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Nursing Principals 2
| Question | Answer |
|---|---|
| A patient comments, “I can't wait to get out of here.” Which response should the nurse make that demonstrates the therapeutic communication technique of reflection? | “You can't wait to get out of here.” |
| A nurse assessing a newborn determines that the anterior fontanel is bulging. What is the priority nursing diagnosis? | Fluid volume excess |
| A nurse is completing documentation on a chart outside the patient's room and hears a loud thud coming from the room. What is the priority nursing action? | Log out of computer and return to the room. |
| A parent asks the nurse how to approach the child's temper tantrums because they are becoming more frequent. What is the best nursing response? | Set consistent limits. |
| A nurse is assessing an older adult patient who was brought into the emergency department for an undetermined illness. The patient lives with an adult child and grandchildren. Which assessment finding will cause the nurse to consider the possibility of el | Patient has multiple bruises in various stages of healing. |
| A nurse is working on a nursing unit and moving a patient up in the bed. Which observation by the nurse manager warrants immediate intervention? | The patient's bed is in the lowest position. |
| A nurse provides care for a patient who is actively dying. The patient's spouse tells the nurse, “I am worried that my husband is not getting enough fluids.” Which response by the nurse is most appropriate? | It is natural to become dehydrated before death. It will actually make him more comfortable.” |
| A school-age child is admitted to the hospital for an outpatient surgical procedure. What is the best approach that the nurse can use related to preoperative teaching? | Use doll therapy. |
| A nurse is using infant mannequins to provide teaching sessions for a group of new parents. Which observation warrants immediate action by the nurse? | Parent turns back on infant mannequin while it is on changing table. |
| A nurse is caring for a patient who has been attending a local university to earn a law degree. The patient states, “I want to earn my degree so that I can fight for justice and human rights for people throughout the world.” The nurse recognizes that the | Postconventional morality |
| A patient reports living in an apartment located in an area of high crime and drive-by shootings. Which leading health indicator most likely will affect this patient's health? | Injury and violence Environmental quality |
| A patient has been admitted for palliative care with a clinical diagnosis of chronic obstructive pulmonary disease (COPD). What intervention should the nurse anticipate that the health-care provider (HCP) will order? | Breathing treatments |
| Which is the priority action for a nurse to take when providing care to a pediatric patient? | Safety |
| A nurse is preparing to administer a vaccination to a patient who has many allergies. After donning gloves and wiping the patient's arm with an alcohol swab, the nurse notices the patient has begun to develop hives, swelling, watery eyes, and a cough. Whi | Allergic response to latex |
| A nurse gathers data for a child who imitates the parents' behaviors about religion. Based on Fowler's stages of spiritual development, which stage would the nurse document in the child's medical record? | Intuitive-projective |
| A patient has been admitted to the medical unit and the nurse is awaiting orders from the health-care provider (HCP). Other than the admitting diagnosis of uncontrolled hypertension (HTN), there is no other information. What type of precaution should the | Standard |
| A nurse is admitting a 65-year-old patient with a diagnosis of transient ischemic attack. The patient is alert and responds appropriately to questions. Based on this information, what type of intervention should the nurse take to maintain patient safety? | Initiate fall assessment protocol. |
| A nurse is extinguishing a fire that has broken out in the workplace. Which is the first step the nurse should take? | Pull the pin found between the handles. |
| A patient being seen in the clinic reports having pain on the right side of the abdomen. In which phase of illness is this patient? | Seeking help |
| A patient from a non-English-speaking culture becomes visibly upset when the phlebotomist arrives to draw a blood sample, and he changes clothes to leave the hospital. What should the nurse do at this time? | Find an interpreter to help with communication. |
| A nurse instructs a postpartum patient who wishes to breastfeed to gently touch the newborn's cheek that is closest to the breast to cause the baby to turn toward the breast and open the mouth to find milk. Which reflex is the nurse describing the patient | Rooting reflex |
| A patient reports not having a gynecological examination or Pap smear for five years since the health-care provider (HCP) made a comment about the patient's body weight. Which barrier to health care did this patient experience? | Stereotyping |
| A nurse is assisting family members who have recently suffered the loss of a parent. Which statement best represents a compassionate approach by the nurse? | “I am here to listen to your stories.” |
| A nurse is reviewing the social health determinants of Healthy People 2030. Which findings would lead to decreased health disparity? | Presence of local grocery stores |
