Exam # 1 Part 2

1. 1You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure.

   1. AAccountability
   2. BConfidentiality
   3. CAdvocacy
   4. DResponsibility
2. 2A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request.

   1. AAdvocacy
   2. BResponsibility
   3. CAccountability
   4. DConfidentiality
3. 3You tell your patient that you will return in 30 minutes to give him his next pain medication.

   1. AResponsibility
   2. BAccountability
   3. CConfidentiality
   4. DAdvocacy
4. 4The agreement to keep promises and the unwillingness to abandon patients

   1. AFidelity
   2. BAutonomy
   3. CBeneficence
   4. DNonmaleficence
5. 5The best interests of the patient remain more important than self-interest

   1. ABeneficence
   2. BNonmaleficence
   3. CJustice
   4. DFidelity
6. 6Fairness

   1. Ajustice
   2. Bfidelity
   3. Cautonomy
   4. DBeneficence
7. 7Commitment to include patients in decisions about care
   

   1. Aautonomy
   2. BBeneficence
   3. CNonmaleficence
   4. Djustice
8. 8Avoidance of harm or hurt

   1. ANonmaleficence
   2. Bjustice
   3. Cfidelity
   4. Dautonomy
9. 9A health care issue often becomes an ethical dilemma because:
   

   1. ADecisions must be made based on value systems
   2. BThe choices involved do not appear to be clearly right or wrong
   3. CDecisions must be made quickly, often under stressful conditions
   4. DA patient’s legal rights coexist with a health professional’s obligations
10. 10Which statement about an institutional ethics committee is correct?
    

    1. AThe ethics committee would be the first option in addressing an ethical dilemma.
    2. BThe ethics committee replaces decision making by the patient and health care providers.
    3. CThe ethics committee relieves health care professionals from dealing with ethical issues.
    4. DThe ethics committee provides education, policy recommendations, and case consultation.

11. 11The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is:
    

    1. AExploring reasonable courses of action
    2. BIdentifying people who can solve the difficulty
    3. CClarifying values related to the cause of the dilemma
    4. DCollecting all available information about the situation
12. 12Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient’s only treatment choice. This example describes the ethical principle of:
    

    1. Aautonomy
    2. Bfidelity
    3. Cjustice
    4. DNonmaleficence.
13. 13If a nurse decides to withhold a medication because it might further lower the patient’s blood pressure, the nurse will be practicing the principle of:
    

    1. Aresponsibility
    2. Baccountability
    3. CCompetency
    4. DMoral behavior
14. 14A nurse is working with a terminally ill adult patient. The nurse decides to tell the adult children that they need to decide how to advise their father about taking analgesics during the terminal phase of his illness. This step of processing an ethical dilemma is:
    

    1. AArticulation of the problem
    2. BEvaluation of the action
    3. CNegotiation of the outcome
    4. DDetermination of values surrounding the problem
15. 15A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.)

    1. AInformation provided by the head nurse
    2. BPolicies and procedures of the employing hospital
    3. CState Nurse Practice Act
    4. DRegulations identified in The Joint Commission manual
    5. EThe American Nurses Association standards of nursing practice
16. 16A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.)

    1. AThe nurse does not need any representation.
    2. BThe pt must prove injury, damage, or loss occured
    3. CThe person filing the lawsuit has to show a compensable damage, such as lost wages, occurred.
    4. DThe pt must prove that a breach in the prevailing standard of care caused an injury.
    5. EThe burden of proof is always the responsibility of the nurse.
17. 17A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation?

    1. AThe nurse's automobile insurance
    2. BThe nurse's homeowner's insurance
    3. CThe Good Samaritan law, which grants immunity from suit if there is no gross negligence
    4. DThe Patient Care Partnership, which may grant immunity from suit if the injured party consents
18. 18A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?

    1. Afamily member
    2. Bsurgeon
    3. Cnurse
    4. Dnurse manager
19. 19A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility?

    1. AObtain a court order to give the blood
    2. BCoerce the husband into giving the blood
    3. Ccall security and have the husband removed from the hospital
    4. DA durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
20. 20A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act?

    1. APatient Protection and Affordable Care Act (PPACA)
    2. BPatient Self-Determination Act (PSDA)
    3. CHIPPA
    4. DEmergency Medical Treatment and Active Labor Act
21. 21A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow?

    1. AA living will allows an appointed person to make health care decisions when the patient is in an incapacitated state.
    2. BA living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
    3. CThe patient cannot make changes in the advance directive once admitted to the hospital.
    4. DA durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
22. 22Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.)

    1. ATaking or selling controlled substances
    2. BRefusing to provide health care information to a patient's child
    3. CReporting suspected abuse/neglect of a child
    4. DApplying physical restraints without a written physician's order
    5. ECompleting an occurrence report on the unit
23. 23The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the 314patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)?

