Final Question Review

Chapter 2 Legal and Ethical Aspects of nursing
1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an
appropriate court. What is this document called?
A. Deposition
B. Appeal
C. Complaint
D. Summons
2. The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care. What
is this legally binding situation?
A. Nurse-patient relationship
B. Accountability
C. Advocacy
D. Standard for care
3. What are the universal guidelines that define appropriate measures for all nursing interventions?
A. Scope of practice
B. Advocacy
C. Standard of care
D. Prudent practice
4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute
care setting. What law should this nurse refer to before initiating this intervention?
A. Standard of care
B. Regulation of practice
C. American Nurses' association code
D. Nurse practice act
5. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be
found guilty of:
A. Malpractice
B. Harm to the patient
C. Negligence
D. Failure to follow the nurse practice act
6. Patients have expectations regarding the health care services they receive. To protect these
expectations, which of the following has become law?
A. American Hospital Association's Patient's Bill of Rights
B. Self-Determination Act
C. American Hospital Association's Standards of Care
D. The Joint Commission's rights and responsibilities of patients
7. The nurse is preparing the patient for at Horace tesis. What must be completed before the procedure
may be performed?
A. Physical assessment
B. Interview
C. Informed consent
D. Surgical checklist
8. When a nurse protects the information in a patient's record, what ethical responsibility is the nurse
fulfilling?
A. Privacy
B. Disclosure
C. Confidentiality
D. Absolute secrecy
9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder
abuse. What is the best nursing action?
A. Cover the bruises with bandages
B. Take photographs of the bruises
C. Ask the patient if anyone has hit her
D. Report the bruises to the charge nurse
10. What is the best way for the nurse to avoid a lawsuit?
A. Carry malpractice insurance
B. Spend time with the patient
C. Provide compassionate, competent care
D. Answer all call lights quickly
11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may
disagree with this order, what is his or her legal obligation?
A. To question the health care provider
B. To seek advice from the family
C. To discuss it with the patient
D. To follow the order
12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an
abortion, what is the most appropriate action for the nurse to take?
A. Ask for another assignment
B. Leave work
C. Transfer to another floor
D. Protest to the supervisor
13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What
resource will be best provide this information?
A. Nurse practice act
B. Standards of care
C. Scope of nursing practice
D. Professional organization
14. What role is the nurse who diligently works for the protection of patients' interests playing?
A. Caregiver
B. Health care administrator
C. Advocate
D. Health care evaluator
15. When asked to perform a procedure that the nurse has never done before, what should the nurse do to
legally protect himself or herself?
A. Go ahead and do it
B. Refuse to perform it, citing lack of knowledge
C. Discuss it with the charge nurse, asking for direction
D. Ask another nurse who has performed the procedure
16. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and
thoughts related to the situation. What is the most appropriate action for the nurse?
A. Compare values with those of the patient
B. Make a judgement
C. Withhold an opinion
D. Give advice.
17. What fundamental principle must the nurse first observe when confronted with an ethical decision?
A. Autonomy
B. Beneficence
C. Respect for people
D. Nonmaleficence
18. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the
patient's health, safety, and well-being. Given this knowledge, which of the following is most necessary
for the nurse to report?
A. Unethical behavior of other staff members
B. A worker who arrives late
C. Favoritism shown by nursing administration
D. Arguments among the staff
19. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of
regarding malpractice insurance provided by the hospital?
A. Only offers protection while on duty
B. Is limited in the amount of coverage
C. Is difficult to renew
D. Can be terminated at any time
20. Which is a nursing care error that violates the Health Insurance Probability and Accountability
(HIPAA)?
A. Administering a stronger dose of drug than was ordered
B. Refusing to give a patient's daughter information over the phone
C. Informing the patient's medical power of attorney of a medication change
D. Leaving a copy of the patient's history and physical in the photocopier
21. Which of the following could cause a nurse to be cited for malpractice?
A. Refusing to give 60mg of morphine as ordered
B. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines
C. Dragging an injured motorist off the highway and causing further injury
D. Informing a visitor about a patient's condition
22. A lumbar puncture was performed on a patient without a signed informed consent form. This patient
might sue for:
A. Punitive damages
B. Civil battery
C. Assault
D. Nothing, no violation has occurred.
23. A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's
indwelling urinary catheter but forgets to unclamped it. The patient develops a urinary tract infection.
What do the nurse's actions exemplify?
A. Malpractice
B. Battery
C. Assault
D. Neglect of duty
24. What is true about nurse practice acts?
A. They informally define the scope of nursing practice
B. They provide for unlimited scope of nursing practice
C. Only some states have adopted a nurse practice act.
D. The nurse must know the nurse practice act within his or her state
25. How can the medical record be used in litigation? (Select all that apply)
A. Public record
B. Proof of adherence to standards
C. Evidence of omission of care
D. Documentation of time lapses
E. Evidence by only the plaintiff
26. During lunch break, an emergency department (ED) nurse truthfully tells another nurse about the
condition of a patient who came to the ED last night. What is the ED nurse guilty of ? (Select all that
apply)
A. HIPPA violation
B. Slander
C. Libel
D. Invasion of privacy
E. Defamation
27. A nurse failed to monitor a patient's respiratory status after medicating the patient with a narcotic
analgesic. The patient's respiratory status worsened, requiring intubation. the patient's family claimed the
nurse committed malpractice. What must be present for the nurse to beheld liable? (Select all that apply)
A. A nurse-patient relationship exists.
B. The nurse failed to perform in a reasonable manner.
C. There was harm to the patient.
D. The nurse was prudent in her performance.
E. The nurse did not cause the patient harm.
F. Duty does not exist.
28. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person's
behavior in a given situation are referred to as__________.
ANS: Values
29. Acts whose performance is required, permitted, or prohibited are defined by____________ of
____________.
ANS: standards; care
30. A nurse reinforces teaching nursing students with which of the following is the term to mean oral
defamation.
A. Slander
B. Libel
C. Breech
D. Confidentiality
31. A nurse reinforces teaching nursing students with which of the following is the term to mean written
defamation.
A. Libel
B. Breech
C. Confidentially
D. Slander
32. A nurse reinforces teaching nursing students with which of the following is an example of negligence
by commission?
A. Not checking BP before giving antihypertensive medication.
B. Starting an IV in a patient
C. Not doing wound dressings as ordered
D. Starting to take vital signs before each shift
33. A nurse reinforces teaching nursing students with which of the following is an example negligence by
omission?
A. Not checking BP before giving antihypertensive medication as ordered
B. Starting an IV in a patient
C. Not administering IV medication as ordered
D. Starting to take vital signs before each shift
34. A nurse reinforces teaching nursing students with which of the following defines a nurse scope of
practice?
A. Nursing Practice Act
B. Standard of Care
C. OBRA
D. Joint Commission
35. A nurse observes an assistive personnel reprimanding a client for not using the urinal properly. The
AP tells the client that diapers will be used next time the urinal is used improperly. Which of the
following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of property
36. A nurse is caring for a competent adult client who tells the nurse, “ I am leaving the hospital this
morning whether the doctor discharges me or not.” The nurse believes that this is not in the client's best
interest, and prepares to administer a PRN sedative medication the client has not requested along with the
scheduled morning medication. Which of the following types of tort is the nurse commit?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
37. A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for
surgery the following week. The client tells the nurse that he will prepare his advance directives before he
goes to the hospital. Which of the following statements made by the client should indicate to the nurse an
understanding of advance directives?
A. “I’d rather have my brother make decisions for me. But I know it has to be my wife.”
B. “I know they won’t go ahead with the surgery unless I prepare these forms.”
C. “I plan to write that I don’t want them to keep me on a breathing machine.”
D. “I will get my regular doctor to approve my plan before I hand it at the hospital.”
38. A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should
take which of the following actions regarding informed consent? (Select all that apply.)
A. Make sure the surgeon obtained the client's consent.
B. Witness the client's signature on the consent form.
C. Explain the risks and benefits of the procedure
D. Describe the consequences of choosing not to have the surgery
E. Tell the client about alternatives to having the surgery
38. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy
and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room
when she was not on a break. Which of the following actions should the nurse take?
A. Alert the American Nurses Association
B. Fill out an incident report
C. Report the observation to the nurse manager on the unit
D. Leave the nurse alone to sleep
Chapter 5 Nursing process
1. What best defines the nursing process?
A. A Method to ensure that the physicians orders are implemented correctly.
B. A series of assessments that isolate a patient’s health problem.
C. A framework for the organization of individualized nursing care.
D. A preset formula for the design of nursing care.
2. All of the following patients have been admitted to the acute care setting. On admission, which patient
should receive a focused assessment?
A. 53-year-old admitted with a perforated ulcer
B. 5-year-old admitted for the implant of grommets in the middle ear
C. 76-year-old admitted for a knee replacement
D. 40-year-old admitted for possible bowel obstruction
3. What subjective data does the nurse record following a head-to-toe examination?
A. Rash on back
B. Prolonged nausea
C. Blood pressure of 190/100
D. White blood cell count of 19,000
4. What objective data should the nurse include after a patient assessment?
A. Headache of 3 days duration
B. Severe stomach cramps
C. Flatulence
D. Anxiety
5. What is classified as information provided by the family when a patient is unable to provide data
during assessment?
A. Primary
B. Secondary
C. Unreliable
D. Biased
6. What are the two primary methods used to collect data?
A. Written report by patient and family
B. Review of the chart and the nurse ‘s notes
C. Interview and physical examination
D. Review of the physicians’ orders and the Kardex
7. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as
manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition.
What is the major difference between these diagnoses?
A. The second diagnosis needs no defined nursing interventions.
B. The second diagnosis needs medical intervention.
C. The second diagnosis will not need to be evaluated.
D. The second diagnosis reflects a problem that does not yet exist.
8. What framework does the establishment of priorities of care during the planning phase of the nursing
process often use?
A. Erikson’s developmental tasks
B. Piaget’s cognitive table
C. Maslow’s hierarchy of needs
D. Freud’s classifications
9. What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway
clearance related to thick secretions?
A. The patient will increase intake to 1000 mL daily to liquefy secretions.
B. The patient will cough more frequently within 3 days.
C. The patient will breathe better within 3 days.
D. The patient will perform deep-breathing exercises four times daily.
10. What is the primary purpose of nursing orders?
A. To support physician’s orders
B. To provide direction for all caregivers
C. To provide broad, general statements
D. To clarify nursing principles
11. What documentation reflects implementation?
A. “Patient selected low-sugar snacks independently.”
B. “Patient was medicated with Tylenol 500 mg PO for pain.”
C. “Patient was ambulated for 15 minutes after lunch.”
D. “Patient participated in group therapy session without reminder.”
12. Which nursing order is complete and correct?
A. “May 10: Nursing assistants will ambulate patient. A. Nurse”
B. “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”
C. “Nursing assistants will serve 8 oz glass of juice at each meal, 5/10.”
D. “P.M. nurse will ensure that heel protectors are in place before bedtime.”
13. A patient with a urinary tract infection is assessed using a clinical pathway. When a projected
outcome is not met by a predetermined date, it is determined that what has occurred?
A. Omission
B. Variance
C. Failure
D. Error
14. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry,
hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the
basis of a nursing diagnosis plan. What does this data represent?
A. Symptoms
B. Data clustering
C. Signs of fluid overload
D. Urinary retention
15. What type of assessment is performed continuously throughout nurse-patient contact?
A. Complete
B. Body systems
C. Focused
D. Subjective
16. What assists the nurse in the identification of nursing diagnoses?
A. Objective data
B. Subjective data
C. Data clustering
D. Validated data
17. What organized approach might the nurse use when performing a complete physical examination?
A. Maslow’s hierarchy of needs
B. A head-to-toe assessment
C. Subjective data collection
D. Objective data collection
18. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?
A. Physician
B. LPN/LVN
C. RN
D. Technician
19. What is the basis for designing and selecting nursing interventions to meet patient needs?
A. Nursing diagnosis
B. Care plan
C. Physician’s orders
D. Nurse’s notes
20. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in
this situation?
A. Contributing to the patient’s recovery
B. A risk factor
C. Difficult to maintain
D. A nursing responsibility
21. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?
A. A syndrome nursing diagnosis
B. An actual nursing diagnosis
C. A risk for diagnosis
D. A possible nursing diagnosis
22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in
which phase of the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
23. What is an important consideration when developing the care plan?
A. Ensure the number of interventions is limited
B. Ensure the patient is involved in the process
C. Ensure interventions will be easy to implement
D. Ensure evaluation of the nursing diagnoses is possible
24. From where are the risk for nursing diagnoses identified?
A. The care plan
B. The interventions
C. The assessment
D. The evaluation
25. What expected outcome exemplifies accepted criteria?
A. Nurse will assess vital signs every day
B. Resident will observe safety guidelines while smoking
C. Resident will take part in one activity daily for the next 90 days
D. Nurse will monitor O2 saturation to maintain at greater than 90%
26. During an admission assessment, the nurse collects objective and subjective data. What is an example
of subjective data?
A. The patient complains of nausea.
B. The patient is vomiting.
C. The patient experiences tachycardia.
D. The patent is pacing the halls.
of subjective data?
A. The patient is asleep.
B. The patient is tearful.
C. The patient has facial grimacing.
D. The patient states, I hurt all over.
of subjective data?
A. The patient is coughing.
B. The patient has cyanosis of the lips.
C. The patient experiences tachypnea.
D. The patient complains of generalized discomfort.
of objective data?
A. The patient complains of chest pain.
B. The patient states, I feel nauseous.
C. The patient complains of feeling faint.
D. The patient is short of breath on exertion.
of objective data?
A. The patient is jaundiced.
B. The patient states, I am nervous.
C. The patient complains of palpitations.
D. The patient denies dizziness when ambulating.
of objective data?
A. The patient complains of feeling depressed.
B. The patient states, I hear voices in my head.
C. The patient complains of auditory hallucinations.
D. The patient is pacing back and forth while chanting.
32. What is an example of an appropriate nursing diagnosis?
A. Impaired skin integrity
B. Skin breakdown noted
C. Turn patient every 2 hours
D. The patient has scabies on his back
33. What is an example of an appropriate nursing diagnosis?
A. Constipation
B. Patient complains of constipation
C. Need for laxatives
D. Patient has a duodenal ulcer
34. A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing
diagnosis?
A. Risk for impaired skin integrity related to physical immobilization
B. Physical immobilization secondary to risk for impaired skin integrity
C. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
D. Physical immobilization secondary to decreased cognitive ability
35. Which is an example of a nursing diagnosis?
A. Pneumonia
B. Diabetes mellitus
C. Impaired skin integrity
D. Congestive heart failure
36. Which is an example of a medical diagnosis?
A. Constipation
B. Diabetes mellitus
D. Altered nutrition: less than body requirements
A. Pain
B. Anxiety
C. Pneumonia
D. Impaired skin integrity
38. Which are acceptable secondary sources for data? (Select all that apply.)
A. Patient
B. Family members
C. Other health professionals
D. Diagnostic reports
E. Textbooks
39. Which are official categories of nursing diagnoses? (Select all that apply.)
A. Actual
B. Risk
C. Wellness
D. Syndrome
E. Potential
40. Which are considered phases of the nursing process? (Select all that apply.)
A. Diagnosis
B. Prediction
C. Assessment
D. Evaluation
E. Implementation
F. Outcome identification
41. NANDA International meets to reorganize diagnosis labels and language every ______ years.
ANS: 2
42. The standards that name and measure patient outcomes are referred to as ___________.
ANS: NOC (Nursing Outcome Classification)
43. The document that outlines a multidisciplinary plan for care interventions over a specified time frame
is a _______ ________.
ANS: Clinical pathway
44. A systematic method by which nurses plan and provide care for patients is known as the _________
____________.
ANS: Nursing process
45. A systemic, dynamic process by which the nurse, through interaction with the patient, significant
others, and health care providers, collects and analyzes data about the patient is known as
______________________.
ANS: Assessment
46. Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a
______________.
ANS: Problem
47. A clinical judgment about individual, family, or community responses to actual or potential health
problems/life processes is known as a _____________ ___________.
ANS: Nursing diagnosis
48. The human responses to health conditions/life processes that exist in an individual, family, or
community are known as a(n) _________ _______________ __________.
ANS: Actual nursing diagnosis
49. Human responses to health conditions and life processes that may develop in a vulnerable individual,
family, or community are known as a(n) __________ __________ ____________.
ANS: Risk nursing diagnosis
50. Human responses to levels of wellness in an individual, family, or community that have a readiness
for enhancement are known as a _____________ ____________ ____________.
ANS: Wellness nursing diagnosis
51. The identification of a disease or condition by a scientific evaluation of physical signs, symptoms,
history, laboratory tests, and procedures is known as a _________ _______.
ANS: Medical diagnosis
52. A health care system that provides control over health care services for a specific group of individuals
in an attempt to control cost is known as ___________ ______________.
ANS: Managed care
53. A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-
risk, high-volume, and high-cost types of cases is known as a ___________ ____________.
ANS: Critical pathway
54. A nurse reinforces teaching nursing students with which of the following is an appropriate nursing
diagnosis of pneumonia?
A. Impaired gas exchange
B. Impaired airway clearance
C. Altered breathing pattern
D. Atelectasis
diagnosis for a client with a tracheostomy and on a ventilator?
D. Atelectasis
diagnosis for a client with bronchitis and very thick mucus?
D. Atelectasis
57. A nurse is looking into a pressure ulcer of a patient who is just admitted. What phase of the nursing
process is she in?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Implementation
E. Evaluation
58. A nurse is administering anti-hypertensive medications daily to a client with chronic hypertensive
disease. What phase of the nursing process is she in?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Implementation
E. Evaluation
diagnosis for a client with an endotracheal tube and on a ventilator?
D. Atelectasis
A. Pain
B. Chronic obstructive Lung Disease
C. Altered Breathing pattern
D. Impaired skin integrity
61. A nurse reinforces teaching using students with which of the following wound an obstetrical history
fall under?
A. Review of system
B. History of present illness
C. Past history
D. Chief complaint
62. A nurse reinforces teaching nursing students with which of the following is the description of the
chief complaint?
A. Review of system
B. History of present illness
C. Past history
D. Chief complaint
Chapter 7 Asepsis
1. What is true regarding surgical asepsis?

A. It inhibits growth of pathogenic organisms.
B. It is known as a cleaning technique
C. It includes hand hygiene.
D. It is known as a sterile technique.
2.What action exemplifies a nurse practicing medical asepsis in performing daily care?
A. Lifting a sterile swab from a sterile field
B. Using disposable sterile gowns
C. Washing hands for 5 minutes between patients
D. Keeping bed linens off the floor
3. What bacteria can lie dormant when conditions for growth are not favorable?
A. Residue
B. Capsules
C. Spores
D. Flagella
4. A patient with a respiratory infection report that he is not yet on an antibiotic. The nurse
explains that the physician is waiting on the results of the culture and sensitivity. What does this
test determine?
A. What media the bacteria requires to grow
B. How fast the bacteria grow
C. Which antibiotics stop bacterial growth
D. When the bacteria colonize
5. What bacterium is responsible for more diseases than any other organism?
A. Staphylococcus
B. Pseudomonas aeruginosa
C. Haemophilus influenzae
D. Streptococcus
6. What additional complication does a disease caused by a virus have compared to a disease
caused by bacteria?
A. Multiplies rapidly
B. Returns frequently
C. Is not killed by antibiotics
D. Is unable to be cultured
7. A patient with ringworm asks the nurse if she has worms. What does the nurse inform the
patient about the cause of ringworm?
A. Bacteria
B. Protozoa
C. Virus
D. Fungi
8. What should the nurse be diligent in to provide a safe environment for the patient?
A. Keeping a light on at night to prevent falls
B. Hand hygiene between patient contacts
C. Regulating the temperature to avoid drafts
D. Changing the bed linen to diminish microorganisms
9. What does the nurse describe when giving an example of a fomite vehicle?
A. Rabid dog
B. Person with AIDS
C. Contaminated stethoscope
D. Infected wound
10. The nurse observes a patient demonstrating wound cleaning. What action indicates the need
for further instruction?
A. Using sterile gloves to perform the cleaning
B. Applying an antiseptic to the area
C. Cleaning the area from the outside in
D. Washing hands with soap
11. The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly
develops a urinary tract infection (UTI). What type of infection is this UTI considered?
A. Viral infection
B. Bacterial infection
C. Health care–associated infection
D. Spore infection
12. The nurse prioritizes the care of four patients. Which patient has a systemic infection?
A. 14-year-old with acute appendicitis
B. 80-year-old with a urinary tract infection
C. 40-year-old with AIDS
D. 50-year-old with arthritis
13. What assessment does the nurse recognize as an inflammatory response in a surgical wound
on the leg of a patient?
A. A foul drainage is coming from the wound
B. The affected leg is cooler than the other leg
C. There are raised, red, pruritic welts on the leg
D. Rubor and edema appear around the wound
14. The infection control practitioner plans an in-service on control of health care-associated
infections. What should be the focus of this program?
A. Observing nurses caring for patients
B. Screening patients who are admitted to the hospital
C. Educating hospital personnel about aseptic practices
D. Discharging infectious patients from the hospital
15. A health care worker is stuck by a needle left on the patient’s bedside table. The staff
member appropriately reports the needlestick. What will the indicated treatment be combatting?
A. Hepatitis B
B. Streptococcal infections
C. Staphylococcal infections
D. Influenza
16. What technique should the nurse use when disposing of linens contaminated with feces?
A. Don gown, gloves, and mask
B. Wash hands for 5 minutes after disposal
C. Don gloves only
D. Double-bag the sheets
17. The nurse is instructing a patient about the most important preventive technique for breaking
the chain of infection. What technique is the patient learning about?
A. Sterilization
B. Standard Precautions
C. