Review Fundamentals of Nursing Practice Exam 1

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Fundamentals of Nursing Practice Exam 1

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Total Questions : 86

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Question 1:

Which site will the nurse use to measure the patient’s pulse rate before administering the cardiac medication Digoxin?

A. Apical B. Carotid C. Radial D. Brachial

Answer and Explanation

Choice A:

This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.

Choice B:

This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.

Choice C:

This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.

Choice D:

This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.

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Question 2:

The nurse is caring for a patient whose temperature has dropped from 102.4°F to 99.4°F. The nurse notes that the patient’s face is flushed. What is the reason for this assessment finding?

A. The patient’s core temperature has dropped too low. B. Vasodilation is working to lower the body temperature. C. The patient is exhausted from shivering. D. The patient’s infection has spread to the bloodstream.

Answer and Explanation

Choice A:

This is an incorrect choice because the patient’s core temperature has not dropped too low. The normal body temperature range is 97.7°F to 99.5°F¹. The patient’s temperature is still within this range, although it has decreased from a feverish level.

Choice B:

This is the correct choice because vasodilation is the process of widening the blood vessels to increase blood flow and heat loss². This is a natural response of the body to lower the temperature when it is too high. Vasodilation can cause the skin to appear flushed and feel warm to the touch³.

Choice C:

This is an incorrect choice because the patient is not exhausted from shivering. Shivering is another mechanism of the body to increase the temperature when it is too low². Shivering involves involuntary muscle contractions that generate heat³. The patient’s temperature is not too low, so shivering is not likely to occur.

Choice D:

This is an incorrect choice because the patient’s infection has not spread to the bloodstream. A bloodstream infection, or sepsis, is a serious condition that can cause a high fever, not a low one. Sepsis can also cause other symptoms, such as chills, rapid breathing, and confusion. The patient’s temperature has dropped, not increased, and there is no evidence of sepsis.

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Question 3:

The nurse is caring for a patient with the following vital signs:
Temperature: 98.9°F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?

A. Ask the patient about his usual blood pressure results. B. Apply a cool washcloth to the patient's forehead. C. Administer oxygen at 2 L/minute via nasal cannula. D. Document the findings in the patient's medical record.

Answer and Explanation

Choice A:

This is an incorrect choice because asking the patient about his usual blood pressure results is not a priority action. The patient's blood pressure is elevated, but not dangerously high. The nurse should monitor the blood pressure and report any significant changes to the physician, but this is not an urgent intervention.

Choice B:

This is an incorrect choice because applying a cool washcloth to the patient's forehead is not a priority action. The patient's temperature is normal, and there is no indication of fever or heat stroke. The nurse should ensure the patient is comfortable and hydrated, but this is not an urgent intervention.

Choice C:

This is the correct choice because administering oxygen at 2 L/minute via nasal cannula is a priority action. The patient's pulse oximetry is low, indicating hypoxia or inadequate oxygenation of the tissues. The nurse should provide supplemental oxygen to improve the patient's oxygen saturation and prevent further complications.

Choice D:

This is an incorrect choice because documenting the findings in the patient's medical record is not a priority action. The nurse should document the patient's vital signs and any interventions performed, but this is not an urgent intervention. The nurse should prioritize the patient's safety and well-being over documentation.

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Question 4:

Which vital signs are most important for a patient who is experiencing shortness of breath?

A. Temperature, pulse, blood pressure B. Pulse, respirations, oxygen saturation C. Temperature, pulse, respirations D. Respirations, blood pressure, pain

Answer and Explanation

Choice A:

This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.

Choice B:

This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.

Choice C:

This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.

Choice D:

This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.

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Question 5:

Which technique will provide the most accurate measurement of the patient’s core temperature?

A. Axillary B. Orally C. Rectally D. Forehead

Answer and Explanation

Choice A:

This is an incorrect choice because the axillary method is not the most accurate measurement of the core temperature. The axillary method involves placing a thermometer under the patient's armpit and measuring the temperature of the skin surface. This method can be affected by factors such as sweating, clothing, and ambient temperature. The axillary method can underestimate the core temperature by 0.5°C to 1.5°C¹.