    1. ADiscussing patient conditions in the nursing report room at the change of shift
    2. BAllowing nursing students to review patient charts before caring for patients to whom they are assigned
    3. CPosting medical information about the patient on a message board in the patient's room
    4. DReleasing patient information regarding terminal illness to family when the patient has given permission for information to be shared
24. 24A nurse is caring for a patient who states, “I just want to die.” For the nurse to comply with this request, the nurse should discuss:
    

    1. Aliving wills
    2. Bassisted suicide
    3. CPassive euthanasia
    4. DAdvance directives
25. 25A student nurse employed as a nursing assistant may perform care:
    

    1. AAs learned in school.
    2. BExpected of a nurse at that level.
    3. CIdentified in the hospital’s job description
    4. DRequiring technical rather than professional skills
26. 26You are about to administer an oral medication and you question the dosage. You should:
    

    1. AAdminister the medication.
    2. BNotify the physician
    3. CWithhold the medication
    4. DDocument that the dosage appears incorrect.
27. 27A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?

    1. A“Avoid rushing when documenting an entry in the medical record.”
    2. B“Use correction fluid to remove the entry.”
    3. C“Draw a single line through the statement and initial it.”
    4. DEnter only objective and factual information about a patient in the medical record.
28. 28A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse:

    1. AReads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone
    2. BDocuments the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record.
    3. CGives a newly ordered medication before entering the order in the patient's medical record.
    4. DAsks the preceptor to listen in on the phone conversation.
29. 29As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, “I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this.” Which of the following is the most appropriate way for the nurse to document this observation of the patient?

    1. A“The patient has a defiant attitude and is demanding test results.”
    2. B“The patient appears to be upset with the nurse because he wants his test results immediately.”
    3. C“The patient is demanding and is complaining about the doctor.”
    4. D“The patient stated feelings of frustration from the lack of information received regarding test results.”
30. 30The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, “I'm not familiar with these HIPAA regulations. How will they affect my care?” Which of the following is the best response?

    1. AHIPAA allows all hospital staff access to your medical record.
    2. BHIPAA limits the information that is documented in your medical record.
    3. CHIPAA provides you with greater protection of your personal health information.
    4. DHIPAA enables health care institutions to release all of your personal information to improve continuity of care.
31. 31A patient states, “I would like to see what is written in my medical record.” What is the nurse's best response?

    1. A“Only your family can read your medical record.”
    2. B“You have the right to read your record.”
    3. C“Patients are not allowed to read their records.”
    4. D“Only health care workers have access to patient records.”
32. 32Which of the following documentation entries is most accurate?

    1. A“Patient walked up and down hallway with assistance, tolerated well.”
    2. B“Patient up, out of bed, walked down hallway and back to room, tolerated well.”
    3. C“Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.”
    4. D“Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise.”
33. 33Label each line of documentation with the appropriate SOAP category: Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.

    1. Asubjective
    2. Bobjective
    3. Cassessment
    4. Dplan
34. 34Label each line of documentation with the appropriate SOAP category: “The pain increases every time I try to turn on my left side.”

    1. Asubjective
    2. Bobjective
    3. Cassessment
    4. Dplan
35. 35Label each line of documentation with the appropriate SOAP category: Acute pain related to tissue injury from surgical incision.

    1. Asubjective
    2. Bobjective
    3. Cassessment
    4. Dpain
36. 36Label each line of documentation with the appropriate SOAP category: Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

    1. Asubjective
    2. Bobjective
    3. Cassessment
    4. Dpain
37. 37While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider's offices over the past 6 months. This type of feature is most common in a patient database.

    1. AVerdadero
    2. BFalso
38. 38The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.)

    1. AThe patient's name, age, and admitting diagnoses
    2. BThe discussion of any allergies to food and medications that the patient has
    3. CThat the nurse receiving the report was advised that the patient is “needy” and “on the call light all the time”
    4. DThat the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
    5. EDescription of any unresolved problems and current interventions in place
39. 39The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.)

    1. ADocuments a medication given by another nursing student.
    2. BIncludes the date and time of the entry into the medical record.
    3. CEnters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room.
    4. DLeaves a slip of paper with her user name and password in the patient's room.
    5. EStarts to enter “Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, “I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse,” as a narrative comment.
40. 40A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?

    1. A“CPOE reduces transcription errors.”
    2. B“CPOE reduces the time needed for health care providers to write orders.”
    3. C“CPOE eliminates verbal and telephone orders from health care providers.”
    4. D“CPOE reduces the time nurses use to communicate with health care providers.”
41. 41The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system?

    1. AEHR
    2. BClinical documentation
    3. CClinical decision support system
    4. DComputerized physician order entry
42. 42While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is “WDL” (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this?

    1. AThe nurse caring for the patient forgot to document on the pulmonary system
    2. BThe EMR uses a charting-by-exception format.
    3. CThe computer shut down unexpectedly when the nurse was documenting the assessment.
    4. DBecause of HIPAA regulations, physicians are not authorized to view the nursing assessment.
43. 43What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record?

    1. ARip the papers up into small pieces and place the pieces into a standard trash can
    2. BPlace all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit
    3. CPlace papers with patient information in a secure canister marked for shredding
    4. DBurn documents with patient information in the steel sink located within the dirty supply room on the patient care unit
44. 44Objective, ongoing reviews to determine the degree to which quality improvement standards are met
    

    1. AAuditing
    2. BCommunication
    3. CLegal documentation
    4. DDiagnostic-related groups (DRGs)
45. 45Learning the nature of an illness and the individual patient’s responses
    

    1. AEducation
    2. BResearch
    3. CAuditing
    4. DCommunication
46. 46Means by which patient needs and progress, individual therapies, patient education, and discharge planning are conveyed to others in the health care team
    

