During the change-of-shift report the
Commitment
night nurse states that a client
mentioned having a bad experience
with surgery in the past. The nurse
was called away and was unable to
continue the conversation with the
client. The nurse tells the day shift
nurse about the comment and notes
that the client appears anxious. When
the day shift nurse visits the client to
clarify the client's bad experience with
surgery, the nurse is exhibiting which
aspect of critical thinking?
A. Integrity
B. Discipline
C. Confidence
D. Perseverance
D. Discipline
Discipline includes completing the
task at hand, including
assessments (which were not
completed on the previous shift).
Integrity includes recognizing
when one's opinions conflict with
those of others and finding a
mutually satisfying solution.
Confidence is demonstrated in
one's presentation and belief in
one's knowledge and abilities.
Perseverance helps the critical
thinker to find effective solutions
to client care problems, especially
when they have been previously
unresolved.
A client tells the nurse, "I'm not happy
with the way the patient care
technician did my bath. He just
seemed to be in a hurry and did not
wash my back like I asked." The nurse
decides to go talk with the technician
to learn his side of the story as well.
This is an example of:
A. Fairness
B. Curiosity
C. Risk taking
D. Responsibility
A. Fairness
Fairness involves analyzing all
viewpoints to understand the situation
completely before making a decision.
Curiosity gives the critical thinker the
motivation to continue to ask
questions and learn more. Risk taking
involves trying different ways to solve
problems.
The surgical unit has initiated the use
of a pain rating scale to assess the
severity of clients' pain during their
postoperative recovery. The nurse
assigned to a client can look at the
pain flow sheet to see the client's pain
scores over the last 24 hours. Use of
the pain scale is an example of
adherence to which intellectual
standard?
D. Consistency
Using the same pain scale for all
clients and ratings promotes
consistency—each nurse has the
same measurement scale to compare
assessments. Relevance refers to
how applicable the assessment is. An
assessment has depth when it deals
with less obvious issues. Specificity
refers to the ability of the assessment
to provide information about the
particular problem of interest.
During the day the nurse spends time
instructing a client in how to self-
administer insulin. After discussing
the technique and demonstrating an
injection, the nurse asks the client to
try it. After the client makes two
attempts it is clear that the client does
not understand how to prepare the
correct dose. The nurse discusses the
situation with the charge nurse and
asks for suggestions. This is an
example of:
A. Reflection
B. Risk taking
C. Problem solving
D. Client assessment
C. Problem Solving
This is an example of problem solving
because the nurse is taking a problem
to a supervisor for help in finding a
different approach. Reflection is the
process of purposefully thinking back
and recalling a situation to discover its
purpose or meaning. Risk taking
involves trying a different approach.
Client assessment is the first step in
the process of instruction.
A nurse uses an institution's
procedure manual to confirm how to
insert a Foley catheter. The level of
critical thinking the nurse is using is:
A.
B. Scientific method
C. Basic critical thinking
D. Complex critical thinking
C. Basic critical thinking
At the basic level of critical thinking, a
learner trusts the experts and follows
a procedure step by step. Complex
critical thinkers separate themselves
from authorities and analyze and
examine choices more
independently. Commitment is the
third level of critical thinking in which
the person anticipates the need to
make choices without assistance
from others. The scientific method is
a process of problem solving.
A nurse refers to a client's
postsurgical written plan of care,
noting that the client has a drainage
device collecting wound drainage.
The surgeon is to be notified when
drainage in the device exceeds 100
ml for the day. The nurse carefully
notes the amount of drainage
currently in the device. This is an
example of:
A. Planning
B. Evaluation
C. Assessment
D. Intervention
C. Assessment
Assessment is the process of
observing and collecting data.
Planning is the step in which the
diagnosis is analyzed for problem
resolution. Intervention consists of the
steps actually taken after planning.
Evaluation measures the
effectiveness of the plan.
The nurse asks a client how she feels
about impending surgery for breast
cancer. Before initiating the
discussion the nurse reviewed
information about loss and grief in
addition to therapeutic
communication principles. The critical
thinking component involved in the
nurse's review of the literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making
C. Knowledge application
The nurse sought appropriate
information to be able to
communicate more knowledgeably
with the client. Experience is acquired
through clinical learning situations.
Problem solving is a series of steps to
resolve a problem. Clinical decision
making is a process in which critical
thinking steps are followed for
problem resolution.
Which of the following is the most
accurate information to give a nurse
during change-of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left
anterior knee.
C) Client encouraged to consume
more fluids.
D) Client expressed concern about
pending surgery.
B. Client reports sharp pain in elft
anterior knee
The information in option 2 represents
objective data that the nurse can use
as part of baseline information.
"Encouraged" and "more" are vague
terms. "Concern" is also vague;
relating the exact concern would be
more accurate. Option 1 may be true,
but accurate data would also report
why the client refused medication.
On entering a client's room during
change-of-shift rounds, the nurse
notices that the client and spouse
have their backs turned to each other,
and both have their arms folded
across their chests. The best action
for the nurse to take at this time is to:
A) Introduce himself or herself and
begin discharge teaching.
B) Proceed with the tasks the nurse
was intending to perform.
C) Say nothing and leave quickly,
closing the door behind.
D) Ask the client and spouse if they
need some time alone right now.
The nurse is demonstrating
D. Ask the client and spouse if they awareness of the effect of insulin,
need smoe time alone right now. which is to lower blood glucose level.
Because the client will be NPO status
for a long period of time, no calories
will be consumed. Giving the usual
The situation suggests that the nurse injection of insulin could cause the
entered during a stressful time. client to experience hypoglycemia.
Offering privacy would be
appropriate. Because the situation
indicates tension between the couple,
this is not the time to initiate teaching. The client is a 65-year-old overweight
woman with multiple medical
diagnoses, including diabetes
mellitus type 2, hypertension, and
The nurse is assessing the urinary residual right-sided weakness
history of a middle-aged married resulting from a previous
woman. The nurse asks her if she cerebrovascular accident. What tool
gets up at night. She replies, "Yes." should be used to plan her care?
What other question should the nurse
ask? A) Care plan
A) "How many times do you get up at B) Care map
night?"
C) Concept map
B) "How long have you been getting
up at night?" D) Critical thinking
C) "Why do you get up at night?" C. Concept map
D) "How easily do you go back to
sleep after you get up?"
A concept map is a visual
C. "Why do you get up at night?" representation of client problems and
interventions that shows their
relationships to each other and allows
easy synthesis of data about the
Perhaps it is the client's husband who client.
is getting up in the middle of the night
because of a prostate problem, and
this is why she is awakened. The
nurse should not assume nocturia A client newly admitted to the hospital
without further assessment begins to have chest pain. Before
questions. calling the physician, the nurse
should gather what additional data?
(Select all that apply.)
A client with diabetes mellitus who A) Pain intensity
takes daily insulin injections is
scheduled for surgery the next day. B) Location of pain
The client is to take nothing by mouth
(NPO status) after midnight. The C) Character of pain
nurse questions whether insulin
should be given the morning of D) Radiation of pain
surgery. This is an example of:
E) Meaning of pain to the client
A) Problem solving
F) Family history of myocardial
B) Previous experience infarctions
C) Clinical practice guideline A, B, C, D, and E
D) Scientifically based clinical
judgment
The nurse should gather the data the
physician will need to determine
D. Scientifially based clinical
judgment whether the chest pain represents a
myocardial infarction. Family history
is important in comprehensive pain
assessment; however, taking time to
obtain this information
inappropriate in this critical situation.
The purpose of assessment is to:
A) Make a diagnostic conclusion.
B) Delegate nursing responsibility.
C) Teach the client about his or her
health.
D) Establish a database concerning
the client.
D. Establish a database concerning
the client
The purpose of assessment is to
establish a database about the
client's perceived needs, health
problems, and responses to these
problems. The data also reveal
related experiences, health practices,
goals, values, and expectations. The
other options are not purposes of
assessment.
Assessment data must be
descriptive, concise, and complete. In
performing an assessment the nurse
should not:
A) Include subjective data from the
client.
B) Perform a thorough physical
examination.
C) Use interpersonal and cognitive
skills.
D) Include inferences or interpretative
statements not supported with data.
D. Include inferences or interpretative
statements not supported with data
The nurse should not generalize or
form judgments not supported by the
collected data. Inferences and
interpretive statements must be
supported by data. Assessments do
include conducting a thorough
physical examination, using
interpersonal and cognitive skills, and
obtaining subjective data from the
client.
is
A nurse assessing a client who comes
to the pulmonary clinic asks, "Tell me
what medications you are taking for
your breathing problem. I see from
your last visit that Dr. Russell
recommended routine exercise. Can
you also tell me how successful you
have been in following his plan?" The
nurse's assessment covers which of
Gordon's functional health patterns?
A) Value-belief pattern
B) Cognitive-perceptual pattern
C) Coping/stress tolerance pattern
D) Health perception/health
management pattern
D. Health perception/health
management patern
The health perception/health
management pattern involves the
client's self-report of health and well-
being, how the client manages his or
her health, and knowledge of
preventative health practices. The
cognitive-perceptual pattern involves
sensory-perceptual patterns,
language adequacy, memory, and
decision-making abilities. The
coping/stress tolerance pattern
involves the client's ability to manage
stress, sources of support, and the
effectiveness of the patterns in terms
of stress tolerance. The value-belief
pattern involves the values, beliefs,
and goals that guide the client's
choices or decisions.
The nurse asks a client, "Ms. Neil,
describe for me your typical diet over
a 24-hour day. What foods do you
prefer? Have you noticed a change in
your weight recently?" This series of
questions would likely occur during
which phase of a client interview?
A) Working
B) Orientation
C) Termination
A. Working
The nurse's questions exemplify the
working phase of the interview.
During data clustering, a nurse:
A) Provides documentation of nursing
care
B) Reviews data with other health
care providers
C) Makes inferences about patterns
of information
D) Organizes cues into patterns that
lead to identification of nursing
diagnoses
D. Organizes cues into paterns that
lead to identification of nursing
diagnoses
During data clustering, the nurse
organizes cues into patterns that
indicate individualized nursing
diagnoses and identify collaborative
problems. The other options are
incorrect.
What type of interview technique is
the nurse using when the nurse asks
the question, "Do you have pain or
cramping?"
A) Active listening
B) Open-ended questioning
C) Closed-ended questioning
D) Problem-oriented questioning
C. Closed-ended question
The example is a closed-ended
question which the client can answer
with a one-word reply. Open-ended
questions allow the client to answer
with more information. The other
options are not correct.
Which of the following is subjective
information to be entered in the
client's medical record?
A) Skin warm and dry.
B) Pain intensity 8 out of 10.
C) Breath sounds clear to
auscultation.
D) Amber urine in sufficient quantities.