Choice B:

This is an incorrect choice because the oral method is not the most accurate measurement of the core temperature. The oral method involves placing a thermometer in the patient's mouth and measuring the temperature of the sublingual pocket. This method can be affected by factors such as eating, drinking, smoking, and mouth breathing. The oral method can underestimate the core temperature by 0.3°C to 0.8°C¹.

Choice C:

This is the correct choice because the rectal method is the most accurate measurement of the core temperature. The rectal method involves inserting a thermometer into the patient's rectum and measuring the temperature of the rectal mucosa. This method reflects the temperature of the blood flowing through the core of the body. The rectal method is considered the gold standard for measuring the core temperature¹.

Choice D:

This is an incorrect choice because the forehead method is not the most accurate measurement of the core temperature. The forehead method involves placing a thermometer on the patient's forehead and measuring the temperature of the temporal artery. This method can be affected by factors such as sweating, hair, and ambient temperature. The forehead method can overestimate or underestimate the core temperature by 0.5°C to 1°C¹.

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Question 6:

Which key elements are included in decentralized decision making? (Select all that apply)

A. Autonomy B. Authority C. Prioritization D. Responsibility E. Accountability

Answer and Explanation

Choice A:

This is a correct choice because autonomy is a key element of decentralized decision making. Autonomy refers to the ability and right of individuals or groups to make their own decisions without interference from others. Decentralized decision making empowers the employees to exercise their autonomy and use their own judgment and expertise to solve problems and improve performance².

Choice B:

This is a correct choice because authority is a key element of decentralized decision making. Authority refers to the power and legitimacy to make decisions and take actions. Decentralized decision making delegates the authority from the top management to the lower levels of the organization, allowing them to make decisions that affect their work and outcomes².

Choice C:

This is an incorrect choice because prioritization is not a key element of decentralized decision making. Prioritization refers to the process of ranking tasks or goals according to their importance and urgency. Decentralized decision making does not necessarily involve prioritization, as different individuals or groups may have different criteria and preferences for setting their priorities².

Choice D:

This is a correct choice because responsibility is a key element of decentralized decision making. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. Decentralized decision making assigns the responsibility to the individuals or groups who make the decisions and hold them accountable for their actions and outcomes².

Choice E:

This is a correct choice because accountability is a key element of decentralized decision making. Accountability refers to the expectation and requirement to report and explain the decisions and actions taken and the results achieved. Decentralized decision making ensures that the individuals or groups who make the decisions are accountable for their performance and quality, and that they receive feedback and recognition for their work².

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Question 7:

Which leadership skills will the nursing student use when caring for patients? (Select all that apply)

A. Careful delegation B. Team communication C. Case management D. Time management E. Priority setting

Answer and Explanation

Choice A:

This is a correct choice because careful delegation is a leadership skill that involves assigning tasks to the appropriate staff members based on their scope of practice, competence, and availability. Careful delegation ensures that the nursing student can focus on the most important aspects of patient care while supervising and supporting the delegated staff¹.

Choice B:

This is a correct choice because team communication is a leadership skill that involves exchanging information, ideas, and feedback with other members of the health care team in a clear, respectful, and timely manner. Team communication facilitates collaboration, coordination, and continuity of care for the patients².

Choice C:

This is a correct choice because case management is a leadership skill that involves planning, organizing, and evaluating the care of a specific group of patients across the continuum of care. Case management ensures that the patients receive the best quality of care while optimizing the use of resources and reducing costs³.

Choice D:

This is a correct choice because time management is a leadership skill that involves prioritizing, scheduling, and completing tasks within the available time. Time management helps the nursing student to balance the demands of patient care, education, and personal life while avoiding stress and burnout.

Choice E:

This is a correct choice because priority setting is a leadership skill that involves identifying the most urgent and important tasks and goals and allocating the appropriate time and resources to them. Priority setting helps the nursing student to provide safe and effective care for the patients while meeting their needs and expectations.

