Test Bank For Fundamentals Nursing Care Skills 2nd Edition By Ludwig Burton

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Fundamentals Nursing Care Skills 2nd Edition By Ludwig Burton

 

Chapter 4. The Nursing Process and Decision Making

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   When educating a class of nursing students about the nursing process, the nursing instructor teaches that the nursing process is a

A. Decision-making framework used by nurses to determine the needs of patients.
B. Decision-making framework used by social workers when discharging patients.
C. Decision-making framework used by nursing assistants when caring for patients.
D. Decision-making framework used by physicians to determine the needs of patients.

 

 

____    2.   When reviewing the nursing diagnoses in a student nurse’s written care plan, the nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of:

A. “Pain related to abdominal incision.”
B. “Altered sensory perception related to surgery.”
C. “Chronic fatigue syndrome related to poor diet.”
D. “Altered nutrition related to nausea and vomiting.”

 

 

____    3.   The nurse encourages the student nurse to practice using skillful reasoning and logical thought to determine the merits of a belief or action. This approach best describes

A. Critical thinking.
B. Sensory overload.
C. Concrete thinking.
D. Logical reasoning.

 

 

____    4.   The nurse receives an order from the physician for an anticoagulant to be administered to a patient who has a deep vein thrombosis. The nurse recognizes that the patient has a critical international normalized ratio (INR) level. The nurse should

A. Redraw the INR level.
B. Call the lab for clarification.
C. Inform the physician of the INR level.
D. Administer the anticoagulant in 1 hour.

 

 

____    5.   While caring for a newly admitted patient, the nurse interviews the patient to obtain a health history, performs a head-to-toe assessment, and reviews laboratory and diagnostic tests. This step in the nursing process is called

A. Planning.
B. Evaluation.
C. Assessment.
D. Implementation.

 

 

____    6.   When caring for a patient who complains of abdominal pain, the nurse determines that analgesics must be given to manage the patient’s pain. This step in the nursing process is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____    7.   The nurse is caring for a patient who has a hip spica cast. The nurse monitors the patient for pain, pallor, parasthesia, pulselessness, and paralysis. When the patient complains of pain, the nurse administers analgesics. When the nurse medicates the pain, he or she is performing the step in the nursing process that is called

A. Planning.
B. Evaluation.
C. Assessment.
D. Implementation.

 

 

____    8.   The nurse is caring for a patient with a diagnosis of asthma who is experiencing increased dyspnea. The nurse notifies the respiratory therapist who administers a nebulizer treatment. After the treatment, the patient continues to experience dyspnea. The nurse reflects on treatment to determine if the goal of relief from dyspnea has been accomplished. When the nurse determines if the goal has been met, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Evaluation.
D. Implementation.

 

 

____    9.   The nurse has just finished completing an admission assessment of a newly admitted patient. Next the nurse should

A. Implement the plan of care.
B. Plan the nursing interventions.
C. Formulate a nursing diagnosis.
D. Evaluate the effects of interventions.

 

 

____  10.   The nurse receives a patient who was a direct admission. The nurse initially completes an assessment on the patient and gathers a health history. The nurse determines the top-priority nursing diagnosis. Next the nurse should

A. Implement the plan of care.
B. Plan the nursing interventions.
C. Implement the nursing interventions.
D. Evaluate the effects of interventions.

 

 

____  11.   The nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer analgesics as needed. When the patient complains of pain, the nurse medicates the patient. Next the nurse should

A. Assess the patient’s lab values.
B. Create a new nursing diagnosis.
C. Administer an additional analgesic.
D. Evaluate the effects of the analgesic.

 

 

____  12.   A patient arrives to the nursing unit as a direct admit. First the nurse should

A. Assess the patient.
B. Ambulate the patient.
C. Create a nursing diagnosis.
D. Evaluate the patient’s nursing goals.

 

 

____  13.   When the nurse gathers information through signs and symptoms and obtains the patient history, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  14.   When the nurse formulates nursing diagnoses through analysis of the assessment information, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  15.   When the nurse determines priorities and what nursing actions should be performed to help resolve or manage each patient problem, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  16.   When the nurse takes actions to resolve a patient’s problems, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Assessment.
D. Implementation.

 

 

____  17.   When the nurse reflects on the interventions that he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step, he or she is performing the step in the nursing process that is called

A. Planning.
B. Diagnosis.
C. Evaluation.
D. Implementation.

 

 

____  18.   The registered nurse (RN) supervises the licensed practical nurse (LPN/LVN). The RN recognizes that the most appropriate task to delegate to the LPN/LVN is

A. Formulating a nursing diagnosis.
B. Performing an initial admission assessment.
C. Obtaining a patient’s morning weight.
D. Administering an intramuscular analgesic.

