lOMoARcPSD|52574771

PNLE Reviewer-NP1

Bachelor of Science in Nursing (Xavier University - Ateneo de Cagayan)

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PNLE REVIEWER B. A client who had a CVA in the past two

months
1. The registered nurse is planning to delegate C. A client with Chronic renal failure
tasks to unlicensed assistive personnel (UAP). D. A client with chronic venous insufficiency
Which of the following task could the registered 5. The nurse in the medication unit passes the
nurse safely assigned to a UAP? medications for all the clients on the nursing
unit. The head nurse is making rounds with the
A. Monitor the I&O of a comatose toddler physician and coordinates clients’ activities with
client with salicylate poisoning other departments. The nurse assistant changes
B. Perform a complete bed bath on a 2-year- the bed lines and answers call lights. A second
old with multiple injuries from a serious nurse is assigned for changing wound dressings;
fall a licensed practitioner nurse takes vital signs and
C. Check the IV of a preschooler with bathes theclients. This illustrates of what method
Kawasaki disease of nursing care?
D. Give an outmeal bath to an infant with
eczema A. Case management method
2. A nurse manager assigned a registered nurse B. Primary nursing method
from telemetry unit to the pediatrics unit. There C. Team method
were three patients assigned to the RN. Which of D. Functional method
the following patients should not be assigned to 6. A registered nurse has been assigned to six
the floated nurse? clients on the 12-hour shift. The RN is
responsible for every aspect of care such as
A. A 9-year-old child diagnosed with formulating the care of plan, intervention and
rheumatic fever evaluating the care during her shift. At the end
B. A young infant after pyloromyotomy of her shift, the RN will pass this same task to
C. A 4-year-old with VSD following cardiac the next RN in charge. This nursing care
catheterization illustrates of what kind of method?
D. A 5-month-old with Kawasaki disease
A. primary nursing method
3. A nurse in charge in the pediatric unit is B. case method
absent. The nurse manager decided to assign the C. team method
nurse in the obstetrics unit to the pediatrics unit. D. functional method
Which of the following patients could the nurse 7. A newly hired nurse on an adult medicine unit
manager safely assign to the float nurse? with 3 months experience was asked to float to
pediatrics. The nurse hesitates to perform
A. A child who had multiple injuries from a pediatric skills and receive an interesting
serious vehicle accident assignment that feels overwhelming. The nurse
B. A child diagnosed with Kawasaki disease should:
and with cardiac complications
C. A child who has had a nephrectomy for A. resign on the spot from the nursing position
Wilm’s tumor and apply for a position that does not
D. A child receiving an IV chelating therapy require floating
for lead poisoning B. Inform the nursing supervisor and the
4. The registered nurse is planning to delegate charge nurse on the pediatric floor about
task to a certified nursing assistant. Which of the the nurse’s lack of skill and feelings of
following clients should not be assigned to a hesitations and request assistance
CAN? C. Ask several other nurses how they feel
about pediatrics and find someone else who
A. A client diagnosed with diabetes and who is willing to accept the assignment
has an infected toe

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D. Refuse the assignment and leave the unit 12. A nurse caring to a client with Alzheimer’s
requesting a vacation a day disease overheard a family member say to the
8. An experienced nurse who voluntarily trained client, “if you pee one more time, I won’t give
a less experienced nurse with the intention of you any more food and drinks”. What initial
enhancing the skills and knowledge and action is best for the nurse to take?
promoting professional advancement to the
nurse is called a: A. Take no action because it is the family
member saying that to the client
A. mentor B. Talk to the family member and explain that
B. team leader what she/he has said is not appropriate for
C. case manager the client
D. change agent C. Give the family member the number for an
9. The pediatrics unit is understaffed and the Elder Abuse Hot line
nurse manager informs the nurses in the D. Document what the family member has
obstetrics unit that she is going to assign one said
nurse to float in the pediatric units. Which 13. Which is true about informed consent?
statement by the designated float nurse may put
her job at risk? A. A nurse may accept responsibility signing a
consent form if the client is unable
A. “I do not get along with one of the nurses B. Obtaining consent is not the responsibility
on the pediatrics unit” of the physician
B. “I have a vacation day coming and would C. A physician will not subject himself to
like to take that now” liability if he withholds any facts that are
C. “I do not feel competent to go and work on necessary to form the basis of an intelligent
that area” consent
D. “ I am afraid I will get the most serious D. If the nurse witnesses a consent for surgery,
clients in the unit” the nurse is, in effect, indicating that the
10. The newly hired staff nurse has been signature is that of the purported person
working on a medical unit for 3 weeks. The and that the person’s condition is as
nurse manager has posted the team leader indicated at the time of signing
assignments for the following week. The new 14. A mother in labor told the nurse that she was
staff knows that a major responsibility of the expecting that her baby has no chance to survive
team leader is to: and expects that the baby will be born dead. The
mother accepts the fate of the baby and informs
A. Provide care to the most acutely ill client the nurse that when the baby is born and
on the team requires resuscitation, the mother refuses any
B. Know the condition and needs of all the treatment to her baby and expresses hostility
patients on the team toward the nurse while the pediatric team is
C. Document the assessments completed by taking care of the baby. The nurse is legally
the team members obligated to:
D. Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby A. Notify the pediatric team that the mother
boy who needs emergency surgery. The nurse has refused resuscitation and any treatment
prepared the consent form and it should be for the baby and take the baby to the
signed by: mother
B. Get a court order making the baby a ward
A. The Physician of the court
B. The Registered Nurse caring for the client C. Record the statement of the mother, notify
C. The 15-year-old mother of the baby boy the pediatric team, and observe carefully
D. The mother of the girl