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Question 8:

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action?

A. Professional shared governance B. Nursing care delivery model C. Interprofessional communication D. Continuing staff education

Answer and Explanation

Choice A:

This is an incorrect choice because professional shared governance is not a patient care action, but an organizational model that empowers nurses and other health care professionals to participate in decision making and policy development within their practice settings.

Choice B:

This is an incorrect choice because nursing care delivery model is not a patient care action, but a framework that defines how nursing care is organized, coordinated, and delivered to the patients. Examples of nursing care delivery models include primary nursing, team nursing, and case management.

Choice C:

This is the correct choice because interprofessional communication is a patient care action that involves exchanging information, ideas, and feedback among health care professionals from different disciplines who work together to provide comprehensive care for the patients. Interprofessional communication enhances collaboration, quality, and safety of care.

Choice D:

This is an incorrect choice because continuing staff education is not a patient care action, but a professional development activity that involves updating and enhancing the knowledge and skills of the health care staff through formal or informal learning opportunities. Continuing staff education improves the competence and performance of the staff.

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Question 9:

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action?

A. Professional shared governance B. Nursing care delivery model C. Interprofessional communication D. Continuing staff education

Answer and Explanation

Choice A:

Choice B:

Choice C:

Choice D:

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Question 10:

Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

A. Perform a focused patient assessment. B. Conduct the patient’s health history. C. Create the nursing care plan for the patient. D. Administer prescribed medications.

Answer and Explanation

Choice A:

This is the correct choice because performing a focused patient assessment is the first action of the nurse when starting care for the patient at the beginning of the shift. A focused patient assessment involves collecting data about the patient's current condition, needs, and preferences. This data helps the nurse to identify any changes, problems, or risks that require immediate attention or intervention.

Choice B:

This is an incorrect choice because conducting the patient’s health history is not the first action of the nurse when starting care for the patient at the beginning of the shift. A health history involves collecting data about the patient's past and present health status, medical history, family history, and social history. This data helps the nurse to understand the patient's background, risk factors, and health goals. A health history is usually conducted during the admission process or the initial assessment, not at the beginning of each shift.

Choice C:

This is an incorrect choice because creating the nursing care plan for the patient is not the first action of the nurse when starting care for the patient at the beginning of the shift. A nursing care plan involves developing a set of interventions and outcomes based on the patient's assessment data, diagnosis, and goals. This plan guides the nurse to provide individualized and holistic care for the patient. A nursing care plan is usually created after the initial assessment and updated regularly throughout the care process, not at the beginning of each shift.

Choice D:

This is an incorrect choice because administering prescribed medications is not the first action of the nurse when starting care for the patient at the beginning of the shift. Administering prescribed medications involves giving the patient the right drug, dose, route, time, and documentation according to the physician's order and the nursing standards. This action requires the nurse to check the patient's assessment data, allergies, vital signs, and laboratory results before giving the medication. Administering prescribed medications is usually done after performing a focused patient assessment, not before.

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Question 11:

A nurse is using SBAR. Which information will the nurse report for the “B”?

A. The nurse requests that the primary health care provider examines the patient. B. The patient has a fractured right leg with a cast that was applied 2 days ago. C. The patient’s toes are cool and pale and the patient reports that the foot feels numb. D. The patient is reporting severe pain 1 hour after pain medication was given.

Answer and Explanation

Choice A:

This is an incorrect choice because the nurse requests that the primary health care provider examines the patient is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The nurse's request is part of the “R”, which stands for recommendation, which is the action that the nurse suggests or requests.

Choice B:

This is the correct choice because the patient has a fractured right leg with a cast that was applied 2 days ago is the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's fracture and cast are part of the patient's background that the nurse should share with the primary health care provider.

Choice C:

This is an incorrect choice because the patient’s toes are cool and pale and the patient reports that the foot feels numb is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's toes and foot are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

Choice D:

This is an incorrect choice because the patient is reporting severe pain 1 hour after pain medication was given is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's pain and medication are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

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Question 12:

Which characteristic qualifies the hospital for Magnet Recognition status?

