EXAM 1 Flashcards
1
Q
A nurse is posting on social media about an event that occurred during a shift. Which regulation should the nurse consider when sharing information about patients?
A. Nursing Practice Act
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Labor Act (EMTALA)
D. Patient Self-Determination Act
A
Answer: B. Health Insurance Portability and Accountability Act (HIPAA)
Rationale: HIPAA mandates protection of patient privacy and prohibits sharing identifiable patient information on social media.
2
Q
Which of the following is the primary responsibility of the Texas Board of Nursing?
A. Advocate for higher wages for nurses
B. Ensure that all nurses maintain continuing education credits
C. Protect the public from unsafe nursing practices
D. Support nurses in legal disputes with employers
A
Answer: C. Protect the public from unsafe nursing practices
Rationale: The Texas Board of Nursing’s main goal is to protect the public by ensuring nurses are competent in their practice.
3
Q
A client asks the nurse if they have the right to refuse treatment. The nurse responds by referencing which regulation?
A. Emergency Medical Treatment and Labor Act (EMTALA)
B. Nursing Practice Act
C. Patient Self-Determination Act
D. Affordable Care Act
A
Answer: C. Patient Self-Determination Act
Rationale: The Patient Self-Determination Act ensures clients have the right to make their own decisions about their healthcare, including the right to refuse treatment.
4
Q
A nurse is providing care in an emergency department and is aware that the Emergency Medical Treatment and Labor Act (EMTALA) mandates that:
A. Patients must be transferred to a different facility for treatment if they lack insurance
B. Hospitals must provide emergency treatment regardless of a patient’s ability to pay
C. Healthcare providers can withhold treatment for uninsured clients if they are stable
D. Patients have a right to sue for malpractice after receiving emergency care
A
Answer: B. Hospitals must provide emergency treatment regardless of a patient’s ability to pay
Rationale: EMTALA requires hospitals to provide emergency care to all individuals, regardless of their financial status.
5
Q
What is the primary purpose of the Texas Nurse Practice Act?
A. To protect the safety of the public
B. To promote the autonomy of nurses
C. To regulate healthcare institutions
D. To advance nursing research
A
Answer: A. To protect the safety of the public
Rationale: The Texas Nurse Practice Act provides regulations to ensure that nursing practice is safe and in line with professional standards.
6
Q
A nurse in Texas wants to delegate a task to a Certified Nursing Assistant (CNA). Under the Texas Nursing Practice Act, what must the nurse ensure before delegating the task?
A. The task is within the CNA’s job description
B. The CNA agrees to complete the task
C. The nurse provides direct supervision throughout the task
D. The task is approved by a physician
A
Answer: A. The task is within the CNA’s job description
Rationale: The nurse must ensure that any delegated task is within the scope of practice and competency of the CNA.
7
Q
Which of the following statements best describes the role of the ANA Code of Ethics in nursing practice?
A. It is a legal document that enforces nursing regulations
B. It provides a framework for ethical decision-making
C. It outlines specific procedures for nursing practice
D. It protects nurses from legal action
A
Answer: B. It provides a framework for ethical decision-making
Rationale: The ANA Code of Ethics guides nurses in ethical practice and decision-making but does not function as a legal document.
8
Q
A nurse refuses to administer a treatment that they believe will cause harm to the client. Which ethical principle is the nurse following?
A. Justice
B. Autonomy
C. Nonmaleficence
D. Beneficence
A
Answer: C. Nonmaleficence
Rationale: Nonmaleficence is the ethical principle of doing no harm, which the nurse is upholding by refusing to administer harmful treatment.
9
Q
Which act ensures that patients can amend or request changes to their medical records?
A. Patient Self-Determination Act
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Labor Act (EMTALA)
D. Nurse Practice Act
A
Answer: B. Health Insurance Portability and Accountability Act (HIPAA)
Rationale: HIPAA allows patients to inspect, request copies of, and amend their medical records.
10
Q
A nurse is teaching a group of students about professional boundaries. Which of the following statements indicates a breach in professional boundaries?
A. “I accepted a small gift from a client’s family during the holiday season.”
B. “I friended a client on social media after discharge.”
C. “I shared my contact information with a client for follow-up questions.”
D. “I discussed the client’s case with a family member present in the room.”
A
Answer: B. “I friended a client on social media after discharge.”
Rationale: Engaging with clients on social media after discharge crosses professional boundaries and can lead to ethical and legal complications.
11
Q
According to the Nursing Practice Act, which of the following actions can result in disciplinary action by the Texas Board of Nursing?
A. Refusing to administer a medication that could harm the patient
B. Failing to renew a nursing license within the required timeframe
C. Administering medication based on a verbal order from a physician
D. Requesting clarification of a physician’s order
A
Answer: B. Failing to renew a nursing license within the required timeframe
Rationale: Nurses must renew their licenses according to the guidelines set by the Board of Nursing. Failure to do so can result in disciplinary action.
12
Q
Which law requires healthcare providers to offer treatment to patients with life-threatening conditions, regardless of their ability to pay?
A. Affordable Care Act
B. Emergency Medical Treatment and Labor Act (EMTALA)
C. Nurse Practice Act
D. Americans with Disabilities Act
A
Answer: B. Emergency Medical Treatment and Labor Act (EMTALA)
Rationale: EMTALA mandates that hospitals provide treatment to individuals with emergency medical conditions, regardless of their financial situation.
13
Q
A nurse is caring for a patient who has just been diagnosed with a terminal illness. The patient states they do not want to know about further treatment options. Which ethical principle is the nurse prioritizing?
A. Justice
B. Veracity
C. Autonomy
D. Fidelity
A
Answer: C. Autonomy
Rationale: Autonomy involves respecting the patient’s decision to not receive information about their treatment options.
14
Q
Which of the following is a negative consequence of not adhering to ethical and legal nursing practices?
A. Improved patient care
B. Enhanced patient advocacy
C. Malpractice litigation
D. Increased patient satisfaction
A
Answer: C. Malpractice litigation
Rationale: A negative consequence of not following ethical and legal guidelines in nursing practice can be malpractice litigation.
15
Q
A nurse is performing a comprehensive assessment on a client and discovers discrepancies in the client’s medication list. The nurse’s priority is to follow which standard of practice?
A. Obtaining supervision from a colleague
B. Providing safe and effective care
C. Reporting the discrepancy to the physician
D. Documenting the finding in the electronic medical record
A
Answer: B. Providing safe and effective care
Rationale: The nurse’s priority is to provide safe and effective care by addressing and resolving any discrepancies.
16
Q
A nurse receives a new assignment involving the care of clients in a highly specialized unit where they have little experience. According to the Texas Nursing Practice Act, what is the nurse’s best action?
A. Accept the assignment and learn as they go
B. Delegate all complex tasks to more experienced nurses
C. Refuse the assignment and leave the unit
D. Notify the supervisor about the lack of competency
A
Answer: D. Notify the supervisor about the lack of competency
Rationale: Nurses are responsible for only accepting assignments they are competent to perform. The nurse must notify the supervisor if they lack the required skills.
17
Q
A nurse witnesses a colleague administering the wrong medication to a patient and failing to report it. Which action is required under the Nursing Practice Act?
A. Document the incident in the colleague’s file
B. Discuss the error with the colleague privately
C. Report the error to the nurse manager
D. Confront the colleague about the mistake
A
Answer: C. Report the error to the nurse manager
Rationale: The Nursing Practice Act mandates reporting errors to ensure patient safety and prevent further harm.
18
Q
Under the Health Insurance Portability and Accountability Act (HIPAA), which of the following actions is a violation of patient confidentiality?
A. Reviewing a patient’s chart during a care team meeting
B. Sharing information about a patient’s condition in a public elevator
C. Discussing patient care with the healthcare team during shift handoff
D. Logging off the computer after completing patient documentation
A
Answer: B. Sharing information about a patient’s condition in a public elevator
Rationale: Discussing patient information in public settings is a violation of HIPAA and patient confidentiality.
19
Q
The Texas Nursing Practice Act requires nurses to demonstrate which of the following attributes in their practice?
A. Strict adherence to the facility’s policies, regardless of client needs
B. Competency in nursing care and adherence to ethical standards
C. Focus on legal guidelines only, leaving ethics to the employer
D. Fulfilling all tasks assigned by physicians without question
A
Answer: B. Competency in nursing care and adherence to ethical standards
Rationale: Nurses are required to maintain competency in their practice while adhering to both legal and ethical standards.
20
Q
A nurse has accepted a client assignment in the ICU but feels unsure about performing complex procedures. Which step should the nurse take according to ethical and legal practice?
A. Ask another nurse to perform the procedures
B. Perform the procedures and hope for the best
C. Inform the charge nurse about the lack of competency
D. Research the procedures while on duty
A
Answer: C. Inform the charge nurse about the lack of competency
Rationale: Nurses must report any lack of competency or training to ensure patient safety, as required by legal and ethical guidelines.
21
Q
A nurse who fails to administer a medication within the prescribed time window and does not document the delay is violating which standard of nursing practice?
A. Adherence to patient confidentiality
B. Safe and accurate documentation
C. Proper delegation of tasks
D. Compliance with physician orders
A
Answer: B. Safe and accurate documentation
Rationale: Proper documentation of all nursing actions, including medication administration, is a critical legal and ethical responsibility.
