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Nursing Principles 1
| Question | Answer |
|---|---|
| A student nurse is preparing to sit for National Council Licensure Examination for Practical Nursing. Which statement indicates that additional teaching is needed as it relates to NCLEX-PN? | |
| The test includes a clinical component. | |
| A student nurse is demonstrating how to obtain pulse assessments on a mannequin in a simulation laboratory. Which observation by the nursing instructor indicates additional instruction is needed? | Palpating carotids bilaterally |
| A nurse who is performing a physical assessment is preparing to auscultate breath sounds. Which position is most favorable for performing the assessment of breath sounds? | High Fowler's position |
| A nurse discovers a patient lying on the floor. Which should the nurse write when completing an incident report? | “Found patient lying face down on the floor beside the bed. |
| A nurse is reviewing requests from multiple patients for hospice care. Which factor would alert the nurse that hospice care is not indicated for a patient? | Patient is admitted for acute appendectomy after rupture of the appendix. |
| A nurse is assessing the patient's respiratory system. Which finding is consistent with normal respiratory function? | Equal thoracic excursion |
| A 48-year-old patient is complaining of occasional dizziness upon position change and has been admitted to the hospital for observation. Which action should the nurse take when attempting to ambulate the patient for the first time to the bathroom? | Take vital signs prior to ambulation. |
| A nurse is preparing to instruct a patient on changing an ostomy appliance. What should be addressed prior to beginning this teaching session to ensure optimal learning occurs? | Address lower-level needs. |
| A nursing medical unit has 20 beds and the following staffing: 1 RN, 2 LPNs, and 2 CNAs. Which type of nursing delivery system is best utilized to provide services? | Team nursing |
| A nurse reviews the purpose and functions of a skilled nursing facility (SNF) with a new nurse colleague. Which statement by the new nurse indicates that additional teaching about an SNF is required? | “My patient will never get to go home again if he's transferred to an SNF.” |
| A patient has been referred to cardiac rehabilitation post-cardiac event. Which essential service would be provided to the patient? | Dietary counseling |
| The test includes a clinical component. | |
| A patient has had an endoscopy as an outpatient in a hospital setting and requires additional observation after the procedure. Which type of order would the nurse expect the health-care provider to write? | Admit for observation. |
| A nurse is reviewing a family's health insurance, which is provided under the Affordable Care Act (ACA). Which statement is correct as it relates to ACA? | The son, age 25, is covered. |
| A nurse is reviewing Maslow's hierarchy of needs. Which option represents the highest level of human need? | Self-actualization |
| A charge nurse notes a patient's blood pressure at 8:00 a.m. was 124/80 mm Hg. It is now 12:00 p.m., and the patient's blood pressure is 152/94 mm Hg. Which suggestion about the plan of care should the charge nurse make to the graduate nurse? | Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours. |
| A nurse is performing the morning assessment for a patient who is receiving a tube feeding. Which finding warrants immediate intervention? | Patient is lying flat in bed. |
| Which certified nursing assistant (CNA) action while making a bed for a patient who is out receiving therapy requires an intervention by the nurse? | Puts soiled linens on the floor |
| A nurse is preparing to provide patient teaching related to care and management of casted extremity. Which information is essential for the nurse to include in the teaching plan? | Allow for patients to provide return demonstration. |
| While assessing a patient, the nurse notes that the pulse is easily detected, feels strong, and is easily counted but can be obliterated with moderate pressure. How should the nurse document this pulse? | 2+ |
| A patient is able to brush their teeth but unable to floss and can bathe herself but can't style her hair. How should the nurse best categorize the patient's care level as it relates to activities of daily living (ADLs)? | Requires partial assist with ADLs |
| A patient being treated for a deep vein thrombosis (DVT) with anticoagulant therapy wants a shave. What is the nurse's best action to the patient's request? | Secure an electric razor to use. |
| A nurse is unable to obtain a patient's dorsalis pedis pulse on the right foot but can detect a 2+ pulse on the left foot. What should the nurse do next? | Obtain a Doppler |
| A group of nurses assigned to a unit are discussing methods of nursing supervision. Which option represents best practice? | Providing positive direction |
| A pediatric patient in the family clinic has a low-grade fever of 100°F (37.78°C). The patient's family wants you to administer aspirin (ASA). What is the best nursing response? | Ask additional questions about the patient's condition. |
| A nurse is documenting a temperature for a patient and finds it is lower than previously recorded temperatures. How should the nurse interpret this finding? | Axillary route was used. |