A. The hospital is affiliated with a nationally recognized medical school. B. The hospital participates in nursing research and implements the findings. C. The hospital is owned by a religious order that offers daily prayer services. D. The hospital receives federal grant funding for advanced medical research.

Answer and Explanation

Choice A:

This is an incorrect choice because the hospital is affiliated with a nationally recognized medical school is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's affiliation with a medical school is not related to its nursing performance or outcomes.

Choice B:

This is the correct choice because the hospital participates in nursing research and implements the findings is a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's participation in nursing research and implementation of the findings demonstrates its commitment to evidence-based practice and innovation in nursing.

Choice C:

This is an incorrect choice because the hospital is owned by a religious order that offers daily prayer services is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's ownership and religious affiliation are not related to its nursing performance or outcomes.

Choice D:

This is an incorrect choice because the hospital receives federal grant funding for advanced medical research is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's funding and research activities are not related to its nursing performance or outcomes.

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Question 13:

Which action by the nurse demonstrates the concept of nurse autonomy?

A. The nurse braids the patient’s long hair to prevent tangles. B. The nurse checks the policy manual before changing the central line dressing. C. The nurse counts the patient’s pulse before administering digoxin. D. The nurse directs the nursing assistant to obtain the patient's weight.

Answer and Explanation

Choice A:

This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B:

This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C:

This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D:

This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.

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Question 14:

Which patient assignment demonstrates the concept of team nursing?

A. The hospice RN works closely with the patient’s daughter to ensure that the patient’s dying requests are met. B. The RN cares for the same five patients every day during their stay following joint replacement surgery. C. The RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift. D. The RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed.

Answer and Explanation

Choice A:

This is an incorrect choice because the hospice RN works closely with the patient’s daughter to ensure that the patient’s dying requests are met is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Working closely with the patient’s daughter is an example of family-centered care, not team nursing.

Choice B:

This is an incorrect choice because the RN cares for the same five patients every day during their stay following joint replacement surgery is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Caring for the same five patients every day is an example of primary nursing, not team nursing.

Choice C:

This is the correct choice because the RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift is a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Each member of the team performs specific duties appropriate to their role to provide total patient care. Teams may include licensed practical nurses (LPNs) and unlicensed assistive personnel (UAP) that are supervised by a registered nurse (RN). Less experienced, or non-critical care RNs, may be assigned to a team in a critical care unit led by an experienced critical care RN. Each team member plays a vital role.

Choice D:

This is an incorrect choice because the RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Coordinating care of the patient with the physician assistant is an example of interprofessional collaboration, not team nursing.

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Question 15:

Which action by the nurse best demonstrates the concept of right supervision?

A. The nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task. B. The nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift. C. The nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight. D. The nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch.

Answer and Explanation

Choice A:

This is the correct choice because the nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task is an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By checking the hospital policy, the nurse ensures that the task is within the scope of practice and competency of the licensed practical nurse and that the delegation is consistent with the standards of care.

Choice B:

This is an incorrect choice because the nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By confirming the documentation, the nurse is performing a quality check, but not providing supervision of the delegated task.

Choice C:

This is an incorrect choice because the nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By ensuring the accuracy of the scale, the nurse is preparing the equipment, but not providing supervision of the delegated task.

Choice D:

This is an incorrect choice because the nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By directing the nursing assistant, the nurse is assigning the task, but not providing supervision of the delegated task.

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Question 16:

Which nursing care concept is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient?

A. Accountability B. Responsibility C. Empowerment D. Delegation

Answer and Explanation

Choice A:

This is the correct choice because accountability is the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Accountability refers to the expectation and requirement to report and explain the actions taken and the results achieved. The nurse is accountable for the accuracy and completeness of the documentation and for the quality and safety of the patient care⁴. By correcting the assessment information, the nurse demonstrates accountability for their own mistake and prevents potential harm to the patient.