 

 

____  19.   The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

A. Formulating a nursing diagnosis.
B. Administering subcutaneous insulin.
C. Culturing a patient’s wound drainage.
D. Obtaining a patient’s morning weight.

 

 

____  20.   The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

A. Writing medication orders.
B. Obtaining a urine culture.
C. Checking a patient’s blood sugar.
D. Administering a transdermal patch.

 

 

____  21.   The registered nurse (RN) recognizes that there are three components to the assessment of patients when he or she gathers information about their problems and needs. These three components are

A. Interviewing, problem solving, and prioritizing.
B. Interviewing, assessment, and creating a list of nursing diagnoses.
C. Interviewing, assessment, and reviewing laboratory and diagnostic tests.
D. Interviewing, setting goals for the patient, and implementing those goals.

 

 

____  22.   The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as objective data that

A. The patient reports feelings of depression.
B. The patient demonstrates facial grimacing.
C. The patient complains of feeling nauseated.
D. The patient complains of visual disturbances.

 

 

____  23.   The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as subjective data that

A. The patient is short of breath.
B. The patient has wound drainage.
C. The patient demonstrates guarding.
D. The patient reports feelings of fatigue.

 

 

____  24.   When performing an admission history on a confused patient, the registered nurse (RN) collects secondary data, an example of which is that

A. The patient reports history of chest pain.
B. The patient complains of chronic constipation.
C. The patient verbalizes anxiety about hospitalization.
D. The patient’s spouse reports experiencing marital issues.

 

 

____  25.   When performing an admission history on a patient, the nurse collects primary data. An example of primary data is that

A. The patient’s spouse reports patient has difficulty sleeping.
B. The patient’s caregiver complains of feeling overwhelmed.
C. The patient reports history of chronic obstructive pulmonary disease.
D. The patient’s daughter appears anxious about patient’s hospitalization.

 

 

____  26.   A nursing instructor is teaching a class of nursing students about performing a patient assessment and formulating nursing diagnoses. The nursing instructor states that the health care team member responsible for performing a patient assessment and formulating nursing diagnoses is

A. The medical doctor (MD).
B. The registered nurse (RN).
C. The licensed practical nurse (LPN).
D. The unlicensed assistive personnel (UAP).

 

 

____  27.   When performing an initial admission assessment, the nurse visually examines the patient’s body for rashes, breaks in the skin, and normal appearance of eyes, ears, nose, mouth, limbs, and genitals. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  28.   When performing an initial admission assessment, the nurse touches and feels the patient’s pulses bilaterally. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  29.   When performing an initial admission assessment, the nurse listens to the patient’s heart and lung sounds. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  30.   When performing an initial admission assessment, the nurse taps on the patient’s abdomen to detect abnormalities. This is an example of the assessment technique that is called

A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.

 

 

____  31.   The nurse educates the student nurse that the formulation of nursing diagnoses is a function of the

A. Physician.
B. Registered nurse.
C. Nurse practitioner.
D. Physician’s assistant.

 

 

____  32.   The registered nurse (RN) formulates four nursing diagnoses for her patient. The nurse recognizes that the priority nursing diagnosis is

A. Altered nutrition.
B. Risk for infection.
C. Chronic low self-esteem.
D. Ineffective airway clearance.

 

 

____  33.   A patient is admitted to the hospital with pneumonia. The assessment reveals that he is short of breath at rest, has a weak cough, and is unable to bring up mucus that can be heard in his lungs and throat. He complains of chest discomfort and has a temperature of 101.6°F, pulse of 110, respirations 23, and blood pressure 126/82. When auscultating his lungs, the nurse hears crackles and wheezes. The patient is weak and becomes short of breath with exertion. His oxygen saturation is 96% at rest. The nurse selects as a priority nursing diagnosis

A. Risk for infection.
B. Activity intolerance.
C. Impaired gas exchange.
D. Ineffective airway clearance.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.   A nursing instructor is educating a student nurse about how to formulate an outcome statement on a care plan. The student nurse demonstrates understanding when stating (select all that apply):

A. “An outcome statement should be a realistic, specific action.”
B. “An outcome statement should be a specific action to be taken by the nurse.”
C. “An outcome statement is an action that is measurable and can be evaluated.”
D. “An outcome statement should be an action the patient is unable to perform.”
E. “An outcome statement should be a specific action to be taken by the patient.”
F. “An outcome statement has a definite time frame for completion of the action.”