22
Q
Under the Nursing Practice Act, which action could be considered unprofessional conduct?
A. Failing to report suspected abuse of a vulnerable client
B. Delegating tasks to unlicensed assistive personnel (UAP)
C. Refusing to participate in an unfamiliar procedure
D. Asking for clarification on an unclear physician order
A
Answer: A. Failing to report suspected abuse of a vulnerable client
Rationale: Nurses have a legal and ethical obligation to report any suspected abuse of clients under their care.
23
Q
According to the Nurse Practice Act, which of the following tasks can be delegated to a Certified Nursing Assistant (CNA)?
A. Performing a sterile dressing change
B. Assessing a client’s response to a treatment
C. Administering medication
D. Obtaining vital signs
A
Answer: D. Obtaining vital signs
Rationale: CNAs can perform tasks such as obtaining vital signs, while tasks that require clinical judgment, such as assessments, are reserved for licensed nurses.
24
Q
The Patient Self-Determination Act requires healthcare facilities to:
A. Allow nurses to refuse assignments they are uncomfortable with
B. Honor a patient’s advance directives and choices about care
C. Ensure that patients do not leave the hospital without treatment
D. Provide the highest level of care possible regardless of patient wishes
A
Answer: B. Honor a patient’s advance directives and choices about care
Rationale: The Patient Self-Determination Act ensures that patients’ decisions about their care, including advance directives, are respected.
25
A nurse is reviewing the ANA Code of Ethics before making a care decision. The nurse is primarily focused on which of the following concepts?
A. Following the law at all costs
B. Protecting the nurse’s license from disciplinary action
C. Promoting the patient’s best interest and upholding professional integrity
D. Ensuring that the hospital’s policy is followed
Answer: C. Promoting the patient’s best interest and upholding professional integrity
Rationale: The ANA Code of Ethics focuses on ethical care, professional integrity, and patient advocacy.
26
A nurse is explaining to a group of students the importance of the Texas Nurse Practice Act. Which statement by the nurse best summarizes the Act?
A. "It outlines how nurses should advocate for their patients."
B. "It defines the minimum standard of care and the legal scope of nursing practice."
C. "It allows nurses to practice without physician oversight."
D. "It ensures that nurses will not be held accountable for errors."
Answer: B. "It defines the minimum standard of care and the legal scope of nursing practice."
Rationale: The Texas Nurse Practice Act establishes the legal scope of practice for nurses and defines the minimum standards they must follow.
27
Which federal law allows patients to inspect their medical records and request corrections if errors are found?
A. Affordable Care Act
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Labor Act (EMTALA)
D. Nursing Practice Act
Answer: B. Health Insurance Portability and Accountability Act (HIPAA)
Rationale: HIPAA grants patients the right to review and request corrections to their medical records.
28
A nurse is asked to administer a medication they are unfamiliar with. According to ethical and legal standards, what should the nurse do?
A. Administer the medication as ordered
B. Ask another nurse to administer the medication
C. Refuse the assignment without explanation
D. Research the medication before administering it
Answer: D. Research the medication before administering it
Rationale: Nurses are responsible for understanding the medications they administer. Researching the medication ensures safe and informed care.
29
A nurse works in a hospital where physicians frequently give verbal orders. According to the Nursing Practice Act, what must the nurse ensure before carrying out a verbal order?
A. The verbal order is immediately documented in the medical record
B. The physician is present while the order is being carried out
C. Another nurse verifies the order
D. The order is repeated back to the physician for confirmation
Answer: D. The order is repeated back to the physician for confirmation
Rationale: To avoid errors, nurses must repeat verbal orders back to the physician to ensure accuracy.
30
A nurse is preparing to discharge a client but has concerns that the client will not be able to manage at home. Which ethical principle should the nurse apply in this situation?
A. Beneficence
B. Autonomy
C. Nonmaleficence
D. Justice
Answer: A. Beneficence
Rationale: Beneficence involves acting in the best interest of the client, which includes ensuring the client is discharged safely.
31
A nurse who observes unethical behavior by a colleague is required by the ANA Code of Ethics to:
A. Ignore the behavior if no harm was caused
B. Report the behavior to the appropriate authority
C. Speak to the colleague privately
D. Document the incident without taking further action
Answer: B. Report the behavior to the appropriate authority
Rationale: The ANA Code of Ethics requires nurses to report unethical behavior to protect patients and maintain professional integrity.
32
Which of the following is an example of a positive consequence of adhering to ethical and legal nursing practices?
A. Disciplinary action
B. Moral distress
C. Patient safety
D. Legal liability
Answer: C. Patient safety
Rationale: Adhering to ethical and legal nursing practices leads to positive outcomes, such as patient safety and quality care.
33
A nurse is providing care to a client who has an advance directive in place. According to the Patient Self-Determination Act, what is the nurse’s responsibility?
A. Ensure the client’s wishes in the advance directive are followed
B. Convince the client to reconsider their decisions
C. Allow the family to override the advance directive
D. Discuss the directive only if the client asks
Answer: A. Ensure the client’s wishes in the advance directive are followed
Rationale: The Patient Self-Determination Act ensures that the client’s advance directives are respected and followed.
34
Which of the following situations could lead to litigation under the Nursing Practice Act?
A. Administering a vaccine without the patient’s consent
B. Refusing to administer a harmful treatment
C. Requesting a second opinion on a client’s care
D. Delegating tasks to licensed personnel
Answer: A. Administering a vaccine without the patient’s consent
Rationale: Administering any treatment without a patient’s consent could result in legal action.
35
A nurse must comply with the Texas Board of Nursing’s standards of practice. Which of the following is one of those standards?
A. Administering medications only under direct physician supervision
B. Maintaining confidentiality and respecting the rights of patients
C. Documenting care only at the end of each shift
D. Reporting only major errors that cause patient harm
Answer: B. Maintaining confidentiality and respecting the rights of patients
Rationale: One of the Texas Board of Nursing standards is maintaining patient confidentiality and ensuring their rights are respected.
36
A nurse is participating in a healthcare team meeting and is asked to advocate for the client’s wishes. Which ethical principle is the nurse applying?
A. Beneficence
B. Fidelity
C. Justice
D. Autonomy
Answer: D. Autonomy
Rationale: Autonomy refers to respecting and advocating for the client’s decisions and rights.
37
A nurse in Texas is licensed to practice in multiple states under the Nurse Licensure Compact (NLC). Which of the following is true about this compact?
A. The nurse is only allowed to practice in their home state
B. The nurse can practice in any state that is part of the NLC
C. The nurse must obtain a separate license for each state
D. The nurse must be supervised by a nurse in each new state
Answer: B. The nurse can practice in any state that is part of the NLC
Rationale: The Nurse Licensure Compact allows nurses to practice in multiple states that are part of the agreement without needing separate licenses.
38
A nurse is caring for a client who has refused treatment. According to the Nursing Practice Act, what is the nurse’s responsibility?
A. Respect the client’s decision and document the refusal
B. Convince the client to change their mind
C. Seek legal intervention to force the treatment
D. Administer the treatment without informing the client
Answer: A. Respect the client’s decision and document the refusal
Rationale: Nurses must respect a client’s right to refuse treatment and document the refusal.
39
A nurse administering medications realizes they have given the wrong dose. According to ethical and legal standards, what should the nurse do first?
A. Complete an incident report
B. Notify the client’s family
C. Inform the client’s physician
D. Monitor the client for adverse effects
Answer: D. Monitor the client for adverse effects
Rationale: The nurse’s first responsibility is to ensure the client’s safety by monitoring for adverse effects, then report the error appropriately.
40
Which federal law mandates confidentiality and protection of clients' health information?
A. Emergency Medical Treatment and Labor Act (EMTALA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Patient Self-Determination Act
D. Affordable Care Act
Answer: B. Health Insurance Portability and Accountability Act (HIPAA)
Rationale: HIPAA mandates confidentiality and protection of client health information.
41
A nurse is administering medications and realizes a near miss occurred when a dose of insulin was almost given to the wrong patient. What should the nurse do first?
A. Complete an incident report
B. Administer the correct medication to the patient
C. Notify the physician immediately
D. Report the near miss to the charge nurse
Answer: D. Report the near miss to the charge nurse
Rationale: Near misses should be reported immediately to the charge nurse to prevent future errors.
42
Which of the following is an example of a latent error in a healthcare system?
A. Administering the wrong medication
B. Incorrectly labeling laboratory samples
C. A faulty infusion pump that intermittently malfunctions
D. Forgetting to document vital signs
Answer: C. A faulty infusion pump that intermittently malfunctions
Rationale: Latent errors are system errors that may not be immediately apparent but contribute to adverse events.
43
A nurse realizes that a medication was not administered to a patient during the scheduled time. This is an example of which type of error?
A. Diagnostic error
B. Communication error
C. Treatment error
D. Preventive error
Answer: C. Treatment error
Rationale: A treatment error occurs when there is a failure to administer a treatment, such as medication, at the appropriate time.
44
A nurse is preparing to perform a wound dressing change for a surgical patient. Which of the following describes surgical asepsis?
A. Cleaning hands with soap and water
B. Using gloves to perform personal care
C. Wearing gloves and a gown during the procedure
D. Maintaining a sterile field during the procedure
Answer: D. Maintaining a sterile field during the procedure
Rationale: Surgical asepsis, or sterile technique, involves maintaining a sterile environment to prevent the introduction of microorganisms.