Choice B:

This is an incorrect choice because responsibility is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. The nurse is responsible for conducting and documenting the assessment and for providing appropriate care for the patient⁴. By correcting the assessment information, the nurse is not fulfilling their responsibility, but rather rectifying their error.

Choice C:

This is an incorrect choice because empowerment is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Empowerment refers to the ability and right of individuals or groups to make their own decisions without interference from others. The nurse is empowered to use their own judgment and expertise to solve problems and improve performance⁴. By correcting the assessment information, the nurse is not exercising their empowerment, but rather admitting their fault.

Choice D:

This is an incorrect choice because delegation is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Delegation refers to the process of assigning tasks or activities to other staff members based on their scope of practice, competence, and availability. The nurse is responsible for delegating tasks safely and effectively and for supervising and evaluating the delegated staff⁴. By correcting the assessment information, the nurse is not delegating any task, but rather correcting their own work.

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Question 17:

Which patient’s needs must be addressed first by the registered nurse?

A. The patient who is nauseated and vomiting after receiving narcotic pain medication. B. The patient who is waiting for discharge teaching in order to go home. C. The patient with chest pain after two doses of sublingual nitroglycerin. D. The constipated patient who needs to use the toilet after receiving a laxative.

Answer and Explanation

Choice A:

This is an incorrect choice because the patient who is nauseated and vomiting after receiving narcotic pain medication is not the most urgent patient. Nausea and vomiting are common side effects of narcotic pain medication and can be managed with antiemetics and hydration. The patient's condition is not life-threatening and does not require immediate intervention.

Choice B:

This is an incorrect choice because the patient who is waiting for discharge teaching in order to go home is not the most urgent patient. Discharge teaching is an important part of patient education and care transition, but it can be delayed until the more critical patients are attended to. The patient's condition is stable and does not require immediate intervention.

Choice C:

This is the correct choice because the patient with chest pain after two doses of sublingual nitroglycerin is the most urgent patient. Chest pain is a sign of myocardial ischemia, which can lead to myocardial infarction or heart attack. Sublingual nitroglycerin is a medication that dilates the coronary arteries and relieves chest pain. If the chest pain persists after two doses of sublingual nitroglycerin, the patient may have unstable angina or acute coronary syndrome, which are medical emergencies that require immediate intervention⁴.

Choice D:

This is an incorrect choice because the constipated patient who needs to use the toilet after receiving a laxative is not the most urgent patient. Constipation is a common gastrointestinal problem that can be treated with laxatives and dietary changes. The patient's condition is not life-threatening and does not require immediate intervention.

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Question 18:

The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient?

A. Perceived constipation related to expectation of daily bowel movements. B. Impaired bowel elimination related to abdominal muscle weakness. C. Risk for constipation related to irregular defecation habits. D. Constipation related to side effects of pain medication.

Answer and Explanation

Choice A:

This is an incorrect choice because perceived constipation related to expectation of daily bowel movements is not an appropriate nursing diagnosis for this patient. Perceived constipation is a subjective problem that occurs when the patient's bowel elimination pattern does not meet their personal expectations. The patient may not have any objective signs of constipation, such as hard stools, straining, or abdominal discomfort. This diagnosis is not applicable to this patient, who has objective signs of constipation and a clear cause of the problem.

Choice B:

This is an incorrect choice because impaired bowel elimination related to abdominal muscle weakness is not an appropriate nursing diagnosis for this patient. Impaired bowel elimination is a problem that occurs when the patient has difficulty in passing stools or has a change in bowel habits. Abdominal muscle weakness is a possible factor that can affect bowel function, but it is not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who has a normal muscle strength and a clear cause of the problem.

Choice C:

This is an incorrect choice because risk for constipation related to irregular defecation habits is not an appropriate nursing diagnosis for this patient. Risk for constipation is a potential problem that occurs when the patient is vulnerable to developing constipation due to various factors. Irregular defecation habits are a possible factor that can increase the risk of constipation, but they are not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who already has constipation and a clear cause of the problem.