| A nurse provides care to a patient who is dying of colon cancer who states, “I know I can beat this cancer if I just change the things that I eat.” Based on Kübler-Ross's stages of grief, which stage would the nurse document in the medical record that the | Bargaining |
| A nurse is assessing a toddler during a pediatric well-child office visit. Which action should the nurse use to confirm object permanence? | Use a paper towel to cover the stethoscope and then remove. |
| A nurse is obtaining information from a patient admitted the hospital with influenza. Which question addresses the prodromal phase of illness? | When did you first realize that you were not feeling well? |
| An 89-year-old patient's family member at the clinic asks for an antibiotic to be prescribed to treat seasonal flu symptoms. What is the best nursing response? | “Antibiotics are not used to treat viral infections such as influenza.” |
| A patient with a terminal illness is angry with God. Which intervention should the nurse use to address this patient's spiritual distress? | Be present. |
| When responding to a patient's call light, the nurse says, “What can I do to help you?” Which therapeutic communication technique is the nurse using? | Offering self |
| A nurse admits to the medical unit a terminally ill patient who has an advance directive. Which priority action should the nurse implement? | Check the chart for the advance directive. |
| A nurse refuses to take care of patient in the hospital setting because the patient yelled at the nurse during a prior hospitalization. What is the best action for the charge nurse to take while there is short staffing? | Tell the nurse that discriminatory behavior is being exhibited against the patient and reassign the care of the patient to another nurse. |
| A nurse is taking a telephone order from a health-care provider (HCP). Which information is essential to the receipt of a telephone order? | Time order was received |
| A patient has developed a urinary tract infection after being catheterized during surgery. What would the nurse anticipate that the health-care provider will prescribe? | Antibiotic |
| A patient states that they have been seeing a reflexologist to treat ongoing stress. What type of health care belief is the patient exhibiting? | Folk healing |
| A group of nurses are discussing care of older patients in long-term care (LTC) facilities. One of the nurses states, “This happens to everyone as they age; they become mean.” How would the nurse manager characterize this conversation? | Nurse is exhibiting ageism. |
| A nurse provides care to a terminally ill patient. Assessment reveals periods of apnea followed by shallow breaths. What priority action should the nurse take? | Continue to monitor. |
| A nurse is using standard precautions while taking care of a patient. The patient is admitted for observation post motor vehicle accident. Which priority action should the nurse take? | Perform hand hygiene. |
| A nurse is talking to a child who is in 6th grade. Which finding indicates that additional observation is warranted? | Shows no reaction to parents' divorce |
| A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions. The nursing instructor would intervene if the student nurse is observed doing what? | Keeping the bed at the highest position at all times |
| A nurse is assessing an 82-year-old patient who has diabetes mellitus. Based on the individual's age, which assessment is considered essential? | Feet |
| A nurse is caring for a patient with a hearing deficit who wears bilateral hearing aids. Which action would best promote therapeutic communication? | Speak directly to the patient. |
| A nurse is caring for a patient admitted with a clinical diagnosis of congestive heart failure with deteriorating vital signs who has stopped breathing. The nurse has checked the patient's chart for a do-not-attempt-resuscitation (DNAR) order and does not | Initiate the code. |
| A nurse is offering support to a family member who is caring for a patient diagnosed with Alzheimer's disease. Which comment by the family member does the nurse recognize as a possible contributor for patient abuse? | “I feel like I am caring for a stranger; I don't relate to this person at all.” |
| A nurse notices that a patient has dizziness, blurred vision, weakness, numbness in the left arm, and difficulty swallowing that lasts for about 10 minutes. The nurse suspects an interruption of oxygen supply to the patient's brain. Which conclusion would | It fits the symptoms of a transient ischemic attack. |
| A nurse provides care to a terminal patient who states, “I don't need anything from you. Leave me alone!” Based on this information, the nurse documents that the patient is likely experiencing which stage of grief? | Anger |
| A charge nurse is aware that two staff members are having ongoing conflict on the medical unit. Which action would best help to resolve the conflict? | Listen to both nurses individually before making any judgments. |
| A nurse is reviewing body defense mechanisms against infection. Which finding represents a secondary defense? | Complement cascade |
| A nurse is admitting a patient with a history of heart disease. The patient has SOB, blood pressure 180/120, respiratory rate of 24, and a labored breathing pattern. How should the nurse classify the phase of illness? | Acute exacerbation of a chronic illness |
| A patient with arthritis complains of increased pain and stiffness in cold, damp weather. Which term should the nurse use to explain the patient's symptoms? | Exacerbation |
Created by:
Kfayia