B. Pain intensity 8 out of 10
Pain is purely a subjective
phenomenon. Although the pain
intensity rating is an objective
number, it depends on the client's
report. The other options are
objective data.
Which of the following is objective
information to be recorded in the
client's medical record?
A) Anxious over upcoming test.
B) Increasing stress over past 2
months.
C) Performs breast self-examination
monthly.
D) Expelled 1 tablespoon of yellow
sputum.
D. Expelled 1 tablespoon of yellow
sputum
Objective data are measurable data.
Options 1, 2, and 3 describe data that
cannot be measured by the nurse but
depend on the client's reports; thus
they are subjective data.
A client who is alert and awake is
being transferred to another hospital
with a copy of his medical records.
Before the transfer the nurse must:
A) Ask the hospital lawyer if this
requires approval from the risk
management department.
B) Discuss the need to copy the
medical records with the client's
family.
C) Be certain that the physician writes
an order for the record to be copied.
D) Obtain written permission to copy
the medical records for the receiving
hospital.
D. Obtain written permissin to copy
the medical records for the receiving
hospital
Obtaining permission to copy the
records demonstrates the nurse's
understanding of the provisions of the
Health Insurance Portability and
Accountability Act (HIPAA).
Discussing medical records with the
client's family is inappropriate
because the client's family does not
make the decision for a client who is
capable of making his own decision.
Policies and procedures would
already be in place for the nurse with
regard to copying medication records.
It is not necessary to call the hospital
lawyer. Copying a client's medical
record does not require a physician's
order.
Which of the following is an open-
ended question the nurse might use
when interviewing a client?
A) "Do you have any concerns right
now?"
B) "Is your family worried about your
being in the hospital?"
C) "What do you mean when you say,
'I don't feel quite right'?"
D) "How many times do you get up to
go to the bathroom at night?"
C. "What do you mean when you say,
'I don't feel quite right'?"
The way the nurse asks question 3
allows the client to respond
completely and with more than a one-
word answer. The other options allow
the client to respond with one word
and make it unlikely that the client will
give additional information.
The nurse asks the client whether the
client has any allergies. This is an
example of:
A) Health history data
B) Biographical information
C) History of present illness
D) Environmental history data
A. Health history data
Known allergies are a part of historical
data. Biographical data include age,
address, occupation, work status,
marital status, course of health care,
and insurance. The history of the
present illness includes when the
symptoms began, whether they
began suddenly or gradually, whether
they come and go, and other
information about the illness. The
environmental history includes data
about the client's home and working
environments.
The nursing assessment is which
phase of the nursing process?
A) First
B) Second
C) Third
D) Fourth
A. First
The nursing process cannot proceed
unless the nurse first conducts a client
assessment. The other phases of the
nursing process occur after
assessment.
What techniques encourage a client
to tell his or her full story? (Select all
that apply.)
A) Active listening
B) Back channeling
C) Use of open-ended questions
D) Use of closed-ended questions
A, B, and C
Options 1, 2, and 3 encourage clients
to tell their full stories. Closed-ended
questions allow clients to answer with
one or two words, which makes it
more difficult to obtain all the
information required for a full story.
The other options give clients the
opportunity to tell their stories and feel
supported. Active listening helps
them feel that they, and their stories,
are important.
The nurse gathered the following
assessment data. Which of these
cues form a pattern? (Select all that
apply.)
A) Client is restless.
B) Respirations are 24/min and
irregular.
C) Client states feeling short of
breath.
D) Fluid intake for 8 hours is 800 ml.
E) Client has drainage from surgical
wound.
F) Client reports loss of appetite for
over 2 weeks.
A, B, and C
The data in items 1, 2, and 3—rapid
irregular breathing, complaints of
shortness of breath, and
restlessness—form a pattern
indicating that the client may be
experiencing hypoxia, because all are
signs and symptoms characteristic of
this condition. The other information,
although important, is not related to
hypoxia.
The nurse asks the client's spouse,
"Mrs. Smith, your husband told me
that for the past week he has not been
eating the meals you prepare. Do you
agree?" This is an example of
__________________ of
assessment data.
Validation
16. A review of systems (ROS) is
based on information obtained from
the client during the interview. This
information is an example of
______________ data.
Subjective
nursing diagnosis is:
A) The diagnosis and treatment of
human responses to health and
illness
B) The advancement of the
development, testing, and refinement
of a common nursing language
C) A clinical judgment about
individual, family, or community
responses to actual and potential
health problems or life processes
D) The identification of a disease
condition based on a specific
evaluation of physical signs,
symptoms, the client's medical
history, and the results of diagnostic
tests
C. A clinical judgment about
individual, family, or community
responses toa ctual and potential
health problems or life processes
A nursing diagnosis is a clinical
judgment about individual, family, or
community responses to actual and
potential health problems or life
processes. It is not a disease
condition or medical diagnosis, or the
diagnosis and treatment of human
responses to health and illness.
Nursing diagnoses are not a
development or refinement in nursing
language.
The nurse reviews data regarding a
client's pain symptoms, comparing
the defining characteristics for Acute
pain with those for Chronic pain. In
the end the nurse selects Acute pain
as the correct diagnosis. This is an
example of avoiding which type of
error?
A) Error in data clustering
B) Error in data collection
C) Error in data interpretation
D) Error in making a diagnostic
statement
D. Error in making a diagnostic
statement
When a nurse compares collected
assessment data with defining
characteristics for two diagnoses, the
selection of the correct diagnosis is an
example of avoiding an error in
making a diagnostic statement. There
is no indication the data clustering or
interpretation were incorrect.
One of the purposes of the use of
standard formal nursing diagnostic
statements is to:
A) Evaluate nursing care.
B) Gather information on client data.
C) Help nurses to focus on the role of
nursing in client care.
D) Facilitate understanding of client
problems by different health care
providers.
D. Facilitate understanding of client
problems by different health care
providers.
The use of standard formal nursing
diagnostic statements provides a
precise definition that gives all
members of the health care team a
common language for understanding
the client's needs. The other options
are not part of the reason for the
development of nursing diagnostic
statements.
The nursing diagnosis 'Readiness' for
enhanced communication is an
example of which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis
D. Wellness nursing diagnosis
The term readiness indicates a
wellness nursing diagnosis. An actual
nursing diagnosis describes a human
response to health conditions or life
processes in an individual, family, or
community. A potential nursing
diagnosis is a risk for diagnosis.
The nursing diagnosis Hypothermia is
an example of which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis
B. Actual nursing diagnosis

An actual nursing diagnosis describes
a human response to health
conditions or life processes in an
individual, family, or community. The
term readiness is present in a
wellness nursing diagnosis. A
potential nursing diagnosis is a risk for
diagnosis.
In the examples given below, which
nurse is acting to avoid a data
collection error?
A) The nurse asks her colleague to
chart her assessment data.
B) The nurse considers conflicting
cues in deciding on the correct
nursing diagnosis.
C) The nurse who assesses the
edema in a client's lower leg is unsure
of its severity and asks her co-worker
to check it with her.
D) After performing an assessment
the nurse critically reviews his level of
comfort and competence with
interviewing and physical assessment
skills.
C. The nurse who assesses the
edema in a client's lower leg is unsure
of its severity and asks her co-worker
to check it with her.
A nurse who is uncertain and asks a
colleague to consult is avoiding a data
collection error. The nurse reviewing
his level of comfort and competence
is being complete but can miss his
own errors. Considering conflicting
clues does not help avoid data
collection errors. Asking a colleague
to chart data is incorrect.
"Unhappy and worried about health"
is not a scientifically-based nursing
diagnosis, and it can lead to error in:
A) Data collection
B) Date clustering
C) Diagnostic label
D) Medical diagnosis
C. Diagnostic label
The diagnostic label is the name of
the nursing diagnosis as approved by
the North American Nursing
Diagnosis Association (NANDA)
International. The question does not
discuss data collection, medical
diagnosis, or data clustering.
After establishing a nursing diagnosis
of Acute pain, the nurse develops
which of the following appropriate
client-centered goals?
A) Determine effect of pain intensity
on client function.
B) Reduce pain intensity to the level
of a client rating of 3 or below during
the client's hospital stay.
C) Encourage client to implement
guided imagery when pain begins.
D) Administer analgesic 30 minutes
before physical therapy treatment.
B. Reduce pain intensity to the level
of a client rating of 3 or below during
the client's hopsital stay
When developing a nursing care plan
for a client with a fractured right tibia,
the nurse includes in the plan of care
independent nursing interventions,
including which of the following?
A) Apply a cold pack to the tibia.
B) Elevate the leg 5 inches above the
heart.
C) Perform range-of-motion
movement with right leg every 4
hours.
D) Administer aspirin 325 mg every 4
hours as needed.
B. Elevate the leg 5 inches above the
heart
Elevation of the leg does not need a
physician's order. Applying a cold
pack and administering medication do
require a physician's order. Range-of-
motion movement of the fractured
tibia is inappropriate.
Which of the following nursing
interventions is written correctly?
A) Change dressing once a shift.
B) Perform neurovascular checks.
C) Elevate head of bed 30 degrees
before meals.
D) Apply continuous passive motion
machine during day.
C. Elevate head of bed 30 degrees
before meals
Option 3 is specific—it indicates what
to do and when
A client's wound is not healing and
appears to be worsening with the
current treatment. What is the first
option the nurse should consider?
A) Notifying the physician
B) Calling the wound care nurse
C) Consulting with another nurse
D) Changing the wound care
treatment
B. Calling the wound care nurse
Calling in the wound care nurse as a
consultant is appropriate because he
or she is a specialist in the area of
wound management. Professional
and competent nurses recognize
limitations and seek appropriate
consultation. Notifying the physician
may be appropriate after the nurse
decides on a plan of action with the
wound care nurse specialist. The
nurse may need to obtain orders for
special wound care products. Unless
the nurse is knowledgeable in wound
management, changing the wound
care treatment could delay wound
healing. Also, the current wound
management plan might have been
ordered by the physician. Another
nurse most likely will not be
knowledgeable about wounds, and
the primary nurse would know the
history of the wound management
plan.
When calling a nurse consultant
about a difficult client-centered
problem, which of the following
should the primary nurse report?
A) Client's concern about the current
treatment
B) Length of time current treatment
has been in place
C) Spouse's reaction to the client's
current treatment
D) Physician's reluctance to change
the current treatment plan
B. Length of time current treatment
has been in place
Reporting the length of time the
current treatment has been used
gives the consulting nurse facts that
will influence formulation of a new
plan. The other options are subjective
and emotional issues or conclusions
about the current treatment plan and
may bias the nurse consultant's
decision regarding a new treatment
plan.
The primary nurse asked a clinical
nurse specialist (CNS) to consult on a
difficult nursing problem. The primary
nurse is obligated to do which of the
following?