45
What is the first step in preventing the transmission of infections in a healthcare setting?
A. Wearing gloves
B. Isolating patients with infections
C. Performing hand hygiene
D. Disinfecting surfaces
Answer: C. Performing hand hygiene
Rationale: Hand hygiene is the most effective way to prevent the transmission of infections.
46
A patient develops a urinary tract infection after having an indwelling catheter for several days. This is an example of which type of event?
A. Sentinel event
B. Never event
C. Adverse event
D. Near miss
Answer: C. Adverse event
Rationale: An adverse event is an unintended injury caused by medical management rather than the patient's underlying condition.
47
A patient experiences a fall while trying to get out of bed without assistance. What should the nurse do first?
A. Document the fall in the medical record
B. Perform a full assessment to check for injuries
C. Assist the patient back into bed
D. Notify the physician
Answer: B. Perform a full assessment to check for injuries
Rationale: After a fall, the priority is to assess the patient for any injuries before taking further action.
48
What is the purpose of a safety culture in healthcare?
A. To hold individuals accountable for errors
B. To create a blame-free environment where errors can be reported and learned from
C. To ensure patients are punished for not following safety protocols
D. To provide strict disciplinary action for every mistake
Answer: B. To create a blame-free environment where errors can be reported and learned from
Rationale: A safety culture promotes reporting errors without fear of punishment, allowing for learning and improvement.
49
A nurse is caring for a patient who has tested positive for tuberculosis. What type of precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective precautions
Answer: C. Airborne precautions
Rationale: Tuberculosis requires airborne precautions, including the use of an N95 respirator and a negative pressure room.
50
A nurse is reviewing the concept of just culture with colleagues. Which of the following statements is true about just culture?
A. Just culture focuses on blaming individuals for their mistakes
B. Just culture encourages learning from mistakes without fear of retribution
C. Just culture is only relevant for medication errors
D. Just culture promotes harsh punishment for all errors
Answer: B. Just culture encourages learning from mistakes without fear of retribution
Rationale: Just culture seeks a balance between learning from mistakes and ensuring accountability.
51
What is the most important factor in preventing falls in hospitalized older adults?
A. Using physical restraints
B. Administering sedatives to calm the patient
C. Regularly assessing the patient’s fall risk
D. Encouraging the patient to remain in bed all day
Answer: C. Regularly assessing the patient’s fall risk
Rationale: Regularly assessing fall risk and implementing prevention strategies are key to reducing falls.
52
A nurse is caring for a patient who has been placed on droplet precautions. Which of the following is an appropriate personal protective equipment (PPE) measure?
A. Wearing a surgical mask when entering the patient’s room
B. Using an N95 respirator for all patient interactions
C. Wearing sterile gloves when touching the patient
D. Wearing protective eyewear only during procedures
Answer: A. Wearing a surgical mask when entering the patient’s room
Rationale: Droplet precautions require wearing a surgical mask to prevent the transmission of infections.
53
A nurse enters a room to administer a medication and notices the patient's ID band is missing. What is the best course of action?
A. Administer the medication without checking the ID band
B. Ask the patient to verbally confirm their identity
C. Verify the patient’s identity with another nurse
D. Replace the ID band and then administer the medication
Answer: D. Replace the ID band and then administer the medication
Rationale: The nurse must ensure proper identification by replacing the ID band before administering any medication.
54
Which of the following is an example of a preventive error?
A. Failure to perform appropriate hand hygiene before wound care
B. Administering a double dose of insulin
C. Delayed response to abnormal lab results
D. Failing to provide follow-up care after surgery
Answer: D. Failing to provide follow-up care after surgery
Rationale: Preventive errors occur when there is inadequate monitoring or follow-up care after treatment.
55
A patient is being treated for an infection with contact precautions in place. Which of the following PPE is required before entering the patient’s room?
A. Gown and gloves
B. Surgical mask
C. N95 respirator
D. Sterile gloves
Answer: A. Gown and gloves
Rationale: Contact precautions require the use of gown and gloves to prevent transmission through direct contact.
56
A nurse notices a medication error that was made by another nurse but did not result in harm to the patient. According to the culture of safety, what is the nurse's next action?
A. Do nothing since no harm occurred
B. Inform the patient about the error
C. Report the error to the nurse manager
D. Reprimand the nurse who made the error
Answer: C. Report the error to the nurse manager
Rationale: Errors should be reported even if no harm occurred, as part of a safety culture that promotes learning from mistakes.
57
What is a sentinel event in healthcare?
A. A minor error that causes no harm
B. An event that results in serious injury or death
C. An error that is caught before reaching the patient
D. An adverse event that occurs infrequently
Answer: B. An event that results in serious injury or death
Rationale: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury.
58
A nurse is caring for a patient on neutropenic precautions. Which of the following should the nurse avoid?
A. Allowing visitors to bring flowers into the room
B. Wearing a gown when entering the room
C. Washing hands before and after patient care
D. Using disposable equipment when available
Answer: A. Allowing visitors to bring flowers into the room
Rationale: Patients on neutropenic precautions are immunocompromised, and fresh flowers can introduce bacteria.
59
Which of the following is an example of a never event?
A. A patient develops a mild rash from a prescribed medication
B. A nurse administers the wrong blood type during a transfusion
C. A patient experiences nausea after chemotherapy
D. A nurse documents vital signs late in the shift
Answer: B. A nurse administers the wrong blood type during a transfusion
Rationale: A never event is a serious, preventable incident that should never occur, such as administering the wrong blood type.
60
A nurse enters a patient’s room to administer an injection. The patient’s ID bracelet is missing. What is the nurse’s next action?
A. Administer the injection after verifying the patient’s identity verbally
B. Administer the injection and then replace the ID bracelet
C. Refuse to administer the injection until the ID bracelet is replaced
D. Check the room number to ensure it's correct and proceed with the injection
Answer: C. Refuse to administer the injection until the ID bracelet is replaced
Rationale: Proper patient identification is critical before administering medications or treatments. The ID bracelet must be replaced first.
61
A nurse is teaching a new group of nurses about medication safety. Which of the following is the most important step to ensure safe medication administration?
A. Asking another nurse to check your medications
B. Always administering medications on time
C. Identifying the patient using two identifiers
D. Documenting medications immediately after administration
Answer: C. Identifying the patient using two identifiers
Rationale: The most important step in medication safety is verifying the correct patient using two identifiers before administration.
62
A nurse is preparing to administer a medication but notices that the dosage seems higher than usual. What should the nurse do?
A. Administer the medication as prescribed
B. Ask a colleague if the dosage is correct
C. Contact the prescriber to verify the dosage
D. Administer half the dose to be safe
Answer: C. Contact the prescriber to verify the dosage
Rationale: The nurse should always verify a questionable dose with the prescriber before administration to ensure patient safety.
63
Which of the following actions can help reduce the risk of infection in patients?
A. Using hand sanitizer after removing gloves
B. Only washing hands when they are visibly soiled
C. Wearing gloves for all patient interactions
D. Changing gloves between tasks with the same patient
Answer: A. Using hand sanitizer after removing gloves
Rationale: Using hand sanitizer after removing gloves helps reduce the risk of infection, as gloves do not provide full protection against pathogens.
64
What is the first action a nurse should take after a patient falls in their hospital room?
A. Help the patient back into bed
B. Document the fall in the medical record
C. Assess the patient for injuries
D. Notify the physician
Answer: C. Assess the patient for injuries
Rationale: The nurse’s first action should be to assess the patient for injuries following a fall.
65
A nurse receives an order to administer a medication that the patient is allergic to. What is the most appropriate response by the nurse?
A. Administer the medication with an antihistamine
B. Contact the provider to clarify the order
C. Administer the medication and observe the patient for a reaction
D. Refuse to administer the medication without contacting the provider
Answer: B. Contact the provider to clarify the order
Rationale: The nurse must contact the provider to clarify the order if it conflicts with the patient’s known allergies.
66
A nurse is about to administer a medication through a feeding tube but realizes the medication should not be crushed. What is the appropriate action?
A. Crush the medication and administer it slowly
B. Dissolve the medication in warm water
C. Contact the provider for an alternative medication form
D. Administer the medication via IV instead
Answer: C. Contact the provider for an alternative medication form
Rationale: If a medication cannot be crushed, the nurse should contact the provider for an alternative form or route.
67
Which of the following personal protective equipment (PPE) is required when caring for a patient on airborne precautions?
A. Surgical mask
B. N95 respirator
C. Face shield
D. Sterile gloves
Answer: B. N95 respirator
Rationale: Airborne precautions require the use of an N95 respirator to prevent the inhalation of airborne pathogens
68
A patient is admitted with a deep pressure ulcer. Which assessment tool should the nurse use to evaluate the patient’s risk for skin breakdown?
A. Morse Fall Scale
B. Glasgow Coma Scale
C. Braden Scale
D. Norton Scale
Answer: C. Braden Scale
Rationale: The Braden Scale is used to assess a patient’s risk for skin breakdown and pressure ulcers.
69
A nurse is reviewing an incident report related to a medication error. Which of the following is the primary purpose of an incident report?
