Foundations of Nursing 7th EditionBy Kim Cooper- Kelly Gosnell – Test Bank

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Foundations of Nursing 7th EditionBy Kim Cooper- Kelly Gosnell – Test Bank

Chapter 2: Legal and Ethical Aspects of Nursing

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called?
a. Deposition
b. Appeal
c. Complaint
d. Summons

 

 

ANS:  C

A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   1

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse caring for a patient in the acute care setting assumes responsibility for a patient’s care. What is this legally binding situation?
a. Nurse-patient relationship
b. Accountability
c. Advocacy
d. Standard of care

 

 

ANS:  A

When the nurse assumes responsibility for a patient’s care, the nurse-patient relationship is formed. This is a legally binding “contract” for which the nurse must take responsibility. Accountability is being responsible for one’s own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What are the universal guidelines that define appropriate measures for all nursing interventions?
a. Scope of practice
b. Advocacy
c. Standard of care
d. Prudent practice

 

 

ANS:  C

Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention?
a. Standards of care
b. Regulation of practice
c. American Nurses’ Association Code
d. Nurse practice act

 

 

ANS:  D

It is the nurse’s responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses’ code are not laws that the nurse should refer to before initiating this treatment.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   5

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:
a. malpractice.
b. harm to the patient.
c. negligence.
d. failure to follow the nurse practice act.

 

 

ANS:  A

The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law?
a. American Hospital Association’s Patient’s Bill of Rights
b. Self-determination act
c. American Hospital Association’s Standards of Care
d. The Joint Commission’s rights and responsibilities of patients

 

 

ANS:  A

Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patient’s Bill of Rights. The Self-determination act, American Hospital Association’s Standards of Care, and The Joint Commission’s rights and responsibilities do not address patients’ expectations regarding health care.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3| 4

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
a. Physical assessment
b. Interview
c. Informed consent
d. Surgical checklist

 

 

ANS:  C

The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   8

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. When a nurse protects the information in a patient’s record what ethical responsibility is the nurse fulfilling?
a. Privacy
b. Disclosure
c. Confidentiality
d. Absolute secrecy

 

 

ANS:  C

The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   9

TOP:   Confidentiality                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action?
a. Cover the bruises with bandages.
b. Take photographs of the bruises.
c. Ask the patient if anyone has hit her.
d. Report the bruises to the charge nurse.

 

 

ANS:  D

The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   9

TOP:   Elder abuse    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is the best way for a nurse to avoid a lawsuit?
a. Carry malpractice insurance
b. Spend time with the patient
c. Provide compassionate, competent care
d. Answer all call lights quickly

 

 

ANS:  C

The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   8

TOP:   Avoiding a lawsuit                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation?
a. To question the doctor
b. To seek advice from the family
c. To discuss it with the patient
d. To follow the order

 

 

ANS:  D

When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the doctor, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   10| 14

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take?
a. Ask for another assignment
b. Leave work
c. Transfer to another floor
d. Protest to the supervisor

 

 

ANS:  A

The nurse should not abandon the patient, but ask for another assignment.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   9| 16

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information?
a. Nurse practice act
b. Standards of care
c. Scope of nursing practice
d. Professional organizations

 

 

ANS:  B

Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   5

TOP:   Standards of care                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What role is the nurse who diligently works for the protection of patients’ interests playing?
a. Caregiver
b. Health care administrator
c. Advocate
d. Health care evaluator

 

 

ANS:  C

A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient’s interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   9| 12

TOP:   Advocate       KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
a. Go ahead and do it
b. Refuse to perform it, citing lack of knowledge
c. Discuss it with the charge nurse, asking for direction
d. Ask another nurse who has performed the procedure

 

 

ANS:  C

The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   8

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse?
a. Compare values with those of the patient
b. Make a judgment
c. Withhold an opinion
d. Give advice

 

 

ANS:  C

The nurse can assist the patient in values clarification without giving an opinion.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3| 8

TOP:   Values clarification                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What fundamental principle must the nurse first observe when confronted with an ethical decision?
a. Autonomy
b. Beneficence
c. Respect for people
d. Nonmaleficence

 

 

ANS:  C

The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   13| 15

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient’s health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report?
a. Unethical behavior of other staff members
b. A worker who arrives late
c. Favoritism shown by nursing administration
d. Arguments among the staff

 

 

ANS:  A

A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Unethical behavior                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital?
a. Only offers protection while on duty
b. Is limited in the amount of coverage
c. Is difficult to renew
d. Can be terminated at any time

 

 

ANS:  A

Most institutional insurance only provides liability coverage if the nurse is on duty at that facility.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2

TOP:   Malpractice insurance                     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
a. Administering a stronger dose of drug than was ordered
b. Refusing to give a patient’s daughter information over the phone
c. Informing the patient’s medical power of attorney of a medication change
d. Leaving a copy of the patient’s history and physical in the photocopier

 

 

ANS:  D

Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patient’s daughter information over the phone is appropriate practice.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   7

TOP:   Health Insurance Portability and Accountability Act (HIPAA)

KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Which of the following could cause a nurse to be cited for malpractice?
a. Refusing to give 60 mg of morphine as ordered
b. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines
c. Dragging an injured motorist off the highway and causing further injury
d. Informing a visitor about a patient’s condition

 

 

ANS:  B

Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for:
a. punitive damages.
b. civil battery.
c. assault.
d. nothing; no violation has occurred.

