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142 Cards in this Set

  • Front
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During which of the 5 steps in the Nursing Process does the nurse determine whether outcomes of care are achieved?
Evaluation.
When considering the Nursing process, the word "observe is to "assess" as the word "explore" is to:

1. Plan
2. Analyze
3. Evaluate
4. Implement
2. Analyze

The defns of the words observe and assess are similar. Observe means to view something scientifically, and assess means to collect information. The word analyze fits the analogy. Explore means to examine. Analysis means to investigate.
The concept that is cornerstone of the Nursing Process is that it:

1. Is dynamic rather than static
2. Focuses on the role of the nurse
3. Moves from the simple to the complex
4. Is based on the patient's medical problem
1.
The Nursing Process IS a dynamic 5-step problem-solving process (A, D, P,I, E) designed to diagnose and treat human responses to health problems.
A nurse is caring for a pt with a urinary elimination problem. Which is the most accurately stated goal? "The pt will:

1. Be taught how to use a bedpan when on bed rest."
2. Experience fewer incontinence episodes at night"
3. Transfer independently and safely to a toilet before discharge"
4. Be assisted to the commode every two hours and whenever necessary
3. This is a correctly worded goal. Goals must be patient-centered, measurable, realistic, and include the timeframe in which the expected goal is to be achieved. The word independently indicates that no help is needed, and the word safely indicates that no injury will occur. The time frames is before discharge.
Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the pt holistically?

1. Teacher
2. Advocate
3. Surrogate
4. Counselor
2. When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating, and affirming in all areas to help a patient navigate the health-care system, maintain autonomy, and achieve the best possible health outcomes.
What word is most closely associated with scientific principles?

1. Data
2. Problem
3. Rationale
4. Evaluation
3. The word rationale (justification based on reasoning) is closely associated with the term scientific principles (established rules of action). Scientific principles are based on rationales.
A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is most directly related to this concept?

1. Defining characteristics
2. Outcome criteria
3. Etiology
4. Goal
3. The etiology (aka as "related to" or "contributing factors") are the conditions, situations, or circumstances that cause the development of the human response identified in the problem statement of the nursing diagnosis. The etiology precipitates the human response just as a pebble dropped in a pond causes ripples on the surface of water.
A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the Nursing process is associated with this nursing intervention?

1. Planning
2. Analysis
3. Evaluation
4. Implementation
4. This is an example of the Implementation step of the Nursing process. It is during the Implementation step that planned nursing care is delivered.
A pt is admitted to the hospital with a tentative medical Dx and multiple diagnostic tests are performed. Where in the pt's chart can the nurse find documentation about the current medical diagnosis after the diagnostic tests results are reviewed by the practitioner?

1. Progress Notes
2. Admission Sheet
3. History and Physical
4. Social Service Record
1. Generally the Progress Notes contain documentation by all members of the health-care team. After a pt is admitted and diagnostic tests are completed, the pt's medical diagnosis may change. The ongoing changes and current status of the pt are documented in the Progress Notes.
A nurse is caring for a pt with a fever. Which is a well-designed goal for this pt? "The pt will:

1. have a lower temperature."
2. be taught how to take an accurate temp.
3. maintain fluid intake sufficient to prevent dehydration.
4. be given aspirin every eight hours whenever necessary.
3. Well-written goal. Goals must be pt-centered, specific, measurable, and realistic and have a time frame in which the expected outcome is achieved. The words sufficient and dehydration are based on generally accepted criteria against which to measure the pt's actual outcome. The word maintain connotes continuously, which is a time frame.
What should the nurse do during the Evaluation step of the Nursing Process?

1. Establish outcomes
2. Determine priorities
3. Revise a plan of care
4. Set the time frames for goals
3. Revising a plan of care takes place in the Eval step of the NP. If during eval it is determined that the goal was not met, the reasons for failure have to be identified and the plan modified.
A nurse determines that the appropriateness of a Nursing Dx is supported by its:
1. Defining characterisists
2. Planned interventions
3. Diagnostic statement
4. Related risk factors
1. The defining characteristics are the major and minor cues that form a cluster that support or validate the presence of Nursing Dx. At least one major defining characteristic must be present for a Nursing Dx to be considered appropriate for the pt.
Determining what nursing actions will be employed occurs in which step of the NP?
1. Implementation
2. Assessment
3. Planning
4. Analysis
3. The identification of nursing actions designed to help a pt achieve a goal occurs during the Planning step of the Nursing Process.
What is the primary goal of the Assessment phase of the NP?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical Dx
3. ...Collect data from various sources using a variety of approaches.
Which human response identified by the nurse is an example of objective data?
1. Irregular radial pulse of 50 beats per min.
2. Pain rated as a 5 on a 0-to-10 pain scale
3. Shortness of breath
4. Dizziness
1. Radial pulse is OD.
What most directly influences the Planning step of the NP?

1. Related factors
2. Diagnostic label
3. Secondary factors
4. Medical Dx
1. Related factors (aka etiology) contribute to the problem statement of the Nursing Dx and directly impact on the Planning step of the NP. Nursing interventions are selected to minimize or relieve the effects of the related factors. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the Nursing Diagnosis will resolve.
A nurse collects data about a pt. What should the nurse do next?

1. Plan nursing interventions
2. Write pt-centered goals
3. Formulate nursing dx
4. Determine significance of the information
4. After data are collected, they are clustered to determine their significance.
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the pt?

1. Reassess the pt
2. Examine the "related to" factors
3. Analyze the "secondary to" factors
4. Review the defining characteristics
4. ...to differentiate....compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
What is the primary reason why a nurse performs an admission assessment of a newly admitted patient?
1. Diagnose if the pt is at risk for falls
2. Ensure that the pt's skin is intact
3. Establish a therapeutic relationship
4. Identify important data
4. Primary reason. Data must be collected and then analyzed to determine significance and grouped in meaningful clusters before a Nursing Diagnosis or plan of care can be made.
What pt statement provides subjective data?
1. I'm not sure that I am going to be able to manage at home by myself.
2. I can call a home-care agency if I feel I need help at home.
3. What should I do if I have uncontrollable pain at home?
4. Will a home health aide help me with my care at home?
1. Subjective...Pt's perception, verifiable only by pt.

The other responses were neither subj or obj.
A nurse evaluates a pt's response to a nursing intervention. To which aspect of the nursing process is this eval most directly related?
1. Goal
2. Problem
3. Etiology
4. Implementation
1. To eval the effectiveness of a nursing action the nurse needs to compare the actual pt outcome with the expected pt outcome. The exp outcomes are measurable datea that reflect goal achievement, and the actual outcomes are what really happened.
A nurse concludes that a pt's elevated temp, pulse, respirations, are significant. What step of the NP is being used when the nurse comes to this conclusion?
1. Analysis
2. Eval
3. Assessment
4. Implementation
1. Analysis - data is critically analyzed and interpreted; inference are made and validated; cues and clusters of cues are compared with defining characteristics of nursing diagnoses; contributing factors are identified; and nursing Dx are identified and organized in order of priority.
When the nurse considers the NP, the word "identify" is to "recognize" as the word "do" is to:

1. Plan
2. Analyze
3. Evaluate
4. Implement
4. In the analogy identify = recognize; same with do and implement; both mean to carry out some action.
A nurse collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information?
1. Observing
2. Inspecting
3. Auscultation
4. Interviewing
4. Interviewing a pt is the most effective data collection method when collecting subjective data associated with a pt's anxiety. The pt is the primary source for subjective data about beliefs, values, feelings, perceptions, fears, and concerns.
Which nursing action reflects an activity associated with the Analysis step of the Nursing process?
1. Formulating a plan of care
2. Identifying the pt's potential risks
3. Designing ways to minimize a pt's stressors
4. Making decisions about the effectiveness of pt care
2. Potential risk factors are identified during the Analysis step of the Nursing process. Risk diagnoses are designed to address situations in which patients have a particular vulnerability to health problems.
A nurse is interviewing a patient. Which patient statement is an example of objective data?