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for signs of impaired bonding and neglect 18. A staff nurse has had a serious issue with her
as a reasonable suspicion of child abuse colleague. In this situation, it is best to:
D. Do nothing except record the mother’s
statement in the medical record A. Discuss this with the supervisor
15. The hospitalized client with a chronic cough B. Not discuss the issue with anyone. It will
is scheduled for bronchoscopy. The nurse is probably resolve itself
tasks to bring the informed consent document C. Try to discuss with the colleague about the
into the client’s room for a signature. The client issue and resolve it when both are calmer
asks the nurse for details of the procedure and D. Tell other members of the network what
demands an explanation why the process of the team member did
informed consent is necessary. The nurse 19. The nurse is caring to a client who just gave
responds that informed consent means: birth to a healthy baby boy. The nurse may not
disclose confidential information when:
A. The patient releases the physician from all
responsibility for the procedure. A. The nurse discusses the condition of the
B. The immediate family may make decision client in a clinical conference with other
against the patient’s will. nurses
C. The physician must give the client or B. The client asks the nurse to discuss the her
surrogates enough information to make condition with the family
health care judgments consistent with their C. The father of a woman who just delivered a
values and goals. baby is on the phone to find out the sex of
D. The patient agrees to a procedure ordered the baby
by the physician even if the client does not D. A researcher from an institutionally
understand what the outcome will be. approved research study reviews the
16. A hospitalized client with severe necrotizing medical record of a patient
ulcer of the lower leg is schedule for an 20. A 17-year-old married client is scheduled for
amputation. The client tells the nurse that he will surgery. The nurse taking care of the client
not sign the consent form and he does not want realizes that consent has not been signed after
any surgery or treatment because of religious preoperative medications were given. What
beliefs about reincarnation. What is the role of should the nurse do?
the RN?
A. Call the surgeon
A. call a family meeting B. Ask the spouse to sign the consent
B. discuss the religious beliefs with the C. Obtain a consent from the client as soon as
physician possible
C. encourage the client to have the surgery D. Get a verbal consent from the parents of the
D. inform the client of other options client
17. While in the hospital lobby, the RN 21. A 12-year-old client is admitted to the
overhears the three staff discussing the health hospital. The physician ordered Dilantin to the
condition of her client. What would be the client. In administering IV phenytoin (Dilantin)
appropriate nursing action for the RN to take? to a child, the nurse would be most correct in
mixing it with:
A. Tell them it is not appropriate to discuss the
condition of the client A. Normal Saline
B. Ignore them, because it is their right to B. Heparinized normal saline
discuss anything they want to C. 5% dextrose in water
C. Join in the conversation, giving them D. Lactated Ringer’s solution
supportive input about the case of the client 22. The nurse is caring to a client who is
D. Report this incident to the nursing hypotensive. Following a large hematemesis,
supervisor how should the nurse position the client?

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A. Feet and legs elevated 20 degrees, trunk A. administering insulin-replacement therapy

horizontal, head on small pillow B. providing a low-sodium diet
B. Low Fowler’s with knees gatched at 30 C. restricting fluids to 1500 ml/day
degrees D. reducing physical and emotional stress
C. Supine with the head turned to the left 28. The nurse is to perform tracheal suctioning.
D. Bed sloped at a 45 degree angle with the During tracheal suctioning, which nursing action
head lowest and the legs highest is essential to prevent hypoxemia?
23. The client is brought to the emergency
department after a serious accident. What would A. aucultating the lungs to determine the
be the initial nursing action of the nurse to the baseline data to assess the effectiveness of
client? suctioning
B. removing oral and nasal secretions
A. assess the level of consciousness and C. encouraging the patient to deep breathe and
circulation cough to facilitate removal of upper-airway
B. check respirations, circulation, neurological secretions
response D. administering 100% oxygen to reduce the
C. align the spine, check pupils, check for effects of airway obstruction during
hemorrhage suctioning.
D. check respiration, stabilize spine, check 29. An infant is admitted and diagnosed with
circulation pneumonia and suspicious-looking red marks on
24. A nurse is assigned to care to a client with the swollen face resembling a handprint. The
Parkinson’s disease. What interventions are nurse does further assessment to the client. How
important if the nurse wants to improve nutrition would the nurse document the finding?
and promote effective swallowing of the client?
A. Facial edema with ecchymosis and
A. Eat solid food handprint mark: crackles and wheezes
B. Give liquids with meals B. Facial edema, with red marks; crackles in
C. Feed the client the lung
D. Sit in an upright position to eat C. Facial edema with ecchymosis that looks
25. During tracheal suctioning, the nurse should like a handprint
implement safety measures. Which of the D. Red bruise mark and ecchymosis on face
following should the nurse implements? 30. On the evening shift, the triage nurse
evaluates several clients who were brought to
A. limit suction pressure to 150-180 mmHg the emergency department. Which in the
B. suction for 15-20 seconds following clients should receive highest
C. wear eye goggles priority?
D. remove the inner cannula
26. The nurse is conducting a discharge A. an elderly woman complaining of a loss of
instructions to a client diagnosed with diabetes. appetite and fatigue for the past week
What sign of hypoglycemia should be taught to B. A football player limping and complaining
a client? of pain and swelling in the right ankle
C. A 50-year-old man, diaphoretic and
A. warm, flushed skin complaining of severe chest pain radiating
B. hunger and thirst to his jaw
C. increase urinary output D. A mother with a 5-year-old boy who says
D. palpitation and weakness her son has been complaining of nausea
27. A client admitted to the hospital and and vomited once since noon
diagnosed with Addison’s disease. What would A 80-year-old female client is brought to the
be the appropriate nursing action to the client? emergency department by her caregiver, on the
nurse’s assessment; the following are the

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manifestations of the client: anorexia, cachexia A. outline the kidney vasculature

and multiple bruises. What would be the best B. determine the size, shape, and placement of
nursing intervention? the kidneys
C. test renal tubular function and the patency
A. check the laboratory data for serum of the urinary tract
albumin, hematocrit, and hemoglobin D. measure renal blood flow
B. talk to the client about the caregiver and 36. A client visits the clinic for screening of
support system scoliosis. The nurse should ask the client to:
C. complete a police report on elder abuse
D. complete a gastrointestinal and A. bend all the way over and touch the toes
neurological assessment B. stand up as straight and tall as possible
32. The night shift nurse is making rounds. C. bend over at a 90-degree angle from the
When the nurse enters a client’s room, the client waist
is on the floor next to the bed. What would be D. bend over at a 45-degree angle from the
the initial action of the nurse? waist
37. A client with tuberculosis is admitted in the
A. chart that the patient fell hospital for 2 weeks. When a client’s family
B. call the physician members come to visit, they would be adhering
C. chart that the client was found on the floor to respiratory isolation precautions when they:
next to the bed
D. fill out an incident report A. wash their hands when leaving
33. The nurse on the night shift is about to B. put on gowns, gloves and masks
administer medication to a preschooler client C. avoid contact with the client’s roommate
and notes that the child has no ID bracelet. The D. keep the client’s room door open
best way for the nurse to identify the client is to 38. An infant is brought to the emergency
ask: department and diagnosed with pyloric stenosis.
The parents of the client ask the nurse, “Why
A. The adult visiting, “The child’s name is does my baby continue to vomit?” Which of the
____________________?” following would be the best nursing response of
B. The child, “Is your name____________?” the nurse?
C. Another staff nurse to identify this child
D. The other children in the room what the A. “Your baby eats too rapidly and overfills
child’s name is the stomach, which causes vomiting
34. The nurse caring to a client has completed B. “Your baby can’t empty the formula that is
the assessment. Which of the following will be in the stomach into the bowel”
considered to be the most accurate charting of a C. “The vomiting is due to the nausea that
lump felt in the right breast? accompanies pyloric stenosis”
D. “Your baby needs to be burped more
A. “abnormally felt area in the right breast, thoroughly after feeding”
drainage noted” 39. A 70-year-old client with suspected
B. “hard nodular mass in right breast nipple” tuberculosis is brought to the geriatric care
C. “firm mass at five ‘ clock, outer quadrant, facilities. An intradermal tuberculosis test is
1cm from right nipple’ schedule to be done. The client asks the nurse
D. “mass in the right breast 4cmx1cm what is the purpose of the test. Which of the
35. The physician instructed the nurse that following would be the best rationale for this?
intravenous pyelogram will be done to the client.
The client asks the nurse what is the purpose of A. reactivation of an old tuberculosis infection
the procedure. The appropriate nursing response B. increased incidence of new cases of
is to: tuberculosis in persons over 65 years old