 

 

ANS:  B

Civil battery charges can be brought against someone performing an invasive procedure without the patient’s informed consent legally documented. This patient could not sue for punitive damages or an assault.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   6| 8

TOP:   Informed consent                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A physician instructs the nurse to bladder train a patient. The nurse clamps the patient’s indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse’s actions exemplify?
a. Malpractice
b. Battery
c. Assault
d. Neglect of duty

 

 

ANS:  A

A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is true about nurse practice acts?
a. They informally define the scope of nursing practice.
b. They provide for unlimited scope of nursing practice.
c. Only some states have adopted a nurse practice act.
d. The nurse must know the nurse practice act within his or her state.

 

 

ANS:  D

The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse’s responsibility to know the nurse practice act that is in effect for her geographic region.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   1

TOP:   Nurse practice acts                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. How can the medical record be used in litigation? (Select all that apply.)
a. Public record
b. Proof of adherence to standards
c. Evidence of omission of care
d. Documentation of time lapses
e. Evidence by only the plaintiff

 

 

ANS:  A, B, C, D

The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

TOP:   Legal properties of medical record KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
a. HIPAA violation
b. Slander
c. Libel
d. Invasion of privacy
e. Defamation

 

 

ANS:  A, D

The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   7

TOP:   Disclosure of information              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse failed to monitor a patient’s respiratory status after medicating the patient with a narcotic analgesic. The patient’s respiratory status worsened, requiring intubation. The patient’s family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.)
a. A nurse-patient relationship exists.
b. The nurse failed to perform in a reasonable manner.
c. There was harm to the patient.
d. The nurse was prudent in her performance.
e. The nurse did not cause the patient harm.
f. Duty does not exist.

 

 

ANS:  A, B, C

For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

COMPLETION

 

  1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person’s behavior in a given situation are referred to as ___________.

 

ANS:

values

 

Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   11| 12

TOP:   Values            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Acts whose performance is required, permitted, or prohibited are defined by ___________ of ______________.

 

ANS:

standards, care

 

Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Standards of care                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

Chapter 14: Surgical Wound Care

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Deliberate intention

 

 

ANS:  C

When wounds are kept open by a drain, they heal by tertiary intention.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 311-312

OBJ:   4                    TOP:   Tertiary intention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What technique will the nurse implement to assist the postoperative patient to cough?
a. Support the patient’s back
b. Offer an antitussive
c. Splint the abdomen with a pillow
d. Lean patient against the bedside table

 

 

ANS:  C

To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.

 

DIF:    Cognitive Level: Application          REF:   Page 312        OBJ:   8

TOP:   Suture lines    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?
a. Serosanguineous
b. Sanguineous
c. Serous
d. Purulent

 

 

ANS:  B

The term sanguineous means bloody. It is indicative of active bleeding.

 

DIF:    Cognitive Level: Application          REF:   Page 314, Table 13-2

OBJ:   1                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the advantage of an occlusive dressing?
a. Allows air to the incision
b. Keeps the incision moist
c. Delays epithelialization
d. Does not have to be changed

 

 

ANS:  B

Occlusive dressings keep the incision moist and increase epithelialization.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 315        OBJ:   7

TOP:   Occlusive dressings                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
a. Call the RN
b. Gently remove the gauze with sterile forceps
c. Cover with occlusive dressing
d. Moisten the dressing with sterile water

 

 

ANS:  D

When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.

 

DIF:    Cognitive Level: Application          REF:   Page 316        OBJ:   7

TOP:   Dry dressings                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound?
a. 2.5 inches
b. 6 inches
c. 12 inches
d. 18 inches

 

 

ANS:  C

When wound irrigation is done at home with a hand-held showerhead, the showerhead should be held approximately 12 inches from the wound.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 323        OBJ:   11

TOP:   Wound irrigation                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
a. From the area of least contamination to the area of most contamination
b. Forcefully into the wound
c. Gently over the skin into the wound
d. From a distance of about 12 inches

 

 

ANS:  A

The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.

 

DIF:    Cognitive Level: Application          REF:   Page 321,       OBJ:   11

TOP:   Wound irrigation                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
a. Call the RN
b. Cover the bowel with a sterile saline dressing
c. Turn the patient to the side of the evisceration
d. Raise the patient up to a high Fowler position

 

 

ANS:  B

Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler position to relieve strain on the suture line.

 

DIF:    Cognitive Level: Application          REF:   Page 324        OBJ:   8

TOP:   Evisceration   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
a. Remove 7 more alternate staples and securely tape with Steri-Strips
b. Cover with moist dressing and apply a binder
c. Continue to remove staples as ordered because this is an expected outcome
d. Leave the 12 staples in place and record the separation

 

 

ANS:  D

If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.

 

DIF:    Cognitive Level: Application          REF:   Page 325        OBJ:   9

TOP:   Staple removal                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
a. Weigh the patient to estimate the weight of the saturated dressing
b. Reinforce the dressing
c. Circle and date the outline of the exudate on the dressing
d. Count each dressing as 1 mL of drainage

 

 

ANS:  C

Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.

 

DIF:    Cognitive Level: Application          REF:   Page 328        OBJ:   7

TOP:   Draining wounds                            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
a. Dirty wound
b. Clean-contaminated wound
c. Contaminated wound
d. Clean wound

 

 

ANS:  D

A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   5

TOP:   Wounds         KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?
a. Fibrin
b. Thrombin
c. Protime
d. Calcium

 

 

ANS:  A

Fibrin in the clot begins to hold the wound together.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 311        OBJ:   1

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation

 

 

ANS:  B

During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   1

TOP:   Wounds         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What marked advantage does primary intention have over other phases of wound healing?
a. Healing is rapid
b. Healing rarely becomes infected
c. Minimal scarring results
d. Healing is painless

 

 

ANS:  C

Wounds that heal by primary intention have minimal scarring.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   4

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?
a. Every 30 minutes
b. Every 60 minutes
c. Every 2 to 4 hours
d. Every 5 to 8 hours

 

 

ANS:  C

The nurse inspects the dressing every 2 to 4 hours for the first 24 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 314        OBJ:   6

TOP:   Wounds         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
a. After the dressing change
b. At least 15 minutes before the dressing change
c. At least 30 minutes before the dressing change
d. At least 1 hour before the dressing change

 

 

ANS:  C

It may help to give an analgesic at least 30 minutes before exposing the wound.