1. I am hungry.
2. I feel very warm.
3. I ate half my lunch.
4. I have the urge to urinate.
3. The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed.
A nurse responds to a patient's call bell. Which patient statement is subjective data?

1. I just went in the urinal and it needs to be emptied.
2. My pain feels like a 5 on a scale of 0 - 5.
3. The physician said I can go home today.
4. I ate only 50% my breakfast.
2. A patient's perception about a pain level is subjective information. Subjective data are those responses, feelings, beliefs, preferences, and information that only the patient can confirm.
A nurse assesses that a pt has slurred speech and stasis of food in the mouth. What additional pt assessment should be clustered with this group of signs and symptoms?
1. Plaque
2. Halitosis
3. Drooling
4. Dyspepsia
3. Drooling. The body continuously secretes saliva (approx. 1000 mL/day) that usually is swallowed it dribbles out of the mouth (drooling). Drooling in addition to the pt's other clinical manifestations indicates that the pt may have impaired swallowing.
The nurse assesses a pt and collects a variety of data. Identify the human responses that are subjective data. Select all that apply.

1. Nausea
2. Jaundice
3. Dizziness
4. Diaphoresis
5. Hypotension
1. Nausea is an unpleasant, wave-like sensation in the back of the throat, epigastrium, or abdomen that may lead to vomiting. It is considered subjective data because it cannot be measured by the nurse objectively. It is experienced only by the patient.
3. This is subjective information because it is the patient's perception and can be verified only by the pt. Subjective data are those responses, feelings, beliefs, preferences, and information that only the pt can confirm.
Nurses use the NP to provide nursing care. These statements reflect nursing care being provided to a variety of patients. Place the statements in order as the nurse progresses through the steps of the NP starting with Assessment and ending with Evaluation.
1. I am going to give you an enema.
2. What brought you to the hospital today?
3. The pt's clinical manifestations indicate dehydration.
4. The pt will have a bowel movement in the morning.
5. Did you sleep last night after I gave you the sleeping medication?
#2. Obj and Subj data must be collected, verified, and communicated during the Assessment step of the NP.
#3. Data are clustered and analyzed, and their significance is determined, leading to a conclusion about the pt's condition, during the Analysis step of the Nursing Process.
#4. Identifying goals, projecting outcomes, setting priorities, and identifying interventions are all part of the Planning step of the Nursing Process.
#1. Planned actions are initiated and completed during the Implementation step of the NP.
#5. Identifying responses to care, comparing actual outcomes to expected outcomes, analyzing factors that affected outcomes, and modifying the plan of care if necessary are all part of the Evaluation step of the NP.
The instructions with a medication states to use the Z-track method. What should the nurse do that is specific to this procedure?

1. Pinch the state thu out the procedure
2. Massage the site after the needle is removed
3. Remove the needle immediately after the medication is injected
4. Change the needle after the medication is drawn into the syringe.
4. The Z-track method is used with viscid or caustic solutions. Changing the needle ensures that medication is not on the outside of the needle, which prevents tracking of the medication into subcutaneous tissue during needle insertion.
A nurse instructs a pt to close the eyes after the administration of eye drops. What rationale for this instruction should the nurse explain to the pt?

1. Limits corneal irritation
2. Squeezes excess medication from the eyes.
3. Disperses the medication over the eyeballs
4. Prevents medication from entering the lacrimal duct
3. Closing the eyes moves the medication over the conjunctiva and eyeball and helps ensure an even distribution of medication.
Which route is unrelated to the parenteral administration of medications?

1. Buccal
2. Z-track
3. Intravenous
4. Intradermal
1. A parenteral route is one that is outside the gastrointestinal tract. A medication administered by the buccal route dissolves between the cheeks and gums, where it acts on the oral mucous membranes or is swallowed with saliva. Most troches are used for local effect.
How often should "docusate sodium (Colace) 100 mg b.i.d." be given?

1. Three times a day
2. Two times a day
3. Every other day
4. At bedtime
2. The abbreviation b.i.d. represents twice a day.
Which intervention is uniquely related to the administration of an intradermal injection?

1. Using the air-bubble technique
2. Pinching the skin during needle insertion
3. Inserting the needle with the bevel upward
4. Massaging the area after the fluid is instilled
3. When medication is injected with the bevel up, a small wheal will form under the skin. This technique is used only with intradermal injections.
A nurse is preparing to reconstitute a medication in a multiple-dose vial. What is the most essential step in the preparation of this medication?

1. Instilling an accurate amt of diluent into the vial.
2. Using a filtered needle when drawing up the medication from the vial
3. Instilling air into the vial before withdrawing the reconstituted solution
4. Wiping the rubber seal of the vial with alcohol before and after each needle insertion.
1. The required amount of diluent must be followed exactly in a multiple-dose formulation to ensure accurate dosage preparation. The diluent for a single dose formulation also must be exact so that the medication is diluted enough not to injure body tissues.
Which characteristic is associated with a subcutaneous injection of 5000 units of heparin?

1. 3-mL syringe
2. 22-gauge needle
3. 1.5 inch needle Length
4. 90-degree angle of insertion
4. A 0.5-inch needle inserted at a 90-degree angle will ensure that the heparin is inserted into subcutaneous tissue.
A home care nurse observes the spouse of a pt inserting a rectal suppository. What behavior indicates that the nurse must provide teaching about suppository administration?
1. Lubricates the tip of the suppository
2. Inserts the suppository while wearing a glove.
3. Inserts the suppository while the pt bears down
4. Places the suppository a finger length into the rectum
4. In an adult, a suppository should be inserted 4 inches to ensure it is beyond the internal sphincter.
A practitioner prescribes a medication that must be administered via the intramuscular route. Which site should be the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection?
1. Vastus lateralis
2. Rectus femoris
3. Ventrogluteal
4. Dorsogluteal
4. The dorsogluteal site has the highest risk for injury because of the close proximity of the sciatica nerve, blood vessels, and bone.
It is most important for the nurse to use a filtered needle when preparing a parenteral medication that:

1. Has to be reconstituted
2. Is supplied in an ampule
3. Appears cloudy in the vial
4. Is to be mixed with another medication
2. The top of an ampule must be snapped off at its neck to access the fluid. A filtered needle prevents glass particles from being drawn into the syringe.
What should the nurse use when administering a subcutaneous injection?
1. 5-mL syringe
2. 25-gauge needle
3. Tuberculin syringe
4. 1.5 inch long needle
2. A subcutaneous injection should use a 25- to 29-gauge needle, which minimizes tissue trauma. The diameter of a needle is referred to as its gauge, which ranges from 28 (small) to 14 (large).
A practitioner prescribes nose drops to be administered twice a day. What should the nurse do when instilling nose drops?