A. To assign blame for the error
B. To ensure the error is documented in the patient’s chart
C. To identify ways to prevent future errors
D. To notify the patient and family of the error
Answer: C. To identify ways to prevent future errors
Rationale: Incident reports are used to analyze errors and develop strategies to prevent them in the future.
70
A nurse is preparing to assist a patient with ambulation. Which of the following actions will help prevent a fall?
A. Raising the bed to its highest position
B. Encouraging the patient to walk quickly to avoid fatigue
C. Using a gait belt to support the patient
D. Having the patient walk without assistance to build independence
Answer: C. Using a gait belt to support the patient
Rationale: A gait belt provides support during ambulation and helps prevent falls
71
A nurse is caring for a patient who is agitated and at risk for pulling out their IV line. What is the nurse’s priority action?
A. Apply physical restraints
B. Ask the physician for a sedative order
C. Use therapeutic communication to calm the patient
D. Remove the IV line to prevent injury
Answer: C. Use therapeutic communication to calm the patient
Rationale: The nurse should first use non-invasive techniques such as therapeutic communication to calm the patient.
72
A patient with a history of falls is admitted to the hospital. Which intervention should the nurse implement to prevent falls?
A. Apply restraints at all times
B. Encourage the patient to stay in bed
C. Place a fall risk sign outside the patient’s room
D. Lower the bed to its lowest position and place the call light within reach
Answer: D. Lower the bed to its lowest position and place the call light within reach
Rationale: Lowering the bed and ensuring the call light is within reach are effective interventions to prevent falls.
73
A nurse is caring for a patient with contact precautions. Which of the following is the correct method for doffing PPE?
A. Gloves, gown, mask, eyewear
B. Gown, mask, gloves, eyewear
C. Gloves, gown, eyewear, mask
D. Mask, gloves, gown, eyewear
Answer: C. Gloves, gown, eyewear, mask
Rationale: PPE should be removed in this order: gloves first, then gown, followed by eyewear and mask.
74
A nurse is caring for a patient who is on seizure precautions. Which of the following actions should the nurse take?
A. Place the patient in soft restraints
B. Ensure suction equipment is readily available
C. Administer anti-seizure medication prophylactically
D. Position the patient flat on their back
Answer: B. Ensure suction equipment is readily available
Rationale: Suction equipment should be readily available to clear the airway during or after a seizure.
75
A nurse is caring for a patient who has a wound that requires sterile dressing changes. Which of the following actions will help maintain sterility during the procedure?
A. Keeping the sterile field below waist level
B. Donning sterile gloves after preparing the sterile field
C. Reaching over the sterile field to grab supplies
D. Touching the edges of the sterile dressing with ungloved hands
Answer: B. Donning sterile gloves after preparing the sterile field
Rationale: Sterile gloves should be donned before handling any sterile items to maintain sterility.
76
A nurse is performing a time-out before a surgical procedure. Which of the following is the purpose of a time-out?
A. To ensure the patient is aware of the surgery risks
B. To verify the correct patient, procedure, and site
C. To ensure the surgeon is prepared for the procedure
D. To allow the patient to ask any last-minute questions
Answer: B. To verify the correct patient, procedure, and site
Rationale: The purpose of a time-out is to ensure the surgical team verifies the correct patient, procedure, and surgical site.
77
A patient is admitted to the hospital with pneumonia and is placed on droplet precautions. Which of the following is an appropriate action by the nurse?
A. Place the patient in a private room
B. Wear an N95 respirator when caring for the patient
C. Allow visitors without restriction
D. Provide the patient with a negative-pressure room
Answer: A. Place the patient in a private room
Rationale: Droplet precautions require the patient to be in a private room to reduce the spread of infection.
78
A nurse is caring for a patient on a neutropenic diet. Which of the following should be included in the dietary restrictions?
A. Avoid all dairy products
B. Avoid raw fruits and vegetables
C. Avoid all cooked meats
D. Avoid all grains
Answer: B. Avoid raw fruits and vegetables
Rationale: Patients on a neutropenic diet should avoid raw fruits and vegetables to reduce the risk of infection.
79
A patient is being treated for an infection with airborne precautions in place. Which of the following PPE should the nurse wear?
A. Gloves and gown
B. Surgical mask
C. N95 respirator
D. Face shield only
Answer: C. N95 respirator
Rationale: An N95 respirator is required for airborne precautions to prevent the inhalation of infectious particles.
80
A nurse is caring for a patient who is at high risk for falls. Which of the following interventions should be implemented to prevent falls?
A. Use bed alarms to alert staff when the patient attempts to get up
B. Place the patient in restraints
C. Administer sedatives to keep the patient in bed
D. Lower all four side rails to ensure easy access
Answer: A. Use bed alarms to alert staff when the patient attempts to get up
Rationale: Bed alarms alert staff when a patient at risk for falls attempts to get up, allowing for timely intervention.
81
A nurse is documenting a medication error that occurred during the administration of a patient's IV antibiotic. Which of the following should be included in the documentation?
A. A detailed description of the nurse's role in the error
B. The time the error was discovered and the patient’s response
C. A statement apologizing to the patient
D. A note blaming the pharmacy for the error
Answer: B. The time the error was discovered and the patient’s response
Rationale: Documentation should include objective information about the error, including when it was discovered and the patient’s condition.
82
A nurse is caring for a patient with contact precautions due to a wound infection. What is the correct order for donning PPE?
A. Gloves, gown, mask
B. Mask, gown, gloves
C. Gown, mask, gloves
D. Mask, gloves, gown
Answer: C. Gown, mask, gloves
Rationale: The correct order for donning PPE is gown first, then mask, followed by gloves.
83
A nurse is caring for a patient with a high risk for pressure ulcers. Which of the following interventions should the nurse implement?
A. Turn the patient every 4 hours
B. Apply alcohol to bony prominences to keep them dry
C. Use a pressure-reducing mattress
D. Place the patient in a semi-Fowler's position for long periods
Answer: C. Use a pressure-reducing mattress
Rationale: A pressure-reducing mattress helps distribute weight and reduce the risk of pressure ulcers.
84
A nurse is reviewing a patient's fall risk assessment using the Morse Fall Scale. Which of the following factors increases a patient’s fall risk?
A. The patient has a history of falls
B. The patient uses a walker
C. The patient wears eyeglasses
D. The patient is on a fluid restriction
Answer: A. The patient has a history of falls
Rationale: A history of falls significantly increases the risk of future falls and should be considered in the fall risk assessment.
85
A nurse is documenting care for a patient who experienced a near miss during medication administration. Which of the following should be included in the report?
A. Blaming the physician for the error
B. The patient's response to the near miss
C. Steps taken to prevent the near miss
D. A detailed description of the nurse’s involvement
Answer: C. Steps taken to prevent the near miss
Rationale: A near miss report should focus on identifying preventive measures to avoid future errors.
86
A nurse is administering an IV medication and realizes the incorrect dose was given. What is the nurse’s priority action?
A. Notify the physician immediately
B. Document the error in the patient’s chart
C. Monitor the patient for adverse effects
D. Complete an incident report
Answer: C. Monitor the patient for adverse effects
Rationale: The nurse’s first priority is the patient’s safety. The nurse should monitor for any adverse effects and then report the error.
87
A patient with a history of falls is admitted to the hospital. Which of the following fall prevention strategies should the nurse implement?
A. Keep the patient’s bed in a high position
B. Place a fall risk armband on the patient
C. Restrain the patient to prevent falls
D. Keep the call light out of reach to prevent unnecessary movement
Answer: B. Place a fall risk armband on the patient
Rationale: A fall risk armband helps alert all staff to the patient’s fall risk and prompts extra precautions.
88
A nurse is preparing to care for a patient with airborne precautions. Which of the following interventions is appropriate?
A. Place the patient in a room with negative airflow
B. Wear a face shield during all patient interactions
C. Limit the use of disposable equipment
D. Allow visitors without restrictions
Answer: A. Place the patient in a room with negative airflow
Rationale: A room with negative airflow is required for airborne precautions to prevent the spread of infectious agents.
89
A nurse is preparing to assist a patient who has right-sided weakness with ambulation. Which of the following is the correct way to support the patient?
A. Stand behind the patient during ambulation
B. Support the patient from the left side
C. Support the patient from the right side
D. Allow the patient to walk independently
Answer: C. Support the patient from the right side
Rationale: The nurse should stand on the weak side (right side in this case) to provide support during ambulation.
90
A nurse is teaching a patient with a history of falls about home safety. Which of the following instructions should the nurse include?
A. "Remove all rugs from your home to prevent tripping."
B. "Use dim lighting to avoid glare when walking at night."
C. "Avoid installing grab bars in the bathroom."
D. "Avoid wearing shoes inside the house."
Answer: A. "Remove all rugs from your home to prevent tripping."
Rationale: Removing rugs helps prevent tripping, which is a common cause of falls, especially in older adults.
91
Which of the following is NOT a key component of professionalism in nursing?
A. Self-awareness
B. Ethical values
C. Personal autonomy
D. Advanced practice specialization
D. Advanced practice specialization - Professionalism is more fundamental and is not contingent on specialization.
92
What is the foundation of professionalism in nursing?
A. Nursing theories
B. Advocacy and integrity
C. Personal and professional values
D. Lifelong learning
C. Personal and professional values - Values drive professional behavior.
93
Which of the following factors best describes nursing professionalism at its optimal state?