 

DIF:    Cognitive Level: Application          REF:   Page 316        OBJ:   7

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
a. Destruction of tissue
b. Bleeding
c. Mechanical debridement
d. Prevention of infection

 

 

ANS:  C

The primary purpose of a wet-to-dry dressing is to debride a wound mechanically.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 318        OBJ:   7

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings?
a. Pain shock
b. Dehydration
c. Internal hemorrhage
d. Acute infection

 

 

ANS:  C

If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.

 

DIF:    Cognitive Level: Analysis               REF:   Page 324        OBJ:   3

TOP:   Postoperative                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the usual length of time before suture removal?
a. 2 to 3 days
b. 4 to 5 days
c. 5 to 6 days
d. 7 to 10 days

 

 

ANS:  D

Sutures are generally removed within 7 to 10 days.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 324        OBJ:   9

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
a. 50 mL
b. 100 mL
c. 200 mL
d. 300 mL

 

 

ANS:  D

Drainage greater than 300 mL in 24 hours is considered abnormal.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 327        OBJ:   3

TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the classification for the Jackson-Pratt drainage removal system?
a. Sterile drainage system
b. Closed drainage system
c. Open drainage system
d. Self-measuring drainage system

 

 

ANS:  B

The Jackson-Pratt removal system is a type of closed drainage system.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 329        OBJ:   10

TOP:   Drainage        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
a. Offer fluids every 4 hours
b. Encourage the consumption of large meals
c. Encourage up to 1000 mL of daily fluid intake
d. Encourage the consumption of small frequent meals

 

 

ANS:  D

To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 312        OBJ:   2

TOP:   Wound healing                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
a. Smoking increases the amount of tissue oxygenation.
b. Smoking increases the amount of functional hemoglobin in blood.
c. Smoking may decrease platelet aggregation and cause hypercoagulability.
d. Smoking interferes with normal cellular mechanisms that promote release of oxygen.

 

 

ANS:  D

Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 313        OBJ:   6

TOP:   Smoking         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
a. Improves overall tissue perfusion
b. Promotes release of oxygen to tissues
c. Causes hemoglobin to have a greater affinity for oxygen
d. Causes hemoglobin to have a decreased affinity for oxygen

 

 

ANS:  C

Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 313, Table 13-1

OBJ:   6                    TOP:   Diabetes mellitus

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a patient’s wound notes a clear watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

 

 

ANS:  A

Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 314, Table 13-2

OBJ:   5                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

 

 

ANS:  B

Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 314, Table 13-2

OBJ:   5                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

 

 

ANS:  D

Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 314, Table 13-2

OBJ:   5                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a patient’s wound notes bright red drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

 

 

ANS:  C

Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 314, Table 13-2

OBJ:   5                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
a. Cellulitis
b. Dehiscence
c. Evisceration
d. Extravasation

 

 

ANS:  B

Dehiscence is separation of a surgical incision or rupture of a wound closure.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 323, Table 13-3

OBJ:   8                    TOP:   Dehiscence    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the physician. What is an advantage of gauze bandages?
a. Provision of warmth
b. Applies strong pressure
c. Antibacterial effects
d. Prevents skin maceration

 

 

ANS:  D

Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation that helps prevent skin maceration (the softening and breaking down of skin from prolonged exposure to moisture). Flannel bandages provide warmth. Elastic bandages are effective for pressure application. Gauze bandages do not have antibacterial effects.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   13

TOP:   Bandages and binders                               KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese. The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority?
a. Infection
b. Altered nutrition: more than body requirements
c. Impaired skin integrity
d. Altered peripheral tissue perfusion

 

 

ANS:  B

The nurse’s assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority nursing diagnosis for this patient is Altered Nutrition: more than body requirements related to diet noncompliance.

 

DIF:    Cognitive Level: Analysis               REF:   Page               OBJ:   14

TOP:   Nursing Diagnosis                          KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service? (Select all that apply.)
a. Positive pressure is applied by this device
b. Healing is facilitated by decrease in drainage
c. Promotes formulation of granulation tissue
d. Reduces local and peripheral edema
e. Drops bacterial level in wound

 

 

ANS:  C, D, E

Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   12

TOP:   Vacuum-assisted device                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammation
d. Granulation
e. Maturation

 

 

ANS:  A, B, C, E

The steps in wound healing are hemostasis, inflammation,reconstruction, and maturation.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 311        OBJ:   1

TOP:   Wound healing                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer
c. Acetic acid
d. Dakin
e. Lysol

 

 

ANS:  A, B, C, D

Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 318        OBJ:   7

TOP:   Wet-to-dry dressings                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What are the advantages of a transparent dressing? (Select all that apply.)
a. Adheres to undamaged skin
b. Contains the exudate
c. Reduces wound contamination
d. Serves as a barrier to external bacteria
e. Slows epithelial growth

 

 

ANS:  A, B, C, D

Transparent dressings have the advantages of adhering to undamaged skin, containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 320        OBJ:   7

TOP:   Transparent dressings                                KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by _______ formation.