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C. greater exposure to diverse health care stenosis. The appropriate nursing response
workers would be:
D. respiratory problems are characteristic in
this population A. There is no way to determine this
40. The nurse is making a health teaching to the preoperatively
parents of the client. In teaching parents how to B. Their baby was born with this condition
measure the area of induration in response to a C. Their baby developed this condition during
PPD test, the nurse would be most accurate in the first few weeks of life
advising the parents to measure: D. Their baby acquired it due to a formula
allergy
A. both the areas that look red and feel raised 45. A male client comes to the clinic for check-
B. The entire area that feels itchy to the child up. In doing a physical assessment, the nurse
C. Only the area that looks reddened should report to the physician the most common
D. Only the area that feels raised symptom of gonorrhea, which is:
41. A community health nurse is schedule to do
home visit. She visits to an elderly person living A. pruritus
alone. Which of the following observation B. pus in the urine
would be a concern? C. WBC in the urine
D. Dysuria
A. Picture windows 46. Which of the following would be the most
B. Unwashed dishes in the sink important goal in the nursing care of an infant
C. Clear and shiny floors client with eczema?
D. Brightly lit rooms
42. After a birth, the physician cut the cord of A. preventing infection
the baby, and before the baby is given to the B. maintaining the comfort level
mother, what would be the initial nursing action C. providing for adequate nutrition
of the nurse? D. decreasing the itching
47. The nurse is making a discharge instruction
A. examine the infant for any observable to a client receiving chemotherapy. The client is
abnormalities at risk for bone marrow depression. The nurse
B. confirm identification of the infant and gives instructions to the client about how to
apply bracelet to mother and infant prevent infection at home. Which of the
C. instill prophylactic medication in the following health teaching would be included?
infant’s eyes
D. wrap the infant in a prewarmed blanket and A. “Get a weekly WBC count”
cover the head B. “Do not share a bathroom with children or
43. A 2-year-old client is admitted to the pregnant woman”
hospital with severe eczema lesions on the scalp, C. “Avoid contact with others while receiving
face, neck and arms. The client is scratching the chemotherapy”
affected areas. What would be the best nursing D. “Do frequent hand washing and maintain
intervention to prevent the client from scratching good hygiene”
the affected areas? 48. The nurse is assigned to care the client with
infectious disease. The best antimicrobial agent
A. elbow restraints to the arms for the nurse to use in handwashing is:
B. Mittens to the hands
C. Clove-hitch restraints to the hands A. Isopropyl alcohol
D. A posey jacket to the torso B. Hexachlorophene (Phisohex)
44. The parents of the hospitalized client ask the C. Soap and water
nurse how their baby might have gotten pyloric D. Chlorhexidine gluconate (CHG)
(Hibiclens)

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49. The mother of the client tells the nurse, “ I’m blood and sputum samples for analysis.
not going to have my baby get any Which standard of practice is performed?
immunization”. What would be the best nursing
response to the mother?
a. diagnosis
b. evaluation
A. “You and I need to review your rationale
c. assessment
for this decision”
B. “Your baby will not be able to attend day d. implementation
care without immunizations”
C. “Your decision can be viewed as a form of 3. A patient in the emergency department
child abuse and neglect” has developed wheezing and shortness of
D. “You are needlessly placing other people at breath. The nurse gives the ordered
risk for communicable diseases” medicated nebulizer treatment now and in 4
50. The nurse is teaching the client about breast hours. Which standard of practice is
self-examination. Which observation should the performed?
client be taught to recognize when doing the
examination for detection of breast cancer?
a. planning
A. tender, movable lump b. evaluation
B. pain on breast self-examination c. assessment
C. round, well-defined lump d. implementation
D. dimpling of the breast tissue
4. A nurse is caring for a patient with end-
stage lung disease. The patient wants to go
home on oxygen and be comfortable. The
1. You are preparing presentation for you family wants the patient to have a new
classmates regarding the clinical care surgical procedure. The nurse explains the
coordination conference for a patient with risk and benefits of the surgery to the family
terminal cancer. As part of the preparation and discusses the patient's wishes with
you have your classmates read the Nursing them. The nurse is acting as the patient's:
Code of Ethics for Professional Registered
Nurses. Your instructor asks the class why a. educator
this document is important. Which of the b. advocate
following statements best describes this c. caregiver
code? d. case manager

a. improves self-health care 5. The nurse spends time with the patient
b. protects the patient's confidentiality and family reviewing the dressing change
c. ensures identical care to all patients procedure for the patient's wound. The
d. defines the principles of right and wrong patient's spouse demonstrates how to
to provide patient care change the dressing. The nurse is acting in
which professional role?
2. An 18-year old woman is in the
emergency department with fever and a. educator
cough. The nurse obtains her vital signs, b. advocate
listens to her lung and heart sounds, c. caregiver
determines her level of comfort, and collects d. case manager

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6. The examination for registered nurse models is expected from health care
(RN) licensure is exactly the same in every reform?
state in the United States. This examination:
a. moving from an acute illness to a health
a. guarantees safe nursing for all patients promotion, illness prevention model
b. ensures standard nursing care for b. moving from an illness prevention to a
patients health promotion model
c. ensures that honest and ethical care is c. moving from an acute illness to a disease
provided management model
d. provides a minimal standard of d. moving from a chronic care to an illness
knowledge for an RN in practice prevention model

7. Contemporary nursing requires that the 10. A nurse meets with the registered
nurse has knowledge and skills for a variety dietician and physical therapist to develop a
of professional roles and responsibilities. plan of care that focuses on improving
Which of the following are examples? nutrition and mobility for a patient. This is an
(Select all that apply.) example of which Quality and Safety in the
Education of Nurses (QSEN) competency?
A. Caregiver
B. Autonomy and accountability a. patient-centered care
C. Patient advocate b. safety
D. Health promotion c. teamwork and collaboration
E. Lobbyist d. informatics