    1. ALegal documentation
    2. BDiagnostic-related groups (DRGs)
    3. CEducation
    4. DResearch
47. 47 Gathering of statistical data of clinical disorders, complications, therapies, recovery, and deaths
    

    1. Aresearch
    2. Bauditing
    3. Ccommunication
    4. Dlegal documentation
48. 48 Gathering of statistical data of clinical disorders, complications, therapies, recovery, and deaths
    

    1. Alegal documentation
    2. Bdiagnostic-related groups (DRG)
    3. Ceducation
    4. Dresearch
49. 49Classification system based on patients’ medical diagnoses that supports reimbursement
    

    1. ADiagnostic-related groups (DRGs)
    2. Beducation
    3. Cresearch
    4. Dauditing
50. 50 Incorporates a multidisciplinary approach to documenting patient care
    

    1. ACase management
    2. BCritical pathways
    3. Cnarrative
    4. DProblem-oriented medical record (POMR)
51. 51 Focuses on deviations from the established norm or abnormal findings; highlights trends and changes

    1. ACharting by exception
    2. BCase management
    3. CCritical pathways
    4. Dnarrative
52. 52Database, problem list, care plan, and progress notes
    

    1. AProblem-oriented medical record (POMR)
    2. BSOAP
    3. CSOAPIE
    4. DPIE
53. 53Multidisciplinary care plans that include patient problems, key interventions, and expected outcomes
    

    1. ACritical pathways
    2. Bnarrative
    3. CProblem-oriented medical record (POMR)
    4. DSOAP
54. 54 One of several formats or structured notes within a POMR
    

    1. AProgress notes
    2. BCharting by exception
    3. CCase management
    4. DCritical pathways
55. 55 SOAP with intervention and evaluation added

    1. ASOAPIE
    2. BPIE
    3. CFocus charting
    4. DProgress notes
56. 56 Use of DAR (data, action, and response)

    1. AFocus charting
    2. BProgress notes
    3. CCharting by exception
    4. DCase management
57. 57 Problem, intervention, and evaluation with a nursing origin

    1. APIE
    2. BFocus charting
    3. CProgress notes
    4. DCharting by exception
58. 58Subjective, objective, assessment, and plan

    1. ASOAP
    2. BSOAPIE
    3. CPIE
    4. DFocus charting
59. 59Story-like format that has the tendency to have repetitious information and be time consuming
    

    1. Anarrative
    2. BProblem-oriented medical record (POMR)
    3. CSOAP
    4. DSOAPIE
60. 60Includes medications, diet, community resources, and follow-up care
    

    1. ADischarge summary forms
    2. BAdmission nursing history forms
    3. Cflow sheets
    4. Dpt care summary
61. 61Level is based on the type and number of nursing interventions required over a 24-hour period
    

    1. AAcuity records
    2. BStandardized care plans
    3. CDischarge summary forms
    4. DAdmission nursing history forms
62. 62Provides current information that is accessible to all members of the health care team
    

    1. Aflow sheets
    2. BPatient care summary
    3. CAcuity records
    4. DStandardized care plans
63. 63 Provides baseline data to compare with changes in the patient’s condition
    

    1. AAdmission nursing history forms
    2. Bflow sheets
    3. CPatient care summary
    4. DAcuity records
64. 64Provides the most current information that has been entered into the EHR
    

    1. APatient care summary
    2. BAcuity records
    3. CStandardized care plans
    4. DDischarge summary forms
65. 65Preprinted, established guidelines used to care for the patient
    

    1. AAdmission nursing history forms
    2. Bflow sheets
    3. CPatient care summary
    4. DAcuity records
66. 66The primary purpose of a patient’s medical record is to:
    

    1. AProvide validation for hospital charges
    2. BSatisfy requirements of accreditation agencies
    3. CProvide the nurse with a defense against malpractice
    4. DCommunicate accurate, timely information about the patient
67. 67 Which of the following is correctly charted according to the six guidelines for quality recording?

    1. AWas depressed today.
    2. BRespirations rapid; lung sounds clear.
    3. CHad a good day. Up and about in room.
    4. DCrying. States she doesn’t want visitors to see her like this.
68. 68During a change-of-shift report:

    1. ATwo or more nurses always visit all patients to review their plan of care.
    2. BThe nurse should identify nursing diagnoses and clarify patient priorities.
    3. CNurses should exchange judgments they have made about patient attitudes.
    4. DPatient information is communicated from a nurse on a sending unit to a nurse on a receiving unit.
69. 69An incident report is:

    1. AA legal claim against a nurse for negligent nursing care
    2. BA summary report of all falls occurring on a nursing unit
    3. CA report of an event inconsistent with the routine care of a patient
    4. DA report of a nurse’s behavior submitted to the hospital administration
70. 70If an error is made while recording, the nurse should:

    1. AErase it or scratch it out
    2. BLeave a blank space in the note
    3. CDraw a single line through the error and initial it
    4. DObtain a new nurse’s note and rewrite the entries
71. 71Develops self-awareness and a positive self-esteem

    1. Ainterpersonal
    2. Bintrapersonal
    3. Cpublic
    4. Dsmall group
72. 72One-to-one interaction between a nurse and another person

    1. Ainterpersonal
    2. Bintrapersonal
    3. Csmall group
    4. Dpublic
73. 73Factors within both the sender and the receiver that influence communication
    

    1. AInterpersonal variables
    2. BEnvironment
    3. CVerbal communication
    4. DConnotative meaning
74. 74Motivates one person to communicate with another

    1. AReferent
    2. Bsender
    3. CReceiver
    4. Dmessage
75. 75Interpretation of a word’s meaning influenced by the thoughts and feelings that people have about the word

    1. AConnotative meaning
    2. BIntonation
    3. Ctiming
    4. Dpacing
76. 76Tone of voice

    1. AIntonation
    2. Btiming
    3. Cpacing
    4. DClarity and brevity
77. 77In demonstrating the method for deep breathing exercises, the nurse places his or her hands on the patient’s abdomen to explain diaphragmatic movement. This technique involves the use of which communication element?
    