A. Critical thinking and patient-focused care
B. Autonomy and financial success
C. Ethical practice and social status
D. Patient advocacy and minimal supervision
A. Critical thinking and patient-focused care - These are key components of nursing professionalism.
94
What are some of the consequences of compromised professionalism in nursing? (Select all that apply)
A. Unsafe patient care
B. Loss of professional license
C. Improved patient satisfaction
D. Violation of practice standards
A, B, D - All of these are consequences of compromised professionalism.
95
The primary goal of nursing is to:
A. Perform medical procedures effectively
B. Administer medications properly
C. Advocate for patient's legal rights
D. Promote health, prevent illness, and care for patients
D. Promote health, prevent illness, and care for patients - This is the holistic goal of nursing.
96
Which nursing role encompasses responsibility, autonomy, and accountability?
A. Clinical nurse educator
B. Registered nurse
C. Nurse administrator
D. Nurse researcher
B. Registered nurse - The RN role encompasses autonomy, accountability, and responsibility.
97
Benner’s stages of nursing proficiency include all of the following EXCEPT:
A. Novice
B. Proficient
C. Advanced expert
D. Competent
C. Advanced expert - There is no such stage in Benner's model.
98
Which of the following historical figures founded the first school of nursing?
A. Clara Barton
B. Florence Nightingale
C. Mary Mahoney
D. Lillian Wald
B. Florence Nightingale - Nightingale is credited with establishing the first school of nursing.
99
True or False: Nurses are required to be involved in professional organizations as part of their professional identity development.
False - Involvement in organizations is encouraged, but not required.
100
Which element is fundamental to nursing's social contract?
A. Responsibility
B. Patient's autonomy
C. Integrity and compassion
D. Community involvement
C. Integrity and compassion - These are key elements of the social contract between nursing and society.
101
True or False: Critical thinking is a fundamental part of both the art and science of nursing.
True - Critical thinking is crucial in both the art and science of nursing.
102
Which of the following is part of nursing's scope of practice? (Select all that apply)
A. Advocacy for patients
B. Personal decision-making based on preference
C. Education of patients
D. Delivery of evidence-based care
A, C, D - Advocacy, education, and evidence-based care are all part of the nursing scope.
103
What outcomes are expected from maintaining high standards of nursing professionalism?
A. Increased patient complaints
B. Continuity of care and safe environment
C. Limited patient advocacy
D. Violation of practice ethics
B. Continuity of care and safe environment - These are positive outcomes of professionalism.
104
The core nursing values include all of the following EXCEPT:
A. Courage
B. Advocacy
C. Financial responsibility
D. Compassion
C. Financial responsibility - While important, this is not a core nursing value.
105
Which foundation has spearheaded the Campaign for Action to improve nursing practice?
A. Florence Nightingale Foundation
B. Robert Wood Johnson Foundation
C. American Nurses Association
D. International Council of Nurses
B. Robert Wood Johnson Foundation - The RWJF has led the Campaign for Action.
106
What is the key characteristic of advanced practice registered nurses (APRNs)?
A. Ability to perform surgery
B. Specialization in a specific area of nursing practice
C. Administrative roles in healthcare facilities
D. Basic nursing skills
B. Specialization in a specific area of nursing practice - APRNs specialize in areas like midwifery or anesthesiology.
107
True or False: Autonomy in nursing refers to the nurse's ability to make independent decisions regarding patient care.
True - Nurses practice independently within their scope.
108
Which practice standard is regulated by state boards of nursing?
A. Code of ethics
B. Nurse scope of practice
C. Financial compensation for nurses
D. Professional socialization
B. Nurse scope of practice - State boards regulate nursing practice standards.
109
Which of the following historical nurses significantly contributed to public health nursing?
A. Florence Nightingale
B. Clara Barton
C. Mary Brewster
D. Mary Mahoney
C. Mary Brewster - Brewster contributed to public health nursing.
110
True or False: Florence Nightingale was the first practicing epidemiologist.
True - Florence Nightingale was the first practicing epidemiologist.
111
Which characteristics are associated with professional identity in nursing? (Select all that apply)
A. Integrity
B. Compassion
C. Authority over all patient decisions
D. Humility
A, B, D - Integrity, compassion, and humility are all key to professional identity.
112
What are some of the roles of a registered nurse in a healthcare setting? (Select all that apply)
A. Communicator
B. Advocate
C. Accountant
D. Caregiver
A, B, D - These are fundamental roles of a nurse in healthcare.
113
Benner’s stages of nursing proficiency include which of the following? (Select all that apply)
A. Novice
B. Expert
C. Advanced expert
D. Competent
A, B, D - Benner’s stages include novice, expert, and competent.
114
Which areas of nursing practice are regulated by Nurse Practice Acts (NPAs)? (Select all that apply)
A. Professional ethics
B. Licensure and certification
C. Nurse-patient ratios
D. Scope of practice
B, D - Licensure and scope of practice are regulated by NPAs.
115
Which of the following are considered advanced practice registered nurse roles? (Select all that apply)
A. Clinical Nurse Specialist
B. Nurse Practitioner
C. Registered Nurse
D. Nurse Educator
A, B, D - These are examples of advanced practice roles.
116
Which of the following describe nursing professionalism? (Select all that apply)
A. Lifelong learning
B. Critical thinking
C. Patient-centered communication
D. Minimal accountability
A, B, C - Lifelong learning, critical thinking, and communication are key components of professionalism.
117
True or False: The ANA’s Code of Ethics guides the professional conduct of nurses.
True - The ANA’s Code of Ethics is foundational to professional nursing conduct.
118
True or False: Nurse-midwives are an example of advanced practice registered nurses.
True - Certified nurse-midwives are a recognized APRN role.
119
True or False: Responsibility and accountability are two separate concepts, and nurses must only focus on one at a time.
False - Nurses must focus on both responsibility and accountability.
120
True or False: Nursing practice focuses exclusively on the treatment of disease.
False - Nursing practice encompasses prevention, health promotion, and care beyond disease treatment.
121
Which statement best describes the art of nursing?
A. Nursing based purely on critical thinking and problem-solving
B. The scientific knowledge required to perform clinical tasks
C. The compassionate and creative approach to patient care
D. The technical skills necessary for medical interventions
C. The compassionate and creative approach to patient care - The art of nursing focuses on the personal and caring aspect of practice.
122
Which of the following is an example of a nurse demonstrating advocacy?
A. Administering medications correctly
B. Teaching a patient about their discharge instructions
C. Speaking up for a patient's needs when they cannot do so themselves
D. Following all hospital protocols without question
C. Speaking up for a patient's needs when they cannot do so themselves - Advocacy involves defending and protecting the rights and interests of patients.
123
A nurse is preparing to teach a group of novice nurses about accountability in practice. Which of the following should be emphasized?
A. Delegating tasks without follow-up
B. Taking ownership of patient outcomes
C. Performing tasks only when supervised
D. Following the lead of senior staff without question
B. Taking ownership of patient outcomes - Accountability in nursing means being responsible for the quality and outcomes of patient care.
124
Which of the following are characteristics of a nurse practicing lifelong learning? (Select all that apply)
A. Engaging in continuous education courses
B. Remaining current with nursing research and practices
C. Referring to outdated protocols and textbooks
D. Attending professional nursing conferences
A, B, D - Lifelong learning involves engaging in continuing education, staying up-to-date with research, and participating in professional development activities.
125
Which historical nurse is known for founding the American Red Cross?
A. Florence Nightingale
B. Clara Barton
C. Lillian Wald
D. Isabel Hampton Robb
B. Clara Barton - Clara Barton is known for founding the American Red Cross.
126
Which of the following factors is fundamental to maintaining professional boundaries in nursing practice?
A. Sharing personal experiences with patients frequently
B. Establishing trust through respectful and therapeutic relationships
C. Forming personal friendships with patients
D. Communicating with patients outside of work hours
B. Establishing trust through respectful and therapeutic relationships - Maintaining professional boundaries involves developing trust while keeping relationships therapeutic.
127
True or False: The Nurse Practice Act (NPA) varies by state but universally aims to regulate the scope of practice and ensure patient safety.
True - NPAs regulate nursing practice and vary by state but have the universal goal of ensuring patient safety and proper scope of practice.
128
Which nursing role is best described as the one who bridges communication between the patient and the rest of the healthcare team?
A. Nurse Educator
B. Nurse Researcher
C. Nurse Administrator
D. Nurse Advocate
D. Nurse Advocate - A nurse advocate acts as the voice for the patient within the healthcare team.
129
True or False: The ANA's Standards of Professional Nursing Practice include both standards of care and standards of performance.
True - The ANA’s Standards of Professional Nursing Practice encompass both care standards and performance standards.
130
Which statement about integrity in nursing is correct?
A. Integrity in nursing means following personal preferences over protocols
B. Integrity involves being honest and adhering to moral and ethical principles
C. Integrity means focusing on personal gains and achievements
D. Integrity is less important in clinical practice than in administrative roles
B. Integrity involves being honest and adhering to moral and ethical principles - Integrity is about upholding ethical values and being honest in all nursing practices.
131
What is the primary focus of the assessment phase in the nursing process?