8. Match the advanced practice nurse 11. A critical care nurse is using a
specialty with the statement about the role. computerized decision support system to
correctly position her ventilated patients to
1. Clinical nurse specialist - B reduce pneumonia caused by accumulated
2. Nurse anesthetist- D respiratory secretions. This is an example of
3. Nurse practitioner- C which Quality and Safety in the Education of
4. Nurse-midwife- A Nurses (QSEN) competency?

a. Provides independent care, including a. patient-centered care

pregnancy and gynecological services b. safety
b. Expert clinician in a specialized area of c. teamwork and collaboration
practice such as adult diabetes care d. informatics
c. Provides comprehensive care, usually in
a primary care setting, directly managing 12. The nurses on an acute care medical
the medical care of patients who are healthy floor notice an increase in pressure ulcer
or have chronic conditions formation in their patients. A nurse
d. Provides care and services under the consultant decides to compare two types of
supervision of an anesthesiologist treatment. The first is the procedure
currently used to assess for pressure ulcer
9. Healthcare reform will bring changes in risk. The second uses a new assessment
the emphasis of care. Which of the following instrument to identify at-risk patients. Given

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this information, the nurse consultant exchange before the designated deadline to
exemplifies which career? make sure I had health insurance"
d. "since I have now been diagnosed with
a. clinical nurse specialist diabetes, my health insurance plan cannot
b. nurse administrator charge me higher premiums"
c. nurse educator
d. nurse researcher 16. Which activity performed by a nurse is
related to maintaining competency in
13. Nurses in an acute care hospital are nursing practice?
attending a unit based education program to
learn how to use a new pressure-relieving a. asking another nurse about how to
device for patients at risk for pressure change the settings on a medication pump
ulcers. This is which type of education? b. regularly attending unit staff meetings
c. participating as a member of the
a. continuing education professional nursing council
b. graduate education d. attending a review course in preparation
c. in-service education for a certification examination
d. professional registered nurse education
17. A patient tells a nurse that she is
14. Which of the following Internet enrolled in a preferred provider organization
resources can help consumers compare (PPO) but does not understand what this is.
quality care measures? (Select all that What is the nurse's best explanation of a
apply) PPO?

a. WebMD a. this health plan is for people who cannot

b. Hospital Compare afford their own health insurance
c. Magnet Recognition Program b. this health plan is operated by the
d. Hospital Consumer Assessment of government to provide healthcare to older
Healthcare adults
e. The American Hospital Association's c. this health plan gives you a list of
webpage physicians and hospital from which you can
choose
15. A community center is presenting a d. this is a fee-for-service plan in which you
nurse-led program on the Patient Protection can choose any physician or hospital
and Affordable Care Act. Which statement
made by a participate indicates a need for 18. Which of the following are examples of a
the further teaching? nurse participating in primary care
activities? (Select all that apply)
a. "my small company will now have to offer
the 75 employees health insurance or pay a a. providing prenatal teaching on nutrition to
penalty" a pregnant woman during the first trimester
b. "as long as my son is a full-time student b. assessing the nutritional status of older
in college, I will be able to keep him on my adults who come to the community center
health insurance until he is 26 year olds" for lunch
c. "I signed up for the state health insurance c. working with patients in a cardiac

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rehabilitation program c. Rapid-improvement event (RIE)

d. providing home wound care to a patient d. A randomized controlled trial
e. teaching a class to parents at the local
grade school about the importance of 22. Which of the following are
immunizations characteristics of managed care systems?
(Select all that apply)
19. Nurses on a nursing unit are discussing
the processes that led up to a near-miss a. provider receives a predetermined
error on the clinical unit. They are outlining payment for each patient in the program
strategies that will prevent this in the future. b. payment is based on a set fee for each
This is an example of nurses working on service provided
what issue in the health care system? c. system includes a voluntary prescription
drug program for an additional cost
a. patient safety d. system tried to reduce costs while
b. evidence-based practice keeping patients healthy
c. patient satisfaction e. focus of care is on prevention and early
d. maintenance of competency intervention

20. Which of the following statements is true 23. Which of the following nursing activities
regarding Magnet status recognition for a is provided in a secondary health care
hospital? environment?

a. nursing is run by a Magnet manager who a. conducting blood pressure screenings for
makes decisions for the nursing units older adults at the Senior Center
b. nurses in Magnet hospitals make all of b. teaching a clinic patient with chronic
the decisions on the clinical units obstructive pulmonary disease purse-lipped
c. Magnet is a term that is used to describe breathing techniques
hospitals that are able to hire the nurses c. changing the postoperative dressing for a
they need patient on a medical surgical unit
d. Magnet is a special designation for d. doing endotracheal suctioning for a
hospitals that achieve excellence in nursing patient on a ventilator in the medical
practice intensive care unit

21. A group of staff nurses notice an 24. A nurse is using the Plan-Do-Study-Act
increased incidence of medication errors on (PDSA) strategy to do a quality
their unit. After further investigation it is improvement project to decrease patient
determined that the nurses are not falls on a nursing unit. Place the steps in the
consistently identifying the patient correctly. correct sequence for PDSA.
A change is needed quickly. What type of
quality improvement method would be most a. bedside change of shift report is piloted
appropriate? on tow medical surgical units
b. patient satisfaction levels after
a. PDSA implementation of the bedside report are
b. Six Sigma compared to patient satisfaction levels
before the change

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c. the nursing council develops a strategy b. pay for performance

for bedside change of shift report c. capitation payment system
d. After modifications are made in the shift d. managed care systems
report elements, bedside shift report is
implemented on all nursing units 28. A nurse is using data collected from the
-C, A, B, D unit to monitor the incidence of falls after the
unit implemented a new fall protocol. The
25. The nursing staff is developing a quality nurse is working in which area?
program. Which of the following are nursing-
sensitive indicators from the National a. Quality improvement (QI)
Database of Nursing Quality Indicators b. health care patient system
(NDNQI) that the nurses can use to c. nursing informatics
measure patient safety and quality for the d. computerized nursing network
unit? (Select all that apply)
29. The nurses on a medical unit have seen
a. use of physical restraints an increase in the number of pressure
b. pain assessment, intervention, and ulcers that develop in their patients. They
reassessment decide to initiate a quality improvement
c. patient satisfaction with food preparation project using the Plan-Do-Study-Act (PDSA)
d. registered nurse (RN) education and model. Which of the following is an example
certification of "Do" from that model?
e. number of outpatient surgical cases per
year a. implementing the new skin care protocol
on all medicine units
26. A nurse is providing restorative care to a b. reviewing the data collected on patients
patient following an extended hospitalization cared for using the protocol
for an acute illness. Which of the following is c. reviewing the quality improvement reports
an appropriate goal for restorative care? on the six patients who developed ulcers
over the last 3 months
a. patient will be able to walk 200 feet d. based on findings from patients who
without shortness of breath developed ulcers, implementing an
b. wound will heal without signs of infection evidence-based skin care protocol
c. patient will express concerns related to
return home 30. The patient for whom you are caring
d. patient will identify strategies to improve needs a liver transplant to survive. This
sleep habits patient has been out of work for several
months and doesn't have health insurance
27. A nursing is presenting information to a or enough cash. Even though several
management class of nursing students on ethical principles are at work in this case,
the topic of financial reimbursement for list the principles from highest to lowest
achievement of established, measurable priority.
patient outcomes. The nurse is presenting
information on the class on which topic? a. accountability: you as the nurse are
accountable for the well-being of this patient
a. prospective payment system b. respect for autonomy: this patient's