1. Place the pt in the supine position with the head tilted backward.
2. Pinch the nares of the nose together briefly after the drops are instilled
3. Instruct the pt to blow the nose 5 minutes after the drops are instilled
4. Insert the drop applicator 1/8 inch into the nose toward the base of the nasal cavity.
1. This ensures that gravity will promote the flow of medication to the posterior pharynx.
When the nurse brings the pills to a paitent, the pt is unable to hold the paper cup with the medications. What should the nurse do?
1. Crush the pills and mix it with applesauce
2. Have the practitioner prescribe the liquid form of the drug
3. Use the paper cup to introduce the pills into the pt's mouth
4. Put the pills into the pt's hand and have the pt self-administer the pills.
3. The pt needs assistance. Keeping medication in the cup, rather than touching it with the hands, maintains medical asepsis.
A nurse teaches a pt how to self-administer a corticosteroid via metered-dose inhaler with an extender. Which behavior indicates to the nurse that the pt understands the teaching?
1. Rinses the mouth with water after the treatment
2. Rolls the canister between the hands slowly before using the inhaler
3. Positions the mouthpiece directly in front of the mouth while inhaling
4. Assumes the semi-Fowler position with the head supported on a pillow.
1. Rinsing the mouth removes any remaining medication. This prevents irritation to the oral mucosa and tongue and prevents oral fungal infections.
What route is inappropriate for a topical medication?
1. Intradermal
2. Bladder
3. Rectum
4. Vagina
1. An intradermal injection is inserted below, not on top of, the epidermis.
A nurse adds a medication to an intravenous fluid bag. Which nursing action is the priority?
1. Attaching a completed IV additive label to the bag
2. Mixing the medication and solution by rotating the bag
3. Maintaining sterile technique throughout the procedure
4. Ensuring that the drug and the IV solution are compatible
4. An incompatibility can increase, decrease, or neutralize the effect of the medication. Also, it may cause a compound or precipitate that can harm the pt. This must be done before proceeding with subsequent steps of the procedure.
A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. What is the rationale for this action?
1. Conceal the label from the curiosity of others.
2. Prevent the soiling of the label by spilled liquid
3. Ensure the accuracy of the measurement of the dose
4. Guarantee the label is read before pouring the liquid
2. Liquid medication may drip down the side of the bottle and soil the label, which may interfere with the ability to read the label accurately.
A practitioner prescribes a medicated powder to be applied to a patient's skin. What is most essential for the nurse to do when applying the medicated powder?
1. Apply a thin layer in the direction of hair growth.
2. Protect the pt's face with a towel
3. Dress the area with dry sterile gauze
4. Ensure that the skin surface is dry
4. Moisture harbors microorganisms and when mixed with a powder will result in a paste-like substance. The site should be clean and dry before medication administration to ensure effective action of the drug.
A nurse must administer a medication that is supplied in an ampule. What should the nurse do first to access the ampule?
1. Inject the same amt of air as the fluid to be removed
2. Wipe the constricted neck with an alcohol swab
3. Break the constricted neck using a barrier
4. Insert the needle into the rubber seal
3. A barrier, such as a commercially manufactured ampule opener, gauze, or an alcohol swab, should be used to protect the hands from broken glass.
A nurse must administer a medication into the ear of an adult. What should the nurse do to limit patient discomfort when administering ear drops?
1. Warm the solution to body temperature
2. Place the patient in a comfortable position
3. Pull the pinna of the ear upward and backward
4. Instill the fluid in the center of the auditory canal
1. Instilling cold medication into the ear canal is uncomfortable and can cause vertigo and nausea. Holding the bottle of medication in the hand for several minutes warms the solution to body temperature.
A nurse instructs a patient to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The patient asks, "Why do I have to hold my breath?" The nurse responds, "This technique will:
1. Prolong treatment.
2. Limit hyperventilation
3. Disperse the medication
4. Prevent bronchial spasms.
3. A pause at the height of inspiration will promote distribution and absorption of the medication before exhalation begins.
Which abbreviation indicates that the practitioner wants a medication administered before meals?
1. pc
2. qh
3. po
4. ac
4. The abbreviation for before meals is a.c. (ante cibum).
Where is medication absorbed when the nurse administers a suppository?
1. Ear
2. Nose
3. Mouth
4. Rectum
4. Rectum. Suppositories - semisolid, cone-shaped, or oval-shaped masses that melt at the body temperature -- are inserted into the rectum.
A home care nurse is helping a patient with short-term memory loss how to remember multiple drugs thru out the day. What should the nurse do when teaching this patient?
1. Suggest that the pt wear a watch with an alarm
2. Ask a family member to call the pt when meds are to be taken
3. Design a chart of the meds the pt takes each day during the week
4. Instruct the pt to put medications in a weekly organizational pill container
4. Pill distribution can be set up once a week. After the medication is taken, the empty section reminds the pt that the medication was taken, which prevents excessive doses. This is a major tissue for pts with short-term memory loss.
A nurse is to administer an eye irrigation to a pt's right eye. What should the nurse do?
1. Direct the flow of solution from the inner to outer canthus
2. Irrigate with an asepo syringe several inches from the eye
3. Don sterile gloves before beginning the procedure
4. Position the pt in a right lateral position
1. This prevents secretions and fluid from entering and irrigating the lacrimal ducts.
A medication is delivered by the Z-track method when the nurse:
1. Uses a special syringe designed for Z-track injections.
2. Pulls laterally and downward on the skin before inserting the needle
3. Administers the injection in the muscle on the anterolateral aspect of the thigh
4. Injects the needle in a separate spot for each dose on a Z-shaped grid on the abdomen.
2. This creates a zigzag track through the various tissue layers that prevents backflow of medication up the needle track when simultaneously removing the needle and releasing the traction on the skin.
A nurse must reconstitute a powdered medication. What should the nurse do?
1. Keep the needle below the initial fluid level as the rest of the fluid is injected.
2. Instill the solvent that is consistent with the manufacturer's directions