 

ANS:

collagen

 

Collagen forms as an immature scar over a new surgical wound.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 311        OBJ:   1

TOP:   Immature scarring                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.

 

ANS:

2000

two thousand

 

A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 312        OBJ:   2

TOP:   Fluid intake    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When preparing to remove a dressing, the nurse should don __________ gloves.

 

ANS:

clean

 

To remove a dressing, clean gloves are appropriate.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 315        OBJ:   7

TOP:   Removal of a dressing                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions?
a. Hyperalimentation
b. IV fluids and electrolyte replacement
c. Hormone replacement therapy
d. Vitamin supplements

 

 

ANS:  B

Medical treatment is aimed at meeting fluid and electrolyte replacement.

 

DIF:    Cognitive Level: Application          REF:   Pages 884-885

OBJ:   1                    TOP:   Hyperemesis gravidarum

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse?
a. A large for gestational age infant
b. Anorexia nervosa
c. Preterm delivery
d. Maternal or fetal death

 

 

ANS:  D

If untreated, hyperemesis gravidarum can result in maternal or fetal death.

 

DIF:    Cognitive Level: Application          REF:   Page 885        OBJ:   1

TOP:   Hyperemesis gravidarum                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. How should twins who share a placenta and come from one fertilized ovum be identified?
a. Dizygotic
b. Trizygotic
c. Genetically different
d. Monozygotic

 

 

ANS:  D

Monozygotic twins, also known as identical twins, originate from one fertilized ovum and share a placenta. Monozygotic twins carry the same genetic code. Dizygotic twins are the result of two separate ova being fertilized at the same time.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 886        OBJ:   1

TOP:   Multifetal pregnancy                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What complication of delivery should the nurse expect with the birth of multiple fetuses?
a. An ectopic tendency
b. Difficulty with breastfeeding
c. A vaginal delivery
d. Loss of uterine tone

 

 

ANS:  D

Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes multiple fetuses are delivered by cesarean. An ectopic tendency would present before delivery. While it can be difficult to breastfeed multiple infants, this does not relate to the delivery.

 

DIF:    Cognitive Level: Application          REF:   Page 886        OBJ:   1

TOP:   High-risk pregnancy                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient?
a. Long-term bed rest
b. Episodes of extreme hypertension
c. Surgery to remove the embryo/fetus
d. Treatment for dehydration

 

 

ANS:  C

An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention.

 

DIF:    Cognitive Level: Application          REF:   Page 888        OBJ:   1

TOP:   Ectopic pregnancy                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What percent of first-trimester  pregnancies spontaneously abort?
a. 5% to 10%
b. 10% to15%
c. 20% to 25%
d. 40% to 50%

 

 

ANS:  B

It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 889        OBJ:   1

TOP:   Abortions       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. What symptom, no matter what stage of pregnancy, should be reported immediately?
a. Backache
b. Urinary frequency
c. Vaginal bleeding
d. Uterine tightening

 

 

ANS:  C

Women should be instructed to contact their physician if any bleeding occurs during pregnancy.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 890        OBJ:   2

TOP:   Vaginal bleeding                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect?
a. Abruptio placentae
b. Hemorrhage
c. Placenta previa
d. Placentitis

 

 

ANS:  C

Placenta previa is a serious condition that consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy. The major symptoms of abruptio placentae are severe abdominal pain and uterine rigidity.

 

DIF:    Cognitive Level: Application          REF:   Page 891        OBJ:   2

TOP:   Placenta previa                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain?
a. Placenta previa
b. Appendicitis
c. Ectopic pregnancy
d. Abruptio placentae

 

 

ANS:  D

The major symptoms of abruptio placentae are severe pain and a rigid abdomen. Placenta previa consists of painless bleeding.  Appendicitis is not usually accompanied by a rigid abdomen. Symptoms of an ectopic pregnancy would usually occur in the first trimester.

 

DIF:    Cognitive Level: Application          REF:   Page 892        OBJ:   2

TOP:   Abruptio placentae                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient?
a. Prone position
b. Trendelenburg position
c. Supine position
d. Modified side-lying position

 

 

ANS:  D

A modified side-lying position facilitates uterine-placental perfusion.

 

DIF:    Cognitive Level: Application          REF:   Page 893        OBJ:   2

TOP:   Abruptio placentae                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect?
a. Allergy
b. Protein deficiency
c. Circulatory problem
d. Gestational hypertension

 

 

ANS:  D

Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy.

 

DIF:    Cognitive Level: Analysis               REF:   Page 895        OBJ:   4

TOP:   Pregnancy-induced hypertension (PIH)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What is the cause of gestational hypertension?
a. Too much salt
b. A toxin
c. Unknown
d. Diabetes

 

 

ANS:  C

The cause of gestational hypertension is unknown.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 896        OBJ:   4

TOP:   Pregnancy-induced hypertension (PIH)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse hope to identify by keeping a record of a patient’s blood pressure during prenatal visits?
a. Ketoacidosis
b. Placenta previa
c. Gestational diabetes
d. Gestational hypertension

 

 

ANS:  D

Blood pressure should be assessed routinely during pregnancy, because symptoms of gestational hypertension include hypertension.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 895        OBJ:   4

TOP:   Pregnancy-induced hypertension (PIH)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing a “kick count” for a patient with gestational hypertension. What result should be a cause for concern?
a. Less than three kicks per hour
b. Less than five kicks per hour
c. Less than seven kicks per hour
d. Less than nine kicks per hour

 

 

ANS:  A

A kick count of fewer than three per hour is considered serious and a cause for concern.