    1. AReferent
    2. Bmessage
    3. Cfeedback
    4. DTactile channel
78. 78Which statement about nonverbal communication is correct?
    

    1. AThe nurse’s verbal messages should be reinforced by nonverbal cues.
    2. BIt is easy for a nurse to judge the meaning of a patient’s facial expression.
    3. CThe physical appearance of the nurse rarely influences nurse–patient interaction.
    4. DWords convey meanings that are usually more significant than nonverbal communication.
79. 79The term referring to the sender’s attitude toward the self, the message, and the listener is:

    1. ADenotative meaning
    2. BMetacommunication
    3. CConnotative meaning
    4. DNonverbal communication
80. 80The referent in the communication process is:

    1. AInformation shared by the sender
    2. BThe means of conveying messages
    3. CThat which motivates the communication
    4. DThe person who initiates the communication
81. 81A nurse is conducting an admission interview with a patient. To maintain the patient’s territoriality and maximize communication, the nurse should sit:

    1. A4 to 12 feet from the patient
    2. B0 to 18 inches from the patient
    3. C12+ feet from pt
    4. D18 inches to 4 feet from pt
82. 82A nurse is evaluating various scenarios related to the basic codes of ethics set forth by the American Nurses Association. Which situation is an example of following the principle of accountability?

    1. AA nurse carefully monitors all tasks that have been delegated to nursing assistive personnel
    2. BAt the client’s request, a nurse refrains from telling the client’s caregivers about the client’s condition.
    3. CA nurse explains to a client’s caregivers why the client requires a particular emergency procedure to be done
    4. DA nurse ensures that all nursing actions performed during care can be explained to the client and the hospital.
83. 83A registered nurse distributes a task to four healthcare professionals. When are both accountability and responsibility transferred to the healthcare professional?

    1. AWhen the task is given to another registered nurse (RN)
    2. BWhen the task is given to a licensed practical nurse (LPN)
    3. CWhen the task is given to a licensed vocational nurse (LVN)
    4. DWhen the task is given to an unlicensed nursing personnel (UNP)
84. 84Case management is being implemented in a major city hospital. What should the manager include when instructing the nursing staff about this care delivery method? Select all that apply.

    1. A"The case manager advocates for the client and family."
    2. B"The case manager identifies outcomes and coordinates care activities."
    3. C"Case managers help control the costs for high-risk, high-cost client populations."
    4. D"Identifying tasks that can be performed by other care providers is just one activity."
    5. E"Case management includes the client, family, and all healthcare provider involvement."
85. 85The nurse is teaching a group of nursing students about case management. What should the nurse explain as being the goal of case management?

    1. AMaximize the skill level of all care providers
    2. BIntegrate care with cost-effective approaches
    3. CEliminate the need for unlicensed assistive personnel (UAP).
    4. DEnsure all resources for client care are located within a geographic location
86. 86Which of these refers to the accountability element of the decision making process?

    1. AIndividuals being answerable for their actions
    2. BFreedom of choice and responsibility for the choices
    3. CDuties and activities that an individual is employed to perform
    4. DAuthority to give commands and make final decisions specific to a given position
87. 87Which description of accountability is correct?

    1. AAccomplishment of the task and fulfilling the requirements
    2. BProvision of guidance and oversight of a delegated nursing task
    3. CObligation to accomplish work with reliability and dependability
    4. DDetermination of appropriate actions and provide detailed explanations of the actions
88. 88The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? Select all that apply.
    

    1. A"I will avoid involving clients as decision-makers and participants in care."
    2. B"I will discuss complex cases with other members of the healthcare team."
    3. C"I will identify the nursing diagnoses and collaborative problems of each client."
    4. D"I will consider the period it takes to care for clients whose problems have higher priority."
    5. E"I will decide to perform activities individually to resolve more than one client problem at a time."
89. 89How many rights of delegation are there in the nursing practice?

    1. A5
    2. B6
    3. C7
    4. D10
90. 90Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?
    

    1. ARight task
    2. BRight person
    3. CRight supervision
    4. DRight communication
91. 91A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving?

    1. ARight task
    2. BRight direction
    3. CRight supervision
    4. DRight circumstance
92. 92What does the basic principle of advocacy provide to the nurse according to the American Nurses Association (ANA) code of ethics?

    1. AThe basic principle of advocacy helps the nurse remain competent in nursing practice.
    2. BThe basic principle of advocacy helps the nurse provide care on the basis of the client’s specific needs
    3. CThe basic principle of advocacy helps the nurse make a unique contribution to the understanding of the client’s point of view
    4. DThe basic principle of advocacy helps the nurse ensure that professional actions can be explained to clients and the employer.
93. 93A registered nurse is educating a nursing student about the similarities and differences between the deontological and utilitarianism systems of ethics. What information should the nurse provide? Select all that apply.