3. Score the neck of the ampule before breaking it
4. Shake the vial to dissolve the powder.
2. The medication should be opened and administered immediately to the patient, limiting the potential for contamination. Reading the label immediately before the opening the package is an additional safety check. Immediate administration prevents accidental disarrangement of medications that may result in a medication error.
A nurse is preparing to administer a tablet to a pt. When should the nurse remove the medication from its unit dose package?
1. Outside the door to pt's room.
2. At the pt's bedside
3. In the medication room
4. At the medication cart
2. The med should be opened and admin immediately to the pt, limiting the potential for contamination. Reading the label immediately before opening the package is an additional safety check. Immediate administration prevents accidental disarrangement of medications that may result in a medication error.
Which nursing action is most appropriate when administering an analgesic?
1. Reassess drug effectiveness every 8 hours
2. Follow the prescription exactly for the first 24 hours
3. Ask the practitioner to include a medication prescription for breakthrough pain
4. Seek a new prescription after two doses that do not achieve a tolerable level of relief.
4. Two doses is enough time to evaluate the effectiveness of a medication for pain. Patients should not have to endure intolerable levels of pain.
The practitioner prescribes a troche. The nurse should administer it by placing it in the patient's:
1. Ear
2. Eye
3. Mouth
4. Rectum
3. A troche, a lozenge-like tablet, is dissolved slowly in the mouth in the buccal cavity to provide a localized effect.
A pt has a prescription for 2 puffs of a bronchodilator via a metered-dose inhaler. What should the nurse teach the pt to do when self-administering the medication?
1. Start breathing in while compressing the canister
2. Hold the inspired breath for several seconds
3. Deliver 2 puffs with each inspiration
4. Inhale slowly for 8-10 seconds
1. This ensures that a maximum amount of the drug is inhaled while the medication is still aerosolized.
A nurse teaches a patient about taking a sublingual nitroglycerin tablet. The nurse evaluates that the pt understands the teaching when the pt states, "I should place it:
1. On my skin."
2. Inside my cheek."
3. Under my tongue."
4. In my eye on the lower lid."
3. A sublingual medication is placed under the tongue. It is absorbed quickly through the mucous membranes into the systemic circulation.
A nurse plans to administer a bolus dose of a medication via currently running intravenous infusion. What should the nurse do first?
1. Use a volume-control infusion set with microdrip tubing
2. Ensure that it is compatible with the IV solution being infused
3. Pinch the tubing above the infusion port while instilling the bolus
4. Instill it into a 50-mL bag of normal saline and infuse it via a secondary line
2. An incompatible solution can increase, decrease, or neutralize the effects of the medication. In addition, an incompatibility may result in a compound or cause a precipitate may result in a compound or cause a precipitate that is harmful to the patient.
A practitioner prescribes a rectal suppository for an adult pt. What should the nurse do when administering the rectal suppository?
1. Lubricate the medication before insertion.
2. Warm the medication to body temperature
3. Insert the medication just inside the rectum's external sphincter
4. Place the pt in the prone position to administer the medication
1. Lubrication eases insertion by reducing friction, which limits tissue trauma and discomfort.
A nurse is administering an intradermal injection. At what angle should the nurse insert the needle?
1. 90-degree angle
2. 45-degree angle
3. 30-degree angle
4. 15-degree angle
4. An intradermal injection is administered by inserting a needle at a 10-to-15-degree angle through the skin with the bevel of the needle facing upward toward the skin. The small volume of medication instilled just below the epidermis causes the formation of a wheal (localized area of swelling that appears like a small bubble.)
A nurse plans to administer a 3-mL intramuscular injection. Which muscle is the least desirable to use for the administration of this medication?
1. Deltoid
2. Dorsogluteal
3. Ventrogluteal
4. Vastus lateralis
1. The deltoid, on the lateral aspect of the upper arm, is a small muscle that is incapable of absorbing large medication volume. This site is more appropriate for 1 mL solution.
A nurse is preparing to administer a subcutaneous injection of insulin. What site should the nurse use to best promote its absorption?
1. Upper lateral arms
2. Anterior thighs
3. Upper chest
4. Abdomen
4. The abdomen is the preferred site for administration of insulin because it is a large area that promotes a systematic rotation of injections and it has the fastest rate of absorption.
What should a nurse use when placing a cream into a patient's vaginal canal?
1. A finger
2. A gauze pad
3. An applicator
4. An irrigation kit
3. The consistency of a cream requires an applicator be used to ensure that the medication is depositied along the full length of the vaginal canal.
A pract. prescribes a med that must be administered transdermally. The nurse determines that a drug administered transdermally is:
1. Inhaled into the respiratory tract
2. Dissolved under the tongue
3. Absorbed through the skin
4. Inserted into the rectum
3. A medication patch or disk can be applied directly to the skin where the med is released and absorbed over time. This method ensures a continuous therapeutic drug level and reduces fluctuations in circulating drug levels.
What should the nurse do to limit discomfort when administering an injection.
1. Pull back on the plunger before injecting the med
2. Apply the ice to the area before the inj
3. Pinch the area while inserting the needle
4. Inject the med slowly
4. Injecting slowly allows the fluid to be dispersed gradually, which limits tissue trauma and discomfort.
A nurse is preparing to draw up medication from a vial. What should the nurse do first?
1. Ensure that the needle is firmly attached to the syringe
2. Rub vigorously back and forth over the rubber cap with an alcohol swab
3. Inject air into the vial with the needly bevel below the surface of the medication
4. Draw up slightly more air than the volume of medication to be withdrawn from the vial
1. This will ensure a tight seal and a closed system. If not firmly connected, the hub of the needly may disengage from the barrel of the syringe during preparation or administration of the medication when internal and external pressures are exerted on the needle and syringe.
A nurse is interviewing a newly admitted client in the process of completing a nursing admission history and physical. What information should be included in a medication reconciliation. Select all that apply.

