Professional Nursing
Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
a. “Patient care is based on clinical judgment, experience, and traditions.”
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
c. “Research from all published articles are used as a guide for planning patient care.”
d. “Recommendations are based on research, clinical expertise, and patient preferences.”
What is D?
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise and consideration of patient preferences. Clinical judgment based on the nurse’s clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but data analysis is not required to use EBP. All published articles do not provide research evidence; interventions should be based on credible research, preferably randomized controlled studies with a large number of subjects.
A patient who is actively bleeding is admitted to the emergency department. Which approach would the nurse use to obtain an accurate health history?
a. Briefly interview the patient while obtaining vital signs.
b. Obtain subjective data about the patient from family members.
c. Omit subjective data collection and obtain the physical examination.
d. Use the health care provider’s medical history to obtain subjective data.
What is A?
In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider’s medical history. Family members may be able to provide some data, but only the patient will be able to give subjective information about the bleeding. Because the subjective data about the cause of the patient’s bleeding will be essential, obtaining the physical examination alone will not provide sufficient information.
A middle-aged patient with diabetes tells the nurse, “I want to know how to give my own insulin so I don’t have to bother my wife all the time.” Which action would the nurse take?
a. Demonstrate how to draw up and administer insulin.
b. Discuss the use of exercise to decrease insulin needs.
c. Teach about differences between the various types of insulin.
d. Provide handouts about therapeutic and adverse effects of insulin.
What is A?
Adult education is most effective when focused on information that the patient thinks is needed right now. Teaching will be most effective if the nurse starts with the patient’s stated priority topic, which is administering insulin. Other pertinent information can be included when planning additional teaching for this patient.
A nurse is assigned to care for a patient with a detached retina. Which finding would the nurse expect to be documented in the patient's record?
a. blurred visionb. pain in the affected eye
c. a yellow discoloration of the sclera
d. a sense of a curtain falling across the field of vision
What is A?
A characteristic clinical manifestation of a retinal detachment is described by clients the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual activity is still normal.
A nurse notes that the health care provider has documented a diagnosis of presbycusis on the patient's chart. The nurse understands that this condition is accurately described as:
a. tinnitus that occurs with aging
b. nystagmus that occurs with aging
c. a conductive hearing loss that occurs with aging
d. a sensorineural hearing loss that occurs with aging
What is D?
Prsbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss causes by nerve degeneration in the inner ear of the auditory nerve.
The nurse is caring for an older adult patient who needs continued nursing care and physical therapy to improve mobility after surgery to repair a fractured hip. The nurse would help to arrange for transfer of the patient to which type of facility?
a. A skilled care facility
b. A transitional care facility
c. A residential care facility
d. An intermediate care facility
What is B?
Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility.
Which physical assessment action should the nurse take after inspecting a patient’s abdomen?
a. Feel for any masses.
b. Palpate the abdomen.
c. Listen for bowel sounds.
d. Percuss the liver borders.
What is C?
When assessing the abdomen, auscultation is done before palpation or percussion because palpation and percussion can cause changes in bowel sounds and alter the findings. All of the techniques are appropriate, but auscultation should be done first.
The nurse plans to teach a patient and the caregiver how to manage high blood pressure. Which action would the nurse take first?
a. Teach the caregiver how to use a manual blood pressure cuff.
b. Ask the patient to select information from a list of related topics.
c. Give the patient and caregiver written information about hypertension
d. Have the dietitian meet with the patient and caregiver to discuss a low-sodium diet
What is B?
Because adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions may also be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important.
The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider?
a. The patient reports that the vision has not improved.
b. The patient requests a prescription refill for next week.
c. The patient feels uncomfortable wearing an eye patch.
d. The patient reports eye pain rated 5 (on a 0 to 10 scale).
What is D?
Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.
A client with Menier's disease is experiencing severe vertigo. The nurse instructs the client to do which of the following to assist in controlling the vertigo?
a. increase sodium in the diet
b. lie still and watch TV
c. avoid sudden head movements
d. increase fluid intake to 3000mL/day
What is C?
The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are something prescribed. Watching TV can increase the vertigo.
When developing the plan of care, which components would the nurse include in the clinical problem statement?
a. The problem and the suggested patient goals or outcomes
b. The problem, its causes, and the signs and symptoms of the problem
c. The problem with the possible etiology and the planned interventions
d. The problem, its pathophysiology, and the expected outcome
What is B?
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to support the problem’s existence should be included. Goals, outcomes, and interventions are not included in the problem statement.
A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which data would be a pertinent negative finding?
a. Patient has several bruised and swollen areas on the right leg.
b. Patient states that there have been no other recent health problems.
c. Patient refuses to bend the right knee because of the associated pain.
d. Patient denies having pain when the area over the fracture is palpated
What is D?
The nurse expects that a patient with a leg fracture will have pain over the fractured area. The bruising and swelling and pain with bending are positive findings. Having no other recent health problems is neither a positive nor a negative finding with regard to a leg fracture.
The nurse is planning a teaching session with a patient who is newly diagnosed with migraine headaches. To assess the patient’s readiness to learn, which question should the nurse ask first?
a. “What kind of work and leisure activities do you do?”
b. “What information do you think you need right now?”
c. “Can you describe the types of activities that help you learn new information?”
d. “Do you have any cultural beliefs that are inconsistent with the planned treatment?”
