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RNSG 1413 - Exam 3 (9, 14, 15, 16, 17, 18, 19, 20, 22, 23, 35)
RNSG 1413 - Exam 3 (9, 14, 15, 16, 17, 18, 19, 20, 22, 23, 35)
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RNSG 1413 - Exam 3 (9, 14, 15, 16, 17, 18, 19, 20,22, 23, 35)
1. Which findings will alert the nurse that stress is present when making a clinical decision?
(Select all that apply.) - ANS-Tense muscles,
Reactive responses,
Trouble concentrating,
Very tired feelings
A 15-year-old patient is concerned because her mother wants her to receive the human
papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by
the nurse is most therapeutic? - ANS-Ask the patient what concerns she may have about the
vaccination.
A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation
after death. Which action by the nurse is correct? - ANS-Instruct the patient to talk with parents
about the desire to donate organs.
A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge
nurse to follow up? - ANS-Developing nursing diagnoses before completing the database
A charge nurse is reviewing outcome statements using the SMART approach. Which patient
outcome statement will the charge nurse praise to the new nurse? - ANS-The patient will feed
self at all mealtimes today without reports of shortness of breath.
A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates
the charge nurse needs to intervene? - ANS-Making a clinical decision based on previous shift
assessments
A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps
touching these needed items for care. The nurse has tried to explain to the patient that these
lines should not be touched, but the patient continues. Which is the best action by the nurse at
this time? - ANS-Try other approaches to prevent the patient from touching these care items.
A female nursing student in the final term of nursing school is overheard by a nursing faculty
member telling another student that she got to insert a nasogastric tube in the emergency
department while working as a nursing assistant. Which advice is best for the nursing faculty
member to give to the nursing student? - ANS-"You are not allowed to perform any procedures
other than those in your job description even with the nurse's permission."
,A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient
behavior will indicate to the nurse achievement of this outcome? - ANS-States feels better after
talking with family and friends
A home health nurse notices that a patient's preschool children are often playing on the
sidewalk and in the street unsupervised and repeatedly takes them back to the home and talks
with the patient, but the situation continues. Which immediate action by the nurse is mandated
by law? - ANS-Contact the appropriate community child protection facility.
A hospital's wound nurse consultant made a recommendation for nurses on the unit about how
to care for the patient's dressing changes. Which action should the nurses take next? -
ANS-Include dressing change instructions and frequency in the care plan.
A mother brings her 12-year-old daughter into a clinic and inquires about getting a human
papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother
and daughter about the HPV vaccine? - ANS-Protects against cervical cancer
A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement
made by the nursing preceptor is most accurate? - ANS-"Nurses use evaluation to determine
the effectiveness of nursing care."
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented.
The patient's daughter is present in the room. Which action by the nurse will require follow-up by
the charge nurse? - ANS-The nurse speaks only to the patient's daughter.
A new nurse is confused about using evaluative measures when caring for patients and asks
the charge nurse for an explanation. Which response by the charge nurse is most accurate? -
ANS-"Evaluative measures include assessment data used to determine whether patients have
met their expected outcomes and goals."
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the
nurse take? - ANS-Develop good communication skills.
A new nurse notes that the health care unit keeps a listing of patient names in a closed book
behind the front desk of the nursing station so patients can be located easily. Which action is
most appropriate for the nurse to take? - ANS-Use the book as needed while keeping it away
from individuals not involved in patient care.
A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing
diagnosis will cause the nurse manager to intervene? - ANS-Hemorrhage
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom
for the first time. Which action should the nurse take initially? - ANS-Review the patient's activity
orders.
, A newly hired experienced nurse is preparing to change a patient's abdominal dressing and
hasn't done it before at this hospital. Which action by the nurse is best? - ANS-Check the policy
and procedure manual for the facility's method.
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse
document? - ANS-Decreased cardiac output related to altered myocardial contractility.
A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased
gastrointestinal motility secondary to pain medication administration as evidenced by the patient
reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which
element did the nurse write as the defining characteristic? - ANS-Abdominal distention
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood
pressure was low when it was taken at 0830. The NAP states that was busy and had not had a
chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed.
The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing
process did the nurse first make an error? - ANS-Assessment
A nurse agrees with regulations for mandatory immunizations of children. The nurse believes
that immunizations prevent diseases as well as prevent spread of the disease to others. Which
ethical framework is the nurse using? - ANS-Utilitarianism
A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask
to assist in establishing a nursing diagnosis of Urinary retention? - ANS-"Do you feel like you
need to go to the bathroom?"
A nurse completes a thorough database and carries out nursing interventions based on priority
diagnoses. Which action will the nurse take next? - ANS-Evaluation
A nurse determines that the patient's condition has improved and has met expected outcomes.
Which step of the nursing process is the nurse exhibiting? - ANS-Evaluation
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of
pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the
nurse write? - ANS-Impaired gas exchange related to alveolar-capillary membrane changes
A nurse has already set the agenda during a patient-centered interview. What will the nurse do
next? - ANS-Ask about the chief concerns or problems.
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation,
the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will
the nurse take next? - ANS-Reassess the patient and situation.
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