A. Developing nursing interventions
B. Collecting subjective and objective data
C. Identifying nursing diagnoses
D. Evaluating patient outcomes
B - The primary focus of assessment is collecting data.
131
In which phase of the nursing process does the nurse prioritize patient problems?
A. Assessment
B. Planning
C. Evaluation
D. Analysis
D - The analysis phase involves prioritizing patient problems.
132
Which of the following is an example of subjective data?
A. Respiratory rate of 20 breaths per minute
B. Patient states, "I feel nauseous."
C. Blood pressure reading of 120/80 mm Hg
D. Skin is warm and dry to the touch
B - Subjective data is what the patient reports feeling.
133
True or False: The planning phase in the nursing process involves generating patient-specific goals and expected outcomes.
True - Planning involves setting patient-specific goals.
134
Which of the following techniques is most appropriate during a comprehensive assessment?
A. Using close-ended questions to gather information quickly
B. Relying solely on the patient's medical history for data
C. Performing a head-to-toe physical assessment
D. Asking family members to provide all information
C - A comprehensive assessment includes a head-to-toe physical exam.
135
What is the correct order for the steps in the nursing process?
A. Assess, Plan, Diagnose, Implement, Evaluate
B. Assess, Diagnose, Plan, Implement, Evaluate
C. Diagnose, Plan, Implement, Evaluate, Assess
D. Plan, Assess, Diagnose, Implement, Evaluate
B - This is the correct sequence of the nursing process.
136
Which of the following are components of therapeutic communication? (Select all that apply)
A. Active listening
B. Genuineness
C. Giving personal opinions
D. Empathy
A, B, D - Active listening, genuineness, and empathy are key components.
137
When documenting objective data, the nurse would include which of the following?
A. Patient reports pain of 8/10
B. Patient states, "I have been feeling dizzy."
C. Blood pressure is 140/90 mm Hg
D. Patient says they feel nauseous
C - Objective data is measurable, such as blood pressure.
138
True or False: The evaluation phase of the nursing process involves determining whether patient goals were met and modifying the care plan as needed.
True - Evaluation is to determine if goals are met.
139
During a shift assessment, which of the following would be considered a focused assessment?
A. A complete head-to-toe physical exam
B. Assessing lung sounds after a patient complains of shortness of breath
C. Gathering the patient's entire health history
D. Conducting an annual wellness exam
B - A focused assessment addresses a specific issue like shortness of breath.
140
Which of the following are examples of primary sources of data in the nursing assessment process? (Select all that apply)
A. The patient
B. The patient's family
C. The patient's medical chart
D. The healthcare provider's notes
A - The patient is the primary source of data.
141
The analysis phase of the nursing process involves:
A. Implementing nursing interventions
B. Evaluating patient outcomes
C. Analyzing and prioritizing patient data
D. Identifying goals for patient care
C - The analysis phase involves prioritizing and interpreting data.
142
True or False: In the nursing process, subjective data are based on observations made by the nurse during the physical exam.
False - Subjective data comes from the patient, not the nurse's observations.
143
Which action by the nurse demonstrates correct use of critical thinking during data collection?
A. Documenting patient symptoms without further questioning
B. Asking the patient about related symptoms to clarify health history
C. Delegating data collection to a family member
D. Relying on past experiences without questioning the patient
B - Critical thinking involves asking clarifying questions.
144
During the planning phase, the nurse should develop goals that are:
A. Abstract and open-ended
B. Specific, measurable, achievable, relevant, and time-bound (SMART)
C. Short-term only
D. Developed only by the healthcare provider
B - Goals should be SMART.
145
Which of the following types of data are collected during a focused assessment?
A. A comprehensive health history
B. Information related to the patient's chief complaint
C. Data from an annual physical exam
D. A complete family history
B - A focused assessment gathers data related to the patient's chief complaint.
146
True or False: A patient's biographical data should be included in their health history.
True - Biographical data is part of the health history.
147
Which communication techniques should the nurse use when interviewing a patient? (Select all that apply)
A. Active listening
B. Interrupting the patient to ask for clarification
C. Maintaining eye contact
D. Using medical jargon
A, C - Active listening and maintaining eye contact are key strategies.
147
A comprehensive assessment includes all of the following EXCEPT:
A. Head-to-toe physical exam
B. Periodic reassessment of patient's condition
C. Complete health history
D. Detailed family history
B - Periodic reassessments are part of ongoing care.
148
What are the main components of a health history? (Select all that apply)
A. Biographical data
B. Family history
C. Financial status
D. Review of systems
A, B, D - These are the key components of a health history.
149
True or False: A focused assessment is conducted when the patient's condition remains stable and unchanged.
False - A focused assessment is conducted for changes in the patient's condition.
150
When prioritizing patient care during the analysis phase, which problem should the nurse address first?
A. Risk for impaired skin integrity
B. Decreased appetite
C. Acute airway obstruction
D. Mild anxiety
C - Airway issues are always the highest priority.
150
Which of the following is considered a secondary source of data?
A. Patient report of pain level
B. Nurse's observations during physical exam
C. Family member's description of the patient's symptoms
D. Patient's own explanation of symptoms
C - Family members can provide secondary data.
151
True or False: Nurses should avoid using family members as interpreters when a language barrier exists.
True - Family members should not be used as interpreters due to potential biases.
152
During the intervention/implementation phase, what must the nurse consider when providing care?A. Whether the patient is agreeable to the care plan
B. The nurse's preferences and time constraints
C. Evidence-based scientific rationale for interventions
D. Completing tasks as quickly as possible
C - Interventions should have a scientific rationale.
153
A health assessment includes which of the following? (Select all that apply)
A. Establishing a baseline health history
B. Identifying personal goals and aspirations
C. Conducting a comprehensive physical examination
D. Evaluating social, economic, and spiritual factors
A, C, D - A health assessment includes establishing a baseline and considering multiple factors.
154
Which factor is most important for the nurse to assess in a patient with low health literacy?
A. Educational background
B. Cognitive ability
C. Ability to manage complex medical terms
D. Socioeconomic status
A - Educational background can impact health literacy.
154
Which technique is appropriate when auscultating the abdomen during a physical assessment?
A. Palpating before auscultating
B. Using the bell of the stethoscope
C. Listening to bowel sounds for at least 5 seconds in each quadrant
D. Using the diaphragm of the stethoscope
D - Use the diaphragm to auscultate bowel sounds.
155
True or False: Spiritual and cultural factors should not influence the nurse's data collection process.
False - Spiritual and cultural factors are important in data collection.
156
Which assessment type is most appropriate when a patient complains of chest pain during hospitalization?
A. Comprehensive assessment
B. Shift assessment
C. Focused assessment
D. Admission assessment
C - A focused assessment is appropriate for specific symptoms.
157
True or False: Subjective data include what the patient tells the nurse about their symptoms, whereas objective data are what the nurse observes or measures.
True - Subjective data is what the patient reports, objective is what the nurse observes.
158
Which of the following strategies is effective when assessing a patient with a hearing impairment? (Select all that apply)
A. Speak slowly and clearly
B. Reduce background noise
C. Shout to ensure the patient hears you
D. Use written communication if necessary
A, B, D - Speak clearly, reduce noise, and use written communication if necessary.
159
Which of the following actions should the nurse take before beginning a patient assessment?
A. Ensure patient privacy and comfort
B. Start with a physical exam before asking any questions
C. Skip the health history if the patient appears healthy
D. Conduct the assessment in a noisy, crowded environme
A - Ensuring patient comfort and privacy is essential.
160
True or False: A nurse should validate data with the patient if there is any discrepancy in the information collected.
True - Discrepancies should always be validated.
161
Which of the following are important components of therapeutic communication when assessing a patient? (Select all that apply)
A. Maintaining eye contact
B. Summarizing what the patient says at the end of the conversation
C. Relying on non-verbal cues alone
D. Asking broad opening questions
A, B, D - Maintaining eye contact, summarizing, and asking broad questions are therapeutic communication techniques.
162
Which tool can be used to assist a nurse in gathering data for the health history?
A. The nursing diagnosis manual
B. The OLDCARTS mnemonic
C. The patient's discharge summary
D. A thermometer
B - OLDCARTS is a mnemonic used for health history.
162
What is the most important rationale for gathering a thorough health history during patient admission?
A. To develop rapport with the patient
B. To determine if the patient can pay for services
C. To establish a baseline for care planning
D. To meet legal documentation requirements
C - A baseline helps in developing a care plan.
163
Which of the following communication barriers can impede the accuracy of a health assessment? (Select all that apply)
A. Using medical jargon
B. Rushing the patient through responses
C. Asking open-ended questions
D. Stereotyping the patient
A, B, D - Medical jargon, rushing, and stereotyping are barriers to effective communication.
164
True or False: Cultural sensitivity during a health assessment is essential to avoid miscommunication and provide holistic care.
True - Cultural sensitivity is essential in holistic care.
165
True or False: The nurse should document the health history and physical assessment findings immediately after completing the assessment.
True - Documentation should be done immediately after the assessment.
166
Which of the following is an example of a condition that affects acid-base balance in the body?
A. Hypoglycemia
B. Respiratory acidosis
C. Hypertension
D. Hypernatremia
B - Respiratory acidosis affects the body’s acid-base balance.
Acid-Base Balance: Conditions like respiratory acidosis affect the body's ability to maintain a stable pH by altering the concentration of bicarbonate and carbon dioxide in the body.