 

DIF:    Cognitive Level: Application          REF:   Page 899        OBJ:   3

TOP:   Pregnancy-induced hypertension (PIH)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid?
a. Contact with an infected person
b. Emptying cat litter boxes bare-handed
c. Having unprotected sex
d. Eating excessive amounts of shellfish

 

 

ANS:  B

A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of toxoplasmosis infection.

 

DIF:    Cognitive Level: Application          REF:   Page 903, Box 28-5

OBJ:   6                    TOP:   Infections      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What is a major complication of gestational diabetes that affects the infant?
a. Lack of nutrition
b. Dehydration
c. Hypoglycemia
d. Hyperglycemia

 

 

ANS:  C

A result of gestational diabetes is neonatal hypoglycemia.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 905        OBJ:   1

TOP:   Diabetes         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary?
a. The growing baby will require more glucose.
b. Oral hypoglycemic agents may be teratogenic.
c. Increased hormone levels raise blood glucose.
d. Oral hypoglycemics do not reach the fetus.

 

 

ANS:  B

Oral hypoglycemics are discontinued because of teratogenic effects.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 906        OBJ:   5

TOP:   Diabetes         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Why is the fetus dependent on the mother for glucose control?
a. The insulin requirements are higher.
b. Insulin is destroyed by the placenta.
c. Insulin does not cross the placenta.
d. Insulin is absorbed by the fetus.

 

 

ANS:  C

Insulin will not cross the placenta, but high glucose levels do. Therefore, it is imperative that the mother control glucose levels.

 

DIF:    Cognitive Level: Analysis               REF:   Page 907        OBJ:   5

TOP:   Diabetes         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered?
a. Oxygen administration
b. Administering large amount of IV fluids
c. Positioning the patient on her back
d. Encouraging activity between contractions

 

 

ANS:  A

Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administration is kept to a minimum to prevent fluid overload. The patient would be positioned in a semi-Fowler position to improve circulation. The patient should be encouraged to rest between contractions to conserve energy.

 

DIF:    Cognitive Level: Application          REF:   Page 908        OBJ:   12

TOP:   Cardiovascular defects                   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem?
a. Calcium deficit
b. Cephalopelvic disproportion
c. Bleeding tendency
d. Low hemoglobin levels

 

 

ANS:  B

There are several physiological concerns for pregnant adolescents, including cephalopelvic disproportion.

 

DIF:    Cognitive Level: Analysis               REF:   Page 909        OBJ:   7

TOP:   Adolescent pregnancy                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When should the gestational age of the infant be determined?
a. Within 5 to 10 minutes of delivery
b. Within 1 to 2 hours of delivery
c. Within 2 to 8 hours of delivery
d. Within 12 to 24 hours of delivery

 

 

ANS:  C

The gestational age tests are done within 2 to 8 hours of delivery.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 915        OBJ:   9

TOP:   Gestational age                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant?
a. 20 to 37 completed weeks of pregnancy
b. 38 to 41 completed weeks of pregnancy
c. 14 to 36 completed weeks of pregnancy
d. 42 or more completed weeks of pregnancy

 

 

ANS:  A

The lungs of preterm infants have not fully developed; therefore, they have problems with oxygenation. Preterm infants also lack subcutaneous fat. The gestational age of the preterm is classified as 20 to 37 complete weeks of pregnancy.

 

DIF:    Cognitive Level: Analysis               REF:   Page 916        OBJ:   9

TOP:   Preterm          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants?
a. 1 to 2 times
b. 2 to 3 times
c. 3 to 4 times
d. 4 to 5 times

 

 

ANS:  C

The morbidity and mortality rate for preterm infants is higher by 3 to 4 times that of an older infant of similar weight.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 916        OBJ:   9

TOP:   Preterm          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant?
a. Full term
b. Small for gestational age
c. Preterm
d. Post-term

 

 

ANS:  C

Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded.

 

DIF:    Cognitive Level: Analysis               REF:   Page 917        OBJ:   9

TOP:   Preterm          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. An infant born to a diabetic mother should be closely monitored for the presence of what condition?
a. Hyperglycemia
b. Hypercalcemia
c. Hypoglycemia
d. Cardiac abnormalities

 

 

ANS:  C

The infant of a diabetic mother will frequently exhibit hypoglycemia, hypocalcemia, perinatal asphyxia, congenital abnormalities, and respiratory difficulties.

 

DIF:    Cognitive Level: Analysis               REF:   Page 918        OBJ:   11

TOP:   Diabetes         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies?
a. Rh-negative blood cells
b. Rh-positive blood cells
c. Rh-negative antibodies
d. Rh-positive antibodies

 

 

ANS:  D

If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be produced.

 

DIF:    Cognitive Level: Analysis               REF:   Page 918        OBJ:   10

TOP:   Hemolytic disease                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection?
a. Iron
b. Vitamin B12
c. RhoGAM
d. Type O blood

 

 

ANS:  C

RhoGAM prevents the development of naturally occurring maternal antibodies.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 918        OBJ:   10

TOP:   Hemolytic disease                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth?
a. Within normal limits
b. Pathologic
c. A result of iron deficiency
d. Indicating possible hepatitis

 

 

ANS:  B

Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 918        OBJ:   10

TOP:   Hemolytic disease                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What test is used to identify the maternal level of Rh antibodies in the mother’s blood?
a. Indirect Coombs test
b. Hemolytic test
c. Rh antibody test
d. Direct Coombs test

 

 

ANS:  A

The indirect Coombs test measures the maternal level of antibodies.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 919        OBJ:   3

TOP:   Hemolytic disease                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy?
a. It is initiated when the bilirubin level reaches 5 mg/dL.
b. It converts bilirubin to a water-soluble form to be excreted in the urine.
c. It changes bilirubin to a bile salt to be excreted through the bowel.
d. It requires eye patches to remain in place 24 hours a day.