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autonomy will be violated if he does not

receive the liver transplant a. seeking out the nursing supervisor to talk
c. ethics of care: the caring thing that a with the patient
nurse could provide this patient is resources b. documenting patient fears in the medical
for a liver transplant record in a timely manner
d. justice: the greatest in this situation is c. working to change the hospital
how to determine the just distribution of environment
resources d. assessing the patient's point of view and
- D, B, C, A preparing to articulate it

31. A child's immunization may cause 34. The application of utilitarianism does not
discomfort during administration, but the always resolve an ethical dilemma. Which of
benefits, of protection of disease, both for the following statements best explains why?
the individual and society, outweigh the
temporary discomforts. Which principle is a. utilitarianism refers to usefulness and
involved in this situation? therefore eliminates the need to talk about
spiritual values
a. fidelity b. in a diverse community it can be difficult
b. beneficence to find agreement on a definition of
c. nonmaleficence usefulness, the focus of utilitarianism
d. respect for autonomy c. even when agreement about a definition
of usefulness exists in a community, laws
32. When designing a plan for pain prohibit an application of utilitarianism
management for a postoperative patient. the d. difficult ethical decisions cannot be
nurse assesses that the patient's priority is resolved by talking about the usefulness of
to be as free of pain as possible. The nurse a procedure
and patient work together to identify a plan
to manage the pain. The nurse continually 35. The ethics of care suggests that ethical
reviews the plan with the patient to ensure dilemmas can best be solved by attention to
that the patient's priority is met. Which relationships. How does this differ from
principle is used to encourage the nurse to other ethical practices? (Select all that
monitor the patient's response to the pain? apply.)

a. fidelity a. Ethics of care pays attention to the

b. beneficence environment in which caring occurs.
c. nonmaleficence b. Ethics of care pays attention to the
d. respect for autonomy stories of the people involved in the ethical
issue.
33. A patient is admitted to a medical unit. c. Ethics of care is used only in nursing
The patient is fearful of hospitals. The nurse practice.
carefully assesses the patient to determine d. Ethics of care focuses only on the code of
the exact fears and then establishes ethics for nurses
interventions designed to reduce these e. Ethics of care focuses only on
fears. In this setting how is the nurse understanding relationships.
practicing patient advocacy?

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36. In most ethical dilemmas in health care, This includes the protection of patient
the solution to the dilemma requires privacy. ON the basis of this principle, if you
negotiation among members of the health participate in a public online social network
care team. Why is the nurse's point of view such as Facebook, could you post images
valuable? of a patient's x-ray film if you obscured or
deleted all patient identifiers?
a. nurses understand the principle of
autonomy to guide respect for a patient's a. yes, because patient privacy would not
self-worth be violated since patient identifiers were
b. nurses have a scope of practice that removed
encourages their presence during ethical b. yes, because respect for autonomy
discussions implies that you have the autonomy to
c. nurses develop a relationship with the decide what constitutes privacy
patient that is unique among all professional c. no, because, even though patient
healthcare providers identifiers are removed, someone could
d. the nurse's code of ethics recommends identify the patient on the basis of other
that a nurse be present at any ethical comments that you make online about his or
discussion about patient care her condition and your place of work
d. no, because the principle of justice
37. Ethical dilemmas often arise over a requires you to allocate resources fairly
conflict of opinion. Reliance on a predictable
series of steps can help people in conflict 39. What are the correct steps to resolve an
find common ground. All of the following ethical dilemma on a clinical unit? Place the
actions in order to promote the resolution of steps in correct order.
an ethical dilemma?
a. clarify values
a. list the actions that could be taken to b. ask the question, is this an ethical
resolve the dilemma dilemma
b. agree on a statement of the problem or c. verbalize the problem
dilemma that you are trying to resolve d. gather information
c. agree on a plan to evaluate the action e. identify course of action
over time f. evaluate the plan
d. gather all relevant information regarding g. negotiate a plan
the clinical, social, and spiritual aspects of -B, D, A, C, E, G, F
the dilemma
e. take time to clarify values and distinguish 40. Resolution of an ethical dilemma
between facts and opinions-your own and involves discussion with the patient, the
those of others involved patient's family, and participants from all
d. negotiate a plan health care disciplines. Which of the
-D, E, B, A, F, C following describes the role of the nurse in
the resolution of ethical dilemmas?
38. The ANA code of nursing ethics
articulates that the nurse "promotes, A. To articulate his or her unique point of
advocates for, and strives to protect the view, including knowledge based on clinical
health, safety, and rights of the patients." and psychosocial observations

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B. To await new clinical orders from the of health care ethics

physician e. providers are exempt from fidelity to
C. To limit discussions about ethical people with drug addiction because
principals addiction reflects a lack of personal
D. To allow the patient and the physician to accountability
resolve the dilemma without regard to f. if a new drug is discovered that cures a
personally held values or opinions regarding disease but a great cost per patient, the
the ethical issues principle of justice suggests that the drug
should be made available to those who can
41. It can be difficult to agree on a common afford it
definition of the word quality when it comes
to quality of life. Why? (Select all that apply) 43. Match the examples with the
professional nursing code of ethics:
a. average income varies in different
regions of the country 1. You see an open medical record on the
b. community values influence definitions of computer and close it so no one else can
quality, and they are subject to change over read the record without proper access.
time 2.You administer a once a day cardiac
c. individual experiences influence medication at the wrong time, but nobody
perceptions of quality in different ways, sees it. However, you contact the primary
making consensus difficult care provider and your head nurse and
d. the value of elements such as cognitive follow agency procedure.
skills, ability to perform meaningful work, 3. A patient at the end of life wants to go
and relationship to family is difficult to home to die, but the family wants every care
quantify using objective measures possible. The nurse contacts the primary
e. statistical analysis is difficult to apply care provider about the patients request.
when the outcome cannot be quantified 4.You tell your patient that you will return in
f. whether or not a person has a job is an 30 minutes to give him his next pain
objective measure, but it does not play a medication.
tole in understanding quality of life
a. advocacy - 3
42. Which of the following properly applies b. responsibility- 4
an ethical principle to justify access to c. accountability- 2
health care? (Select all that apply) d. confidentiality- 1

a. access to health care reflects the 44. A nurse is caring for a patient who
commitment of society to principles of recently had coronary bypass surgery and
beneficence and justice now is on the postoperative unit. Which are
b. if low income compromises access to legal sources of standards of care that the
care, respect for autonomy is compromised nurse uses to deliver safe health care?
c. access to health care is a privilege in the (Select all that apply)
US, not a right
d. poor access to affordable health care a. information provided by the head nurse
causes harm that is ethically troubling b. policies and procedures of the employing
because nonmaleficence is a basic principle hospital