    1. AThe difference between utilitarianism and deontology is the focus on outcomes
    2. BUtilitarianism takes into consideration the usefulness of an action; deontology does not look into consequences
    3. CUtilitarianism measures the effect that an act will have; deontology looks to the presence of principles regardless of the outcome
    4. DUtilitarianism and deontology are closely related to the ethics of care because both ideologies promote a philosophy that focuses on understanding relationships
    5. EBoth utilitarianism and deontology look into the nature of relationships and propose that the natural urge to be influenced by relationships is a positive value.
94. 94A registered nurse is educating a nursing student about the utilitarian system of ethics. What information should the nurse provide? Select all that apply.

    1. A"The value of something is decided by its usefulness."
    2. B"The main emphasis is on the outcome or consequence of the action."
    3. C"The system examines a situation for the presence of essential right or wrong."
    4. D"The greatest good for the greatest number of people determines the right action."
    5. E"The actions can be determined whether right or wrong based on their ‘right-making characteristics.’"
95. 95A nursing student is evaluating different scenarios that are examples of following the basic health care principles. Which scenario is an example of following the principle of justice?

    1. AA nurse obtains written consent from a client to let the surgeon perform an open-heart surgery
    2. BA nurse manager encourages the nurses to discuss their mistakes in order to improve the quality of care
    3. CA nurse determines the pros and cons of providing a backrub to a client with a spine injury in order to relieve pain
    4. DA nurse observes that a client is in need of spiritual help and therefore requests the services of the hospital chaplain
96. 96A student nurse is listing different scenarios that comply with basic healthcare ethics. Which scenarios mentioned by the student nurse relate to the healthcare ethic of fidelity? Select all that apply.
    

    1. A"A nurse monitors a client after providing nonpharmacological measures to relieve anxiety due to hospitalization."
    2. B"A nurse notes that the pain relief measures provided to that client have been ineffective. The nurse formulates a different plan of care."
    3. C"A nurse ensures that the client understands the risks and benefits of an experimental treatment before signing the appropriate consent form."
    4. D"A nurse carefully evaluates the advantages and disadvantages of the client’s plan of care to ensure that the risks do not outweigh the benefits."
    5. E"A nurse is caring for a client who refuses to be touched by people of certain skin color. The nurse continues providing care since other colleagues refuse to attend to the client."
97. 97Arrange the actions in the order a nurse should take to resolve an ethical dilemma.
    
    1. Clarify values
    2. Negotiate a plan
    3. Collect relevant case-related information.
    4. Determine possible courses of action.
    5. Evaluate the plan over time
    6. Verbalize the problem

    1. A3, 1, 6, 4, 2, 5
    2. B1,2,3,4,5,6
    3. C6,5,4,3,2,1
    4. D3.4.2.1.6.5
98. 98A client in need of a lung transplant tells the nurse, "I will not take the organ of any person belonging to a different religion." The nurse initiates the process for resolving the ethical dilemma by collaborating with other healthcare team members. What should the team do after agreeing to a statement of the problem?

    1. AThe team should interview the family members of the client
    2. BThe team should initiate negotiations for the appropriate course of action
    3. CThe team should assess whether the client is satisfied with the course of action taken.
    4. DThe team should determine all the possible courses of action based on available information.
99. 99What is considered to be the highest priority for an assault victim who presents to the emergency department?

    1. AMonitoring the client’s vital signs
    2. BPerforming a general physical examination
    3. CEnsuring the client’s emotional and physical safety
    4. DCounseling the client regarding sexually transmitted diseases
100. 100A nurse is evaluating different situations that constitute acts of assault and battery. Which situations would the nurse consider to be instances of battery? Select all that apply.

     1. AA nurse threatens to restrain a client who refuses to consent to having a bath
     2. BA nurse force feeds a client who refuses to eat by opening his mouth.
     3. CA nurse pats an aggressive client to calm him or her down without waiting for the client’s consent.
     4. DA nurse administers an intramuscular injection to a client before obtaining consent for the injection.
     5. EA nurse locks a client in a private room to prevent him or her from going to the cafeteria without obtaining consent
101. 101What information should the registered nurse provide when teaching a nursing student about defamation of character? Select all that apply.
     

     1. A"It is an example of an intentional tort."
     2. B"Speaking falsely about another person is slander."
     3. C"Written defamation of character is also called libel."
     4. D"It is the publication of false statements that may damage a person’s reputation."
     5. E"Defamation of character may occur if nursing care falls below the standards of care."
102. 102What information should the registered nurse provide when educating a nursing student about living wills? Select all that apply.

     1. AHealth care workers should always follow the directions of a client’s living will
     2. BLiving wills provide clinically specific instructions that help in dealing with unforeseen circumstances
     3. CClients use living wills to declare any medical procedures they want or do not want when terminally ill
     4. DLiving wills are written documents that direct the client’s treatments in the event of a terminal illness or condition.
     5. ELiving wills allow authorized individuals to make medical decisions on behalf of the client if he or she is unable to do so.
103. 103What does a nurse understand by the term regulatory law as applied to nursing practice?