Choice D:

This is the correct choice because constipation related to side effects of pain medication is an appropriate nursing diagnosis for this patient. Constipation is a problem that occurs when the patient has infrequent, difficult, or incomplete bowel movements. Pain medication, especially opioids, are a common cause of constipation, as they can slow down the gastrointestinal motility and reduce the stool volume and water content. This diagnosis is applicable to this patient, who has objective signs of constipation and a clear cause of the problem..

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Question 19:

The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse?

A. Insist that the patient remove the bracelet and give it to a family member during surgery. B. Notify the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery. C. Call the operating room staff to determine if the bracelet can stay on during surgery. D. Remove the bracelet from the patient's wrist after sedating medication has been administered.

Answer and Explanation

Choice A:

This is an incorrect choice because insisting that the patient remove the bracelet and give it to a family member during surgery is not the most appropriate action of the nurse. This action may violate the patient's right to autonomy, religious freedom, and cultural sensitivity. The nurse should respect the patient's beliefs and preferences and try to accommodate them as much as possible, unless they pose a significant risk to the patient's safety or the surgical procedure.

Choice B:

This is an incorrect choice because notifying the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery is not the most appropriate action of the nurse. This action may imply that the patient is non-compliant or difficult, and may create a conflict between the patient and the surgeon. The nurse should communicate with the patient and the surgeon in a respectful and collaborative manner, and seek a mutually agreeable solution.

Choice C:

This is the correct choice because calling the operating room staff to determine if the bracelet can stay on during surgery is the most appropriate action of the nurse. This action shows that the nurse is willing to advocate for the patient and to consult with the relevant authorities to find out the best option. The nurse should follow the policies and protocols of the operating room and the infection control guidelines, and ensure that the bracelet does not interfere with the surgical site, the equipment, or the sterile field.

Choice D:

This is an incorrect choice because removing the bracelet from the patient's wrist after sedating medication has been administered is not the most appropriate action of the nurse. This action may be considered unethical, dishonest, or disrespectful, as the nurse is taking advantage of the patient's altered mental status and going against the patient's wishes. The nurse should obtain the patient's informed consent before performing any intervention, and should not deceive or coerce the patient.

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Question 20:

Which statement by the nurse is an example of back-channeling?

A. "When did you first seek health care for your symptoms?" B. "I am sure the doctor will answer all of your questions shortly." C. "I completely understand. Can you tell me more?" D. "Try not to worry. I'm sure that you will be just fine."

Answer and Explanation

Choice A:

This is an incorrect choice because "When did you first seek health care for your symptoms?" is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of an open-ended question, which is another communication technique that involves asking questions that require more than a yes or no answer and elicit more information from the speaker.

Choice B:

This is an incorrect choice because "I am sure the doctor will answer all of your questions shortly." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a reassurance, which is another communication technique that involves expressing confidence or support to the speaker and alleviating their anxiety or fear.

Choice C:

This is the correct choice because "I completely understand. Can you tell me more?" is an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a verbal cue, which involves using words or phrases that show empathy, interest, or agreement, and invite the speaker to elaborate or clarify their message.

Choice D:

This is an incorrect choice because "Try not to worry. I'm sure that you will be just fine." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a false reassurance, which is a communication barrier that involves making unrealistic or unfounded promises or predictions to the speaker and dismissing their concerns or feelings.

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Question 21:

The nurse is caring for a patient with sepsis. The nurse includes potential complication: septic shock in the plan of care. Why is this nursing diagnosis considered to be a collaborative problem?

A. The patient has a history of noncompliance with prescribed therapeutic regimens. B. The patient must be closely monitored in an intensive care unit. C. Prevention of septic shock is not a measurable patient outcome. D. Both nursing and physician-prescribed interventions are required.

Answer and Explanation

Choice A:

This is an incorrect choice because the patient has a history of noncompliance with prescribed therapeutic regimens is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's history of noncompliance is not related to the nature of the problem or the type of intervention required.

Choice B:

This is an incorrect choice because the patient must be closely monitored in an intensive care unit is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's need for close monitoring is not related to the nature of the problem or the type of intervention required.