 

 

____    2.   The nursing instructor is educating a student nurse about indirect patient care. The student nurse demonstrates understanding when identifying an example of indirect patient care as (select all that apply):

 

Chapter 33. Care of the Surgical Patient

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse who is caring for patients on a surgical unit recognizes that which of the following individuals is having corrective surgery?

A. A 39-year-old scheduled for breast reduction.
B. A 14-year-old scheduled for tumor debulking.
C. A 4-month-old scheduled for cleft lip repair.
D. A 55-year-old scheduled for an exploratory laparotomy.

 

 

____    2.   Which of the following is most commonly taught to help prevent post-surgical respiratory complications?

A. Turning, coughing, and deep breathing.
B. Splinting incisions.
C. The use of post-surgical compression stockings.
D. How to measure intake and output.

 

 

____    3.   The nurse who is caring for a patient after a total hip replacement recognizes that further teaching is required if he or she observes that

A. The patient alternately flexes and extends his or her toes.
B. The patient circles his or her ankles clockwise and counterclockwise.
C. The patient bends the knees slightly and helps himself or herself up in bed while using the trapeze.
D. The patient turns on one side, lifts each leg with his or her toes pointed, and then returns to midline.

 

 

____    4.   While determining the appropriate size of thigh-high antithrombolic stockings to order, the nurse would obtain which of the following measurements?

A. Length from gluteal fold to the bottom of the heel.
B. Length from mid-thigh to the tip of the toe.
C. Circumference of the knee.
D. Amount of edema noted in the ankles.

 

 

____    5.   The nurse is providing care for a patient who is wearing antiembolic stockings. The patient’s plan of care should include

A. Turning the stockings off 4 hours each day.
B. Removing the stockings at bedtime and replacing them in the morning.
C. Rolling the stockings down 2 inches to create a band at the top.
D. Removing the stockings twice daily to wash and dry the legs.

 

 

____    6.   The wife of a patient who recently returned from a radical neck dissection asks the nurse why the patient was given Scopolamine. The best response by the nurse is

A. “It is important to dry secretions to reduce the bacteria in his saliva.”
B. “It helps keep him from drooling since it hurts to swallow.”
C. “By reducing the amount of saliva that his body makes, this medication will reduce the swelling in his lips and tongue.”
D. “The Scopolamine will help dry the oral secretions to reduce his chances of aspirating saliva into his lungs.”

 

 

____    7.   The nurse who is caring for a patient who is scheduled for an abdominal hysterectomy obtains the woman’s signature on the consent form and then signs the form himself. The nurse’s signature indicates that

A. The patient does not have any questions about the surgery.
B. The nurse verified that it was the patient who signed the form.
C. The patient understands the risks of the procedure.
D. The nurse has provided verbal and written information about the surgical procedure.

 

 

____    8.   Which of the following members of the surgical team is responsible for monitoring the patient’s vital signs during surgery?

A. The surgeon.
B. The circulating nurse.
C. The first surgical assistant.
D. The anesthesiologist.

 

 

____    9.   Which of the following is a primary benefit of conscious sedation?

A. The patient will remember the procedure.
B. The patient will not require airway support.
C. It will block reflexes such as coughing and gagging.
D. It can be used for procedures that take long periods of time.

 

 

____  10.   The nurse recognizes that which of the following patients may receive spinal anesthesia?

A. A 45-year-old scheduled for a wedge resection.
B. A 29-year-old scheduled for repair of a torn rotator cuff.
C. A 48-year-old scheduled for a hemorrhoidectomy.
D. A 66-year-old scheduled for a bone marrow biopsy.

 

 

____  11.   The nurse is caring for a patient who received spinal anesthesia. The patient reports having a bad headache later that day. The nurse’s best response is

A. “You may have an allergy to the anesthetic used. Have you ever had spinal anesthesia before?”
B. “That can happen due to loss of spinal fluid during anesthesia.”
C. “I will need to call the physician immediately.”
D. “Do you have a history of migraines?”

 

 

____  12.   The nurse who is working in the post-anesthesia care unit (PACU) recognizes that a patient is most likely to experience which of the following complications while in the unit?