A) Implement the specialist's
recommendations.
B) Discuss and review advised
strategies with the CNS.
C) Report the recommendations to
the primary physician.
D) Clarify the suggestions with the
client and family members.
B. Discuss and review advised
strategies wtih the CNS
Because the primary nurse requested
the consultation, it is important that
the primary nurse and the CNS
communicate and discuss
recommendations. The primary nurse
can then accept or reject the CNS's
recommendations. A consultation
requires review of the
recommendations but not immediate
implementation. Reporting the
recommendations to the physician
would be appropriate after the nurse
first talks with the CNS about
recommended changes in the plan of
care and the rationale. Only then
should the primary nurse call the
physician. The client and family do not
have the knowledge to determine
whether new strategies are
appropriate or not. It is better to wait
until the new plan of care is agreed
upon by the primary nurse and
physician before talking with the client
and/or family.
Which of the following are defining
characteristics for the nursing
diagnosis of Impaired urinary
elimination? (Select all that apply.)
A) Nocturia
B) Frequency
C) Urinary retention
D) Inadequate urinary output
E) Receipt of intravenous fluids
F) Sensation of bladder fullness
A, B, and C
The defining characteristics for
Impaired urinary elimination
according to NANDA include nocturia,
frequency, and urinary retention. The
other options are not defining
characteristics from NANDA.
During the planning phase of the
nursing process, the nurse along with
the client decides which of the
following? (Select all that apply.)
A) Interventions
B) Nursing diagnosis
C) Expected outcomes
D) Client-centered goals
E) Nurse-centered priorities
C, and D
Expected outcomes and goals are the
main components of the planning
phase of the nursing process. The
nurse determines these from the
assessment. The client should be the
focus of the planning stage.
Interventions are initially determined
by the nurse.
A nurse is assigned to a client who
has returned from the recovery room
following surgery for a colorectal
tumor. After an initial assessment, the
nurse anticipates the need to monitor
the client's abdominal dressing,
intravenous infusion, and drainage
tubes. The client is in pain and will not
be able to eat or drink until intestinal
function returns. The nurse will have
to establish priorities of care in which
of the following situations?
A) The family comes to visit the client.
B) The client expresses concern
about pain control.
C) The client's vital signs change
showing a drop in blood pressure.
D) The charge nurse approaches the
assigned nurse and requests a report
at the end of the shift.
C. The client's vital signs change
showing a drop in blood pressure
A drop in blood pressure indicates a
possible emergency situation,
including bleeding at the surgical site.
Concern about pain control, including
a thorough assessment focusing the
client's pain, would be the second
priority. The end-of-shift report and
the family's visit are lesser priorities.
A postsurgical client calls for a nurse
and asks to be repositioned. The
nurse finds that the client's drainage
tube is disconnected and the
intravenous (IV) line has 100 ml of
fluid remaining. Which of the following
should be performed first?
A) Reconnect the drainage tube.
B) Inspect the condition of the IV
dressing.
C) Improve the client's comfort and
turn her to her side.
D) Go to the medication room and
obtain the next IV fluid bag.
A. Reconnect the drainage tube
The nurse should reconnect the
drainage tube first to ensure that the
wound is properly draining. The client
should then be turned (with care
taken to ensure that the tubing
remains connected), followed by
replacing the IV fluid bag, checking
the IV site, and restarting the IV fluid.
With 100 ml left, the nurse has a bit of
time to replace the IV bag before it
runs dry, so caring for the client's
wound and comfort should come first.
A nurse has set a time limit for
expected outcomes. What is the
purpose of establishing such a time
frame?
A) Indicate which outcome has
priority.
B) Indicate the time it takes to
complete an intervention.
C) Indicate how long the nurse is
scheduled to care for the client.
D) Indicate when the client is
expected to respond in the desired
manner.
D. Indicate when the client is
expected to respond in the dsired
manner
The time limit sets measurable points
to evaluate the client's response and
movement toward meeting the
outcome goals. The other options are
incorrect.
A client-centered goal is a specific
and measurable behavior or
response that reflects:
A) The physician's goal for the
specific client
B) The client's desire for specified
health care interventions
C) The client's response compared to
that of another client with a similar
problem
D) The client's highest possible level
of wellness and independence in
function
D. The client' highest possible level of
wellness and independence in
function
A client-centered goal is a specific
and measurable behavior or
response that reflects a client's
highest possible level of wellness and
independence in function. The other
options do not meet the definition of a
client-centered goal.
Which of the following is an example
of an expected outcome statement in
measurable terms?
A) Client will be pain free.
B) Client will have less pain.
C) Client will take pain medication
every 4 hours.
D) Client will report pain intensity of
less than 4 on a scale of 0 to 10.
D. Client will report pain intensity of
less than 4 on a scale of 0 to 10
Reporting the level of pain on a
numbered scale is a measurable,
objective goal. The other options do
not specify measurable outcomes.
A client is experiencing nausea and
abdominal distention postoperatively.
The nurse initiates the interventions
listed below. Which of the
interventions is an example of an
independent intervention? (Select all
that apply.)
A) Provides frequent mouth care
B) Maintains intravenous infusion at
100 ml/hr
C) Administers prochlorperazine
(Compazine) via rectal suppository
D) Consults with the dietitian on initial
foods to offer the client
E) Controls aversive odors and
unpleasant visual stimulation that
trigger nausea
A and E
Providing frequent mouth care and
controlling aversive odors and
unpleasant visual stimulation that
trigger nausea are examples of
independent intervention. The other
options are dependent interventions.
7. When discussing the client's care
with a nurse's aide, the nurse
instructs the aide to report any
coughing during meals in the client,
who recently experienced a stroke
and requires feeding. In this situation
the nurse is acting as which of the
following?
A) Educator
B) Delegator
C) Client advocate
D) On-the-job trainer
B. Delegator
The nurse is delegating the task of
feeding to the aide but is also
providing directions.
The nurse prepares a client for a
lumbar puncture. Before the start of
the procedure the nurse is sure to:
A) Have the client void.
B) Place the client in Sims' position.
C) Premedicate the client with
analgesics.
D) Insert a peripheral intravenous (IV)
catheter.
A. Have the client void
The nurse takes care of physical
needs (voiding) that could interrupt
the procedure and possibly increase
the risk of complications. The client
assumes the fetal position or sits
upright with arms over a bedside
table. Because lidocaine is used in
lumbar puncture, analgesics are not
essential. Peripheral IV catheters are
not required for this procedure.
The nurse anticipates that a right-
handed client with a fractured right
arm will require assistance with
activities of daily living. What skill is
the nurse demonstrating?
A) Cognitive skill
B) Behavioral skill
C) Interpersonal skill
D) Psychomotor skill
A. Cognitive skill
The nurse is using sound judgment
and clinical decisions to provide
individualization of care. A decision is
made without direct interaction with
the client but is based on knowledge
about the client. No psychomotor skill
is involved in this decision-making
process. There is no such thing as a
behavioral skill.
A nurse provides counseling to a
family in spiritual distress caused by
the recent, but expected, death of a
family member when the nurse
implements which of the following
interventions?
A) Praying with the family
B) Reminiscing with the family
C) Arranging for the chaplain to visit
the family
D) Obtaining a consult with a
psychiatric clinical nurse specialist
B. Reminiscing with the family
Reminiscing is an active intervention
that allows family members to
remember the deceased in a positive
way. One expects spiritual distress in
the acute stage of loss. Praying with
the family and arranging for a
chaplain's visit may be appropriate
interventions, but they are not
counseling.
The nurse requests a stimulant
laxative for a client who is receiving
an opioid around the clock. What is
the nurse demonstrating?
A) Concern for safety
B) Promotion of client health
C) Colleague health education
D) Control of adverse reactions
D. Control of adverse reactions
The nurse is demonstrating
knowledge of opioid side effects and
being proactive by asking for an
intervention that will most likely
prevent the side effect of constipation
associated with opioids. The
intervention does not promote health;
it is aimed at preventing a side effect
of an opioid. Safety is not an issue.
Requesting a laxative does not
provide education.
Which of the following characteristics
of a goal is missing from the
statement "Client will ambulate
daily"?
A) Observable
B) Measurable
C) Client centered
D) Singular goal or outcome
B. Measurable
Goals must be measurable, such as
"Client will ambulate 15 feet daily."
The other characteristics are met in
this goal statement.
When determining a client's ability to
perform instrumental activities of daily
living, which of the following skills
does the nurse assess? (Select all
that apply.)
A) Ability to cook meals
B) Ability to feed oneself
C) Ability to write checks
D) Ability to bathe oneself
E) Ability to take medications
A, C, and E
The correct options are skills that
allow the client to live independently
in society. They may or may not be
performed on a daily basis. The other
options are activities of daily living.
Which of the following are nurse-
provided indirect care activities?
(Select all that apply.)
A) Delegating
B) Documenting
C) Evaluating new products
D) Administering medications
E) Providing client counseling
A, B, and C
The correct options do not involve
direct interaction with the client or
family. The other options do require
such direct interaction.
The unit policy and procedure manual
states that, for all clients admitted to
the cardiac unit, if the client
experiences chest pain, 1/150 grain
nitroglycerin should be administered
sublingually and an
electrocardiogram should be obtained
immediately. This is an example of
a(n) _____________.
protocol
A 34-year-old client had a surgical
repair of an abdominal hernia in the
morning. At 12 noon, the nurse
records the client's vital signs on the
recovery room flow sheet. What is this
an example of?
A) Psychomotor skill
B) Indirect care measure
C) Physical care technique
D) Anticipating complications
B. Indirect care measures
Recording vital signs is an example of
indirect care. Taking vital signs is an
example of a psychomotor skill.
Anticipating complications is a
cognitive skill that is an assessment
skill. Recording vital signs is a direct
care measure and not a physical care
technique.
Interdisciplinary care plans represent:
A) All nursing personnel having input
in the care plan.
B) Contributions of all disciplines in
caring for the client.
C) The client's express wishes and
advance directives.
D) Physicians and nurses working
together to develop a plan of care.
B. Contributions of all disciplines in
caring for the client
Interdisciplinary care plans include
the contributions of all disciplines
involved in the patient's care. The
client's advance directives and
express wishes may be included, as
well as nursing and physician input,
but other involved disciplines also
contribute their plans.
Environmental factors heavily affect a
client's care. Your first concern for the
client includes which of the following?
A) Safety
B) Nurse staffing
C) Confidentiality
D) Adequate pain relief
A. Safety
Client safety is an environmental
factor and is always the first concern.
Pain relief, staffing, and confidentiality
are important but are not
environmental factors.
In order to determine whether an
intervention was successful, the
nurse evaluates the success of
attaining a goal. Which of the
following is an example of an
evaluation?