 

 

ANS:  B

Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization.

 

DIF:    Cognitive Level: Analysis               REF:   Page 920        OBJ:   10

TOP:   Hemolytic disease                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Why do alcohol and illegal drugs endanger the fetus?
a. Both are absorbed into the bloodstream.
b. Both affect the mother.
c. Both cross the placental barrier.
d. Both increase the heart rate of the fetus.

 

 

ANS:  C

Alcohol and illicit drugs cross the placental barrier and affect the fetus.

 

DIF:    Cognitive Level: Application          REF:   Page 921        OBJ:   8

TOP:   Fetal risk from drugs                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus?
a. Fetal dependency
b. Fetal immaturity
c. Malnutrition dependency
d. Fetal alcohol syndrome

 

 

ANS:  D

Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The fetus may also be born with alcohol dependency and immaturity, but the characteristics noted are specific for fetal alcohol syndrome.

 

DIF:    Cognitive Level: Application          REF:   Page 922, Table 28-4

OBJ:   8                    TOP:   Fetal risk        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What should be specifically monitored in a patient who is hospitalized with gestational hypertension?
a. Blood sugar
b. Temperature
c. Level of consciousness
d. Deep tendon reflexes

 

 

ANS:  D

If the patient is hospitalized for gestational hypertension, deep tendon reflexes are monitored. The blood sugar, temperature, and LOC will also be monitored, but they are not the priority in the hypertensive patient.

 

DIF:    Cognitive Level: Application          REF:   Page 896        OBJ:   4

TOP:   Eclampsia      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the antidote for magnesium sulfate toxicity?
a. Vitamin K
b. Calcium gluconate
c. Potassium sulfate
d. Calcium carbonate

 

 

ANS:  B

The antidote for magnesium sulfate toxicity is calcium gluconate.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 899, Box 28-4

OBJ:   11                  TOP:   Maternal risk

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What is a prominent feature of postpartum depression?
a. Failure to thrive
b. Rejection of the infant
c. Inability to care for the baby
d. Problems with the baby’s father

 

 

ANS:  B

A prominent feature of PPD is rejection of the infant.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 921        OBJ:   1

TOP:   Postpartum depression (PPD)         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. What is the usual treatment for severe postpartum depression?
a. Improved nutrition
b. Vitamin therapy
c. Pharmacologic interventions
d. Support group therapy

 

 

ANS:  C

Support therapy is not enough for major PPD. Pharmacologic interventions are needed in most instances.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 922        OBJ:   1

TOP:   Postpartum depression (PPD)         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.)
a. “You have nothing to worry about. You will be disease free before you deliver.”
b. “The tuberculosis can be transmitted to the fetus in rare occurrences.”
c. “Your newborn will be tested for tuberculosis after delivery.”
d. “There is no approved treatment for the infant if she tests positive for the disease.”
e. “You will not be able to hold your newborn until you have been cleared according to the health department guidelines.”

 

 

ANS:  B, C, E

TB can be transmitted to a fetus in the womb. Newborns of infected mothers are skin tested for TB after birth and treated if the skin test is positive. Mothers who have TB are not allowed to have exposure to their newborn until they have been cleared according to the health department standards.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Pulmonary tuberculosis                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  1. Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of _____________ ______________ _________________.

 

ANS:

disseminated intravascular coagulation (DIC)

disseminated intravascular coagulation

DIC

 

DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding.

 

DIF:    Cognitive Level: Application          REF:   Pages 893-894

OBJ:   2                    TOP:   Disseminated intravascular coagulation (DIC)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peripad in less than ______ minutes.

 

ANS:

15

fifteen

 

The saturation of one peripad within 15 minutes is considered to be excessive bleeding.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 894        OBJ:   3

TOP:   Postpartum hemorrhage                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that severe preeclampsia needs to be controlled because it can develop into another syndrome called _________________.

 

ANS:

HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets)

HELLP

Hypertension, Elevated Liver enzymes, and Low Platelets

 

Progressive preeclampsia can develop into HELLP syndrome.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 900        OBJ:   4

TOP:   Hypertension, Elevated Liver enzymes, and Low Platelets (HELLP)

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a _________ ____________.

 

ANS:

hydatidiform mole

 

Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters are passed.

 

DIF:    Cognitive Level: Application          REF:   Page 887        OBJ:   3

TOP:   Hydatidiform mole                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A woman who is 14 weeks pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a _____________ abortion.

 

ANS:

missed

 

A missed abortion is initiated by a bleeding episode in which the fetus is not expelled. The uterus begins to shrink, but periods do not resume.

 

DIF:    Cognitive Level: Application          REF:   Page 889        OBJ:   3

TOP:   Missed abortion                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

Chapter 40: Professional Roles and Leadership

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. What is the correct term for a concise, one- or two-page summary of educational and work experience, activities and honors, and concrete skills and interests?
a. Introduction
b. Review
c. Résumé
d. Composite

 

 

ANS:  C

A résumé is a one- or two-page summary of the applicant’s education and experience.