167
What is the primary function of fluid and electrolyte balance?
A. Regulate blood sugar levels
B. Maintain extracellular fluid volume and electrolyte concentration
C. Eliminate metabolic waste products
D. Promote digestion of nutrients
B - Fluid and electrolyte balance regulates extracellular fluid volume and plasma concentration of electrolytes.
Fluid and Electrolyte Balance: Maintaining proper fluid and electrolyte balance is critical for homeostasis, and imbalances can lead to severe health problems, such as dehydration or hypervolemia.
168
Which of the following processes is directly involved in the elimination of waste products from the body?
A. Digestion
B. Respiration
C. Excretion
D. Circulation
C - Elimination refers to the excretion of waste products from the body.
Elimination: Elimination processes, including urination and defecation, are essential for removing waste products and maintaining the body’s internal environment.
169
True or False: Comfort is achieved when a patient is in a state of physical ease and free from pain.
True - Comfort involves a state of ease and relief from pain.
Comfort: A state of ease, such as being pain-free, contributes significantly to overall well-being.
170
What is the main purpose of gas exchange in the body?
A. Regulate body temperature
B. Transport oxygen to cells and remove carbon dioxide
C. Facilitate digestion and absorption of nutrients
D. Promote hormonal balance
B - Gas exchange involves the transport of oxygen to cells and carbon dioxide away from cells.
Gas Exchange: Effective oxygen transport to cells and removal of carbon dioxide are vital for cellular metabolism.
171
Which of the following is a key component of functional ability?
A. Ability to interpret sensory information
B. Physical, cognitive, and social ability to perform daily activities
C. Maintaining core body temperature
D. Controlling blood glucose levels
B - Functional ability includes physical, psychological, cognitive, and social aspects of daily living.
Functional Ability: Activities of daily living rely on multiple facets of functional ability, including physical and cognitive health.
172
True or False: Immunity is the body’s ability to provide protection from disease and infections.
True - Immunity protects the body from diseases and infections.
173
Which of the following processes is part of metabolism in the human body?
A. Oxygenation of blood in the lungs
B. Breakdown of food into energy for cells
C. Removal of waste through the kidneys
D. Exchange of gases in the alveoli
B - Metabolism involves the biochemical processes, including the breakdown of food into energy that is used by cells to sustain life.
174
Select all that apply: Which of the following factors are important for proper gas exchange in the lungs?
A. Adequate ventilation
B. Proper circulation of blood
C. Strong skeletal muscles
D. Functioning alveoli
A, B, D - Adequate ventilation, proper circulation, and functioning alveoli are essential for effective gas exchange in the lungs.
174
What is a possible complication of impaired mobility?
A. Increased elimination of waste
B. Muscle atrophy and contractures
C. Improved sensory perception
D. Enhanced tissue integrity
B - Impaired mobility can lead to muscle atrophy, contractures, and decreased range of motion, among other complications.
175
Which of the following is a function of nutrition in the body?
A. Regulation of body temperature
B. Ingestion and absorption of nutrients
C. Removal of metabolic waste
D. Exchange of oxygen and carbon dioxide
B - Nutrition involves the ingestion and absorption of essential nutrients, which the body uses to function properly.
175
True or False: Perfusion refers to the flow of blood through arteries and capillaries, delivering oxygen and nutrients to tissues.
True - Perfusion is the process of delivering blood, oxygen, and nutrients to body tissues through arteries and capillaries.
176
What is a common cause of impaired tissue integrity?
A. Adequate nutrition
B. Chronic skin pressure
C. Proper hydration
D. Deep breathing exercises
B - Chronic pressure on the skin, such as in bedbound patients, can lead to impaired tissue integrity, such as pressure ulcers.
177
Which of the following are examples of factors that affect mobility? (Select all that apply)
A. Muscle strength
B. Joint flexibility
C. Hormonal imbalance
D. Neurological function
A, B, D - Muscle strength, joint flexibility, and neurological function all play a role in mobility. Hormonal imbalance generally affects other body systems.
178
Which of the following is an example of an alteration in thermoregulation?
A. Hyperglycemia
B. Hypothermia
C. Hypervolemia
D. Hypoxia
B - Hypothermia is an example of altered thermoregulation, where the body is unable to maintain its core temperature within a normal range.
178
True or False: Sensory perception involves the body’s ability to receive sensory input and translate it into meaningful information.
True - Sensory perception involves translating sensory input into meaningful information, such as interpreting sounds, sights, and tactile sensations.
179
True or False: Elimination includes the removal of waste products through urination, defecation, and sweating.
True - Elimination involves removing waste from the body through various means, including urination, defecation, and sweating.
179
Which of the following is an essential function of perfusion?
A. Transport oxygen to cells
B. Provide immunity against infections
C. Regulate pH balance
D. Control electrolyte levels
A - Perfusion ensures that oxygen and nutrients are delivered to cells, which is essential for cellular function and overall health.
180
Which of the following factors can impair fluid and electrolyte balance?
A. Excessive water intake
B. Hypovolemia
C. Normal daily exercise
D. High-protein diet
B - Hypovolemia, or low blood volume, can severely impact fluid and electrolyte balance.
181
Which of the following conditions is most likely to affect gas exchange?
A. Chronic obstructive pulmonary disease (COPD)
B. Hypertension
C. Osteoarthritis
D. Hyperthyroidism
A - COPD impairs gas exchange by reducing the efficiency of the lungs' ability to take in oxygen and remove carbon dioxide.
182
What is the primary role of the immune system?
A. Regulate blood pressure
B. Protect the body from disease and infection
C. Promote digestion of food
D. Maintain body temperature
B - The immune system's primary role is to protect the body from disease-causing agents, such as bacteria and viruses.
183
True or False: Metabolism includes processes that convert food into energy necessary for the body's functioning
True - Metabolism includes both the breakdown of food for energy and the biochemical processes necessary for maintaining life.
184
Which of the following is a likely consequence of impaired elimination?
A. Fluid retention and electrolyte imbalance
B. Increased immunity
C. Increased metabolic rate
D. Enhanced comfort
A - Impaired elimination can result in fluid retention and imbalanced electrolytes, which can lead to further health complications.
185
Which of the following is most directly related to sensory perception?
A. Ability to move muscles
B. Processing visual, auditory, or tactile stimuli
C. Maintaining electrolyte balance
D. Increasing nutritional intake
B - Sensory perception is primarily concerned with the body’s ability to receive and process stimuli from the environment, such as vision, hearing, and touch.
185
True or False: Tissue integrity refers to the body’s ability to repair and regenerate tissues after injury.
True - Tissue integrity refers to the body’s ability to repair damaged tissues and maintain healthy physiological processes.
186
Which of the following factors affects thermoregulation?
A. Intake of high-fiber foods
B. Environmental temperature
C. Urinary output
D. Hormone production
B - Environmental temperature directly affects thermoregulation, requiring the body to adjust to maintain a stable core temperature.
187
Which of the following is an example of a disorder related to metabolism?
A. Hyperthyroidism
B. Arthritis
C. Pneumonia
D. Glaucoma
A - Hyperthyroidism is a metabolic disorder that results from an overactive thyroid gland, affecting the body’s energy production and metabolic rate.
188
Which of the following actions can promote tissue integrity? (Select all that apply)
A. Repositioning immobile patients frequently
B. Keeping skin clean and dry
C. Providing a high-carbohydrate diet
D. Encouraging fluid intake
A, B, D - Repositioning patients, keeping skin clean and dry, and ensuring proper hydration help maintain tissue integrity, especially in those at risk of skin breakdown.
188
What is the primary result of effective gas exchange in the lungs?
A. Increased elimination of waste products
B. Oxygenation of body tissues
C. Improved digestion
D. Enhanced immune response
B - The primary result of effective gas exchange is the oxygenation of tissues, which is vital for cellular metabolism and overall function.
189
True or False: Immunity provides a defense mechanism against pathogens and prevents infection.
True - Immunity helps defend the body against pathogens and reduces the likelihood of infections.
190
What happens when perfusion to tissues is impaired?
A. Oxygen and nutrients are not delivered adequately to cells
B. Electrolyte levels increase in the blood
C. Fluid and waste products build up in the bloodstream
D. Sensory perception is enhanced
A - Impaired perfusion leads to insufficient oxygen and nutrient delivery to tissues, which can result in tissue damage or organ dysfunction.
191
True or False: Sleep is a natural state of rest and altered consciousness essential for overall health.
True - Sleep is crucial for mental and physical health, offering the body a time for rest, repair, and regeneration.
192
Which of the following strategies is most effective in maintaining fluid and electrolyte balance?
A. Increasing dietary protein intake
B. Monitoring daily fluid intake and output
C. Avoiding foods high in carbohydrates
D. Taking diuretics regularly
B - Monitoring fluid intake and output helps ensure proper balance and prevents dehydration or fluid overload.
193
True or False: Metabolism includes both anabolic and catabolic reactions that are essential for energy production and cellular growth.
True - Metabolism includes both anabolic (building) and catabolic (breaking down) reactions that are vital for energy production and cell growth.
194
Which of the following patients is at greatest risk for impaired gas exchange?