A) Dressing changed every 8 hours
using sterile technique.
B) Client will ambulate 500 feet 4
times a day with minimal assistance.
C) Client performed quadriceps-
setting exercises to right leg every 4
hours.
D) Wound filling in with granulation
tissue is red to pink without signs of
infection.
D. Wound filling in with granulation
tissue is red to pink without signs of
infection
Evaluation occurs after an
intervention and indicates degree of
achievement of goal attainment. The
qualifier "will" indicates that this is a
future event and does not evaluate
current attainment of goal. Doing an
intervention is not evaluating whether
it was effective or not.
A client was in pain following surgery.
The nurse administered the
prescribed analgesics, but the client's
pain rating stayed the same (8 out of
10). What should the nurse
recognize?
A) The pain plan needs changing.
B) The client is overrating the pain.
C) Complications from surgery are
occurring.
D) Nonpharmacological pain-relieving
strategies are now appropriate.
A. The pain plan needs changing
The current pain medications are not
effectively relieving the pain. The
nurse needs to call the physician and
discuss changing the medication is
some way (type, dose, frequency,
formulation). Pain is what the client
says it is. There is no objective way to
measure pain. The clinician must
accept the client's report of pain.
Nonpharmacological strategies are
adjuncts to the pain plan. They are not
to be used in place of pain
medications. Pain following surgery is
an expectation.
7. Which steps do you follow when
you are asked to perform a procedure
about which you are unfamiliar?
Select all that apply.
A) Seek necessary knowledge
B) Reassess the client's condition
C) Collect all equipment necessary
D) Have an experienced nurse
available to assist
E) Consider all possible
consequences of the procedure
A, B, C, D, and E
Each of the five options is important in
performing a new procedure. Be sure
to seek all necessary knowledge,
consider the possible consequences
of the procedure, reassess the
patient, collect the appropriate
supplies, and ask a nurse
experienced in the procedure to help
out
Nursing's paradigm includes:
A) Health, person, environment, and
theory
B) Concepts, theory, health, and
environment
C) Nurses, physicians, models, and
client needs
D) The person, health,
environment/situation, and nursing
D. The person, health,
environment/situation, and nursing
Nursing's paradigm includes four
linkages: the person, health,
environment/situation, and nursing.
Which of the following statements
about prescriptive theories is
accurate?
A) They describe phenomena.
B) They have the ability to explain
nursing phenomena.
C) They reflect practice and address
specific phenomena.
D) They provide a structural
framework for broad abstract ideas.
C. They reflect paractice and address
specific phenomena
Prescriptive theories address nursing
interventions for a phenomenon and
predict the consequence of a specific
nursing intervention. Descriptive
theories describe the phenomena,
speculate on the reason the
phenomena occur, and predict
nursing phenomena. Grand theories
are broad and complex and provide a
structural framework for broad,
abstract ideas about nursing.
A theory is a set of concepts,
definitions, relationships, and
assumptions that:
A) Formulates legislation
B) Explains a phenomenon
C) Measures nursing functions
D) Reflects the domain of nursing
practice
B. Explains a phenomenon
A theory is a set of concepts,
definitions, relationships, and
assumptions that explains a A) Self-actualization
phenomenon. Theories do not
formulate legislation, measure
nursing functions, or reflect any
domain of nursing practice.
4. There is a contemporary move
toward addressing nursing as a
science or as evidenced-based
practice. This suggests that:
A) One theory will guide nursing
practice.
B) Scientists will make nursing
decisions.
C) Theories will be tested to describe
or predict client outcomes.
D) Nursing will base client care on the
practice of other sciences.
C. Theories will be testing to describe
or predict client outcomes
Theories will be tested to describe or
predict client outcomes as nursing is
addressed as a science and an art.
Scientists will not make nursing
decisions, and nursing will base client
care on the practice of nursing
science, which will be guided by
multiple theories.
6. Which theories describe an orderly
process beginning with conception
and continuing through death?
A) Systems theories
B) Developmental theories
C) Interdisciplinary theories
D) Stress and adaptation theories
B. Developmental theories
Developmental theories discuss
human growth from conception to
death. The other options are incorrect
Maslow's hierarchy of needs is useful
to nurses, who must continually
prioritize a client's nursing care
needs. The most basic or first-level
needs include:
B) Love and belonging
C) Air, water, and food
D) Esteem and self-esteem
C. Air, water, and food
The first level of Maslow's hierarchy of
needs includes the need for air, food,
and water—basic elements of
survival. Love and belonging are on
the second level, esteem and self-
esteem are on the fourth level, and
self-actualization is the final level.
Leininger's theory of cultural care
diversity and universality specifically
addresses:
A) Caring for clients from unique
cultures
B) Understanding the humanistic
aspects of life
C) Identifying variables affecting a
client's response to a stressor
D) Caring for clients who cannot
adapt to internal and external
environmental demands
A. Caring for clietns from unique
cultures
The goal of Leininger's theory is to
provide the client with culturally
specific nursing care, in which the
nurse integrates the client's cultural
traditions, values, and beliefs into the
plan of care.
As an art, nursing relies on knowledge
gained from practice and reflection on
past experiences. As a science,
nursing relies on:
A) Experimental research
B) Nonexperimental research
C) Physician-generated research
D) Scientifically tested knowledge
D. Scientifically tested knowledge
As a science, nursing draws on
scientifically tested knowledge
applied in the practice setting.
Each science has a domain, which is
the perspective of the discipline. This
domain:
A) Represents the recipients of the
benefits of the science or discipline
B) Is a model that explains the linkage
of science, philosophy, and theory
that is accepted and applied by the
discipline
C) Describes the subject, central
concepts, values and beliefs,
phenomena of interest, and central
problems of the discipline
D) Is a dynamic state of being in
which the developmental and
behavioral potential of the individual
is realized to the fullest
C. Describes the subject, central
concepts, values and beliefs,
phenomena of interest, and central
problems of the discipline
The domain contains the subject,
central concepts, values and beliefs,
phenomena of interest, and the
central problems of the discipline. A
paradigm is a model that explains the
linkage of science, philosophy and
theory that is accepted and applied by
the discipline.
A theory is a set of concepts,
definitions, relationships, and
assumptions or propositions to
explain a phenomenon. The purposes
of the components of a theory are to:
A) Describe concepts or connect two
concepts that are factual
B) Formulate a perceptual experience
to describe or label a phenomenon
C) Express the global view about the
individual, situations, or factors of
interest to a specific discipline
D) Describe, explain, predict, and/or
prescribe interrelationships among
the concepts that define the
phenomenon
D. Describe, explain, predict, and/or
prescribe interrelationships among
the concepts that define the
phenomenon
Describing, explaining, predicting,
and/or prescribing interrelationships
among concepts are stated purposes
of research.
Nursing theories focus on the
phenomena of nursing and nursing
care. Which of the following is true of
phenomena?
A) They are aspects of reality that can
be consciously sensed or
experienced.
B) They convey the general meaning
of concepts in a manner that fits the
theory.
C) They are statements that describe
concepts or connect two concepts
that are factual.
D) They are mental formulations of an
object or event that come from
individual perceptual experience.
A. They are aspects of reality that can
be consciously sensed or
experienced.
Phenomena are defined as aspects of
reality that can be consciously sensed
or experienced.
Theories that are broad and complex
are:
A) Grand theories
B) Descriptive theories
C) Middle-range theories
D) Prescriptive theories
A. Grand theories
Grand theories are described as
broad and complex. Middle-range
theories are limited in scope, less
abstract, address specific
phenomena or concepts, and reflect
practice. Descriptive theories
describe phenomena, speculate as to
why the phenomena occur, and
describe the consequences of
phenomena. Prescriptive theories
address nursing interventions and
predict the consequence of a specific
intervention.
Mishel's theory of uncertainty in
illness focuses on the experience of
clients with cancer who live with
continual uncertainty. The theory
provides a basis for nurses to assist
clients in appraising and adapting to
the uncertainty and illness response
and can be described as:
A) A grand theory
B) A descriptive theory
C) A prescriptive theory
D) A middle-range theory
D. A middle-range theory
Middle-range theories are limited in
scope, less abstract than grand
theories, address specific
phenomena or concepts, and reflect
practice. Grand theories are
described as broad and complex.
Prescriptive theories address nursing
interventions and predict the
consequence of a specific nursing
intervention. Descriptive theories
describe phenomena, speculate as to
why the phenomena occur, and
describe the consequences of
phenomena
The type of theory that tests the
validity and predictability of nursing
interventions is:
A) A grand theory
B) A descriptive theory
C) A prescriptive theory
D) A middle-range theory
Prescriptive theory addresses nursing
interventions and predicts the
consequence of a specific nursing
intervention. Middle-range theories
are limited in scope, less abstract
than grand theories, address specific
phenomena or concepts, and reflect
practice. Descriptive theories
describe phenomena, speculate as to
why the phenomena occur, and
describe the consequences of
phenomena. Grand theories are
broad and complex.
17. The nursing process is an
example of an open system. An open
system:
A) Is universal and dynamic
B) Represents a relationship between
two concepts
C) Interacts with the environment by
exchanging information
D) Is a process through which
information is returned to the system
C. Interacts with the environment by
exchanging information
An open system is defined as a
system that interacts with the
environment, exchanging information
between the system and the
environment.
Evidence-based nursing practice is
the end result of:
A) Prescriptive theory
B) Use of practical knowledge
C) Application of theoretical
knowledge
D) Theory-generating and theory-
testing research
D. Theory-generating and theory-
testing research
The result of theory-generating or
theory-testing research is to increase
the knowledge base of nursing. As
these research activities continue,
clients become the recipients of
evidence-based nursing care.
The nursing theory that emphasizes
the delivery of nursing care for the
whole person to meet the physical,
emotional, intellectual, social, and
spiritual needs of the client and family
is:
A) Rogers' theory
B) Abdellah's theory
C) Henderson's theory
D) Nightingale's theory
B. Abdellah's theory
The question describes the nursing
theory developed by Fay Abdellah
and others. Rogers' theory
considered the individual as an
energy field existing within the
universe. Henderson's theory defines
nursing as "assisting the individual,
sick, or well, in the performance of
those activities that will contribute to
health, recovery, or a peaceful death."
Nightingale viewed nursing as
providing fresh air, light, warmth,
cleanliness, quiet, and adequate
nutrition.
A parish nurse for a Catholic church
provides a free blood pressure
screening the first Sunday of every
month. This is what level of
prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention
B. Primary prevention
Primary prevention is true prevention
that precedes disease and is aimed at
clients considered physically and
emotionally healthy. Secondary
prevention involves individuals who
are experiencing health problems or
illnesses and who are at risk for
developing complications or
worsening conditions. Tertiary
prevention occurs when a defect or
disability is permanent and
irreversible, and the aim is to reduce
negative impacts and complications.