A. Hypoventilation
B. Deep vein thrombosis
C. Atelectasis
D. Pneumonia

 

 

____  13.   After assisting with the transfer of a patient from the post-anesthesia care unit into the bed on the unit, the nurse should first

A. Review the physician’s orders.
B. Determine the type and amount of intravenous fluid hanging.
C. Perform a physical assessment.
D. Reassure the patient that he will receive excellent care on the unit.

 

 

____  14.   The nurse is caring for a patient who returned from abdominal surgery 6 hours ago. The nurse notes that the abdominal dressing is nearly saturated with serosanguineous drainage, and a small amount of drainage is leaking from the lower edge of the dressing. The nurse’s best action is to

A. Reinforce the dressing with additional gauze pads.
B. Remove the surgical dressing to assess the site directly.
C. Replace the surgical dressing with fresh dressings.
D. Reinforce the tape edges of the dressing.

 

 

____  15.   The nurse is providing care to a 32-year-old who returned from a thyroidectomy 6 hours previously. The nurse notes that the patient’s temperature is 99.5°F, and that the patient has been taking sips of clear liquids, reports mild nausea, and is using a patient-controlled anesthesia to control her pain, which is 3/10. The nurse should

A. Order a low-salt diet.
B. Document the findings.
C. Contact the physician.
D. Assess the back of the patient’s throat.

 

 

____  16.   The nurse is caring for a 28-year-old man who returned from the repair of a broken jaw 3 hours earlier. The patient reports an urge to urinate and tried to use the urinal in the bed without success. The best action by the nurse is to

A. Call to obtain an order to catheterize the patient.
B. Perform a digital rectal exam.
C. Assist the patient to stand and use the urinal.
D. Use the bladder scanner to determine the degree of distention.

 

 

____  17.   The nurse who is providing care for a patient with a large abdominal wound removes the dressing and notes that the wound has dehisced. The nurse should

A. Cover the wound with a large sterile dressing.
B. Pour sterile saline into the wound bed.
C. Notify the supervisor.
D. Ask the patient, “Did you feel anything pop open?”

 

 

____  18.   The nurse is providing care for a patient with a nasogastric (NG) tube in place 10 hours after a vagotomy and an antrectomy. The patient’s plan of care would include

A. Providing mouth care every 4 hours.
B. Keeping NG to continuous suction.
C. Draping NG tubing over the patient’s shoulder.
D. Providing tube feeding every 3 hours.

 

 

____  19.   Prior to placing antiembolic stockings on a patient for the first time, the nurse should

A. Obtain baseline vital signs.
B. Have the patient lie supine for 15 minutes.
C. Ask the patient to sit at the side of the bed.
D. Instruct the patient to apply lotion to his or her legs.

 

 

____  20.   The nurse would expect an International Normalized Ratio (INR) to be ordered for which of the following patients?

A. A 32-year-old with a history of asthma.
B. A 29-year-old who takes Lanoxin (digoxin).
C. A 53-year-old with a history of cirrhosis.
D. A 71-year-old with a history of benign prostatic hypertrophy (BPH).

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.   The nurse recognizes that which of the following would be classified as an elective surgery? Select all that apply.

A. Tonsilectomy for a 10-year-old with a history of frequent pharyngitis.
B. Appendectomy for a 12-year-old with acute appendicitis.
C. Colectomy with colostomy for an 18-year-old with Crohn’s disease.
D. Mastectomy for a 56-year-old with recently diagnosed breast cancer.
E. Total hip replacement for an 87-year-old with a fractured femur.
F. Gastric bypass surgery for a 39-year-old with morbid obesity.

 

 

____    2.   The nurse who is completing a pre-surgical assessment would include which of the following questions? Select all that apply.

A. “Have you had any prior surgeries?”
B. “Is there a possibility you may be pregnant?”
C. “Are you taking any medications at this time?”
D. “Do you smoke or use tobacco in any form?”
E. “What surgery is planned? Why are you having surgery?”
F. “Do you know the name of your surgeon?”

 

 

____    3.   While caring for a patient in the surgical center, which of the following preoperative lab values would the nurse expect to be included in the orders? Select all that apply.

A. White blood cell (WBC) count
B. Hemoglobin (Hgb)
C. Alcohol level
D. Alkaline phosphatase (Alk Phos)
E. Platelet count (PLT)
F. Urinalysis (UA)

 

 

____    4.   The plan of care for a patient at risk for cardiac complications during the immediate postoperative period would include (select all that apply):

A. Monitoring the patient’s heart rate continuously.
B. Administering intravenous fluids as ordered.
C. Assessing the patient’s skin color and capillary refill frequently.
D. Assessing the patient’s peripheral pulses bilaterally.
E. Evaluating for bowel sounds hourly.
F. Monitoring for evidence of bleeding.