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c. state nurse practice act benefits?

d. regulations identified in The Joint
Commission manual a. family member
e. The Amerian Nurses Association b. surgeon
standards of nursing practice c. nurse
d. nurse manager
45. A nurse is sued for negligence due to
failure to monitor a patient appropriately 48. A woman has sever-life threatening
after a procedure. Which of the following injuries and is hemorrhaging following a car
statements are correct about this lawsuit? accident. The health care provider ordered
(Select all that apply) 2 units of packed red blood cells to treat the
woman's anemia. The woman's husband
a. the nurse does not need any refuses to allow the nurse to give his wife
representation the blood for religious reasons. What is the
b. the patient must prove injury, damage, or nurse's responsibility?
loss occurred
c. the person filing the lawsuit has to show a a. obtain a court order to give the blood
compensable damage, such as lost wages, b. coerce the husband into giving the blood
occurred c. call security and have the husband
d. the patient must prove that a breach in removed from the hospital
the prevailing standard of care caused an d. more information is needed about the
injury wife's preference and if the husband has
e. the burden of proof is always the her medical power of attorney
responsibility of the nurse
49. A nurse note that an advance directive
46. A nurse stops to help in an emergency is on a patient's medical record. Which
at the scene of an accident. The injured statement represents the best description of
party files a suit and the nurse's employing an advance directive guideline that the
institution insurance does not cover the nurse will follow?
nurse. What would probably cover the nurse
in this situation? a. a living will allows an appointed person to
make health care decisions when the
a. The nurse's auto insurance patient is in an incapacitated state
b. The nurse's homeowner's insurance b. a living will is invoked only when the
c. The Good Samaritan laws, which grant patient has a terminal condition or is in a
immunity from suit if there is no gross persistent vegetative state
negligence. c. the patient cannot make changes in the
d. The Patient Care Partnership, which may advance directive once admitted to the
grant immunity from suit if the injured party hospital
contends. d. a durable power of attorney for health
care is invoked only when the patient has a
47. A nurse is planning care for a patient terminal condition or is in a persistent
going into surgery. Who is responsible for vegetative state
informing the patient about the surgery
along with possible risks, complications, and

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50. A nurses notes that the health care unit is dying with the patient's family. Which of
keeps a listing of the patient names at the these actions describes a violation of the
front desk in easy view for health care Health Insurance Portability and
providers to more efficiently locate the Accountability Act (HIPPA)?
patient. The nurse talks with the nurse
manager because this action is a violation a. discussing patient conditions in the
of which act? nursing report room at the change of shift
b. allowing nursing students to review
a. patient protection and affordable care act patient charts before caring for patients to
(PPACA) whom they are assigned
b. patient self-determination act (PSDA) c. posting medical information about the
c. health insurance portability and patient on a message board in the patient's
accountability act (HIPAA) room
d. emergency medical treatment and active d. releasing [patient information regarding
labor act terminal illness to family when the patient
has given permission for information to be
51. Which of the following actions, if shared
performed by a registered nurse, would
result in both criminal and administrative law 53. A patient has a fractured femur that is
sanctions against the nurse? (Select all that placed in skeletal traction with a fresh
apply) plaster cast applied. The patient
experiences decreased sensation and a
a. taking or selling controlled substances cold feeling in the toes of the affected leg.
b. refusing to provide health care The nurse observes that the patient's toes
information to a patient's child have become pale and cold but forgets to
c. reporting suspected abuse and neglect of document this because one of the nurse's
children other patients experienced cardiac arrest at
d. applying physical restraints without a the same time. Two days later the patient in
written physician's order skeletal traction has an elevated
e. completing an occurrence report on the temperature, and he is prepared for surgery
unit to amputate the leg below the knee. Which
of the following statements regarding a
52. The nurse received a hand-off report at breach of duty apply to this situation?
the change of shift in the conference room (Select all that apply)
from the night shift nurse. The nursing
student assigned to the nurse asks to the a. failure to document a change in
nurse review the medical records of the assessment data
patients assigned to them. The nurse b. failure to provide discharge instructions
begins assessing the assigned patients and c. failure to follow the six rights of
lists the nursing care information for each medication administration
patient on each individual patient's message d. failure to use proper medical equipment
board in the patient rooms. The nurse also ordered for patient monitoring
lists the patients' medical diagnoses on the e. failure to notify a health care provider
message board. Later in the day the nurse about a change in the patient's condition
discusses the plan of care for a patient who

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54. A homeless man enters the emergency 57. Which if the following statements
department seeking health care. The heath indicate that the new nursing graduate
care provider indicates that the patient understands ways to remain involved
needs to be transferred to the City Hospital professionally? (Select all that apply)
for care. This action is most likely a violation
of which of the following laws? a. "I am thinking about joining the health
committee at my church"
a. Health Insurance Portability and b. "I need to read newspapers, watch news
Accountability Act (HIPAA) broadcasts, and search the Internet for
b. Americans with Disabilities Act (ADA) information related to health"
c. Patient Self-Determination Act (PSDA) c. "I will join nursing committees at the
d. Emergency Medical Treatment and hospital after I have completed orientation
Active Labor Act (EMTALA) without triage and better understand the issues affecting
completed nursing"
d. "Nurses do not have very much voice in
55. Your are the night shift nurse caring for legislation in Washington DC, because of
a newly admitted patient who appears to be the nursing shortage"
confused. The family asks to see the e. "I will go back to school as soon as I
patient's medical record. What is the priority finish orientation"
nursing action?
58. You are floated to work on a nursing unit
a. give the family the record where you are given an assignment that is
b. discuss the issues that concern the family beyond your capability. Which is the best
with them nursing action to take first?
c. calling the nursing supervisor
d. determine from the medical record if the a. call the nursing supervisor to discuss the
family has been granted permission by the situation
patient to access his or her medical b. discuss the problem with a colleague
information c. leave the nursing unit and go home
d. say nothing and begin your work
56. A home health nurse notices significant
bruising on a 2-year-old patient's heard, 59. What is the proper position to use for an
arms, abdomen, and legs. The patient's unresponsive patient during oral care to
mother describes the patient's frequent falls. prevent aspiration? (Select all that apply)
What is the best nursing action for the home
health nurse to take? a. Prone's position
b. Sim's position
a. document her findings and treat the c. Semi-Fowler's position with head to side
patient d. Trendelenburg position
b. instruct the mother on safe handling of a e. Supine position
2-year-old child
c. contact a child abuse hotline 60. The student nurse is teaching a family
d. discuss this story with a colleague member the importance of foot care for his
or her mother, who has diabetes. Which
safety precautions are important for the