Quaternary prevention is not a
recognized term.
A 72-year-old man diagnosed with
chronic obstructive pulmonary
disease 5 years ago has been
participating for the last 2 years in a
pulmonary rehabilitation exercise
class offered by the local hospital at a
fitness facility. This is what level of
prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention
A. Tertiary prevention
Tertiary prevention occurs when a
defect or disability is permanent and
irreversible, and the aim is to reduce
negative impacts and complications.
Primary prevention is true prevention
that precedes disease and involves
clients considered physically and
emotionally healthy. Secondary
prevention is aimed at individuals who
are experiencing health problems or
illnesses and who are at risk for
developing complications or
worsening conditions. Quaternary
prevention is not a recognized term.
3. Based on the transtheoretical
model of change, what is the most
appropriate response to the following
client statement: "Me, exercise? I
haven't done that since Junior High
gym class and I hated it then!"
A) "That's fine. Exercise is bad for you
anyway."
B) "OK. I want you to walk 3 miles four
times a week and I'll see you in 1
month."
C) "I understand. Can you think of one
reason why being more active would
be helpful for you?"
D) "I'd like you to ride your bike three
times this week and eat at least four
fruits and vegetables every day."
C. "I understand. Can you think of one
reason why being mroe active would
be helpful for you?"
The transtheoretical model of change
describes a series of changes that
clients move through, starting with
precontemplation and ending with
maintenance. The first stage for this
client would be to validate the client's
opinion and move to the first part of
precontemplation. The other options
are later steps in the model.
A client says, "I've noticed how many
people are out walking in my
neighborhood. Is walking good for
you?" What is the best response to
help the client through the stages of
change toward regular exercise?
A) "Walking is OK. I really think
running is better."
B) "Yes, walking is great exercise. Do
you think you could go for a 5-minute
walk this next week?"
C) "Yes, I want you to begin walking.
Walk for 30 minutes every day and
start eating more fruits and
vegetables, too."
D) "They probably aren't walking fast
enough or far enough. You need to
spend at least 45 minutes walking if
you are going to do any good."
B. "Yes, walking is great exercise. Do
you think you could go for a 5-minute
walk this next week?"
This option supports the preparation
stage in which the client is beginning
to consider making small changes.
The other options are not good ones
for this client.

All of the following are examples of
active strategies of health promotion
except:
A) Exercise training
B) Weight reduction
C) Smoking cessation
D) Fluoridation of drinking water
D. Fluoridation of drinking water
Passive strategies of health
promotion benefit individuals without
any action by the individuals
themselves. The fluoridation of
municipal drinking water and the
fortification of homogenized milk with
vitamin D are examples of passive
health promotion strategies. Weight
reduction is considered an active
strategy of health promotion. With
active strategies of health promotion,
individuals are motivated to adopt
specific health programs. Smoking
cessation requires clients to be
actively involved in measures to
improve their present and future
levels of wellness while decreasing
the risk of disease. Exercise training
meets the criteria for active strategies
of health promotion because it
actively involves the client in his or her
own health.
nurse routinely asks clients if they
take any vitamins or herbal
medications, encourages family
members to bring in music that clients
like to help them relax, and frequently
prays with clients if that is important to
them. The nurse is using which model
of care?
A) Holistic
B) Health belief
C) Transtheoretical
D) Health promotion
A. Holistic
The holistic model attempts to create
conditions that promote optimal
health. The holistic model recognizes
the natural healing abilities of the
body and incorporates
complementary and alternative
interventions. The health belief model
addresses the relationship between a
person's beliefs and behaviors. The
transtheoretical model of change
discusses a series of changes
through which clients move, starting
with precontemplation and ending
maintenance. The health promotion
model defines health as a positive,
dynamic state and not merely the
absence of disease.
Different attitudes about illness cause
people to react in different ways when
illness does occur. Medical
sociologists call the reaction to illness:
A) Health belief
B) Illness behavior
C) Health promotion
D) Illness prevention
B. Illness behavior
Illness behavior is the client's reaction
to illness. The other three options are
models of health
The health belief model addresses
the relationship between a person's
belief and behaviors, therefore:
A) A person who smokes does not
follow the model.
B) This model provides a basis for
caring for clients of all ages.
C) A person who does not take
necessary medications does not
follow the model.
D) It provides a way of understanding
and predicting how clients will behave
in relation to their health and how they
will comply with health care regimens.
D. It provides a way of understanding
and predicting how clients will behave
in relation to their health and how they
will comply with health care regimens.
The health belief model provides a
way of understanding and predicting
how clients will behave in relation to
their health and how they will comply
with health care regimens.
A nurse working in a special care unit
for children with severe immunologic
problems cares for a 3-year-old boy
from Greece. The nurse is having
difficulty communicating with the
father. What is the appropriate
action?
A) Care for the boy the same as for
any other client.
B) Ask the manager to talk with the
father and keep him out of the unit.
C) Have another nurse care for the
boy, because maybe that nurse will
communicate better with the father.
D) Search for help in interpreting and
understanding the culture differences
by contacting someone from the local
Greek community.
D. Search for help in interpreting and
understanding the culture differences
by contacting someone from the local
Greek community
Acquiring cultural and language
assistance will help the nurse
understand the needs of both the
father and the son. The other three
options are not culturally sensitive or
helpful to the client and his father.
10. A nurse teaches the importance of
folic acid intake to a group of pregnant
women. This is considered which
level of preventive care?
A) Illness behavior
B) Primary prevention
C) Tertiary prevention
D) Secondary prevention
B. Primary prevention
Primary prevention is considered true
prevention. It aims at maintaining
physical and emotional health in an
already healthy individual.Primary
prevention is considered true
prevention. It aims at maintaining
physical and emotional health in an
already healthy individual.
11. A person's ideas, convictions, and
attitudes about health and illness can
be described as:
A) Moral beliefs
B) Health beliefs
C) Holistic views
D) Negative health behaviors
B. Health beliefs
Health beliefs are an individual's
perceptions of health or illness, which
may be based on factual information
or misinformation, common sense or
myths, or reality or false expectations.
Moral beliefs are learned behaviors
that are in accordance with the
principles of right or wrong. Holistic
views consider the emotional and
spiritual well-being of the individual.
Negative health behaviors include
behaviors that are typically harmful to
health, such as smoking, drug or
alcohol abuse, poor diet, and refusal
to take appropriate medications.
Which of the following models of
health or illness defines health as a
positive, dynamic state, not merely
the absence of disease?
A) Maslow's hierarchy of needs
B) Rosenstoch's health belief model
C) Pender's health promotion model
D) The holistic health model of
nursing
C. Pender's health promotion model
Pender's health promotion model was
developed to be a "complementary
counterpart to models of health
protection." This model defines health
as a positive, dynamic state, not
merely the absence of disease.
Maslow's hierarchy of needs defines
what is necessary for human survival
and health, such as food, water,
safety, and love. Rosenstoch's health
belief model addresses the
relationship between a person's belief
and behaviors. It predicts how clients
will behave in relation to their health
and how they will comply with their
health regimen. The holistic health
model creates conditions that
promote optimal health.
All of the following are considered
internal variables that influence a
client's health beliefs and practices
except:
A) Emotional factors
B) Developmental stage
C) Socioeconomic factors
D) Perception of functioning
C. Socioeconomic factors
Socioeconomic factors are
considered external variables. A
person seeks approval and support
from neighbors, peers, and co-
workers; this affects health beliefs
and practices. Economic variables
may affect a client's level of health.
For example, a client with a fixed
income who needs long-term
medications may determine that food
and shelter are more important than
the medication; therefore, the client's
health suffers. Perception
functioning is an internal variable. It is
defined as the way an individual
perceives his or her physical
functioning and how it affects health
beliefs and practices. Emotional
factors are internal variables. These
include a client's degree of stress,
depression, or fear, which can
influence health beliefs and practices.
An individual's developmental stage
is considered an internal variable. A
client's thinking about health is
dependent on his or her level of
development.
Clients maintain health or enhance
their health by routine exercise and
proper nutrition. This is known as:
A) Illness
B) Health promotion
C) Control of external variables
D) Wellness education
B. Health promotion
Health promotion activities help
clients maintain and enhance their
present level of health. Wellness
education instructs persons on how to
care for themselves in healthy ways
and includes topics such as physical
awareness, stress management, and
self-responsibility. Illness is defined
as poor condition or disease. External
variables are outside factors that
influence a person's health beliefs
and practices. They include family
practices, socioeconomic factors, and
cultural background.
The nurse in a diabetic clinic conducts
monthly seminars for diabetic clients.
During these seminars, the
importance of taking insulin as
directed to prevent diabetic
complications is emphasized. This is
considered which level of preventive
care?
A) Illness prevention
B) Tertiary prevention
C) Primary prevention
D) Secondary prevention
D. Secondary prevention
of
Secondary prevention is prevention
geared toward individuals who are
already experiencing health problems
or illness and who are at risk of
experiencing complications or a
worsening of their condition
A client comes into the clinic for a
complete physical examination. The
nurse obtains a health history and
determines that the client is at risk for
heart disease. Which of the following
would lead the nurse to conclude
this?
A) The client is 25 years old.
B) The client lives near a chemical
plant.
C) The client's father died of a heart
attack at age 40.
D) The client works as a carpet
salesman.
C. The client's father died of a heart
attack at age 40
Genetic predisposition to specific
illnesses is considered a major
physical risk factor. The client's father
died of a heart attack at the age of 40,
which increases the client's risk of
heart disease and heart attack. Age
may increase or decrease a client's
susceptibility to certain illnesses. Age
risk factors are often closely
associated with other risk factors,
such as family history and personal
habits. The client is 25 years old;
therefore, based on age alone, risk is
low for heart disease at this time. The
client lives near a chemical plant; this
constant exposure to chemicals may
lead to health problems. The physical
environment in which a person works
and lives can increase the likelihood
that certain illnesses will occur, but
without further information the nurse
cannot assess the heart disease risk
related to the client's possible
chemical exposure.
Which of the following statements is
the World Health Organization's
definition of health?
A) "Complete freedom from disease"
B) "Mental, social, and spiritual well-
being"
C) "State of complete physical,
mental, and social well-being, not
merely the absence of disease"
D) "A state of being that people define
in relation to their own values,
personality, and lifestyle"
C. "State of complete physical,
mental, and social well-being, not
merely the absence of disease"
The World Health Organization
defines health as a "state of complete
physical, mental, and social well-
being, not merely the absence of
disease or infirmity." There are
several definitions of health. Health is
a state of being that people define in
relation to their own values,
personality, and lifestyle. Health and
illness must be defined in terms of the
individual. Health can include
conditions previously considered to
be illness. Pender, Murdaugh, and
Parsons note that views of health
include mental, social, and spiritual
well-being. Pender notes that not all
people who are free of disease are
equally healthy.