A. A patient with osteoarthritis
B. A patient with chronic bronchitis
C. A patient recovering from a sprained ankle
D. A patient diagnosed with anemia
B - A patient with chronic bronchitis is at high risk for impaired gas exchange due to lung damage and inflammation.
195
What is the main purpose of perfusion in the body?
A. To regulate body temperature
B. To control electrolyte levels
C. To deliver oxygen and nutrients to tissues
D. To aid in digestion and metabolism
C - The primary purpose of perfusion is to deliver oxygen and nutrients to tissues, which is necessary for cellular function.
196
Which of the following interventions helps maintain mobility in an immobile patient?
A. Encouraging the patient to stay in bed as much as possible
B. Performing range-of-motion exercises
C. Limiting fluid intake
D. Administering analgesics regularly
B - Performing range-of-motion exercises helps maintain joint flexibility and muscle strength in immobile patients.
196
Which of the following conditions could affect thermoregulation? (Select all that apply)
A. Fever
B. Hypothermia
C. Dehydration
D. Hypertension
A, B, C - Conditions like fever, hypothermia, and dehydration can affect the body's ability to regulate temperature.
197
Which of the following are signs of fluid imbalance? (Select all that apply)
A. Edema
B. Increased urine output
C. Dry mucous membranes
D. Weight gain or loss
A, C, D - Edema, dry mucous membranes, and weight changes are all signs of fluid imbalance, which can indicate dehydration or fluid overload.
197
True or False: Adequate nutrition is essential for maintaining tissue integrity, immune function, and overall health.
True - Adequate nutrition supports tissue repair, immune function, and overall well-being.
198
What is a common cause of patient harm?
A. Lack of patient education
B. Medication errors
C. Poor communication
D. Surgical asepsis
B. Medication errors - Medication errors are one of the most common causes of patient harm.
199
Which of the following is an example of a diagnostic error?
A. Failing to order an EKG for chest pain
B. Administering the wrong medication
C. Not following up with a patient after discharge
D. Documenting incorrect patient data
A. Failing to order an EKG for chest pain - Failing to order necessary diagnostic tests is an example of a diagnostic error.
200
What is an example of a preventive error?
A. Not administering the correct medication
B. Failing to monitor a patient's condition post-surgery
C. Giving the wrong patient discharge instructions
D. Mislabeling laboratory samples
B. Failing to monitor a patient's condition post-surgery - Preventive errors involve failing to monitor or follow-up with a patient.
201
True or False: A sentinel event refers to a situation where a significant adverse outcome, like patient death, could have been avoided.
True - Sentinel events are serious adverse outcomes, such as patient death, that could have been avoided.
202
What is a latent error?
A. An error made by a physician during surgery
B. An error related to a malfunctioning system, like a broken medication scanner
C. An error in patient communication
D. A nurse failing to document a medication given
B. An error related to a malfunctioning system, like a broken medication scanner - Latent errors are system-related errors, like broken equipment leading to issues.
203
Which of the following describes a never event?
A. Giving the wrong patient medication
B. Performing surgery on the wrong body part
C. Administering an incorrect dosage of medication
D. Leaving the operating room without completing surgery
B. Performing surgery on the wrong body part - A never event is an egregious error that should never happen.
204
Select all that apply: What are reasons someone may not report a near miss?
A. Fear of backlash or repercussions
B. Lack of time to write the report
C. Feeling that the event wasn't serious enough
D. Lack of proper training
A, B - People may fail to report near misses due to fear of backlash or not having enough time to report.
205
What does "just culture" balance in healthcare?
A. Discipline and safety
B. Safety and learning
C. Learning and discipline
D. Policy and procedure
C. Learning and discipline - Just culture focuses on balancing discipline with opportunities for learning.
206
Which of the following are examples of breaking the chain of infection? (Select all that apply)
A. Hand hygiene
B. Vaccination
C. Sharing personal equipment
D. Isolation precautions
A, B, D - Hand hygiene, vaccinations, and isolation precautions are ways to break the chain of infection.
206
True or False: Medical asepsis refers to maintaining a sterile environment to prevent the introduction of microorganisms.
False - Medical asepsis refers to reducing the spread of pathogens, not creating a sterile environment.
207
In what order should personal protective equipment (PPE) be donned?
A. Gloves, mask, gown, face shield
B. Gown, mask, goggles, gloves
C. Mask, gown, gloves, face shield
D. Goggles, mask, gown, gloves
B. Gown, mask, goggles, gloves - This is the correct sequence for donning PPE.
208
True or False: When removing PPE, the gown and gloves should be removed at the same time.
True - Gown and gloves are often removed together as the first step in doffing PPE.
209
What is an example of a disease requiring droplet precautions?
A. Tuberculosis
B. Influenza
C. HIV/AIDS
D. Measles
B. Influenza - Influenza is transmitted via droplet transmission, requiring droplet precautions.
209
Which type of precaution requires an N95 mask?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions
C. Airborne precautions - N95 masks are required for airborne precautions.
210
How far should you maintain distance from a patient when wearing a surgical mask under droplet precautions?
A. One foot
B. Two feet
C. Three feet
D. Five feet
C. Three feet - Droplet precautions require a surgical mask if you're within three feet of the patient.
211
Which of the following diseases would require airborne precautions?
A. Whooping cough
B. Tuberculosis
C. Influenza
D. Meningitis
B. Tuberculosis - TB is transmitted via airborne transmission, requiring airborne precautions.
212
True or False: Protective or neutropenic precautions are used for patients with compromised immune systems.
True - Protective or neutropenic precautions are used for immunocompromised patients.
213
What is the minimum number of patient identifiers required to safely identify a patient?
A. One
B. Two
C. Three
D. Four
B. Two - At least two patient identifiers are needed for safe identification.
214
Which of the following are considered National Patient Safety Goals? (Select all that apply)
A. Improve communication by getting test results to the right person
B. Use only one identifier when identifying patients
C. Ensure alarms are heard and responded to on time
D. Reduce the risk of surgical mistakes
A, C, D - These options align with National Patient Safety Goals
215
What is the goal related to medication safety in the National Patient Safety Goals?
A. Use only generic medications
B. Record and pass along correct information about a patient’s medicines
C. Limit medications to once-daily dosing
D. Only administer medications with a physician present
B. Record and pass along correct information about a patient’s medicines - The goal is to ensure accurate communication of patient medications to avoid errors.
216
Which of the following would help prevent a sentinel event?
A. Cutting off the wrong limb during surgery
B. Implementing a time-out before a surgical procedure
C. Failing to follow-up with a post-op patient
D. Not using sterile techniques during surgery
B. Implementing a time-out before a surgical procedure - A time-out ensures the correct patient, procedure, and site, which can help prevent sentinel events.
217
Which of the following examples demonstrates proper alarm safety?
A. Turning off alarms that are too noisy
B. Ensuring alarms are heard and responded to promptly
C. Only responding to alarms during daytime hours
D. Leaving alarms to alert without manual oversight
B. Ensuring alarms are heard and responded to promptly - Alarm safety focuses on making sure alarms are addressed in a timely manner to prevent patient harm.
218
Which of the following patient safety risks are healthcare providers attempting to identify and reduce according to the National Patient Safety Goals?
A. Medication errors
B. Health care disparities
C. Patient suicide risk
D. Poor communication
C. Patient suicide risk - One of the National Patient Safety Goals is to identify and reduce the risk of patient suicide in healthcare settings.
219
True or False: The Time Out procedure is a strategy used to ensure the right patient, right procedure, and right body part are confirmed before surgery.
True - The Time Out procedure ensures that the right patient, procedure, and surgical site are confirmed before surgery begins, helping to prevent surgical errors.
220
Which type of precautions should be used for a patient with an active case of tuberculosis (TB)?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
C. Airborne precautions - Patients with tuberculosis (TB) require airborne precautions to prevent the spread of the disease through airborne particles.
221
What type of PPE is required for airborne precautions?
A. Surgical mask
B. N95 respirator
C. Face shield
D. Gown only
B. N95 respirator - An N95 respirator is required when caring for patients with airborne-transmitted diseases, such as tuberculosis.
222
How has the culture of safety changed over time in healthcare?
A. It has shifted from being proactive to reactive
B. It used to focus on blaming individuals; now it focuses on system improvement
C. The focus has shifted from learning to discipline
D. Safety goals have become more lenient
B. It used to focus on blaming individuals; now it focuses on system improvement - The culture of safety has shifted from blaming individuals for errors to examining and improving the system to prevent errors.
222
True or False: Droplet precautions require wearing a surgical mask within three feet of the patient.
True - Droplet precautions require wearing a surgical mask when within three feet of the patient to prevent the spread of respiratory droplets.
223
Which of the following are methods to improve health care equity? (Select all that apply)
A. Identifying health care disparities
B. Limiting healthcare access to minority populations
C. Implementing plans to address health care disparities
D. Reducing patient education efforts
A, C - Identifying healthcare disparities and implementing plans to address them are key strategies for improving healthcare equity.
224
What is the annual update process for the National Patient Safety Goals aimed at?
A. Ensuring patient safety goals are aligned with current healthcare trends
B. Making recommendations for new surgical techniques
C. Eliminating unnecessary safety regulations
D. Encouraging the use of outdated practices
A. Ensuring patient safety goals are aligned with current healthcare trends - The National Patient Safety Goals are updated annually to ensure they reflect the latest evidence and healthcare practices.