     1. ARegulatory law provides fair and equitable treatment when civil wrongs or violations occur.
     2. BRegulatory law describes and defines the legal boundaries of the nursing practice within each state
     3. CRegulatory law reflects the decisions made by administrative bodies such as the State Boards of Nursing.
     4. DRegulatory law results from judicial decisions made in courts based on the judgments of individual legal cases
104. 104A registered nurse is educating a nursing student about risk management methods to ensure that appropriate nursing care is provided to a client by identifying and eliminating potential hazards. What information should the registered nurse provide? Select all that apply.
     

     1. A"If an incident occurs, document in the client’s medical record that an occurrence report has been filed."
     2. B"Ensure that the three principles of The Joint Commission’s Universal Protocol are adhered to before starting a surgery on a client."
     3. C"Refrain from depending on the use of electronic monitoring devices completely because they are not always reliable."
     4. D"File an occurrence report in case of an error in technique when administering medication intravenously (IV)."
     5. E"Document that the healthcare provider was contacted, the information that was conveyed, and the response in the occurrence report."
105. 105How is the term "beneficence" in health ethics different from "nonmaleficence"?

     1. ABeneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises
     2. BBeneficence involves taking positive actions to help other,s whereas nonmaleficence is the avoidance of harm or hurt
     3. CBeneficence stands for all health care professionals, whereas nonmaleficence stands for nursing professionals
     4. DBeneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one’s professional obligations
106. 106What steps should a nurse take when caring for a client to prevent nursing malpractice? Select all that apply

     1. ABe alert about common sources of client injuries
     2. BGain knowledge regarding current nursing practices
     3. CRefrain from speaking falsely about a client’s medical condition
     4. DCommunicate with the client regarding tests and treatment plans
     5. ERefrain from divulging medical information to unauthorized persons
107. 107When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, “I use this device to:
     

     1. Ahelp my cough reflex
     2. Bexpand my lungs after surgery
     3. Cincrease my lung capacity.
     4. Ddrain excess fluid from my lungs
108. 108Postoperatively, the nurse instructs the patient to perform leg exercises every hour to:
     

     1. Amaintain muscle tone
     2. Bassess range of motion
     3. Cexercise fatigued muscles
     4. Dincrease venous return
109. 109Choose the correct type of surgical procedure that matches: Restores function lost or reduced as result of congenital anomalies

     1. Aconstructive
     2. Bcosmetic
     3. Cmajor
     4. Dminor
110. 110Choose the correct type of surgical procedure that matches: Excision or removal of diseased body part

     1. Aablative
     2. BPalliative
     3. Crestorative
     4. DProcurement
111. 111Choose the correct type of surgical procedure that matches: Not necessarily emergency

     1. Aurgent
     2. Bemergency
     3. CDiagnostic
     4. Dablative
112. 112Choose the correct type of surgical procedure that matches: Extensive reconstruction, poses great risks to well-being
     

     1. Amajor
     2. Bminor
     3. Celective
     4. Durgent
113. 113Choose the correct type of surgical procedure that matches: Performed to improve personal appearance

     1. Acosmetic
     2. Bmajor
     3. Cminor
     4. Delective
114. 114Choose the correct type of surgical procedure that matches: Restores function or appearance to traumatized tissues

     1. Aresorative
     2. Bprocurement
     3. Cconstructive
     4. Dcosmetic
115. 115Choose the correct type of surgical procedure that matches: Must be done immediately to save life or preserve function of body part

     1. Aemergency
     2. Bdiagnostic
     3. Cablative
     4. Dpalliative
116. 116Choose the correct type of surgical procedure that matches: Involves minimal risks compared with major procedures

     1. Aminor
     2. Belective
     3. Curgent
     4. Demergency
117. 117Choose the correct type of surgical procedure that matches: Exploration that allows diagnosis to be confirmed

     1. Adiagnostic
     2. Bablative
     3. Cpalliative
     4. Drestorative
118. 118Choose the correct type of surgical procedure that matches: Is not essential and is not always necessary for health

     1. Aelective
     2. Burgent
     3. Cemergency
     4. Ddiagnostic
119. 119Choose the correct type of surgical procedure that matches: Removal of organs or tissues from a dead person for transplantation into another

     1. Aprocurement
     2. Bconstructive
     3. Ccosmetic
     4. Dmajor
120. 120Choose the correct type of surgical procedure that matches: Relieves or reduces the intensity of disease symptoms; will not produce cure
     

     1. Apalliative
     2. Brestorative
     3. Cprocurement
     4. Dconstructive
121. 121 Mrs. Young, a 45-year-old patient with diabetes, is having a hysterectomy in the morning. Because of her history, the nurse would expect:

     1. AImpaired wound healing
     2. BFluid and electrolyte imbalances
     3. CAn increased risk of hemorrhaging
     4. DAltered elimination of anesthetic agents
122. 122 The purposes of the nursing history for the patient who is to have surgery include all of the following except:

     1. ADeciding whether surgery is indicated
     2. BIdentifying the patient’s perception and expectations about surgery
     3. CObtaining information about the patient’s past experience with surgery
     4. DUnderstanding the impact surgery has on the patient’s and family’s emotional health
123. 123All of the following patients are at risk for developing serious fluid and electrolyte imbalances during and after surgery except:

     1. APatient F, who is 1 year old and having a cleft palate repair
     2. BPatient H, who is 79 years old and has a history of congestive heart failure
     3. CPatient G, who is 55 years old and has a history of chronic respiratory disease
     4. DPatient E, who is 81years old and having emergency surgery for a bowel obstruction after 4 days of vomiting and diarrhea
124. 124The purpose of postoperative leg exercises is to:

     1. AMaintain muscle tone
     2. BPromote venous return
     3. CAssess range of motion
     4. DExercise fatigued muscles
125. 125The PACU nurse notices that the patient is shivering. This is most commonly caused by:

     1. ACold irrigations used during surgery
     2. BSide effects of certain anesthetic agents
     3. CMalignant hypothermia, a serious condition
     4. DThe use of a reflective blanket on the operating room table
126. 126An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation?