Which of the following terms is
defined as a mental self-image of
strengths and weaknesses in all
aspects of one's personality?
A) Body image
B) Family roles
C) Self-concept
D) Emotional change
C. Self-concept
Self-concept is a mental self-image of
strengths and weaknesses in all
aspects of one's personality. Self-
concept is important in relationships
with other family members. When a
client is ill, his or her self-concept
changes and this may lead to tension
and conflict. Body image is defined as
a subjective concept of physical
appearance. Many illnesses can
cause changes in physical
appearance, and clients and families
react differently to these changes.
Clients react differently to illness or
the threat of illness. Individual
behavioral and emotional reactions
depend on the nature of the illness.
Illness impacts family roles. When an
illness occurs, parents and children
try to adapt to major changes
resulting from a family member's
illness.
A client needs to learn to use a
walker. Acquisition of this skill will
require learning in which domain?
A) Affective domain
B) Cognitive domain
C) Attentional domain
D) Psychomotor domain
D. Psychomotor domain
The psychomotor domain concerns
motor skills. The cognitive domain
involves understanding, and the
affective domain involves attitudes.
The attentional domain is not a
recognized domain. Attentional set is
the mental state that allows the
learner to focus on and comprehend
a learning activity.
The nurse should plan to teach a
client about the importance of
exercise:
A) When there are visitors in the room
B) When the client's pain medications
have taken effect
C) Just before lunch, when the client
is most awake and alert
D) When the client is talking about
current stressors in his or her life
B. When the client's pain medications
have taken effect
It is difficult for a client to learn when
the client is in pain. Pain medications
should be administered and the client
taught while the client is alert but pain
free. A quiet time should be selected
when there are no or few distractions;
the nurse should avoid times when
visitors are present or when the client
is discussing other stressors. The
second best time to teach is when the
client is most awake and alert,
providing that all pain issues have
been addressed.
A client recently diagnosed with
cervical cancer is going home after
undergoing surgery. The client is
avoiding discussion of her illness and
postoperative orders. In going over
discharge instructions with the client,
the nurse:
A) Teaches the client's spouse
B) Focuses on knowledge the client
will need in a few weeks
C) Provides only the information the
client needs to go home
D) Convinces the client that learning
about her health is necessary
C. Provides only the information teh
client needs to go home
Because this client does need to have
some postoperative knowledge, the
teaching should focus on the
information the client will need until
she has had a chance to move
through the grief process. Teaching
the spouse does not focus on caring
for the client, although his knowledge
can be helpful. Teaching ahead about
information that the client will need in
a few weeks is not appropriate. Until
the client is able to process her grief,
convincing her that learning about
health is not productive.
The school nurse is about to teach a
freshman-level health class on
nutrition. To achieve the best learning
outcomes, the nurse:
A) Provides information using a
lecture format
B) Uses simple words to promote
understanding
C) Develops topics for discussion that
require problem solving
D) Completes an extensive literature
search focusing on eating disorders
C. Develops topics for discussion that
require problem solving
The use of problem solving helps
adolescents to achieve learning
outcomes. Providing information in a
lecture format and using simple words
would probably not be successful with
this age group. Literature searches
are not appropriate teaching for this
age group.
A nurse is going to teach a client how
to perform a breast self-examination.
Which of the following statements is
the behavioral objective that best
measures the client's ability to
perform the examination?
A) The nurse will discuss learning
objectives.
B) The client will verbalize the steps
involved in breast self-examination
within 1 week.
C) The nurse will explain the
importance of performing breast self-
examination once a month.
D) The client will demonstrate breast
self-examination on herself by the
end of the teaching session.
D. The client will demonstrate breast
self-examination on herself by the
end of the teaching session.
Option D has a measurable outcome
at a specific time. Options A and B do
not show that the client has learned to
perform the examination. Option C
does not show learning.
A client who is having chest pain is to
undergo emergency cardiac
catheterization. Which of the following
is the most appropriate teaching
approach in this situation?
A) Telling approach
B) Entrusting approach
C) Reinforcing approach
D) Participating approach
A. Telling approach
The telling approach is used when
teaching limited information, such as
in an emergent situation. The
entrusting approach provides the
client the opportunity to manage self-
care. In the participating approach,
the nurse and client set objectives
and become involved in the learning
process together. Reinforcement
requires the delivery of a stimulus that
increases the probability of a
response.
The nurse is teaching a parenting
class for a group of pregnant
adolescents and has given the
adolescents baby dolls to bathe and
talk to. This is an example of:
A) An analogy
B) Role playing
C) A demonstration
D) A return demonstration
B. Role playing
Role playing involves rehearsing a
desired behavior. In demonstration
the nurse shows the client what to do,
whereas in return demonstration the
learner practices the skill to show that
it has been learned. An analogy is a
means of translating complex
language or ideas into words or
concepts that the client understands.
An older man is being given a new
antihypertensive medication. In
teaching the client about the
medication, the nurse should:
A) Speak loudly.
B) Present the information once.
C) Expect the client to understand the
information quickly.
D) Allow the client time to express
himself and ask questions.
D. Allow the client time to express
himself and ask questions
The nurse should allow the client time
to express himself and ask questions.
Speaking loudly is typically not
effective, and information may have
to be presented several times. The
client will learn the information at his
own speed.
A client needs to learn how to
administer a subcutaneous injection.
The nurse knows the client is ready to
learn when the client:
A) Has walked 400 feet
B) Expresses the importance of
learning the skill
C) Can see and understand the
markings on the syringe
D) Has the dexterity needed to
prepare and inject the medication
B. Expresses the importance of
learning the skill
When the client can verbalize the
need to learn, the client is ready to
learn to read the markings on the
syringe, and the nurse can assess
whether the client has the dexterity to
perform the injection. The ability to
walk 400 feet is not a prerequisite for
learning about subcutaneous
injection.
A client who is hospitalized has just
been diagnosed with diabetes. He is
going to need to learn how to give
himself injections. The best teaching
method would be:
A) Role playing
B) Simulation
C) Demonstration
D) Group instruction
C. Demonstration
Demonstration with return
demonstration is the best method to
teach a psychomotor skill. Group
instruction is not typically effective in
teaching specific psychomotor skills,
because it does not allow for
individualized instruction. Role
playing and simulation are not
appropriate in this situation.
When teaching is viewed as
communication, then a specific
learning objective can be said to be
developed from:
A) The message
B) The referent
C) Feedback
D) Intrapersonal variables
B. The referent
The referent is the perceived need for
information. This provides the basis
for the learning objective. The
message refers to the information
taught. Feedback is used to
determine whether or not the learning
objective was achieved. Intrapersonal
variables are assessed to determine
willingness and ability to learn.
12. The client who is most ready to
begin a client teaching session is the
client who has:
A) Experienced nausea and vomiting
for the past 24 hours
B) Just been told that he needs to
have major surgery
C) Voiced a concern about how
insulin injections will affect her
lifestyle
D) Complained bitterly about the low-
fat, low-cholesterol diet he must follow
after his heart attack
C. Voiced a concern about how
insulin injections will affect her
lifestyle
A learning objective for a client taking
digoxin (Lanoxin) is to correctly take a
radial pulse for 1 minute before
medication administration. The
learning objective has been achieved
when the client:
A) States, "I understand."
B) States, "Just place two fingers at
the thumb side of the wrist."
C) Demonstrates correct finger
placement and counts the beats
correctly
D) Demonstrates by placing two
fingers at the inner antecubital space
and counts the beats for 60 seconds
C. Demonstrates correct finger
placement and counts the beats
correctly
Direct observation is a means of
evaluating whether a learning
objective has been achieved. In
option 3 the client demonstrated
radial pulse taking correctly. Option 1
provides no way of measuring if the
client was able to correctly take a
radial pulse. Option 2 does not
indicate if the client was able to count
the number of beats for 1 minute. In
option 4 the fingers were placed in the
antecubital space rather than over the
radial artery. The client demonstrated
incorrect placement.
Which of the following is an example
of an appropriately stated learning
objective?
A) The client will ambulate 100 feet.
B) The nurse will explain the
importance of a diabetic diet.
C) The nurse will demonstrate a
sterile dressing change by the end of
the first hospital day.
D) The client will state three factors
that affect cholesterol by the end of
the teaching session.
D. The client will state three factors
that affect cholesterol by the end of
the teaching session.
This learning objective includes the
required singular behavior,
measurable objective, and time frame
for completion. Option 1 lacks a time
frame for completion and is a
behavioral objective. Options 2 and 3
are teaching objectives rather than
learning objectives.
The nurse is demonstrating the
proper technique for using a
glucometer to a group of clients newly
diagnosed with diabetes. The nurse
smiles and praises one of the clients
when she correctly performs a finger
stick. This teaching approach is
referred to as:
A) Timing
B) Entrusting
C) Reinforcing
D) Group instruction
C. Reinforcing
Social reinforcement includes smiles,
compliments, or words of
encouragement. Timing is not a
teaching approach. It refers to the
planning phase of the teaching
process. Entrusting allows the client
to manage his or her own care, with
the nurse available for assistance if
needed. A client newly diagnosed
with diabetes would not be able to
manage self-care. Group instruction
is an instructional method, not a
teaching approach.

When teaching older adults, the nurse
should:
A) Speak in a loud tone of voice.
B) Begin and end with the most
important information.
C) Avoid repeating information to
reduce confusion.
D) Include as much information as
possible in each teaching session.
B. Begin and end with the most
important information
Short-term memory is often reduced
in older adults; therefore, repeating
important information, and especially
presenting it at the beginning and
end, enhances retention. Speech at
lower voice levels is better
understood by the older adult.
Repeating information does not
create confusion but rather facilitates
learning in the older adult. Older
adults may have slower cognitive
function and will remember more
effectively if the information is paced
properly.
The assessment phase of the
teaching process includes:
A) Determining learning needs
B) Setting priorities
C) Selecting teaching methods
D) Selecting teaching approach
A. Determining learning needs
Information obtained during the
assessment will determine what is
necessary for the client to learn.
Because the health status of the client
may undergo changes, assessment
for learning needs is an ongoing
process. Setting priorities and
selecting teaching methods are part
of the planning phase. Selection of
the teaching approach is part of the
implementation phase.
Which of the following represents the
most complex behavior in the
psychomotor learning domain?
A) Accepting the limitations imposed
by a stroke
B) Understanding the relationship of
insulin, diet, and exercise in diabetes
C) Performing self-catheterization
without acquiring a urinary tract
infection
D) Performing activities of daily living
after acquiring left-sided paralysis
due to a brain injury
D. Performing activities of daily living
after acquiring left-sided paralysis
due to a brain injury
Origination is the most complex
behavior in the psychomotor learning
domain. It is highly complex and
involves developing new
psychomotor skills and abilities from
existing ones, as is seen in paralysis.