 

 

____    5.   After sending a patient to have a bowel resection, the nurse prepares the room for the patient’s return. Preparations would include (select all that apply):

A. Obtaining nasogastric suction equipment.
B. Placing the bed in the lowest position.
C. Placing a lift sheet on the bed.
D. Moving bedside tables away from the bedside.
E. Putting the bed in high-Fowler position.
F. Raising the side rails of the bed.

A.

Bathing a patient.
B. Administering an analgesic.
C. Documenting the patient’s bath.
D. Listening to a patient’s complaints.
E. Informing the physician about patient’s pain.
F. Teaching a patient how to turn, cough, and deep breathe.

 

Chapter 12. Patient Teaching

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is caring for a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). The patient has limited knowledge about COPD and states that he is primarily a kinesthetic learner. The nurse determines that the patient will learn best by

A. Watching a video about management of COPD.
B. Placing medications used to treat COPD in a pill organizer.
C. Listening to an audiotape about the pathophysiology of COPD.
D. Reading a pamphlet about pharmacological treatments for COPD.

 

 

____    2.   A patient who is recovering from a myocardial infarction (MI) asks the nurse about following a heart-healthy diet. The patient states that she is primarily a visual learner. The nurse determines that the patient will learn best by

A. Chopping up fruits and vegetables to eat.
B. Listening to an audiotape about a heart-healthy diet.
C. Reading a chapter in a book about a heart-healthy diet.
D. Attending a lecture in which the speaker talks about a heart-healthy diet.

 

 

____    3.   A patient who underwent a carotid endarterectomy asks the nurse about care of his neck incision. The patient informs the nurse that he is an auditory learner. The nurse determines that the patient will learn best by

A. Watching while the nurse performs incision care.
B. Reading a pamphlet about how to perform incision care.
C. Opening the dressing and applying ointment to the incision.
D. Listening to the nurse’s verbal instructions about care of the incision.

 

 

____    4.   The nurse is instructing a student nurse about the best methods to use when teaching a visual learner. The nurse determines that additional instruction is needed when the student nurse states,

A. “A visual learner learns best by seeing.”
B. “A visual learner learns best by reading.”
C. “A visual learner learns best by touching.”
D. “A visual learner learns best by watching.”

 

 

____    5.   The nurse is instructing a student nurse about the best methods to use when teaching a kinesthetic learner. The student nurse demonstrates understanding when stating,

A. “A kinesthetic learner learns best by doing.”
B. “A kinesthetic learner learns best by seeing.”
C. “A kinesthetic learner learns best by reading.”
D. “A kinesthetic learner learns best by watching.”

 

 

____    6.   A nursing instructor is teaching a student nurse about the best methods to use when teaching an auditory learner. The student nurse demonstrates understanding when stating,

A. “An auditory learner learns best by doing.”
B. “An auditory learner learns best by seeing.”
C. “An auditory learner learns best by reading.”
D. “An auditory learner learns best by listening.”

 

 

____    7.   The nurse is caring for a patient who requires preoperative teaching and who does not speak the same language as the nurse. The nurse best demonstrates a caring demeanor when

A. Speaking more slowly to the patient.
B. Facing the patient when speaking to him or her.
C. Providing the patient with written communication.
D. Arranging for an interpreter or translator to be present.

 

 

____    8.   The nursing instructor educates a student nurse about health-promotion strategies. The nursing instructor recognizes that additional instruction is needed when the student nurse states,

A. “I will encourage patients to consume fewer fresh fruits.”
B. “I will encourage patients to exercise three times a week.”
C. “I will instruct patients about stress-modification strategies.”
D. “I will encourage patients to consume more fresh vegetables.”

 

 

____    9.   The nurse is caring for a patient who is newly diagnosed with diabetes mellitus type 2. The patient requires teaching about antidiabetic medications, including when to take them, what effects are expected, and side effects to report if they occur. When formulating a nursing diagnosis for this patient, the nurse selects

A. “Deficient knowledge.”
B. “Diabetes knowledge deficit.”
C. “Risk for deficient knowledge.”
D. “Readiness for enhanced knowledge.”