1. ____ Vitamins
2. ____ Drug allergies
3. ____ Food supplements
4. ___ Over the counter herbs
5.____ Prescribe medications
See explanations on p. 214 for all
1. Vitamins
2. Food supplements
3. Overthecounter herbs
4. Prescribed medications
What equipment and technique should the nurse use to administer most intramuscular injections? Select all that apply.

1. Use a 1inch needle
2. Use a 25-gauge needle
3. Insert the needle at a 45-degree angle
4. Aspirate before instilling the med
5. Massage the insertion site after needle removal
4. Aspiration is done before instilling the medication to ensure that a blood return does not occur, which indicates that the needle is in a blood vessel.
5. Massage promotes dispersion of the medication.
3.01.A nurse is evaluating a pt's learning regarding nutrition. Which behavior reflects the highest level of learning in the cognitive domain?
1. Modifies favorite recipes by eliminating foods that have to be avoided.
2. Evaluates the benefits associated with avoidance of certain foods.
3. States why a mother's diet may affect breast-feeding.
4. Identifies a list of foods to be avoided.
2. This is an appropriate example of learning on the evaluation level and is the highest level of learning of the 6 levels of learning in the cognitive domain.
3.02. What is the primary reason why nurses attending continuing education programs?
1. Update prof knowledge
2. Network within nursing profession
3. Fulfill requirements for an advanced degree
4. Graduate from an accredited nursing program
1. CE programs are formal learning experiences designed to update and enhance professional knowledge or skills. This is necessary because of the explosion in information and technology within health care. Some states require evidence of continuing education (CEUs) for license renewal.
3.03. A nurse is designing a teaching-learning program for a pt who is to be discharged from the hospital.. What should the nurse do first?
1. Identify the pt's locus of control
2. Formulate an achievable, mea
4. Learners bring their own lifetimes of learning to the learning situation. The nurse needs to customize each teaching plan, capitalize on the pt's previous experience and knowledge, and identify what the pt still needs to know before teaching can begin.
3.04. A nurse is to provide nutritional counseling for an older adult. What should the nurse do first
1. Plan educational sessions in the late afternoon
2. Speak louder when talking
3. Provide large-print books
4. Assess for readiness
4. If the pt does not recognize the need to learn or value the information to be learned, the pt will not be ready.
3.05. A nurse is teaching an older adult how to perform a dressing change. Which nursing action is most important to address a developmental stress of aging?
1. Speak louder when talking to the pt
2. Use terminology understandable to the pt
3. Have the pt provide a return demonstration
4. Allow more time for the pt to process information
4. Reaction time will slow with aging; therefore, older adults need more time to process and respond to information or perform a skill. In addition, some older adults may have less energy, experience more fatigue, and may need shorter, frequent learning sessions.
3.06. A nursing instructor is evaluating a student nurse's knowledge. Which student behavior indicates that learning has occurred in the highest level of learning in the cognitive domain?
1. Identifies the expected properties of urine
2. Explains the importance of producing urine
3. Recognizes when something is contaminated
4. Interprets laboratory results of diagnostic urine testing
4. This is the highest level of learning in the cognitive domain of the choices offered. Interpretation of laboratory results of urine testing reflects learning on the analysis level, which is the fourth of six levels of learning in the cognitive domain.
3.07. A pt asks the nurse, "What does 96 indicate when my blood pressure is 140 over 96?" What is the best response by the nurse?
1. The 96 is the pressure within an artery when the heart is resting between beats.
2. The 96 reflects the lowest pressure within a vein when blood moves through it.
3. Everyone is different so it's really relative to each individual what it means.
4. Let's talk about the concerns you may have about your blood pressure.
1. This response is simple, is direct, and uses language that is easily understood.
3.08. A nurse is planning a weight reduction program with an obese pt. What should the nurse anticipate will be the most important component that will determine the success or failure of this plan?
1. Rewarding compliant behavior with fave foods
2. Encouraging at least 1 hour of exercise daily.
3. Using an 800-calorie daily dietary regimen
4. Setting realistic goals
4. Setting realistic goals is important to the success of a weight-loss plan. Because achieving success is dependent largely on motivation, the teacher and pt should design goals that demonstrate immediate progress or growth. One strategy is to design numerous realistic short-term intermediary goals that are achieved more easily than one long-term goal.
3.09. A nurse is providing health teaching for a pt with a comprehension deficit. Which is the best intervention by the nurse that will support this pt's learning?
1. Establishing a structured environment
2. Asking that unclear words be repeated
3. Speaking directly in front of the pt
4. Making a referral for a hearing evaluation
1. For people who have difficulty with comprehension, participating in a learning program often makes them feel overwhelmed and threatened. The teacher needs to provide a structured environment in which variables are controlled to reduce anxiety and support comprehension. The nurse should minimize ambiguity, provide a familiar environment, teach at the same time each day, limit environmental distractions, and provide simple learning materials.
3.10. A nurse is teaching a pt recently diagnosed with diabetes mellitus the step-by-step procedure of administering an insulin injection. However, after two session the pt is still reluctant to self-administer the insulin. What should the nurse do?
1. Have the pt administer the injection to an orange
2. Keep reinforcing the principles that have been presented
3. Give the pt an opportunity to explore concerns about the injection
4. Determine if a member of the family is willing to administer the insulin
3. When a teaching plan is ineffective the nurse must gather more data and revise the teaching plan to achieve the desired goal.
3.11.Every person who attended a smoking cessation educational program completed a questionnaire. What is this type of evaluation called?
1. Survey
2. Post-test
3. Case study
4. Focus group
1. The terms questionnaire and survey are used interchangeably to describe a type of evaluation tool designed to gather data about a topic.
3.12. A pt is readmitted to the hospital because of complications resulting from nonadherence to the prescribed health-care regimen. What should the nurse do first?
1. Encourage healthy behaviors
2. Develop a trusting relationship
3. Use educational aids to reinforce teaching
4. Establish why the client is not following the regimen
2. A trusting relationship between the pt and the nurse is essential. Pts have to be confident that the nurse will maintain confidentiality, has credibility, and is genuinely interested in their success.
3.13. A nurse is teaching a pt with a hearing impairment. What should the nurse do?
1. Limit educational sessions to 10 minutes
2. Provide information in written format
3. Use at least 2 teaching methods
4. Teach in group settings
3. Varieties of teaching methods facilitate learning because multiple senses are stimulated. When we see, hear, and touch, learning is more effective than when we see or hear alone. In addition, research demonstrates that we remember only 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we see and hear, and %80 of what we say and do.
3.14. A nurse is assessing the results of dietary teaching for a pt with diabetes mellitus. What pt behavior indicates that learning occurred in the affective domain?
1. Discusses which food on the ordered diet must be avoided
2. Eats the food on the special diet ordered by the physician
3. Compiles a list of foods that are permitted on the diet
4. Asks about which foods can be eaten.
2. This is an example of learning on the valuing level in the affective domain. Valuing is demonstrated when learning is incorporated into the learner's behavior because it is perceived as important. Affective learning involves the expression of feelings and the changing of beliefs, attitudes, or values.
3.15.A nurse educator designed various educational programs that employ role-playing as a teaching strategy. Which group of people should the nurse anticipate will benefit the most from role-playing?
1. Older adults preparing to retire from the workforce
2. Men unwilling to admit that they have a drinking problem
3. Adolescents learning to abstain from recreational drug use
4. Middle-aged adults preparing for total-knee replacement surgery
This group should benefit most from role-playing. Role-playing provides a safe environment in which to practice interpersonal skills. It enables the adolescent to rehearse what should be said, learn to response to the emotional environment, and experience the pressures of the person playing the peer using drugs.
3.16.To be most effective, at what grade reading level should the nurse prepare educational medical material?
1. 4th grade
2. 8th grade
3. 10th grade
4. 6th grade
Randomized studies demonstrate that the average reading level of individuals who need health teaching is 6.8 grades of schooling.
3.17. A nurse uses computer-assisted instruction as a strategy when providing preoperative teaching. The nurse explains to preoperative pts that the greatest advantage of computer-assisted instruction is that
1. Learners can progress at their own rate
2. It is the least expensive teaching strategy