Accepting limitations is a behavior in
the affective learning domain.
Understanding relationships is a
behavior in the cognitive learning
domain. Option 3 is a psychomotor
learning behavior that is referred to as
complex overt response, in which the
client performs a motor skill using a
complex movement pattern. It is not
as complex as origination.
The nurse discovers an electrical fire
in a client's room. The nurse's first
action would be to:
A) Activate the fire alarm.
B) Confine the fire by closing all doors
and windows.
C) Evacuate any clients or visitors in
immediate danger.
D) Extinguish the fire by using the
nearest fire extinguisher.
C) Evacuate any clients or visitors in
immediate danger.
The nurse's first step when a fire is
discovered is to evacuate any clients
or visitors in immediate danger. Then
the nurse should activate the fire
alarm, confine the fire, and then
extinguish it.
A parent calls the pediatrician's office
frantic because her 2-year-old son
drank a bottle of cleaner. Which of the
following is the most important
instruction the nurse can give to this
parent?
A) Give the child milk.
B) Call the poison control center.
C) Give the child syrup of ipecac.
D) Take the child to the emergency
department.
B) Call the poison control center.
The poison control center will direct all
care given to a child who has ingested
a substance. Based on the
description of the poison, poison
control center staff will tell the parent
whether the child needs to go to the
emergency department and what
substances should be given to the
child
A couple has brought in their
adolescent daughter for a school
physical. The parents tell the nurse
that they are worried about all the
safety risks for this age group. As the
nurse plans to teach the parents
about these risks, the nurse
remembers that adolescents are at a
greater risk for injury from:
A) Home accidents
B) Poisoning and child abduction
C) Physiological changes of aging
D) Automobile accidents, suicide, and
substance abuse
D) Automobile accidents, suicide, and
substance abuse
Adolescents are more likely to be
involved in automobile accidents,
commit suicide, and engage in
substance abuse than are those in
other age groups. Children are more
susceptible to poisoning and child
abduction, and older adults are more
susceptible to home accidents and
the physiological changes of aging.
During the night shift a client is found
wandering the hospital halls looking
for a bathroom. The nurse's initial
intervention would be to:
A) Insert a urinary catheter.
B) Ask the physician to order a
restraint.
C) Assign a staff member to stay with
the client.
D) Provide scheduled toileting during
the night shift.
D) Provide scheduled toileting during
the night shift.
Providing scheduled toileting during
the night makes it less likely that a
client will wander while being
confused and ensures staff presence
to decrease confusion at the times
when the client is away from bed.
Inserting a urinary catheter is not
necessary. Assigning a staff member
to stay with the client might not be
necessary if the scheduled toileting is
successful. Restraints are
unnecessary in this case.
5. Lisa, a nurse assistant, is working
with the nurse during the nurse's shift.
One of the nurse's clients has upper
limb restraints. In delegating care of
this client to Lisa, the nurse would tell
her to:
A) Secure the restraints to the side
rails.
B) Check to see if the client can have
a medication for sleep.
C) Call the physician if the client
becomes more agitated with the
restraint.
D) Report any signs of redness,
excoriation, or constriction of
circulation under the restraint.
D) Report any signs of redness,
excoriation, or constriction of
circulation under the restraint.
The restraint sites much be checked
regularly for signs of redness,
excoriation, or constriction, and this
task may be delegated. Calling the
physician and performing medication
assessments are nursing
responsibilities. Restraints should
never be secured to the side rails.
The family of the nurse's confused,
ambulatory client insists that all four
side rails be up when the client is
alone. The best way to handle this
situation is to:
A) Ask them to stay with the client at
all times.
B) Inform them of the risks associated
with side rail use.
C) Thank them for being
conscientious and put the four rails
up.
D) Provide the client with a one-to-
one sitter while the side rails are up
B) Inform them of the risks associated
with side rail use.
The use of side rails when a client is
disoriented will cause more confusion
and further injury. A confused client
who is determined to get out of bed
may attempt to climb over the side rail
or climb out at the foot of the bed, and
may fall or experience other injury.
After the nurse has this discussion
with the family, then the nurse should
perform a thorough nursing
assessment and develop a plan to
ensure the client's safety.
During the nurse's assessment of a
56-year-old man, he reports
increased alcohol consumption
because of stress at work. One of the
expected outcomes for this client will
be to:
A) Decrease stress in his life.
B) Teach him ways to promote sleep.
C) Decrease his alcohol intake during
times of stress.
D) Provide the client with information
about stress management classes.
C) Decrease his alcohol intake during
times of stress.
Resources for stress management
and sleep promotion can help
accomplish reduced alcohol intake
during times of stress in the client's
life. Management of stress is the
expectation, but decreasing stress
may not be possible.
A child for which the nurse is caring in
the hospital starts to have a grand mal
seizure while playing in the playroom.
What is the most important
intervention the nurse can do during
this situation?
A) Begin cardiopulmonary
resuscitation.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the
tongue to prevent aspiration.
D) Clear the area around the child to
protect the child from injury.
D) Clear the area around the child to
protect the child from injury.
An area around the child should be
cleared to prevent injury. Restraining
the child or placing a tongue blade in
the child's mouth may actually be a
cause of injury. Cardiopulmonary
resuscitation is required only if heart
function stops after the seizure.
When providing health maintenance
teaching to new employees in the
food-handling department, the nurse
emphasizes the need to perform hand
hygiene after using the bathroom to
prevent:
A) Food poisoning
B) Spread of hepatitis A
C) Bacterial food infections
D) Salmonella contamination
B) Spread of hepatitis A
The hepatitis A virus is spread via
fecal contamination of food, water, or
milk. It is essential that food handlers
wash their hands anytime they use
the bathroom. Food poisoning can be
due to bacterial contamination of food
from a variety of sources, but not
usually feces. Salmonella
contamination usually arises from
uncooked eggs.
A student nurse is designing a health
fair project aimed at reducing motor
vehicle accidents. For which group of
clients would this subject be most
appropriate?
A) Adolescents
B) Older adults
C) Middle-aged adults
D) School-aged children
A) Adoescents
The risk of motor vehicle accidents is
higher among teen drivers than in any
other age group.
As a member of the hospital's
bioterrorism team, the nurse
understands the importance of
knowing how an organism is
transmitted. Smallpox has the
potential to spread quickly because it
is transmitted via which route?
A) Airborne
B) Ingestion
C) Absorption
D) Blood-borne
A) Airborne
Organisms with an airborne route of
transmission can claim many victims
and spread very quickly. Smallpox is
not spread via blood. There is no such
thing as an absorption or ingestion
route of transmission.
After the nurse assists a client with a
history of seizures to a recliner chair,
the client begins to have a seizure.
The nurse should immediately:
A) Turn the client onto his or her
stomach.
B) Recline the client's chair all the way
back.
C) Return the client to the bed and
place the client on his or her side.
D) Slide the client to the floor and
cradle the client's head in the nurse's
lap.
D) Slide the client to the floor and
cradle the client's head in the nurse's
lap.
The nurse's lap is the safest position
for the client's head, and the client is
less likely to sustain an injury if the
client is already on the floor.
Attempting to move the client laterally
by oneself could result in injury to the
client and/or nurse. Placement in a
reclining position could cause excess
secretions to accumulate in the oral
pharynx and obstruct the airway.
Turning the client onto his or her
stomach would decrease access to
the airway.
The nurse delegates to an unlicensed
assistant the task of removing the
restraints from the client's wrists
every ________ hours and reporting
any abnormalities.
A) 2
B) 4
C) 6
D) 8
A) 2
Removal of restraints and inspection
of the contact area every 2 hours is a
requirement of The Joint
Commission. The time periods in the
other options are too long. The client
could experience a serious
complication if restraints are not
removed and the area under the
restraints inspected frequently.
ealth care workers who have direct
contact with individuals suspected of
being contaminated with anthrax
should do which of the following?
(Choose all that apply.)
A) Wear an isolation gown, gloves,
and high-efficiency particle arrestor
(HEPA) mask
B) Prepare the client for transfer to the
radiology department for chest
radiography
C) Instruct the client to wash the
hands and exposed areas with soap
and water
D) Have the client remove clothing
and place it in a sealed biohazard bag
A and D
Anthrax is caused by a spore-forming,
gram-positive bacillus. Humans
become infected through skin
contact, ingestion, and inhalation.
The nurse should wear an isolation
gown, gloves, and a high-efficiency
particle arrestor (HEPA) mask. The
client should remove potentially
contaminated clothing for testing and
decontamination. The client should
remain in isolation until it is certain
that the bacteria have been
contained, not transferred to
radiology. The client should shower
thoroughly with soap and water, not
just wash hands and exposed areas.
While the nurse is administering flu
immunizations in November to a
group of older adults at a community
senior citizens' center, one of the
seniors expresses a fear of
contracting the flu from the injection.
The nurse reassures the senior that
this is not possible because the
vaccine contains a dead virus and
explains that this injection will
produce _________ immunity, in
which the senior's body will make
antibodies to the virus.
active
If an infectious disease can be
transmitted directly from one person
to another, it is:
A) A susceptible host
B) A communicable disease
C) A portal of entry to a host
D) A portal of exit from the reservoir
B) A communicable disease
If an infectious disease is transmitted
directly from one person to another, it
is a communicable disease. Portals of
entry and exit are the mechanisms of
disease transmission. A susceptible
host is a person who can acquire an
infection.
In infectious diseases such as
hepatitis B and C, a reservoir for
pathogens is:
A) The blood
B) The urinary tract
C) The respiratory tract
D) The reproductive tract
A) The blood
The blood is a reservoir for pathogens
in hepatitis B and C. Neither organism
can survive in the urinary,
reproductive, or respiratory tract
The most effective way to break the
chain of infection is by:
A) Practicing good hand hygiene
B) Wearing gloves
C) Placing clients in isolation
D) Providing private rooms for clients
A) Practicing good hand hygiene
Good hand hygiene is the most
effective way to break the chain of
infection. Wearing gloves can help in
decreasing disease transmission, but
clean hands are required for it to be
truly effective. Placing clients in
isolation is costly and often
unnecessary, and clients can be
psychologically harmed by isolation.
Even providing private rooms for
clients will not be effective if health
care workers do not follow good hand
hygiene practices.
4. A nurse is assigned to care for a
client with a deep wound infection.
Which of the following actions would
result in the contamination of sterile
gloves?
A) The nurse grasps a sterile cotton-
tipped swab to clean wound edges.
B) The nurse takes a gauze pad in
hand and places it in the wound.
