cpnre

Question 1

Evidence-based practice is a problem-solving approach to making decisions about patient care that is grounded in: a. the latest information found in textbooks. b. systematically conducted research studies. c. tradition in clinical practice. d. quality improvement and risk management data.

Answer 1

B
The best evidence comes from well-designed, systematically conducted research studies described in scientific journals. Portions of a textbook often become outdated by the time it is published. Many health care settings do not have a process to help staff adopt new evidence in practice, and nurses in practice settings lack easy access to risk management data, relying instead on tradition or convenience. Some sources of evidence do not originate from research.

Question 2

When evidence-based practice is used, patient care will be: a. standardized for all. b. unhampered by patient culture. c. variable according to the situation. d. safe from the hazards of critical thinking.

Answer 2

C
Using your clinical expertise and considering patients’ cultures, values, and preferences ensures that you will apply available evidence in practice ethically and appropriately. Even when you use the best evidence available, application and outcomes will differ; as a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate.

Question 3

When a PICOT question is developed, the letter that corresponds with the usual standard of care is:

a. P.
b. I.
c. C.
d. O.

Answer 3

C
C = Comparison of interest. What standard of care or current intervention do you usually use now in practice? P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem. I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, prognostic factor) do you think is worthwhile to use in practice? O = Outcome. What result (e.g., change in patient’s behavior, physical finding, change in patient’s perception) do you wish to achieve or observe as the result of an intervention?

Question 4

A well-developed PICOT question helps the nurse:

a. search for evidence.
b. include all five elements of the sequence.
c. find as many articles as possible in a literature search. d. accept standard clinical routines.

Answer 4

A
The more focused a question that you ask is, the easier it is to search for evidence in the scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinical routines. Always question and use critical thinking to consider better ways to provide patient care.

Question 5

The patient is scheduled to go home after having coronary angioplasty. What would be the most effective way to provide discharge teaching to this patient?

a. Provide him with information on health care websites. b. Provide him with written information on what he has to do.
c. Sit and carefully explain what is required before his follow-up.
d. Use a combination of verbal and written information.

Answer 5

D
For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction.

Question 6

While preparing for the patient’s discharge, the nurse uses a discharge planning checklist and notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on:

a. the patient’s willingness to go home.
b. the family’s perceived ability to care for the patient.
c. the patient’s ability to live alone.
d. allowing the patient to make her own arrangements.

Answer 6

B
Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are frequently overwhelmed by patient needs, which can lead to unnecessary hospital readmissions.

Question 7

The patient arrives in the emergency department complaining of severe abdominal pain and vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do?

a. Summon the nurse technician to hold the arm down while the IV is inserted.
b. Use a numbing medication before inserting the IV.
c. Document the patient’s refusal and notify the physician. d. Tell the patient that she will be discharged without care unless she complies.

Answer 7

C
The Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- and Medicaid-recipient hospitals to provide patients with information about their right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment.

Question 8

An unconscious patient is admitted through the emergency department. How and when is identification of the patient made?

a. Determined only when the patient is able
b. Postponed until family members arrive
c. Given an anonymous name under the “blackout” procedure
d. Determined before treatment is started

Answer 8

B
If a patient is unconscious, identification often is not made until family members arrive. Delaying treatment can cause deterioration of the patient’s condition. Blackout procedures are intended mainly to protect crime victims.

Question 9

During admission of a patient, the nurse notes that the patient speaks another language and may have difficulty understanding English. What should the nurse do to facilitate communication?

a. Use hand gestures to explain.
b. Request and wait for an interpreter.
c. Work with the family to gather information.
d. Complete as much of the admission assessment as possible using simple phrases.

Answer 9

B
If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology. Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission.

Question 10

The patient has been admitted to the emergency department after being beaten and raped. She is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her?

a. She is safe in the hospital, and she needs to provide her name.
b. She can be admitted to the hospital without anyone knowing it.
c. Her records will be used as evidence in the trial.
d. Since she has come to the hospital, she has to be examined by the doctor.

Answer 10

B
A patient who has been a victim of crime can be admitted anonymously under an agency’s “blackout” or “do not publish” procedure. HIPAA places limits on the institution’s ability to use or disclose the patient’s PHI. The Patient Self-Determination Act prohibits the hospital from requiring her to submit to an examination.

Question 11

The patient is admitted to the ICU after having been in a motor vehicle accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on:

a. examining the patient and treating the pain.
b. orienting the family to the ICU visitation policy.
c. making sure that the consent forms are signed.
d. informing the patient of his HIPAA rights.

Answer 11

A
When a critically ill patient reaches a hospital’s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns.

Question 12

The phase of the discharge process where medical attention dominates discharge planning efforts is known as the _____ phase.

a. transitional
b. continuing
c. acute
d. multidisciplinary

Answer 12

C
The discharge process occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinary stage; the discharge planning process is comprehensive and multidisciplinary.

Question 13

The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says “No,” but the nurse notices a look of surprise on the daughter’s face. What should the nurse do in this circumstance?

a. Speak with the daughter separately.
b. Cancel the discharge immediately.
c. Order a visiting nurse consult.
d. Notify the physician

Answer 13

A
Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It often is necessary to talk with the patient and family separately to learn about their true concerns or doubts.

