Evidence Based Practice
What is evidence-based practice?
A. Following hospital rules without questioning them
B. Using the best current research, clinical expertise, and patient preferences to guide nursing care
C. Only using information from nursing textbooks
D. Providing care based only on a nurse’s personal experience
B. Using the best current research, clinical expertise, and patient preferences to guide nursing care.
A nurse is preparing to call the provider about a client whose blood pressure has dropped from 124/78 to 86/54 mmHg in the past hour. Which statement represents the Situation portion of SBAR?
A. “The client’s BP was stable this morning.”
B. “I am calling about Mr. Jones in room 412 who has hypotension.”
C. “He has a history of hypertension and heart failure.”
D. “I recommend starting IV fluids.”
B. “I am calling about Mr. Jones in room 412 who has hypotension.”
A nurse is reviewing a patient’s electronic chart at the nurses’ station. A visitor asks the nurse about the patient’s diagnosis. What is the nurse’s best response?
Do not disclose any information and explain privacy rules.
A client newly diagnosed with diabetes says, “I don’t think I can give myself insulin shots.” What is the nurse’s best response?
A. “You’ll get used to it over time.”
B. “Why do you feel that way?”
C. “Tell me what concerns you most about giving insulin.”
D. “Your provider says this is necessary.”
Correct Answer: C
Rationale: Open-ended statements encourage expression of feelings and support therapeutic communication. “Why” questions can sound accusatory, and reassurance or authority statements block communication.
A nurse develops the following goal for a patient:
"The patient will feel better soon."
What should the nurse do next?
A. Implement the care plan
B. Revise the goal to make it measurable
C. Document the goal in the chart
D. Notify the physician
B. Revise the goal to make it measurable
Rationale: Expected outcomes should be specific and measurable so the nurse can evaluate whether the goal was achieved.
What does "T" stand for in PICOT?
Time
Which of the following statements belong in the Background portion of SBAR?
(Select all that apply.)
A. “The client was admitted with pneumonia.”
B. “The oxygen saturation is 88% on 2 L nasal cannula.”
C. “The client has a history of COPD.”
D. “The respiratory rate is 32.”
E. “The client received IV morphine 1 hour ago.”
A. “The client was admitted with pneumonia.”
C. “The client has a history of COPD.”
E. “The client received IV morphine 1 hour ago.”
Which statement best explains why documentation is important in nursing care?
It serves as a legal record of care
A hospitalized client is crying quietly after receiving bad news. Which action by the nurse is most therapeutic?
A. Offer advice on coping strategies
B. Sit quietly with the client
C. Tell the client everything will be okay
D. Change the subject to distract the client
Correct Answer: B
Rationale: Presence and silence allow emotional processing and demonstrate support. Premature advice, false reassurance, or distraction are non-therapeutic.
The nurse is using the nursing process to provide care.
Place the five steps in the correct order:
________ → ________ → ________ → ________ → ________
Evaluate.Assess.Diagnose.Implement.Plan.
Assess.Diagnose.Plan.Implement.Evaluate.
A Way to identify knowledge, improve professional education & practice, and use resources effectively.
Nursing Research
Which documentation entry is correctly written in SOAP format?
A. S: Client states pain is 8/10. O: Grimacing and guarding abdomen. A: Acute abdominal pain. P: Administer morphine as prescribed.
B. Client appears uncomfortable and may be exaggerating pain.
C. Patient is probably having appendicitis.
D. Gave pain medication. Will continue to monitor.
A. S: Client states pain is 8/10. O: Grimacing and guarding abdomen. A: Acute abdominal pain. P: Administer morphine as prescribed.
Which charting entry by a nurse is most appropriate?
Patient states pain is 2/10, respirations 16, unlabored
The nurse is teaching a client about a new antihypertensive medication. Which statement by the client indicates effective learning?
A. “I’ll take this medicine only when my blood pressure is high.”
B. “I should stop the medication if I feel better.”
C. “I will take this medication at the same time every day.”
D. “I can double the dose if I miss a pill.”
Correct Answer: C
Rationale: Consistent timing improves therapeutic levels. Antihypertensives are usually taken daily, not PRN, and doses should never be doubled.
The nurse notes a patient’s blood pressure is 88/54, heart rate 118, and the patient appears pale. Is this subjective data, objective data, or both?
Objective data
Scientific peer reviwed journals,are an example of?
Research based evidence
The nurse documents the following note:
“S: Patient is noncompliant and difficult.
O: Refuses medication.
A: Manipulative behavior.
P: Will notify provider.”
Which action is most appropriate?
A. Leave documentation as written.
B. Add more descriptive language about personality.
C. Revise documentation to remove judgmental language.
D. Delete the note entirely
C. Revise documentation to remove judgmental language.
The nurse is calling the provider about a patient’s low blood pressure. Which communication method should the nurse use?
SBAR
The RN is delegating tasks to an AP. Which task is appropriate to delegate?
A. Teaching a client how to use an incentive spirometer
B. Assessing pain after medication administration
C. Ambulating a stable post-op client
D. Evaluating effectiveness of a care plan
Correct Answer: C
Rationale: UAPs can perform routine, non-assessment tasks on stable clients. Teaching, assessment, and evaluation must be done by licensed nurses.
Administering medications is what phase of the nursing process?
A. Implementation
B. Assessment
C. Planning
D.Evaluation
A. Implementation
Rationale: Implementation is when the nurse performs interventions to achieve client outcomes.
What are patient preferences (or patient values)?
The patient’s values, beliefs, and preferences that must be considered when applying evidence to care.
A client with diabetes has a blood glucose of 42 mg/dL and is diaphoretic and confused. Which statement represents the Recommendation portion of SBAR?
A. “The client is confused and diaphoretic.”
B. “The blood glucose is 42.”
C. “The client has Type 1 diabetes.”
D. “I recommend administering IV dextrose.”
D. “I recommend administering IV dextrose.”
When should an incident report be completed?
When an event is inconsistent with routine patient care
The nurse is teaching a client with asthma how to use a metered-dose inhaler. Which statement indicates the client needs further teaching?
A. “I will shake the inhaler before use.”
B. “I will inhale slowly while pressing the canister.”
C. “I will rinse my mouth after using the inhaler.”
D. “I will use the rescue inhaler every day even if I feel fine.”
Correct Answer: D
Rationale: Rescue inhalers are used PRN for symptoms, not daily. The other statements reflect correct technique.
Which nursing intervention is considered direct patient care?
A. Documenting care in the chart
B. Adjusting the patient’s environment
C. Administering IV medication
D. Participating in interdisciplinary rounds
B. Administering IV medication
Rationale Direct care involves hands-on interactions with the patient, such as medication administration or teaching.