C) The nurse picks up a gauze pad
soaked in sterile saline to cleanse the
wound.
D) The nurse pulls up the sheet over
the client's perineum for better
draping.
D) The nurse pulls up the sheet over
the client's perineum for better
draping.
If the nurse touches a sheet
(nonsterile) with sterile gloves, the
gloves are contaminated. The other
actions do not contaminate sterile
gloves.
A client is isolated because the client
has pulmonary tuberculosis. The
nurse notes that the client seems
angry but knows this is a normal
response to isolation. The best
intervention is to:
A) Provide a dark, quiet room to calm
the client.
B) Explain the isolation procedures
and provide meaningful stimulation.
C) Reduce the level of precautions to
keep the client from becoming angry.
D) Limit family and other caregiver
visits to reduce the risk of spreading
the infection.
B) Explain the isolation procedures
and provide meaningful stimulation.
When a client is in isolation, the nurse
should take measures to improve the
client's stimulation and make sure to
explain the isolation procedures.
Darkening the room can increase the
sense of isolation. The nurse should
not change the isolation level but
should provide plenty of emotional
support and make time for the client
to prevent a sense of isolation. As
long as family and caregivers follow
infection precautions, there is no
reason to limit contact with these
individuals.
6. A gown should be worn when:
A) The client's hygiene is poor.
B) The client has acquired
immunodeficiency syndrome (AIDS)
or hepatitis.
C) The nurse is assisting with
medication administration.
D) Blood or body fluids may get on the
nurse's clothing from a task the nurse
plans to perform.
D) Blood or body fluids may get on the
nurse's clothing from a task the nurse
plans to perform.
Gowns should be worn when there is
a possibility that blood or body fluids
could get on the nurse's clothes or
when the client is on contact isolation
status. The other options are not
appropriate uses of gowns.
When a nurse is performing surgical
hand hygiene, the nurse must keep
the hands:
A) Above the elbows
B) Below the elbows
C) At a 45-degree angle
D) In a comfortable position
A) Above the elbows
When surgical hand hygiene is
performed, the hands should always
be kept above the elbows so that the
water runs from the hands to the
elbows.
To remove a glove that is
contaminated, what should the nurse
do first?
A) Rinse the glove before removing it
to minimize contamination.
B) Pull the glove off the back of the
hand until it slides off the entire hand
and discard it.
C) Grasp the outside of the cuff or
palm of the glove and pull it away from
the hand without touching the wrist or
fingers.
D) Put the thumb inside the wrist to
slide the glove over the hand with
minimal touching of the hand by the
other gloved hand.
C) Grasp the outside of the cuff or
palm of the glove and pull it away from
the hand without touching the wrist or
fingers.
When the outside of the cuff is
grasped with the contaminated
gloved hand, then dirty to dirty
remains intact. Pulling the glove away
from the hand entirely without
touching the wrist or fingers further
minimizes the contamination by the
gloved hand. If the nurse puts the
gloved thumb inside the glove, the
nurse has contaminated the bare
hand with a contaminated thumb.
Pulling the glove off by holding it at
the back sounds good and could
minimize contamination, but it is very
difficulty to remove a glove this way
without the risk of tearing the glove
and creating contamination through
the tear. If excessive secretions are
present on gloves, then a towel or the
drape could be used to wipe off
excessive secretions before an
attempt is made to remove the gloves.
What is the single most effective
method by which the nurse can break
the chain of infection?
A) Give all clients antibiotics.
B) Wear gloves when caring for all
clients.
C) Wash hands between procedures
and clients.
D) Make sure housekeeping staff are
using the right chemicals.
C) Wash hands between procedures
and clients.
Adequate hand washing will remove
bacteria and wastes or contaminates
to minimize cross contamination
between clients. Use of alcohol-
based waterless antiseptics between
clients is also effective if the
guidelines for using these cleansers
are followed. Giving all clients
antibiotics is impractical and is a
source of new superinfections when
persons who do not need antibiotics
are given them and then the bacteria
mutate to become resistant to older
drugs. It would be both unethical and
costly to try to control infections by
treating everyone in the facility.
Although wearing gloves to perform
procedures that carry the risk of direct
contact with contaminated material is
a correct method of bacterial control,
wearing gloves at all times is
impractical, expensive, and
unrealistic. Housekeeping staff are
trained to use the correct agents for
decontamination and disinfection of
all surfaces that place clients at risk.
Which of the following statements
reflects the current trend in the
directives from the Centers for
Disease Control and Prevention
(CDC) for minimizing risks of
infection?
A) Discard all dressings into red bags.
B) Do not recap bottles of solutions to
minimize risk of contamination.
C) Recap syringes or break needles
off before discarding into sharps
containers.
D) Keep all drainage tubing below the
level of the waist and/or site of
insertion.
D) Keep all drainage tubing below the
level of the waist and/or site of
insertion.
Keeping the solution in drainage
tubes draining away from the
drainage site on the body reduces the
risk for bacteria growth. Running any
solution backward in the tubing puts
the client at risk by bringing any
bacteria that may be present lower in
the system back to the body, and
cross contamination will occur. As in
surgical areas, anything below the
waist should be considered at
potential risk for infection. Needles
are not to be recapped or cut because
of the increased risk of experiencing
puncture wounds while doing so. Not
all dressings need to be placed in red
bags; only dressings with moisture
require placement in a red bag.
Bottles of solution that are sitting in
the client's room should be closed to
prevent airborne contaminants from
entering and creating an unsterile
situation.
The nurse has just admitted a client to
rule out active hepatitis B. The client
is confused, spitting and scratching
everyone who enters the room. The
nurse should:
A) Wait an hour until the client calms
down and then use gloves when
touching the client.
B) Use gloves, mask, face shield, and
gown when entering the room to
perform the initial assessment.
C) Administer a sedative and then
perform the assessment after the
client is asleep; no precautions would
be needed.
D) Realize that isolation equipment
might further confuse the client and
avoid using a face mask and shield
but use gown and gloves.
B) Use gloves, mask, face shield, and
gown when entering the room to
perform the initial assessment.
Hepatitis virus is a blood-borne virus,
but the client is increasing the risk of
cross contamination by spitting
(saliva can be a source of bacterial
contamination) and scratching others,
which can break the skin and become
a source of risk. All of the barriers
listed would minimize cross
contamination from the client to the
nurse. Even though gloves may be all
that is needed because of limited
contact with the client, after an hour
the client will remain confused and
may not understand. The client may
become aggressive again and spit or
scratch, and other barriers are
needed to stop that source of possible
risks. A sedative may be given if
needed, but trying to perform an
assessment when the client is asleep
is not appropriate and will prevent the
nurse from successfully establishing
rapport with the client. Although
masks and shields might be
frightening to some confused clients,
if the client is spitting and body fluids
could be exchanged, a barrier should
still be used.
12. For which airborne disease(s)
would the nurse be required to use
gloves, respiratory devices, and gown
when in close contact with the client?
A) Herpes simplex, scabies
B) Viral pneumonia, atelectasis
C) Chickenpox, pulmonary
tuberculosis
D) Multidrug-resistant respiratory
syncytial virus
C) Chickenpox, pulmonary
tuberculosis
Airborne precautions are required for
chickenpox and tuberculosis,
because in these diseases small
particles float in the air and a barrier
is required to prevent contamination
of the nurse. A respiratory protection
device is form-fitted to the face to
prevent the escape of air around the
seal. Gloves and gown are also worn
to prevent contamination and
transport of infective particles to other
clients. For viral pneumonia a regular
mask is used as a barrier because the
particles do not float in the air and are
more likely to be found on surfaces
unless coughing or spitting is
occurring. Atelectasis is the collapse
of alveoli, and airborne precautions
are not needed. Herpes and scabies
are spread by contact, and gloves and
gown would be necessary; masks
would not be needed. For multidrug-
resistant respiratory syncytial virus
the protection of the client would be
as important as preventing the spread
of these disorders. Therefore, gown,
gloves, and mask would be used as in
reverse isolation to prevent cross
contamination of the client.
Before the nurse washes the hands
when leaving an isolation room, what
is the last thing that is removed?
A) Mask
B) Gown
C) Goggles
D) Head cover
C) Goggles
Goggles are the least contaminated
item and the last to be removed
before hand washing. The gown and
gloves have been removed first. Head
covers are usually not worn in
isolation rooms as a barrier. The
mask is considered contaminated,
and it should be untied and discarded
after the gown is removed to minimize
contamination from the gown or
gloves.
14. The nurse is setting up a sterile
field for the physician. Which of the
following statements concerning a
sterile field is correct?
A) The sides of the drape over the
table are still sterile until they are
touched.
B) Reaching over the field is not a
source of contamination if the nurse
has on a clean gown and gloves.
C) One inch around the border should
be considered to be the barrier
between the sterile field and under the
table.
D) A liquid spill onto the sterile field is
a source of contamination from the
table below the drape, even if the
barrier is waterproof.
C) One inch around the border should
be considered to be the barrier
between the sterile field and under the
table.
A 1-inch margin is considered
unsterile and is the barrier spacing
between the sterile field in the center
of the drape and the edge of the
drape. Liquids spilled on a waterproof
drape will not absorb from or be
contaminated from the surface
beneath. Although such a situation
could be messy, bacteria would not
cross from the unsterile to the sterile
side. The edge of the table and the 1-
inch border create the edge of the
sterile field. Anything below the edge,
including the side of the drape,
becomes unsterile. Reaching over a
sterile field is always a source of
contamination and should not be
done.
When transferring a sterile item to a
sterile field, the nurse should:
A) Open the outer package and let the
sterile assistant take the item from the
nurse to put on the edge of the drape.
B) Use a sterile lifting tool (forceps) to
pick up the inner package and
transfer it to the middle of the field.
C) Open the outer package and use a
sterile glove to pick up the item and
drop it on the sterile field in the middle
of the drape.
D) Open the package by peeling back
the cover without touching the inner
package and drop the item within the
sterile field without touching the 1-
inch border.
D) Open the package by peeling back
the cover without touching the inner
package and drop the item within the
sterile field without touching the 1-
inch border.
The rule is "sterile to sterile" to
prevent contamination. The outer
cover is considered unsterile. As long
as the inner packet is not touched, the
packet is considered sterile. The 1-
inch border or barrier between the
edge of the drape and the field is the
dividing line for sterile versus
nonsterile. Using a sterile glove to
remove the inner packet is all right,
but dropping it into the middle of the
field will contaminate other items. A
sterile assistant can take the item
from the nurse, but placing it on the
edge of the drape will contaminate the
item because it is not inside the 1-inch
border/barrier. Using sterile forceps to
remove the inner packet is
acceptable, but putting the item into
the middle of the field will again risk
potential contamination from reaching
over the sterile field.