Question 14

The patient is being admitted to the intensive care department with multiple fractures and internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.)

a. Anticipate physical and social deficits to resuming normal activities.
b. Involve the family and significant others in the plan of care.
c. Assist in making health care resources available to the patient.
d. Identify the psychological needs of the patient.

Answer 14

A, B, C, D
The nurse identifies patients’ ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

Question 15

4. Which of the following are considered “advance directives”? (Select all that apply.)
   a. Living will
   b. Power of attorney for health care
   c. Notarized handwritten document
   d. Nursing progress note

Answer 15

A, B, C

Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document.

Question 16

A document that provides a patient’s instructions in terms of future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity is known as an ________________.

Answer 16

advance directive

An advance directive is a document that provides a patient’s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient’s choice in continuing medical care when the patient is unable to speak or make decisions.

Question 17

The patient is a 54-year-old man who has made a living as a construction worker. He dropped out of high school at age 16 and has been a laborer ever since. He never saw any need for “book learning,” and has lived his life “my way” since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of “fast food” while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure?

a. “The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.” b. “There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.”
c. “We have pamphlets here that can explain everything. Let me get you one.”
d. “It’s just like a clogged pipe. All the doctor has to do is ‘Roto-Rooter’ it to get it cleaned out.”

Answer 17

B
To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang.

Question 18

The nurse is assessing a patient who says that she is feeling fine. The patient, however, is wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways?

a. “You seem anxious today. Is there anything on your mind?”
b. “I’m glad you’re feeling better. I’ll be back later to help you with your bath.”
c. “I can see you’re upset. Let me get you some tissue.”
d. “It looks to me like you’re in pain. I’ll get you some medication.”

Answer 18

A
When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, “You seem anxious today. Is there anything on your mind?” It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean.

Question 19

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information?

a. The patient’s parents
b. The patient’s significant other only
c. No one in the hospital until the patient says so
d. The patient’s physician, significant other, and laboratory personnel

Answer 19

D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient.

Question 20

Which of the following is the best example of objective charting?

a. “The patient states that he has been having severe chest discomfort.”
b. “The patient is lying in bed and seems to be in considerable pain.”
c. “The patient appears to be pale and diaphoretic and complains of nausea.”
d. “The patient’s skin is ashen and respiratory rate is 32 and labored.”

Answer 20

D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part.

Question 21

Which of the following is the best example of accurate documentation?

a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.”
b. “OD to be irrigated qd with NS.”
c. “No complaint of abdominal pain this shift.”
d. “Patient watching TV entire shift.”

Answer 21

A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care.

Question 22

The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should:

a. remove the patient’s nail polish to get a pulse oximetry reading.
b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading.
d. check the color of the patient’s nail polish before attempting a reading.

Answer 22

B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators).

Question 23

A person’s core temperature is considered the most accurate since it is:

a. reflective of the surrounding environment.
b. the same for everyone.
c. controlled by the hypothalamus.
d. independent of external influences.

Answer 23

C The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health.

Question 24

Petechiae are noted on the patient as a result of the nurse finding:

a. bluish-black patches.
b. tenting.
c. pinpoint-sized red dots.
d. large areas of raised, irritated skin.

Answer 24

C Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver disease. Bluish-black patches are more indicative of malignant melanoma. With reduced turgor, the skin remains suspended or “tented” for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. Large areas of raised, irritated skin are not characteristic of petechiae.

Question 25

Where is the pulmonic area for auscultation found?

a. Second intercostal space on the right side
b. Second intercostal space on the left side
c. Third intercostal space (Erb’s point)
d. Fourth intercostal space along the sternum

Answer 25

B
The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patient’s right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erb’s point. The tricuspid area is located at the fourth left intercostal space along the sternum.

Question 26

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be?

a. Have the patient turn onto his left side.
b. Have the patient lean forward.
c. Have the patient move to a sitting position.
d. Palpate the PMI to the right of the midclavicular line.

Answer 26

A
If palpating the PMI is difficult, turn the patient onto the left side. This maneuver moves the heart closer to the chest wall. Different positions help to clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lung disease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement.

Question 27

What technique should the nurse implement for assessment of the carotid artery? a. Massaging the arteries briskly b. Using the diaphragm of the stethoscope c. Palpating each carotid artery separately d. Placing the patient in a supine position

Answer 27

C Palpate each carotid artery separately with index and middle fingers around the medial edge of the sternocleidomastoid muscle. Ask the patient to raise the chin slightly, keeping the head straight. Note rate and rhythm, strength, and elasticity of the artery. Also note if the pulse changes as the patient inspires and expires. Do not vigorously palpate or massage the artery. Stimulation of the carotid sinus may cause a reflex drop in heart rate and blood pressure. Place the bell of the stethoscope over each carotid artery, auscultating for a blowing sound (bruit). To assess venous pressure, have the patient recline at a 45-degree angle and slowly recline into the supine position, avoiding neck hyperextension or flexion. Measure the distance between the angle of Louis and the highest point of vein pulsation.