     1. AAssess the client’s mobility
     2. BMonitor respirations and breathing effort
     3. CTeach coughing and deep-breathing exercises.
     4. DDetermine normal activity levels and note when the client tires
127. 127To decrease abdominal distention following a client's surgery, what actions should the nurse take?

     1. AEncourage ambulation
     2. BGive sips of ginger ale
     3. CProvide a straw for drinking
     4. DOffer an opioid analgesic
128. 128Which would the nurse consider to be a potential respiratory system-related complication of surgery?

     1. AAtelectasis
     2. BHyperthermia
     3. CWound dehiscence
     4. DHypovolemic shock
129. 129What are the priorities of a circulating nurse when a surgery is taking place? Select all that apply.

     1. AThe nurse protects the client’s privacy
     2. BThe nurse assesses the client’s blood loss and urine
     3. CThe nurse monitors ventilation for nonintubated clients.
     4. DThe nurse monitors the level of anesthesia provided to the client
     5. EThe nurse provides supplies and equipment on the basis of the surgical team’s needs
130. 130After undergoing minor surgery, a postoperative child has recovered from anesthesia. Which observations may indicate that the child is fit to be discharged? Select all that apply.

     1. AVital signs are stable
     2. BTemperature is 101° F
     3. CThe child is alert and oriented
     4. DPain rate is at baseline level
     5. EOxygen saturation is 75% on room air
131. 131The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?

     1. AX-ray reports
     2. BSeverity of pain
     3. CResults of blood work
     4. DFamily caregiver interview
132. 132The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?

     1. AThe nurse notes nonverbal signs of discomfort
     2. BThe nurse observes the client’s position in bed
     3. CThe nurse asks the client to explain the surgery
     4. DThe nurse asks the client to rate the severity of pain
133. 133The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply.

     1. AThe client reports pain with movement.
     2. BThe client has pain over the surgical area
     3. CThe client wants to know when he can go home
     4. DThe client rates the pain as 8 on a scale of 0 to 10
     5. EThe client has concerns about caring for the wound
134. 134A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. The nurse then notifies the primary healthcare provider. Which standard of practice does the nurse perform?

     1. Aplanning
     2. Bdiagnosis
     3. Cassessment
     4. Dimplementation
135. 135A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

     1. AAssess the patency of airway
     2. BAsk if the client is comfortable.
     3. CDetermine the level of consciousness
     4. DReview the order for intravenous fluids
136. 136After surgery a client is to receive an antibiotic by intravenous piggyback (IVPB) in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtt/mL. The nurse should set the piggyback to flow at 36 gtt/ml.

     1. AVerdadero
     2. BFalso
137. 137After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?

     1. AMonitor for signs of electrolyte imbalance
     2. BChange the tube at least once every 48 hours
     3. CConnect the nasogastric tube to high continuous suction
     4. DAssess placement by injecting 10 mL of water into the tube
138. 138A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action?

     1. AOrient the client to the unit environment
     2. BHave a copy of hospital regulations available
     3. CExplain that there is no reason to be concerned
     4. DReassure the client that the staff is available if the client has questions
139. 139A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the primary healthcare provider if the client does not void?

     1. A4 hours
     2. B8 hours
     3. C10 hours
     4. D12 hours
140. 140A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

     1. APostural drainage
     2. BCupping the chest
     3. CNasotracheal suctioning
     4. DFrequent changes of position
141. 141The nurse is providing postoperative care to a kidney transplant recipient. What is the nurse’s first priority during this period?

     1. ATeaching signs of rejection to the client
     2. BMaintaining fluid and electrolyte balance
     3. CProviding emotional support to the recipient
     4. DAdvising the client to have frequent blood testing
142. 142When should the nurse use hypoallergenic tape or Montgomery straps as the best practice in postoperative skin care?

     1. AWhen conserving the client’s energy
     2. BWhen protecting the fragile skin of the older client
     3. CWhen maintaining the psychosocial health of the older client
     4. DWhen improving perfusion to the wound to promote wound healing
143. 143Which pulmonary risk may be increased in a postoperative client due to anesthesia?

     1. ARhonchi
     2. BFremitus
     3. Cdyspnea
     4. DAtelectasis
144. 144While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?

     1. ARadial and apical pulse
     2. BApical and carotid pulse
     3. CRadial and brachial pulse
     4. DApical and temporal pulse
145. 145A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs?

     1. A1
     2. B2
     3. C3
     4. D4
146. 146When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

     1. Adecreased BP
     2. BIncreased oral temperature
     3. CDiminished peripheral pulses
     4. DUnequal bilateral breath sounds
147. 147A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention?