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family member to know to prevent infection? c. A 60 year old female who experienced a
(Select all that apply) stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg.
a. Cut nails frequently d. A 70 year old patient who has diabetes
b. Assess skin for redness, abrasions, and and dementia and has been incontinent of
open areas daily stool.
c. Soak feet in water at least 10 minutes
before nail care 64. When you are assigned to a patient who
d. Apply lotion to feet daily has a reduced level of consciousness and
e. Clean between toes after bathing requires mouth care, which physical
assessment techniques should you perform
61. A nurse uses long firm, strokes distal to before the procedure? (Select all that apply)
proximal while bathing a patient's legs
because: a. oxygen saturation
b. heart rate
a. It promotes venous circulation c. respiration
b. It covers a larger area of the leg d. gag reflex
c. it completes care in a timely fashion e. response to painful stimulation
d. it prevents blood clots in legs
65. A nurse is listening to a student provide
62. Integrity of the oral mucosa depends on instruction to a patient who is having
salivary secretion. Which of the following difficulty with activities needed to care for
factors impairs salivary secretion? (Select soft contact lenses. Which of the following
all that apply) statements by the nursing student might
require some correction by the nurse?
a. use of cough drops
b. immunosupression a. use tap water to clean soft lenses
c. radiation therapy b. follow recommendations for lens
d. dehydration manufacturer when inserting the lenses
e. presence of oral airway c. keep lenses moist or wet not worn
d. use fresh solution daily when storing and
63. A nurse is assigned to care for the disinfecting lenses
following patients. Which of the patients is
most at risk for developing skin problems 66. The American Dental Association
and thus requiring thorough bathing and suggests that patient who are at risk for
skin care? poor hygiene use the following interventions
for oral care: (Select all that apply):
a. A 44 year old female who has had
removal of a breast lesion and is having her a. Use antimicrobial toothpaste
menstrual cycle. b. Brush teeth 4 times daily
b. A 56 year old male patient who is c. Use 0.12% chlorhexidine gluconate
homelesss and admitted to the emergency (CHG) oral rinses
department with malnutrition and d. Use a soft toothbrush for oral care
dehydration and who has an intravenous e. Avoid cleaning the gums and tongue
line.

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67. While planning morning care, which of b. Raise bed, lower side rail, and position
the following patients would have the patient close to side of bed with head of bed
highest priority to receive his or her bath raised up to 30 degrees
first? c. Using a brush moistened with
chlorhexidine paste, clean chewing and
a. A patient who just returned to the nursing inner tooth surfaces first
unit from a diagnostic test d. For patients without teeth, use a toothette
b. A patient who prefers a bath in the moistened in chlorhexidine rinse to clean
evening when his wife visits and can help oral cavity
him e. Remove partial plate or dentures if
c. A patient who is frequently incontinent present
diarrheal stools and urine f. Gently brush tongue but avoid stimulating
d. A patient who has been awake all nights gag reflex
because of pain 8/10 -B, E, A, C, F, D

68. An 88 year old patient comes to the 70. The nurse delegates needed hygiene
medical clinic regularly. During a recent visit care for an elderly stroke patient. Which
the nurse noticed that the patient had lost intervention would be appropriate for the
10 pounds in 6 weeks without being on a nursing assistive personnel to accomplish
special diet. The patient tells the nurse that during the bath?
he has had trouble chewing his food. Which
of the following factors are normal aging a. Checking distal pulse
changes that can affect an older adult's oral b. Providing range of motion (ROM)
health? (Select all that apply) exercises to extremities
c. Determining type of treatment for stage 1
a. Dentures do not always fit properly pressure ulcer
b. Most older adults have an increase in d. Changing the dressing over an
saliva secretions intravenous site
c. With aging the peridontal membrane
becomes tighter and painful 71. The nurse observes an adult Middle
d. Many older adults are edentulous, and Eastern patient attempting to bathe himself
remaining teeth are often decayed with only his left hand. The nurse
e. The teeth of elderly patients are more recognizes that this behavior likely relates
sensitive to hot and cold to:

69. A patient with a malignant brain tumor a. Obsessive compulsive behavior

requires oral care. The patient's level of b. Personal preferences
consciousness has declined, with the c. The patient's cultural norm
patient only being able to respond to voice d. Controlling behaviors
commands. Place the following steps in the
correct order for administration of oral care. 72. When a nurse delegates hygiene care
for a male patient to a nursing assistive
a. If patient is uncooperative or having personnel, the NAP must use an electric
difficulty keeping mouth open, insert an oral razor to shave the patient with the following
airway diagnosis:

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77. A patient is receiving solifenacin

a. Congestive heart failure succinate. The nurse knows that this drug is
b. Pneumonia used to treat which condition?
c. Arthritis
d. Thrombocytopenia a. Chronic Cystitus
b. Urinary tract stones
73. A patient receiving chemotherapy c. Urinary tract infections
experiences stomatitus. The nurse advises d. Overactive bladder
the patient to use:
78. The patient is taking tolterodine. The
a. Community mouthwash nurse plans to teach the patient to report
b. Alcohol-based mouth rinse which condition?
c. Normal saline rinses
d. Firm toothbrush a. Alkaline urine
b. Urinary retention
74. A patient is taking nitrofurantoin? What c. Excessive tearing
will the nurse teach the patient? d. Reddish orange urine

a. Expect the urine to turn blue 79. The nurse is caring for a patient who is
b. Keep the urine acidic by drinking milk taking nitrofurantoin. Which nursing
c. Rinse the mouth after taking oral interventions are appropriate for this
nitrofurantoin to avoid staining the teeth patient? (Select all that apply)
d. take an antacid with oral nitrofurantoin to
avoid gastrointestinal distress a. Monitor urinary output and urine specific
gravity
75. A patient complains about a burning b. Monitor the patient for peripheral
sensation and pain when urinating. Which neuropathy
urinary analgesic does the nurse suspect c. Advise the patient to take the medication
will be ordered? on an empty stomach to enhance
absorption
a. Tolterodine d. Warn the patient to avoid excess
b. Oxybutynin exposure to sunlight
c. Bethanechol e. Inform the patient that urine may turn a
d. Phenazopyridine harmless brown color
76. A patient is taking the urinary aseptic 80. A patient is scheduled to have an
methenamine for a urinary tract infection intravenous pyelogram (IVP) the next
(UTI). The nurse understands that this drug morning. Which nursing measures should
should not be given concurrently with which be implemented before the test. (Select all
other drug to avoid crystalluria? that apply)

a. Ertapenem a. ask the patient about any allergies and

b. Ciprofloxacin reactions
c. Fosfomycin b. instruct the patient that a full bladder is
d. Trimethoprim-sulfamethoxale required for the test