 

 

____  10.   The nurse is caring for a patient who is newly diagnosed with diabetes mellitus type 2. The patient cares for a spouse at home who also has diabetes mellitus type 2. When formulating a nursing diagnosis for this patient, the nurse selects

A. “Deficient knowledge.”
B. “Diabetes knowledge deficit.”
C. “Risk for deficient knowledge.”
D. “Readiness for enhanced knowledge.”

 

 

____  11.   The nurse is caring for a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The patient cares for a spouse at home who also has COPD. When formulating a nursing diagnosis for this patient, the nurse selects “Readiness for enhanced knowledge.” When the nurse sits down with the patient and presents the information included in his or her teaching plan, the nurse is performing the step in the nursing process called

A. Planning.
B. Evaluation.
C. Assessment.
D. Implementation.

 

 

____  12.   The nurse is caring for a patient who is newly diagnosed with Graves’ disease. The nurse selects the nursing diagnosis “Readiness for enhanced knowledge.” Next the nurse should

A. Create a written teaching plan.
B. Perform an admission assessment.
C. Evaluate the patient’s response to the interventions.
D. Present the information in the teaching plan to the patient.

 

 

____  13.   A nurse is supervising a student nurse. When providing patient teaching, the nurse intervenes when the student nurse states,

A. “You are doing great.”
B. “Show me again how well you can do that.”
C. “Why didn’t you do it the way that I showed you?”
D. “I’m so glad that you remembered that; it is important.”

 

 

____  14.   When educating a newly diagnosed diabetic patient about his illness, the patient asks where he can find information on the Internet. The nurse’s best recommendation is

A. A blog.
B. WebMD.
C. Wikipedia.
D. A commercial site.

 

 

____  15.   When creating handouts for patients, the nurse should keep the handouts at the reading level of a

A. Fourth grader.
B. Fifth grader.
C. Sixth grader.
D. Seventh grader.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.   When conducting an in-service about weight reduction, the nurse recognizes that participants will have accomplished true learning when they are able to demonstrate that they can (select all that apply):

A. Memorize isolated facts.
B. Adhere to a healthier diet.
C. Exercise three times per week.
D. Consume fewer processed foods.
E. Recite a list of heart-healthy foods.
F. Attend a weight-reduction support group.

 

 

____    2.   The nurse is caring for a patient who requires discharge instructions and who is visually impaired. When speaking with the patient, the nurse should (select all that apply):

A. Face the patient directly.
B. Ensure that the patient’s glasses are on.
C. Sit in front of a light that causes a glare.
D. Provide the patient with larger-print handouts.
E. Offer the patient handouts with small print.
F. Stand in front of a window that causes a glare.

 

 

____    3.   When educating a patient about wellness strategies, the nurse instructs the patient to (select all that apply):

A. Maintain a healthy weight.
B. Learn stress-reduction strategies.
C. Increase consumption of sweets.
D. Increase consumption of alcohol.
E. Increase consumption of legumes.
F. Increase consumption of red meat.

 

 

____    4.   A patient is newly diagnosed with non–insulin-dependent diabetes mellitus (NIDDM). The patient asks the nurse about potential complications related to his or her illness. The nurse states that it can lead to (select all that apply):

A. Neuropathy.
B. Retinopathy.
C. Heart disease.
D. Renal disease.
E. Poor circulation.
F. Delayed healing.

 

 

____    5.   A patient has just been informed that he or she has terminal lung cancer. The nurse best demonstrates a caring demeanor when (select all that apply):

A. Sitting quietly with the patient.
B. Providing a supportive environment.
C. Allowing the patient time to develop questions.
D. Educating the patient about treatments for cancer.
E. Allowing the patient time to think about his or her diagnosis.
F. Teaching the patient about how to take his or her medications.

 

 

____    6.   The nurse is caring for a patient who requires preoperative teaching. When performing patient teaching, the nurse should (select all that apply):

A. Ask the patient for feedback.
B. Ensure that the patient is comfortable.
C. Provide teaching in a lecture format.
D. Refrain from asking the patient questions.
E. Establish a comfortable room temperature.
F. Involve the patient by encouraging questions.

 

 

____    7.   The nurse is caring for a patient who requires discharge teaching. When performing patient teaching, the nurse should (select all that apply):

A. Sit near the patient.
B. Stand over the patient.
C. Sit far from the patient.
D. Allow time for the patient to absorb information.
E. Present several pieces of information at once.
F. Present information in a complex-to-simple format.