 

DIF:    Cognitive Level: Knowledge          REF:   Pages 1238-1239

OBJ:   1                    TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An employee failed to perform the duties listed in the employment contract. What is the term for this failure?
a. Lawsuit
b. Termination
c. Breach of contract
d. Reprimand

 

 

ANS:  C

Failure by the nurse or employer to perform contractual duties is known as a breach of contract. A breach of contract may result in a reprimand, termination, or lawsuit.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1242      OBJ:   2

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is the best way to resolve most disagreements?
a. Agreement
b. Argument
c. Communication
d. Withdrawing

 

 

ANS:  C

Most problems can best be resolved by communication at the most basic level.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1242      OBJ:   13

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is another term for promotion?
a. Reward
b. Advancement
c. Lift
d. Bubble

 

 

ANS:  B

Advancement may result from additional preparation or additional experience. It may be gained by learning the position more thoroughly and by assuming new and greater responsibilities.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1243      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When a résumé reflects too many job changes, the employer may question it. How long should an employee remain at the first place of employment?
a. 6 months
b. 3 months
c. 1 year
d. 2 years

 

 

ANS:  C

Resigning from a position properly is another skill that the LPN/LVN will need to have. Employers will sometimes question a résumé that reflects frequent job changes; therefore, it is best to remain at the first place of employment at least 1 year.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1243      OBJ:   1

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Technical and scientific changes have resulted in a multiplicity and complexity of functions placed on nurses, and sometimes job descriptions have not been rewritten. What is true of the role of the LPN/LVN?
a. It is constantly enlarging
b. It is constantly changing
c. It is constantly improving
d. It is constantly growing

 

 

ANS:  B

The role of the LPN/LVN is constantly changing.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1243      OBJ:   6

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which organization specifically supports and meets the needs of the LVN/LPN?
a. NAPNES
b. NLN
c. ANA
d. NCLEX

 

 

ANS:  A

National Association for Practical Nurse Education and Service (NAPNES) is the professional organization that is specifically for LVN/LPNs. The National League for Nursing (NLN) and the American Nurses Association (ANA) are not specific to the LPN. The National Council Licensure Exam (NCLEX) is the test that is taken for licensure.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1245      OBJ:   5

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse may practice in another state if he or she has passed the NCLEX-PN examination in the nurse’s own state and meets the other state’s educational requirements. What is the process of transferring licensure from one state to another called?
a. Auxiliary
b. Co-licensure
c. Endorsement
d. Qualified licensure

 

 

ANS:  C

This licensure transfer from one state to another is called endorsement.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1248      OBJ:   10

TOP:   Licensure       KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is the name of the licensing law that defines the title and regulations governing the practice of nursing and states the requirements for licensure?
a. State practice act
b. Nurse regulation act
c. Nurse practice act
d. Legislative act

 

 

ANS:  C

The nurse practice act defines the title and regulations governing the practice of nursing.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1249      OBJ:   9

TOP:   Licensure       KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is the term for the commission of an act that a prudent nurse should not have done, or the omission of an act a prudent nurse should have done, that results in injury or harm to another person?
a. Malpractice
b. Negligence
c. Neglect
d. Disregard

 

 

ANS:  B

To qualify as negligence, it must be proved that a prudent member of the profession would have acted differently.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1250      OBJ:   10

TOP:   Negligence     KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. In what setting can the LPN/LVN’s management and leadership skills be developed best?
a. Acute care hospital
b. Rehabilitation hospital
c. Trauma center
d. Long-term care facility

 

 

ANS:  D

Management and leadership skills of the LPN/LVN can best be developed in long-term care settings with RN supervision.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1252      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which setting provides greater nurse autonomy and continuity of care and is less costly for insurance companies?
a. Hospice
b. Hospitals
c. Home health
d. Long-term care

 

 

ANS:  C

The advantages of home health are greater nurse autonomy and continuity of care, as well as less cost to insurance.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1252      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which employment setting would likely involve a daytime schedule with weekends off, and would focus on prevention and patient teaching?
a. Long-term care
b. Physician’s office
c. Hospice setting
d. Adult day care

 

 

ANS:  B

Physician offices typically involve a daytime schedule with most weekends off. The setting focuses on prevention and includes opportunities for patient teaching.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1252      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which health care employment setting would provide the nurse a very good salary, the opportunity to refuse to take an assignment, and more flexibility in the personal schedule but with an uncertainty of work availability?
a. Temporary agency
b. Long-term care center
c. Outpatient clinic
d. Adult day care center

 

 

ANS:  A

In a temporary agency, the salary is good, and an LPN/LVN has the right to refuse assignments. However, one disadvantage is the uncertainty of work availability.

 

DIF:    Cognitive Level: Application          REF:   Page 1252      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. In what employment setting does the nurse give total care to one patient; is totally independent; provides care in the home, hospital, or other facility; is paid directly by the patient; and is legally responsible for his or her own actions?
a. Home health nursing
b. Private duty nursing
c. Patient care nursing
d. Agency care nursing

 

 

ANS:  B

The private duty nurse gives total care to one patient and is paid directly by the patient or responsible party. The nurse is legally responsible for his or her own actions.

 

DIF:    Cognitive Level: Application          REF:   Page 1253      OBJ:   12

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A new graduate who has achieved the goal of getting others to do something that is believed necessary has demonstrated what skill?
a. Management
b. Leadership
c. Influence
d. Control

 

 

ANS:  B

Leadership is the art of getting others to want to do something that is perceived as necessary.

