,lung sounds,and pulse oximetry
D) Nasogastric tube and presence of bowel sounds
Q3) Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter?
A) The patient does not wish to get out of bed and ambulate to the toilet.
B) The patient just underwent radical prostatectomy surgery 2 days ago.
C) The drainage bag contains 300 mL of clear yellow urine from the last 4 hours.
D) The patient is to be discharged home after a final assessment by the surgeon.
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