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c. instruct the patient to save all urine in a

special container a. limit oral fluid intake to avoid possible
d. ensure that informed consent has been urinary incontinence
obtained b. expect patient complaints of suprapubic
e. explain that the test includes fullness and discomfort
instrumentation of the urinary tract c. report the time and amount of first voiding
d. instruct patient to stay in bed and use a
81. When assessing a patient's first voided urinal or bedpan
urine of the day, which finding should be
reported to the health care provider? 85. A postoperative patient with a three-way
indwelling urinary catheter and continuous
a. pale yellow urine bladder irrigation (CBI) complains of lower
b. slightly cloudy urine abdominal pain and distention. What should
c. light pink urine be the nurse's initial intervention?
d. dark amber urine
a. increase the rate of the CBI
82. What is a critical step when inserting an b. assess the intake and output from system
indwelling catheter into a male patient? c. decrease the rate of the I
d. assess vital signs
a. slowly inflate the catheter balloon with
sterile saline 86. An ambulatory elderly woman with
b. secure the catheter drainage tubing to the dementia is incontinent of urine. She has
bed side poor short-term memory and has not been
c. advance the catheter to the bifurcation of sen toileting independently. What is the best
the drainage and balloon parts nursing intervention for this patient?
d. advance the catheter until urine flows,
then insert it 1/4 inch more a. recommend that she be evaluated for an
overactive bladder (OAB) medication
83. Which nursing intervention minimizes b. start a scheduled toileting program
the risk for trauma and infection when c. recommend that she be evaluated for an
applying an external/condom catheter? indwelling catheter
d. start a bladder-retraining program
a. leaving a gap of 3 to 5 inches between
the tip of the penis and drainage tube 87. What should the nurse teach a young
b. shaving the pubic area so hair does not women with a history of urinary tract
adhere infections (UTIs) about UTI prevention?
c. washing with soap and water before (Select all that apply)
applying the condom-type catheter
d. applying tape to the condom sheath to a. keep the bowels regular
keep it securely placed b. limit water intake to 1 to 2 glasses a day
c. wear cotton underwear
84. Which instructions should the nurse five d. cleanse the perineum from front to back
the nursing assistive personnel (NAP) e. practice pelvic muscle exercise (Kegel)
concerning the patient who has had an daily
indwelling urinary catheter removed that
day?

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88. Which nursing assessment question indwelling urinary catheter in an adult

would best indicate that an incontinent man patient? (Select all that apply)
with a history of prostate enlargement might
not be emptying his bladder adequately? a. attach a 3 mL syringe to the inflation port
b. allow the balloon to drain into the syringe
a. do you leak urine when you cough or by gravity
sneeze? c. initiate a voiding record/bladder diary
b. do you need help getting to the toilet? d. pull the catheter quickly
c. do you dribble urine constantly? e. clamp the catheter before removal
d. does it burn when you pass your urine?
92. What best describes measurement of
89. Place the following steps for insertion of postvoid residual (PVR)?
an indwelling catheter in a female patient in
appropriate order. a. bladder scan the patient immediately
after voiding
a. insert and advance catheter b. catheterize the patient 30 minutes after
b. lubricate catheter voiding
c. inflate catheter balloon c. bladder scan the patient when he or she
d. cleanse urethral meatus with antiseptic reports a strong urge to void
solution d. catheterize the patient with a 16 Fr/10 mL
e. drape patient with the sterile square and catheter
demonstrated drapes
f. when urine appears, advance another 2.5 93. Which nursing intervention decreases
to 5 cm the risk for catheter-associated urinary tract
g. prepare sterile fields and supplies infection (CAUTI)?
h. gently pull catheter until resistance is felt
i. attach drainage tubing a. cleansing the urinary meatus 3 to 4 times
-E, G, B, D, A, F, C, H, I daily with antiseptic solution
b. hanging the urinary drainage bag below
90. The nursing assistive personnel (NAP) the level of the bladder
reports to the nurse that a patient's catheter c. emptying the urinary drainage bag daily
drainage bag has been empty for 4 hours. d. irrigating the urinary catheter with sterile
What is a priority nursing intervention? water

a. implement the "as-needed" order to 94. There is no urine when a catheter is

irrigate the catheter inserted 3 inches into a female's urethra.
b. assess the catheter and drainage tubing What should the nurse do next?
for obvious occlusion
c. notify the health care provider a. Remove the catheter and start all over
immediately with a new kit and catheter
d. assess the vital signs and intake and b. Leave the catheter there and start over
output record with a new catheter
c. Pull the catheter back and reinsert at a
91. Which nursing interventions should a different angle
nurse implement when removing an

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d. Ask the patient to bear down and insert c. Insomnia

the catheter further d. Dry mouth

95. A patient complains of constipation and 99. When metoclopramide (Reglan) is given
requires a laxative. In providing teaching for for nausea, the nurse plans to caution the
this patient, the nurse reviews the common patient to avoid which substance?
causes of constipation, including which a. milk
cause? b. coffee
c. alcohol
a. Motion sickness d. carbonated beverages
b. Poor dietary habits
c. Food intolerance
d. Bacteria (E. coli)

96. A patient with nausea is taking

ondansetron. She asks the nurse how this
drug works. The nurse is aware that his
medication has which action?

a. Enhances histamine1 receptor sites

b. Blocks serotonin receptors in the
chemoreceptor trigger zone
c. Blocks dopamine receptors in the
chemoreceptor trigger zone
d. Stimulates anticholinergic receptor sites

97. A patient who has constipation is

prescribed as bisacodyl suppository. Which
explanation will the nurse use to explain the
action of bisacodyl?

a. Acts on smooth intestinal muscle to

gently increase perstalsis
b. Absorbs water into the intestines to
increase bulk and peristalsis
c. Lowers surface tension and increases
water accumulation in the intestines
d. Pulls salts into the colon and increases
water in the feces to increase bulk

98. A patient is using scoplamine to prevent

motion sickness. About which common side
effect should the nurse teach the patient?

a. Diarrhea
b. Vomiting

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