 

DIF:    Cognitive Level: Application          REF:   Page 1254      OBJ:   13

TOP:   New graduate                                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What type of leadership involves a leader who displays little trust or confidence in employees and therefore makes all the decisions?
a. Democratic
b. Laissez-faire
c. Autocratic
d. Authoritative

 

 

ANS:  C

The autocratic leader displays little trust in employees, and therefore makes all decisions.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1255      OBJ:   14

TOP:   Leadership     KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What type of leadership uses four different styles—directing, coaching, supporting, and delegating?
a. Autocratic
b. Situational
c. Democratic
d. Authoritative

 

 

ANS:  B

Situational leadership identifies four typical styles for leaders.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1255      OBJ:   14

TOP:   Leadership     KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is the physical, emotional, and spiritual exhaustion that can occur among caregivers?
a. Excessiveness
b. Burnout
c. Fatigue
d. Weariness

 

 

ANS:  B

Physical, emotional, and spiritual exhaustion among caregivers is sometimes called burnout.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1258      OBJ:   22

TOP:   Burnout          KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Why is it important for new graduates to purchase their own malpractice insurance rather than depend on an institutional policy?
a. A private policy will not cover them unless they are on their primary job.
b. A private policy will carry personal liability coverage.
c. A private policy will protect them against all lawsuits.
d. A private policy will protect them from losing their license.

 

 

ANS:  B

The new graduate should purchase private malpractice insurance in addition to that of the institution to ensure that there is personal liability coverage. The private policy will cover the new graduate at any nursing job in which they are employed. No malpractice insurance policy can guarantee that there will not be any lawsuit or loss of license.

 

DIF:    Cognitive Level: Application          REF:   Page 1264      OBJ:   21

TOP:   Malpractice insurance                     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. What are considered duties of a team leader? (Select all that apply.)
a. Receiving reports on assigned patients
b. Making patient assignments for team members
c. Assessing all assigned patients
d. Administering medications to all patients
e. Conferring with team members

 

 

ANS:  A, B, C, E

Receiving reports on assigned patients, making patient assignments, assessing all assigned patients, and conferring with team members are duties of the team leader. Assisting team members with medication administration is a duty of the team leader, not actually administering the medications to all the patients.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1256      OBJ:   15

TOP:   Team leading                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which actions would best aid the new nurse in coping with working the night shift? (Select all that apply.)
a. Eat large meals during the night to stay awake
b. Use dark shades to block out light when sleeping
c. Obtain a prescription for sedatives to aid sleep
d. Wear sunglasses on the drive home from work
e. Go directly to bed when arriving home from work

 

 

ANS:  B, D

Dark shades or room darkening blinds will block the sunshine and allow for darkness when sleeping during the daytime hours. Wear sunglasses on the drive home from work to reduce the melatonin-reducing effect of sunshine. It is best to eat light, balanced meals during the night. Sedatives and alcohol should not be used as an aid to sleep. Allow time to unwind after work before going to bed, and try to follow the same routine daily.

 

DIF:    Cognitive Level: Application          REF:   Page 1256      OBJ:   3

TOP:   Night shift      KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A nursing instructor is preparing her class for the NCLEX-PN examination. Which statements by the students indicate understanding of the testing process? Select all that apply.
a. “It will be a computerized adaptive test.”
b. “I will have a maximum of 265 questions.”
c. “The maximum time allowed for testing is 5 hours.”
d. “The minimum number of questions on the test is 60.”
e. “My state board of nursing must approve my application to test.”

 

 

ANS:  A, C, E

The NCLEX-PN examination is a computerized adaptive test. The minimum number of questions for the PN examination is 85, and the maximum number of questions is 205. The maximum time allowed for the test is 5 hours. The state board of nursing must approve the applicant for testing before the authorization to test is issued.

 

DIF:    Cognitive Level: Application          REF:   Page 1256      OBJ:   7

TOP:   NCLEX exam                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which questions should the nurse consider before delegating care to another team member? (Select all that apply.)
a. Is this the right task?
b. Is this the right time?
c. Is this the right person?
d. Is this the right supervision?
e. Is this the right circumstance?

 

 

ANS:  A, C, D, E

The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision. Right time is not included in the five rights of delegation.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1256      OBJ:   16

TOP:   Delegation      KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What data are necessary to compile an effective end-of-shift report? (Select all that apply.)
a. Patient’s mental status
b. Status of lung sounds
c. All pertinent nursing care
d. The patient’s favorite TV shows
e. Visitors the patient had during the shift

 

 

ANS:  A, B, C

The patient’s mental status, status of lung sounds, and pertinent nursing care performed during the shift should all be included in an end-of-shift report. The patient’s favorite TV shows and visitors that the patient had during the shift would not normally be included in the end-of-shift report.

 

DIF:    Cognitive Level: Application          REF:   Page 1256      OBJ:   20

TOP:   End-of-shift report                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A manager is concerned that one of the nurses on the unit is experiencing burnout. Which symptoms would support the concerns? (Select all that apply.)
a. Fatigue
b. Forgetfulness
c. Increased energy
d. Negative outlook
e. Changes in eating habits

 

 

ANS:  A, B, D, E

Symptoms of burnout include fatigue, forgetfulness, decreased energy, negative outlook, and changes in eating habits.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1256      OBJ:   22

TOP:   Burnout          KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

COMPLETION

 

  1. After transcribing each order in a list of orders, the nurse should ___________ __________ the order.

 

ANS:

check off

 

The nurse should check off each order as it is transcribed to ensure that each order is implemented.

 

DIF:    Cognitive Level: Application          REF:   Page 1261      OBJ:   19

TOP:   Orders            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The experienced nurse who assists a novice to learn the skills of the profession is called a(n) ________________.

 

ANS:

mentor

 

The nurse who guides a novice in the skills of the profession is called a mentor.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 1250      OBJ:   11

TOP:   Mentoring      KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

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