| A nurse manager is reviewing documentation of nursing notes on the unit. Which finding warrants immediate intervention? | Unsigned entry is in a patient's chart. |
| A student nurse is being evaluated by a nursing instructor. Which situation warrants immediate action? | The student nurse is using a personal cell phone while in the clinical environment. |
| A nurse is preparing to document findings of edema for a patient who has bilateral swelling of both feet up to the level of the ankle. There is prolonged indentation after the nurse touches the area, which lasts several minutes. How should the nurse docum | 3+ pitting edema of the feet to ankle bilaterally |
| A nursing student is working on a care plan for a patient while in the clinical setting. Which action if observed by the nursing instructor warrants immediate action? | Writing notes that contain patient identification number |
| A nurse is providing a.m. care to a patient who is 3 days postoperative for a knee replacement. This is the first time that the patient wants to participate in the bathing process after the surgery. Which bathing option should the nurse provide to the pa | Provide water basin and a face cloth so that patient can wash face |
| A nurse is admitting a patient to the medical unit who states that they have pain as their primary problem. Which question should the nurse ask next? | “On a scale of 1 to 10, how would you rate your pain?” |
| A patient is concerned that the health insurance plan will not cover a diagnostic test. Which information should the nurse explain about medical necessity? | “If the test is found reasonable and necessary for your illness, it will be covered.” |
| A nurse assesses a patient's vital signs and finds the patient is febrile. Which intervention represents a dependent intervention? | Administer Tylenol. |
| A nurse is assessing a patient's respiratory status and notes periods of apnea alternating with several deep breaths. What priority action should the nurse take? | Call a rapid response. |
| A nurse is assigned to care for a group of patients on the medical-surgical unit. Which patient has priority to receive oral care? | 48-year-old receiving oxygen therapy admitted with chronic obstructive pulmonary disease (COPD) |
| A nurse provides care to a patient who reports sweating on his forehead, upper lip, and palms during ambulation. When responding to the patient about this occurrence, the nurse recognizes which gland as being responsible for this phenomenon? | Exocrine |
| A nurse manager is reviewing submitted incident reports. Which of the following does not qualify as an incident report? | Patient complaining about dietary services |
| While providing medications, a nurse realizes that an incorrect dose was given to a patient. Which characteristic does the nurse demonstrate when reporting the error to the manager? | Being honest |
| A nurse notes that a patient's blood pressure has dropped. The patient has nausea, dizziness, and abdominal pain. Which characteristic does the nurse demonstrate when the health-care provider (HCP) is notified of the patient's condition? | Being responsible |
| A nurse is discussing (EBP) can how evidence-based practicehelp improve delivery of care to patients. Which statement best describes EBP? | EBP establishes a methodological approach to improve outcomes. |
| A nurse manager is making rounds on the medical unit and comes across two nurses holding onto a patient who has fainted in the patient's room. Which priority action should the nurse manager take? | Have the nurses lower the patient to the floor. |
| A nurse is monitoring a patient who has decreased urinary output despite being on continuous intravenous therapy and drinking fluids. Which assessment should the nurse identify as being a potential cause of this finding? | Abdomen slightly distended |
| A nurse is assisting a patient out of bed to a chair for the first time postoperatively. The patient becomes pale and dizzy during the transfer. What is the best explanation for this presentation? | Orthostatic hypotension |
| A nurse delegates the task of assisting patients with ambulation to a nursing assistant. The nurse intervenes when observing the nursing assistant implementing which action? | Holding the transfer belt loosely near the patient's body while ambulating |
| A student nurse is looking to incorporate cultural diversity in the plan of care for a group of patients. Which nursing theorist should the student nurse research? | Madeleine Leininger |
| A nurse reviews a new medication prescribed for a patient and contacts the pharmacy to ask questions about the prescribed dose and route. Which behavior does the nurse demonstrate in this situation? | Safety |
| A patient accidentally receives an entire liter of IV fluid over 3 hours. Which should the nurse expect when assessing this patient's pulse? | Full and bounding |
| A nurse is preparing to move a patient up in bed to improve comfort. Which step should be included in preparation for this action? | Use a draw sheet |
| A nurse is preparing to obtain vital signs for a morbidly obese patient. Which option is needed to perform an accurate assessment? | Larger BP cuff |
| A nurse is preparing to transfer a patient to a skilled nursing facility (SNF). For which reason will this patient's Medicare policy pay for the care at the SNF? | The patient makes regular progress as documented by medical professionals. |
Created by:
Kfayia