 

 

____    8.   When teaching children, the nurse should (select all that apply):

A. Always tell the truth.
B. Use teaching pamphlets created for adults.
C. Emphasize the importance of hand washing.
D. Refrain from telling a child that something will hurt.
E. Use a doll or teddy bear as the patient when explaining a procedure.
F. Encourage the child to perform a return demonstration on a doll or teddy bear.

 

 

____    9.   When teaching the elderly, the nurse should (select all that apply):

A. Be very patient.
B. Use plenty of repetition.
C. Allow limited time for teaching.
D. Allow plenty of time for teaching.
E. Have a caregiver or family member present.
F. Ignore cues that the patient doesn’t understand.

 

 

____  10.   The nurse is caring for a patient who requires teaching about a heart-healthy diet. The patient states that he is a visual learner. The nurse recognizes that a visual learner learns by seeing, reading, and watching. When selecting handouts for the patient to read, the nurse ensures that the handouts (select all that apply):

A. Are in simple language.
B. Include short sentences.
C. Clearly define medical terms.
D. Are written in complex language.
E. Are at a fifth-grade reading level.
F. Include extensive medical terminology.

Chapter 20. Admission, Transfer, and Discharge

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse recognizes that the patient will develop his or her initial impression of the nurse during the

A. Teaching process.
B. Discharge process.
C. Admission process.
D. Implementation process.

 

 

____    2.   When admitting a patient to a hospital unit, the nurse demonstrates a caring demeanor when

A. Smiling and speaking kindly.
B. Exhibiting terse body language and frowning.
C. Informing the patient he or she is short-handed.
D. Avoiding eye contact and speaking in a clipped manner.

 

 

____    3.   The nurse is admitting a patient to a hospital unit. When admitting the patient, the nurse should

A. Maintain prolonged eye contact.
B. Address the patient by his or her surname.
C. Speak rapidly when interacting with the patient.
D. Use terms of endearment when conversing with the patient.

 

 

____    4.   The nurse is supervising a student nurse on a pediatric nursing unit. The nurse intervenes when the student nurse tells a child

A. “Do you want to hold my stethoscope?”
B. “This shot will not hurt.”
C. “Let’s pretend to give the teddy bear a shot.”
D. “Would you like to take the teddy bear’s temperature?”

 

 

____    5.   The nurse recognizes that most individuals prefer to recover from illness or injury

A. At home.
B. In the hospital.
C. At a care center.
D. In the emergency department.

 

 

____    6.   The nurse recognizes that separation anxiety is particularly common in children and

A. Adolescents.
B. Young adults.
C. The middle aged.
D. Older adults.

 

 

____    7.   When caring for an elderly patient who is experiencing anxiety related to a new diagnosis of cancer, the nurse seeks to alleviate the anxiety by

A. Telling the patient that his or her cancer is curable.
B. Discouraging the patient from asking questions.
C. Encouraging the patient’s spouse to stay with the patient.
D. Explaining cancer to the patient using medical terminology.

 

 

____    8.   The nurse is conducting an admission assessment on a patient with a new diagnosis of AIDS. The nurse demonstrates a caring demeanor when

A. Closing the door to the patient’s room.
B. Asking the patient questions at the nurse’s station.
C. Delivering nursing care as rapidly as possible to allow the patient more time alone.
D. Refraining from telling the patient why personal questions are asked.

 

 

____    9.   The nurse is supervising an unlicensed assistive personnel (UAP). The nurse intervenes when observing the UAP

A. Allowing a patient to wear underwear.
B. Assisting a patient in putting on pajamas.
C. Using a blanket to cover a patient during a bath.
D. Promoting dependence in activities of daily living.

 

 

____  10.   The nurse is supervising a certified nursing assistant (CNA) who is caring for a patient who is alert and oriented and independent with activities of daily living. The nurse intervenes when hearing the CNA say to the patient

A. “You should drink ice water rather than room temperature water.”
B. “Would you like to leave your socks on?”
C. “Do you prefer your drinks with or without a straw?”
D. “Would you prefer a cup of hot coffee, a glass of iced tea or fruit juice, or maybe a carbonated drink?”

 

 

____  11.   When educating a student nurse about hospital identification bands, the nurse recognizes that additional teaching is warranted when the student nurse states

A. “The hospital identification band contains the patient’s name, birth date, and hospital identification number.”
B. “I have taken care of this patient before so I will not need to check the patient’s identification band prior to administering medication.”
C. “I should instruct the patient to state their name and verify that it matches the name on the hospital identification band.”
D. “I should ask the patient to state their date of birth and verify it matches the date of birth listed on the hospital identification band.”

