Nursing Process
Which step in the nursing process would involve promoting a safe environment for the client?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
What is Implementation?
Which health care team member is responsible for providing intravenous medication therapy to a client?
A. Registered nurse (RN)
B. Nursing manager
C. Patient-care associate (PCA)
D. Unlicensed nursing personnel (UNP)
What/Who is the Registered Nurse?
The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear?
A. Mask
B. Clean gloves
C. Sterile gloves
D. Shoe covers
What are clean gloves?
Which statement describes the function of the dermis?
A. Provides cells for wound healing
B. Assists in retention of body heat
C. Acts as mechanical shock absorber
D. Inhibits proliferation of microorganisms
What is provides cells for wound healing?
The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?
A. Caring.
B. Veracity.
C. Advocacy.
D. Confidentiality.
What is Advocacy?
The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation?
A. Planning
B. Evaluation
C. Assessment
D. Diagnosis
What is Assessment?
The nurse administers a vaccine in the patient's right upper arm with the needle at a 90 degree angle (perpendicular to the skin). This type of administration is called:
A. Subcutaneous
B. Intradermal
C. Intramuscular
D. Intraosseous
What is intramuscular?
Which category of isolation would the nurse implement for a client who is positive for Clostridium difficile?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective environment
What are contact precautions?
Many facilities may use terms such as "enhanced contact" or "enteric precautions" for c. diff patients.
The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics?
A. Red blood cell count
B. Collect a wound culture
C. Knee x-ray
D. Urinalysis
What is collect a wound culture?
Which characteristic indicates that nursing is a profession?
A. Performing specific tasks.
B. Following a code of ethics.
C. Having advanced skills.
D. Wearing a mandated uniform.
What is following a code of ethics?
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
A. Planning
B. Evaluation
C. Assessment
D. Implementation
What is Planning?
The health care provider prescribes 1000 mL of total parenteral nutrition (TPN) to be administered in 12 hours. Based on this prescription, how many milliliters of solution will be administered per hour? Round final answer to the whole number.
What is 83 mL/h.
1000 mL of solution divided by 12 hours equals 83.3 mL/h.
Which evaluation method is the most effective way for the nurse to evaluate the teachers’ knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques?
A. Observe the teachers lecture the children about hand hygiene. (Teach one!)
B. Administer an objectively written final examination to the teachers. (Objective assessment)
C. Have the teachers share their knowledge of hand washing. (Verbal readback)
D. Watch the teachers demonstrate infection-control techniques. (Return demonstration)
What is return demonstration?
Which intervention is most effective in reducing tissue necrosis and preventing new wounds from developing.
A. Cleaning the wound
B. Performing wound irrigation
C. Administering oral analgesics
D. Repositioning the client every 1 to 2 hours
What is repositioning the client every 1 to 2 hours?
What is the ethical principle that emphasizes promoting good, actively seeking benefit, and ensuring the client’s well-being?
A. Beneficence
B. Nonmaleficence
C. Justice
D. Advocacy
What is Beneficence?
he nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent?
A. Delegation
B. Implementation
C. Case management
D. Interprofessional teamwork
What is Delegation?
A health care provider prescribes guaifenesin 300 mg four times a day. The dosage strength is 200 mg/5 mL. How many milliliters will the nurse administer for each dose? Record your answer using one decimal place.
What is 7.5 mL
Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis?
A. Place the client on airborne precautions.
B. Notify the client’s health care provider.
C. Auscultate the client’s breath sounds.
D. Notify the public health department.
What is place the patient on airborne precautions?
Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
What is stage IV?
A client decides to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
A. Justice
B. Veracity
C. Autonomy
D. Beneficence
What phase of the nursing process involves collecting comprehensive data pertinent to the client’s health and/or situation?
A. Implementation
B. Evaluation
C. Assessment
D. Planning
What is Assessment?
During a 12-hour shift, a patient has a 6-oz (180-mL) cup of tea and 360 mL of water. The patient vomits 100 ml. The instilled intravenous (IV) fluids equaled the urinary output. Which fluid balance would the nurse record for the 12-hour period?
What is 440 ml.
The patient’s intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which, when subtracted from 540 mL, leaves 440 ml. Since the urinary output and IV hydration cancelled each other out, no other calculations are necessary.
Which nursing interventions require the nurse to wear gloves? Select all that apply. One, some, or all responses may be correct.
A. Giving a back rub
B. Emptying a portable wound drainage system
C. Interviewing a client in the emergency department
D. Obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)
What is emptying a portable wound drainage system?
Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?
A. Electrical stimulation
B. Topical growth factors
C. Hyperbaric oxygen therapy
D. Negative pressure wound therapy
What is negative pressure wound therapy?
Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised?
A. Justice
B. Fidelity
C. Veracity
D. Nonmaleficence
What is Fidelity?