     1. AAttempt to identify the client's concerns
     2. BReassure the client that the surgery is routine
     3. CReport the client's anxiety to the healthcare provider
     4. DProvide privacy by pulling the curtain around the client
148. 148A nurse uses the Braden Scale to predict a client’s risk for developing pressure ulcers. Which data should the nurse use to determine a client’s score on this scale? Select all that apply.

     1. Aage
     2. BAnorexia
     3. CHemiplegia
     4. DHx of DM
     5. EUrinary incontinence
149. 149The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

     1. Asunken eyes
     2. BDry, flaky skin
     3. Cchange in mental status
     4. DDecreased bowel sounds
150. 150A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

     1. AAdminister oxygen
     2. BRaise HOB
     3. CPerform tracheal suctioning
     4. DCall the healthcare provider
151. 151A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.

     1. Achronic stress
     2. BSevere anxiety
     3. Cgeneralized pain
     4. DExcessive caffeine
     5. Echronic depression
     6. FEnvironmental noise/distractors
152. 152A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

     1. AMaintain the head of the bed at 35 degrees or less
     2. BWith the help of another staff member, use a drawsheet when lifting the client in bed.
     3. CReposition the client at least every 2 hours and support the client with pillows.
     4. DAt least once every 8 hours, perform passive range-of-motion exercises of all extremities
153. 153A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?

     1. ASooty-colored sputum
     2. BFrothy, pink-tinged sputum
     3. CDisorientation with twitching
     4. DUrine output of 25 mL/hr
154. 154A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply.

     1. ADrink a glass of wine
     2. BEngage in mild exercise before bedtime
     3. CEat foods containing lysine
     4. DFollow the same bedtime ritual each night
     5. EPerform deep-breathing exercises.
155. 155A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next?

     1. ACheck the record to ascertain the code status
     2. BEncourage increased intake of favorite drink
     3. CPerform a head-to-toe assessment, including vital signs
     4. DContinue to monitor daily weights and edema and to document findings.
156. 156A nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge?

     1. AContact the client's healthcare provider to ask to substitute a liquid form of medications for the pill form
     2. BTeach the client and family members to crush the pills and administer them with applesauce
     3. CContact the client's healthcare provider to discuss use of transdermal medications for pain control
     4. DTeach the client and family members about addiction that may occur as a result of regular opioid use.
157. 157The student nurse is collecting a clean-catch midstream urine specimen from a client suspected of urinary tract infection. After reviewing the results, the head nurse instructs the student nurse to repeat the procedure. Which finding in the urinalysis report supports the head nurse’s instruction?

     1. A10/\2 organisms/mL
     2. B10/\4 organisms/mL
     3. C10/\6 organisms/mL
     4. D10/\8 organisms/mL
158. 158The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply.

     1. ATell a staff member to get the electrocardiogram machine.
     2. BNotify the x-ray department that a chest x-ray exam must be done stat
     3. CHave a staff member notify the nursing supervisor of the change in client status
     4. DNotify the healthcare provider of the change in the oxygen saturation to ask what to do
     5. ETell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen.
     6. FIncrease the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.
159. 159The nurse is caring for a client with complete partial seizures. Put in priority order the care activities performed by the nurse
     
     1. Assessing vital signs
     2. Perform neuro checks
     3. Maintain airway
     4. Record time & duration of seizure

     1. A1, 2, 3, 4
     2. B4, 3, 2, 1
     3. C3, 1, 4, 2
     4. D3, 4, 1, 2
160. 160A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse’s responsibility in regard to this prescription?

     1. AAsking that the prescription indicate the type of restraint
     2. BRecognizing that PRN prescriptions for restraints are unacceptable
     3. CImplementing the restraint prescription when the client begins to act out
     4. DEnsuring that the entire staff is aware of the prescription for the restraints
161. 161A hospice nurse is caring for a dying client while several family members are in the room. When the client dies, the initial nursing intervention during the shock phase of a grief reaction is focused on what?
     

     1. AStaying with the individuals involved
     2. BDirecting the individuals' activities at this time
     3. CMobilizing the support systems of the individuals
     4. DPresenting the full reality of the loss to the individuals
162. 162A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant’s hydration status?
     

     1. ACounting wet diapers
     2. BObtaining daily weights
     3. CMeasuring intake and output
     4. DChecking tissue turgor of the abdomen
163. 163A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what?

     1. ARespiratory rate
     2. BAmount of oxygen in the blood
     3. CPercentage of hemoglobin-carrying oxygen
     4. DAmount of carbon dioxide in the blood
164. 164The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse?

     1. APlace the child on the toilet every 2 hours
     2. BStart by having the child sit on a potty chair
     3. CAvoid bowel training until the child is 2 years old.
     4. DBegin before the child's diet consists mainly of solid foods
165. 165The nurse is instructing a client with an eye disorder who is receiving prednisolone acetate eye drops regarding the precautions to be followed. Which statement made by the client indicates effective learning?

     1. A"I should check for bleeding in the eye."
     2. B"I should protect the drug from sunlight."
     3. C"I should refrain from wearing soft contact lenses."
     4. D"I should shake the bottle vigorously before I use the eye drops."

Descripción

Fundamentals II Test sobre Exam # 1 Part 2, creado por Nicole Buda el 01/11/2016.

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Nicole Buda

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