 

 

____  12.   When conducting an admission assessment and taking an inventory of items that the patient has brought to the hospital, the nurse instructs the patient to send home with a family member his or her

A. Dentures.
B. Eyeglasses.
C. Credit cards.
D. Hearing aids.

 

 

____  13.   When taking an inventory of items that the patient has brought to the hospital, the nurse should document the patient’s diamond and ruby wedding ring as

A. A ring with rubies and diamonds.
B. A gold-colored ring with red and clear stones.
C. A 24-karat gold wedding ring.
D. A 1-carat diamond wedding ring.

 

 

____  14.   When conducting an admission assessment, the nurse recognizes that objective data includes

A. A patient’s family history.
B. A patient’s complaint of pain.
C. A patient’s description of anxiety.
D. A patient’s fruity-smelling breath.

 

 

____  15.   When performing a patient assessment, the nurse recognizes that subjective data includes

A. A patient’s vital signs.
B. A patient’s unsteady gait.
C. A patient’s foul-smelling wound.
D. A patient’s complaint of discomfort.

 

 

____  16.   The charge nurse is preparing for a patient’s admission to the hospital unit. When anticipating the patient’s arrival, the charge nurse assigns the admission assessment to the

A. Registered nurse (RN).
B. Licensed practical nurse (LPN).
C. Certified nursing assistant (CNA).
D. Unlicensed assistive personnel (UAP).

 

 

____  17.   The nurse recognizes that discharge planning should be initiated

A. During the admission process.
B. Before the patient is admitted to the hospital.
C. Immediately prior to discharging the patient.
D. The day after the patient’s hospital admission.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.   During the admission process, the nurse should (select all that apply):

A. Speak in a hurried tone.
B. Shake the patient’s hand.
C. Speak kindly to the patient.
D. Tell the patient his or her credentials.
E. Smile while talking to the patient.
F. Inform the patient that he or she is short-handed.

 

 

____    2.   When working with a pediatric patient, the nurse should (select all that apply):

A. Tell the child that shots hurt a little bit.
B. Inform the child that a shot will not hurt.
C. Distract the child with a story when giving a shot.
D. Tell the child that the pain from a shot is temporary.
E. Encourage the child to take a teddy bear’s tympanic temperature.
F. Allow the child to listen to his or her mother’s heart with a stethoscope.

 

 

____    3.   The nurse is caring for a pediatric patient who appears anxious. To help decrease the patient’s anxiety, the nurse should (select all that apply):

A. Offer the child false reassurance.
B. Encourage the child to ask questions.
C. Send home toys so they do not get lost.
D. Refrain from using medical terminology.
E. Encourage the parent to stay with the child.
F. Provide a long explanation of the child’s diagnosis.

 

 

____    4.   When providing care to a hospitalized patient, the nurse demonstrates a caring demeanor when (select all that apply):

A. Pulling the privacy curtain during a bed bath.
B. Using a sheet to cover a patient during a bath.
C. Encouraging a patient to wear pajamas from home.
D. Allowing a patient to wear his or her own underwear.
E. Providing patients with a second gown to wear backwards.
F. Performing all activities of daily living for a patient who is able to perform the tasks unassisted.

 

 

____    5.   When providing care to a hospitalized patient, the nurse demonstrates a caring demeanor when (select all that apply):

A. Learning a patient’s name quickly.
B. Calling a patient by his or her first name.
C. Referring to a patient by room number.
D. Referring to a patient by his or her disease process.
E. Using a patient’s surname with his or her name.
F. Explaining to a patient why he or she must wear an identification band.

 

 

____    6.   The nurse educates a student nurse about hospital identification bands. The nurse teaches that hospital identification bands contain the patient’s (select all that apply):

A. Age.
B. Name.
C. Birth date.
D. Room number.
E. Physician’s name.
F. Medical diagnosis.

 

 

____    7.   The nurse recognizes that discharge planning would include (select all that apply):

A. Arranging for home health care.
B. Consulting the social worker.
C. Discharge teaching.
D. Reviewing all medications the patient is to take at home.

 

 

____    8.   A physician writes an order to teach the patient about nitroglycerin. The nurse educates the patient that nitroglycerin (select all that apply):

A. Should be swallowed.
B. Is administered sublingually.
C. Is used in the treatment of angina.
D. Should be protected from light and moisture.
E. Should be placed under the tongue prior to chest pain.
F. Should not be taken after the expiration date on the bottle.

 

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