3. There are opportunities for pre- and post-testing
4. Information is presented in a well-organized format
1. Learners progress thru a program at their own pace viewing informational material, answering questions, and receiving immediate feedback. Some programs feature simulated situations that require critical thinking and a response. Correct responses are rationalized, praise is offered, and incorrect responses trigger an explanation of why the wrong answer is wrong and offer encouragement to try again. This is a superior teaching strategy for the learner who may find that group lessons are paced either too fast or too slow for effective learning.
3.18. Which behavior identified by the nurse indicates the highest level of learning in the psychomotor domain?
1. Demonstrating a well-balanced stance with crutches
2. Identifying the correct equipment that is needed for a colostomy irrigation
3. Performing a dry sterile dressing change without contaminating the equipment
4. Recognizing the different between systolic and diastolic pressure sounds
3. This option reflects the highest level of learning of the options offered. When a person achieves the ability to perform a behavior that requires a complex movement pattern with confidence, learning has been achieved on the complex-overt response level of learning in the psychomotor domain.
3.19 A nurse is assessing a pt's readiness to learn about smoking cessation. Which pt factor does the nurse consider is most important when determining if a teaching program is needed by the pt?
1. Previous experience
2. Perceived need
3. Expectations
4. Flexibility
2. Readiness to learn and motivation, which are closely tied together, are the two most important factors contributing to the success of any learning program. The learner must recognize that the learning need exists and that the material to be learned is valuable.
3.20. A nurse is teaching a preschool-age child. What teaching method is most appropriate for the nurse to use when teaching a child in this age group?
1. Demonstrations
2. Coloring books
3. Small groups
4. Videos
2. This is the best approach because it requires preschoolers to be active participants in their own learning. In addition, the child has a product to take home and be proud of, it reduces anxiety associated with learning because coloring is an activity most preschoolers are familiar with, and it is within a preschooler's cognitive level.
3.21. A nurse is attending a class about a new IV pump presented by the hospital staff education department. What is this type of educational program?
1. Continuing education program
2. Inservice education program
3. Certification program
4. Orientation program
2. Inservice programs generally are provided by health-care agencies to reinforce current knowledge and skills or provide new information about such issues as policies, theory, skills, practice or equipment
3.22. A nurse is planning teaching about weight reduction strategies to an obese pt. Before implementing the teaching plan the nurse first should assess the pt's.
1. Intelligence
2. Experience
3. Motivation
4. Strengths
3. If the pt does not recognize the need to learn or value the information to be learned, the pt will not be ready to learn.
3.23. A nurse is planning to engage a pt in a program to learn about a newly diagnosed illness. Which psychosocial response to the illness will have the greatest impact on the pt's future success with learning?
1. Fear
2. Denial
3. Fatigue
4. Anxiety
2. Of all the options presented, the pt in denial is the person least ready and motivated to learn. The pt in denial is unable to recognize the need for learning.
3.24 A nurse must implement a teaching plan for a pt recently diagnosed with heart failure. What should the nurse do first?
1. Identify the pt's level of recognition of the need for learning
2. Frame the goal within the pt's value system.
3. Determine the pt's preferred learning style
4. Assess the pt's personal support system
1. The learner must recognize that the need exists and that the material to be learned is valuable. Motivation is the most important factor influencing learning.
3.25 A teaching-learning concept basic to all teaching plans is to present content from the:
1. Cognitive to the affective domain
2. Formal to the informal
3. Simple to the complex
4. Broad to the specific
3. Complex material is best learned when easily understood aspects of the topic are presented first as a foundation for the more complex aspects. When moving from the simple to the complex, a person works at integrating and incorporating the less complex, new learning into one's body of knowledge and understanding before moving on to more complex information.
3.26. A nurse is planning a teaching plan for an older adult. Which common factor among older adult patients must be considered by the nurse?
1. Learning may require more energy
2. Intelligence decreases as people age
3. Older adults rely more on visual rather than auditory learning
4. Older adult pts are more resistant to change that accompanies new learning
1. Various physiological changes of aging impact on the rate of learning (e.g. declines in sensory perception and speed of mental processing and more time needed for recall), requiring the use of multisensory teaching strategies and a slower approach. In addition, older adults may have less physical and emotional stamina because of more chronic illnesses, so they may require shorter and more frequent learning sessions.
3.27 A nurse is teaching a postoperative patient deep breathing and coughing exercises. Which method of instruction is most appropriate in this situation?
1. Explanation
2. Demonstration
3. Video presentation
4. Brochure with pictures
2. A demonstration is the best strategy for teaching a psychomotor skill. A demonstration is an actual performance of the skill by the teacher who is acting as a role model; usu. followed by a return demonstration; the learner can imitate the teacher during a return demonstration, ask questions, and receive feedback from the instructor.
3.28 A nurse is teaching a pt colostomy in relation to the affective domain. Which teaching method is most effective for this situation?
1. Discussing a pamphlet about colostomy care from the American Cancer Society.
2. Exploring how the pt feels about having a colostomy
3. Providing a demonstration on how to do colostomy care
4. Showing a videotape demonstrating colostomy care
2. This option reflects learning in the affective domain. Affective learning is concerned with feelings, emotions, values, beliefs, and attitudes about the colostomy.
3.29 A school nurse is teaching a class of adolescents about avoiding smoking and includes role-playing as a creative learning activity. What is the primary reason for role-playing?
1. Provides more fun than other methods
2. Eliminates the need for media equipment
3. Requires active participation by the learner
4. Gives the learner the opportunity to be another person
3. Learning activities that actively engage the learner have been shown to be more effective as well as more fun than methods that do not actively engage the learner. When learners are actively involved, they assume more responsibility for their own learning and develop more self-interest in learning the content.
3.30. A culturally competent nurse is planning to teach a pt about a new regimen of self-care. What must the nurse assess first about the pt before implementing the teaching plan?
1. Religious affiliation
2. Support system
3. National origin
4. Health beliefs
4. Individuals have their own beliefs associated with cultural health practices, faith beliefs, diet, illness, death and dying, and lifestyle, which all have a major impact on health beliefs.
3.31 A nurse is assessing a pt to determine educational needs. Which is most important for the nurse to consider?
1. Make no assumptions about the pt
2. Teaching may be informal or formal in nature
3. The teaching plan should be documented on appropriate needs
4. A copy of the teaching/learning contract should be given to the pt
1. Many variables influence an individual's willingness and ability to learn (e.g. readiness, motivation, physical and emotional abilities, education, age, cultural and health beliefs, cognitive abilities.) Because everyone is unique with individual needs, the nurse must avoid making assumptions and generalizations.
3.32 A nurse is preparing a pt with a colostomy for discharge. What pt outcome indicates that learning has occurred in the psychomotor domain?
1. Accepts the need to have a colostomy
2. Understands why certain foods should be avoided
3. Verbalizes the rationale for daily colostomy irrigations
4. Changes a colostomy bag without contaminating the hands
4. Changing a colostomy bag without contaminating the hands is an example of learning in the psychomotor domain. Learning in the psychomotor domain is related to mastering a skill and requires motor activity.
3.34 The unit secretary tells the nurse that the practitioner has just ordered a low-calorie diet for a pt who is overweight. Place these nursing interventions in the order in which they should be implemented.
1. Verify the dietary order
2. Determine food preferences
3. Teach specific about a low-calorie diet
4. Review a meal plan designed by the pt
5. Assess the pt's motivation to follow the diet.
Answer: 1, 5, 2, 3, 4 (See rationale p.154 FS)
Which best describes a pt with an external locus of control? (Select all that apply)
1. ____ Behaving appropriately to obtain the right to watch a tv program
2. ____ Is self-motivated when implementing health promotion behaviors
3. ____ Wants to please family members with efforts to get well
4. ____ Understands the expected outcome of therapy
5. ____ Is a self-actualized adult
1. The person with an external locus of control is motivated by rewards that center on privileges, incentives, or praise received from pleasing significant others or members of the health-care team. Watching television is a privilege in this situation.