What is B?
Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present.
The occupational health nurse is caring for an employee who reports bilateral eye pain after a cleaning solution splashed into the employee’s eyes. Which action will the nurse take?
a. Apply cool compresses.
b. Flush the eyes with saline.
c. Apply antiseptic ophthalmic ointment to the eyes.
d. Cover the eyes with dry sterile patches and shields.
What is B?
In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes.
a. irrigation of the ear
b. instillation of antibiotic ear drops
c. instillation of corticosteroid ointmentd. instillation of mineral oil or diluted alcohol
What is D?
Insects are killed before removal unless they can be coaxed out by a flashlight or humming noise. Mineral oil or diluted alcohol is instilled in the ear to suffocate the insect.
Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select all that apply.)
a. Identifying priority problems
b. Noticing a change in patient status
c. Memorizing the steps of a procedure
d. Assessing data about a patient situation
e. Generating possible solutions to a patient problem
f. Making decisions based on the implications of a patient’s situation
What is A, B, D, E, and F?
Clinical judgment is evident when the nurse assesses data or situations, notices a change in a patient’s status, identifies priority problems, generates the best possible solutions, and makes decisions about patient care based on analysis of the situation. Clinical judgment is not memorizing a list of facts or the steps of a procedure.
The nurse records the following general survey: “The patient is a 50-year-old Asian female accompanied by her husband and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” What additional information should the nurse add to this general survey?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about the condition
What is A?
The general survey also describes the patient’s general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.
A patient who is obese states, “I’ve recently decreased my fat intake, and I’ve stopped smoking.” Which initial response would the nurse make?
a. “Although those are important, it is essential that you make other changes.”
b. “You have accomplished changes that are important for the health of your heart.”
c. “Are you having any difficulty in maintaining the changes you have already made?”
d. “Which additional changes in your lifestyle would you like to implement at this time?”
What is B?
Positive reinforcement of the learner’s achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate in a follow-up discussion but are not the best initial response because they do not provide reinforcement for the changes made.
A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness after administration. Which response would the nurse provide?
a. “Those symptoms may indicate a need for a change in dosage of the eyedrops.”
b. “The drops are uncomfortable, but using them can help to retain your vision.”
c. “These are normal side effects of the drug, which will go away over time.”
d. “Notify your health care provider so that different eyedrops can be prescribed.”
What is B?
Patients would be taught that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change.
In addition to aging, which of the following may contribute to hearing loss in the older adult? (Select all that apply.)
A) Exposure to loud noises
B) Recurrent otitis media and trauma
C)Excessive hair in the ear
D) Certain medications
E) Diabetes
What is A, B, C, and D?
Which actions by the nurse administering medications are consistent with promoting safe delivery of patient care? (Select all that apply.)
a. Discards a medication that is not labeled.
b. Uses hand sanitizer before preparing a medication.
c. Identifies the patient by the room number on the door.
d. Checks laboratory test results before administering a diuretic.
e. Gives the patient a list of current medications upon discharge.
What is A, B, D, and E?
National Patient Safety Goals have been established to promote safe delivery of care. The nurse should use at least 2 reliable ways to identify the patient such as asking the patient’s full name and date of birth before medication administration. Other actions that improve patient safety include performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments before administering medications, and giving a list of the current medicines to the patient and caregiver before discharge.
A patient has arrived at the hospital with severe abdominal pain and hypotension. Which type of assessment would the nurse do at this time?
a. Focused assessment
b. Subjective assessment
c. Emergency assessment
d. Comprehensive assessment
What is C?
Because the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs are essential for the unstable patient.
The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies would the nurse use? (Select all that apply.)
a. Discourage use of the Internet as a source of health information.
b. Avoid asking the patient about reading ability and level of education.
c. Show illustrations and photographs of various types of insulin.
d. Schedule one-to-one teaching sessions to practice insulin administration.
e. Provide videorecordings showing how to perform blood glucose testing.
What is C, D, and E?
For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient’s reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.
An older adult patient who has been diagnosed with age-related macular degeneration (AMD) asks the nurse what actions could help slow or avoid the potential vision loss. Which recommendations would the nurse plan to make? (Select all that apply.)
a. Maintain a healthy body weight.
b. Do not smoke or use tobacco products.
c. Include whole grains in your daily diet.
d. Avoid eating dark green leafy vegetables.
e. Consider taking an antioxidant supplement.
What is A, B, C, and E?
Obesity is a risk factor for AMD, so maintaining a healthy weight can decrease risk. Taking a supplement of antioxidant vitamins (e.g., vitamin C, vitamin E), lutein, zeaxanthin, and zinc may help slow the progression of AMD. Teach the patient to eat dark green, leafy vegetables containing lutein (e.g., kale, broccoli, spinach) and foods, such as beef, pork, dairy, and whole grains, that are high in zinc. Smoking cessation may help in halting the progression of dry AMD.
A 55-year-old male presents to the health care clinic with reports of decreased hearing over the past year. Which subjective data in the client's review of systems should the nurse recognize as risk factors for hearing loss? Select all that apply.
A) Use of antihypertensive medication
B) Chronic ear infections as a child
C) History of measles at 3 years of age
D) Wax blocking the ear canal
E) Drinks six cups of coffee daily
What is B, C, and D?