Choice C:

This is an incorrect choice because prevention of septic shock is not a measurable patient outcome is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The measurability of the patient outcome is not related to the nature of the problem or the type of intervention required.

Choice D:

This is the correct choice because both nursing and physician-prescribed interventions are required is a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The problem of septic shock is a complex and life-threatening condition that involves multiple organ systems and requires both medical and nursing interventions to prevent, treat, and monitor the patient's status.

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Question 22:

The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient’s health status?

A. "Are you having any difficulty breathing right now?" B. "What does your chest pain feel like?" C. "Do you have a family history of heart disease?" D. "How long have you been experiencing chest pain?"

Answer and Explanation

Choice A:

This is an incorrect choice because "Are you having any difficulty breathing right now?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to describe their condition in detail.

Choice B:

This is the correct choice because "What does your chest pain feel like?" is an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question invites the patient to describe the quality, intensity, location, and duration of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.

Choice C:

This is an incorrect choice because "Do you have a family history of heart disease?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to provide more details about their health history or risk factors.

Choice D:

This is an incorrect choice because "How long have you been experiencing chest pain?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a specific time, and does not encourage the patient to provide more information about their symptoms or situation.

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Question 23:

The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?

A. The patient is grouchy and inappropriate, always causing trouble for the nurses. B. The patient’s nurse assistant always took her time to answer his call lights. C. The patient probably urinated on the floor and slipped on the wet floor. D. The patient was found on the floor and his urinal was on the floor next to him.

Answer and Explanation

Choice A:

This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.

Choice B:

This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.

Choice C:

This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.

Choice D:

This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.

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Question 24:

Which question is the most appropriate for the nurse to use to start the health history assessment?

A. "Did you drive yourself to the hospital?" B. "What brings you to the hospital today?" C. "Did you give your insurance card to the receptionist?" D. "Does your family doctor know that you are here?"

Answer and Explanation

Choice A:

This is not the most appropriate question for the nurse to use to start the health history assessment because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.

Choice B:

This is the most appropriate question for the nurse to use to start the health history assessment because it is relevant, open-ended, and comprehensive. The nurse should ask questions that are related to the patient's health status, needs, or goals, and that elicit more information from the patient. This question allows the patient to describe the reason for seeking health care, the onset, duration, and severity of their symptoms, and any other relevant information.

Choice C:

Choice D:

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Question 25:

What is the priority action of the nurse as the assessment process is started for a patient who came to the hospital with acute shortness of breath?

A. Reassure the patient that the shortness of breath will be relieved shortly. B. Pull the curtain around the bed and ensure patient privacy. C. Tell the patient that the physician will be in shortly to start treatment. D. Listen to the patient’s lung sounds and check the pulse oximetry level.

Answer and Explanation

Choice A:

This is an incorrect choice because reassuring the patient that the shortness of breath will be relieved shortly is not the priority action of the nurse as the assessment process is started. Reassurance is a communication technique that involves expressing confidence or support to the patient and alleviating their anxiety or fear. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice B:

This is an incorrect choice because pulling the curtain around the bed and ensuring patient privacy is not the priority action of the nurse as the assessment process is started. Privacy is a patient right that involves protecting the patient's personal information and dignity. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice C:

This is an incorrect choice because telling the patient that the physician will be in shortly to start treatment is not the priority action of the nurse as the assessment process is started. Communication is a nursing skill that involves informing the patient of the plan of care and collaborating with other health care professionals. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice D:

This is the correct choice because listening to the patient’s lung sounds and checking the pulse oximetry level is the priority action of the nurse as the assessment process is started. Assessment is a nursing process that involves collecting and analyzing data about the patient's health status and needs. Listening to the patient’s lung sounds and checking the pulse oximetry level are essential steps to evaluate the patient's respiratory function and oxygenation. These actions can help the nurse to identify the possible cause and severity of the patient's shortness of breath and to initiate appropriate interventions.

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Fundamentals of Nursing Practice Exam 1

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