3. Pleasing other precipitates feedback that is often viewed as positive by the recipient. Positive verbal or nonverbal communication from another is an external reward.
C2.01. An accurate assessment drives the rest of the steps of the nursing process. The nurse in change understands that the mgt function that drives effective mgt is:
1. Planning
2. Directing
3. Organizing
4. Controlling
1. Effective mgt depends on careful planning. Planning activities include deciding what is to be done, when to do it, where and how to do it, and who will do it and with what level of assistance. Planning is multifaceted and involves assessment, problem identification, establishment of goals, identifying interventions based on priorities, and how outcomes will be evaluated.
C2.02. Which action is an example of a nurse working independently?
1. Limiting fluids when a pt has an order for 1000 mL fluid restriction.
2. Assigning another nurse to administer meds
3. Irrigating a pt's wound with normal saline
4. Applying a warm soak on an infiltrated IV site
2. Delegating tasks within the scope of nursing practice is an independent function of the nurse and does not require a practitioner's order.
C2.03 Which is most basic for a nurse new to a mgt position?
1. Strong interpersonal comm skills
2. Awareness of when to be confrontational
3. Knowledge of the role of a change agent
4. Recognition by peers as a leader
1. Strong communication skills are an essential competency of a nurse manager. Research demonstrates that 80-90% of mgr's day is spent communicating verbally and in writingt. Mgrs need to express their thoughts clearly, concisely, and accurately.
C2.04 A unit manager mentors a new unit mgr as part of orientation to the position. Which type of power is being used by the unit mgr mentor?
1. Influence
2. Coercive
3. Referent
4. Expert
4. This is an example of expert power. Expert power is the respect one receives based on one's ability, skills, knowledge, and experience.
C2.05 A nurse mgr considers that there are "Five Rights of Delegation" -- right task, right person, right communication, right time and right:
1. Place
2. Route
3. Feedback
4. Supervision
4. The one who delegates a task is responsible for ensuring that the task is performed safely and according to standards of practice.
C2.06. What should the manager do first to overcome resistance to change?
1. Ensure that the planned change is within the current beliefs and values of the group.
2. Provide incentives to encourage commitment to the change
3. Implement change in small steps rather than large steps
4. Use informational power to ensure that goals are met
1. Change that is consistent with current values and beliefs is easier to implement than change that is inconsistent with current values and beliefs. Values and beliefs are difficult to change.
C2.07 What activities does a nurse manager engage in who values the importance of positive role modeling?
1. Counseling subordinates who fail to meet expectations
2. Holding team meetings to review rules of agency
3. Reviewing job descriptions with employees
4. Following the policies of the agency
4. When the nurse manager follows policies and procedures, the mgr is demonstrating the behavior that is expected. Role modeling is more effective than telling as a teaching strategy.
C2.08 When considering leadership styles, and "autocratic" leader is to "authoritarian" as a "democratic" leader is to:
1. Directive
2. Permissive
3. Oppressive
4. Consultative
4. The word consultative is most closely related to the democratic leadership style. Democratic leaders encourage discussion and decision making within the group. The leader facilitates the work of the group by making suggestions, offering constructive criticism, and providing information.
C2.09 What nursing-care delivery model is based on case management?
1. Pt classification system
2. Diagnostic Related Groups
3. Critical pathways
4. Primary nursing
4. Primary nursing is a case mgt approach in which one nurse is responsible for a number of pts 24 horus a day, 7 days a week. It is a way of providing comprehensive, individualized, and consistent nursing care.
C2.10 Which statement is most significant in relation to the concept of change theory in the health-care environment?
1. Weigh the risks and benefits
2. The stages of change are predictable
3. Change in activity results in positive outcomes
4. A large change is easier to adapt to than multiple smaller changes
1. Risks and benefits must be carefully analyzed before initiating change. Some change is not worth the risk, because the consequences of failure are greater than the benefits.
C2.11 Several nurses complain to the nurse mgr that one of the pt care aides constantly takes extensive lunch breaks. What should the nurse mgr do?
1. Convene a group meeting of all pt care aides to review their responsibliities related to time mgt
2. Talk with the pt care aide to explore the reasons for the behavior and review expectations
3. Arrange a mtg with the nurses so that they can confront the pt care aide as a group
4. Document the pt care aide's behavior and place it in the aide's personnel file
2. Recognition of a problem is the first step in the problem-solving process. Once the unacceptable behavior is identified and acknowledged, then the reasons for the problem can be explored, solutions suggested, and expectations reinforced.
C2.12 What should the nurse do to ensure efficiency when managing a daily assignment?
1. Give care to a pt in isolation first
2. Plan activities to promote nursing convenience
3. Organize care around legally required activities
4. Perform routine bed baths between breakfast and lunch
3. Legally req'd activities must be accomplished because they are dependent functions that support the medical regimen of care. Although legally required activities should be accomplished first, many independent actions by the nurse also must be implemented to maintain a basic standard of care and pt safety. Some nursing interventions, which are not essential, can be implemented after the required activities.
C2.13 A supervisor communicates expectations about a task to be completed and then delegates the task. Which management function is being implemented by the supervisor?
1. Planning
2. Directing
3. Organizing
4. Controlling
2. This is an example of the directing function of mgt. Directing involves getting the work accomplished and includes activities such as assigning and communicating tasks and expectations, guiding and teaching, and decision making.
C2.14 A student nurse in the clinical area is given an appropriate pt assignment by the instructor. What should the student nurse do?
1. Accept the role of leader of the pt's health care team
2. Complete the care indicated on the pt's plan of care
3. Assume accountability for the tasks that are assigned by the instructor
4. Help other students to complete their assigned tasks whenever necessary
3. Students are accountable for the tasks assigned by the instructor or preceptor. As part of accountability, students are obligated to keep the instructor or preceptor informed about the status of the pt, how the assignment is progressing, and whether all interventions are implemented as planned.
C2.15 Which statement is most significant in relation to the concept of change theory in the health-care environment?
1. Barriers to change can be overcome by embracing new ideas uncritically
2. Change generates anxiety by moving away from the comfortable
3. Behaviors are easy to change when change is supported
4. Change is most effective when spontaneous
2. Changes causes one to move from the comfortable to the uncomfortable and is known as "unfreezing: in Lewin's Change Midel. It involves moving away from that which is known to the unknown, from the routine to the new, and from the expected to the unexpected. The unknown, new, and unexpected can be threatening, which can increase anxiety.
C2.16 A pt is to be discharged from the hospital. Which discharge task can be delegated to a nursing assistant?
1. Teaching the pt how to measure weight using a standing scale.
2. Obtaining the pt's temperature, pulse and respiratory rate.
3. Determining if the pt knows how to measure fluid intake
4. Demonstrating to the pt how to use a walker
2. Obtaining vital signs can be delegated to a CNA bc it is not complex task. It requires simple problem-solving skills and a simple level of interaction with the pt. Although this task has the potential to cause harm if the critical elements of the skill are not implemented appropriately, it is within the scope of practice of an unlicensed nursing assistant. It does not require the more advanced competencies of a RN.
C2.17 What is the major focus of nursing management?
1. Accomplishing an objective
2. Empowering others
3. Problem solving
4. Planning
1. Although planning, problem solving, and empowering others are tasks of a manager, the bottom line is for the manager to accomplish the work of the organization.
C2.18 A staff nurse must solve a complex problem. Which is the nurse's most effective resource?
1. Organizational chart of the institution
2. Nursing procedure manual
3. Unit's nurse manager
4. Nursing supervisor
3. Generally, in the chain of command of an organization the staff nurse works under the direction of and reports to the unit's nurse manager. The nurse mgr generally is an experienced nurse and is the primary resource person for the staff nurse. The staff nurse should seek guidance from the nurse manager when assistance is needed to solve a complex problem.
C2.19 When delegating a specific procedure to a pt care aide, the aide refuses to perform the procedure. What should the nurse do first?
1. Assign the procedure to another pt care aide
2. Explain that it is part of the pt care aide's job descr
3. Explore why the pt care aide refused to perform the procedure
4. Send the pt care aide to the procedure manual to review the procedure.
3. This is the issue that the nurse manger needs to explore. The employee may have an acceptable reason for refusing to comply. When the reason is identified, then the nurse manager can take an informed action.
C2.20 What is the first thing the nurse should do when planning to apply for a new position within an agency?
1. Review the JD
2. Provide at least several positive references
3. Identify if power is associated with the position
4. Locate the position on the agency's Table of Organization
1. This is one off the most important actions by the nurse seeking a new position. The job description provides an overview of the requirements and responsibilities of the role. Job descriptions include factors such as educational and experiential requirements, job responsibilities, subordinates to be supervised, and to whom one reports in the chain of command.
C2.21 The most important reason why a nurse aide must fully understand how to implement a delegated procedure is because the nurse aide must be able to:
1. Teach the procedure to another nurse aide
2. Explain the procedure to the pt
3. Complete the procedure safely
4. Perform the procedure quickly
3. Safety of the pt is the priority. The NA must perform only the skills that are within the legal role of the NA, understood, and practiced and have been performed correctly on a return demonstration.
C2.22 The nursing team leader delegates a wound irrigation to a Licensed Practical Nurse (LPN). It has been a long time since the LPN performed this procedure. To ensure patient safety the nursing team leader whould:
1. Verbally describe to the LPN how to perform the procedure
2. Have the LPN demonstrate how to perform the procedure
3. Assign another LPN to assist wtih the procedure
4. Delegate the procedure to another LPN
2. Demonstration is the safest way to assess whether a person has the knowledge and skill to safely perform a procedure. A superior delegating care is responsible for ensuring that the person implementing the care is legally qualified and competent.
C2.23 A nurse manager is informed that a large number of pts will be admitted in response to a terrorist attack. Which type of leadership style is most appropriate in this situation?
1. Collaborative
2. Authoritarian
3. Laissez-faire
4. Democratic
2. This is the most appropriate leadership style in a crisis when urgent decisions are necessary. In a crisis, one person needs to assume the responsibility for decisions. Autocratic leaders give orders and directions and make decisions for the group.
C2.24 A nurse manager is experiencing staff resistance when implementing change. What is the most important action by the nurse manager to overcome resistance to change?
1. This is essential to overcome resistance to change. There are many different reasons ppl resist change. Each person will respond to different strategies. There are four different types of interventions to overcome resistance: providing information, disproving currently held beliefs, maintiaining psychological safety, and administrating an order or command.
C2.25 What is the major focus of leadership?
1. Inspiring people
2. Creating change
3. Controlling others
4. Producing a product
1. Leaders can inspire others with their vision and gain cooperation through their persuasion and communication skills (influence power), the respect others have for their knowledge and abilities (expert power), and their charisma and prior success (referent power).
C2.26 The primary difference between effective leaders and managers is that managers have:
1. Vision
2. Charisma
3. Confidence
4. Responsibility
4. Managers, not leaders, have responsibility. Leaders can be formal or informal. Informal leaders are not assigned to direct others. They are viewd as leaders by the members of the group because of their experience, vision, charisma, confidence, expertise, or age.
C2.27 Which situation is most reflective of the saying, "A stitch in time saves nine?"
1. Obtaining the vital signs for the pts on the unit at the same time
2. Collecting the equipment for a procedure before entering the room
3. Delegating some interventions to the Licensed Practical Nurse
4. Documenting the nursing care given every few hours
2. This action is an appropriate example of the adage.... It means that if you sew a tear when it is small, you need fewer stitches and time to repair it than when it is large. The same adage can be applied to the collection of equipment before a procedure. If the nurse has all the equipment that is needed before beginning a procedure, less time is used than when forgotten equipment is obtained later. Every time the nurse leaves the room for forgotten equipment, the pt is inconvenienced and time is wasted.
C2.28 A RN delegates a procedure to an LPN. What is the primary purpose of delegation?
1. Create change
2. Establish a network
3. Improve productivity
4. Transfer accountability
3. Delegation allows the Registered Nurse to assign tasks to various individuals on the nursing team who are best qualified to complete the task. In today's health-care environment, nursing team members have different levels of educational preparation. The RN must take into account the qualifications and scope of practice of each professional and nonprofessional nursing team member and assign tasks accordingly. When this is done, each person's skills and abilities are used most appropriately and productivity increases.
C2.29 A nurse manager plans to provide feedback to a subordinate who needs a change in behavior. What is the best intervention by the nurse manager?
1. Be assertive
2. EXplore alternatives
3. Identify the unacceptable behavior
4. Document the content of the counseling session
3. Problem recognition is the first step in the problem-solving process. Once the unacceptable behavior is identified and acknowledged, then the reasons for the problem can be explored, solutions suggested, and expectations reinforced.
C2.30 What is the main reason the nurse mgr achieves a consensus when making a decision within a group?
1. Explore possible alternative solutions
2. Demonstrate that staff members are flexible
3. Facilitate cooperative effort toward goal achievement
4. Ensure the use of effective autocratic decision making
3. Cooperation and teamwork are essential for the achievement of any goal. If a consensus is achieved about the value of the expected outcome, people are more likely to work together constructively.
C2.31 The nurse mgr evaluates the performance of a subordinate. Which management function is being implemented by the nurse mgr?
1. Planning
2. Directing
3. Organizing
4. Controlling
4. The controlling function of mgt includes the evaluation of staff members. This is in addition to ensuring that plans are carried out and the outcomes evaluated.
C2.32 Which is most related to systems theory?
1. End result
2. Linear format
3. Trial and error
4. Cyclical process
4. Systems theory is a cyclical process in which a whole broken down into parts and the parts are studied individually as well as how they work together within the system. Every system consists of matter, energy, and communication. Because each part of a system is interconnected, the whole system reacts to changes in one of its parts. The concept of treating a pt holistically is based on an understanding of systems theory.
C2.33 The nurse and a nursing assistant (unlicensed assistive personnel) are working together on a surgical unit. Which nursing activity should the nurse assign to the nursing assistant?
1. Assessing the results of blood glucose monitoring
2. Explaining to a patient how to use an incentive spirometer
3. Emptying a urine collection bag that is attached to continuous bladder irrigation
4. Assisting the postanesthesia care unit nurse to help a pt to make the transition to the surgical unit
3. Emptying and recording the volume of output collected from a urine collection bag is within the legal role of unlicensed assistive personnel. The nurse will then calculate the volume of urine by deducting the volume of irrigating solution instilled from the total output. Calculating the actual urine output is an assessment that requires the skill of a licensed nurse.
C2.34 Which tasks should be delegated to a RN? Select all that apply.
1. ___ Obtaining vital signs
2. ___ Providing discharge teaching
3. ___ Evaluating a pt's response to morphine
4. ___ Administering a cleansing enema to a pt
5. ___ Transporting a pt to the operating room for surgery
2. Discharge teaching requires the knowledge and judgment of a Registered Nurse. It requires synthesizing and summarizing information as well as coordinating a variety of community health-care services to meet pt needs.
3. Evaluation requires the knowledge and judgment of a Registered Nurse. The skill of evaluation requires reassessing, synthesizing and analyzing data, determining significance of data, and diagnosing and responding to the data. In addition, it involves an unpredictable outcome and requires problem solving that may call for innovation in the form of an individually designed plan of care to address the pt's need for pain relief if pain is still being experienced.
C2.35 Lewin's planned change theory progresses through phases. Order these statements by the nurse manager as change moves through the process.
1. "Let's implement a pilot project next week."
2. "This is a new venture that should be exciting."
3. "I know it may be difficult but you are doing a great job."
2, 1, 3.
2. The first phase is called "unfreezing" and is concerned with identifying the need for change, exploring alternative solutions, and stimulating enthusiasm.
1. The second phase is called "moving/changing" and is concerned with creating actual visible change.
3. The third phase is called "refreezing" and is concerned with providing feedback, encouragement, and constructive criticism to reinforce new behavior.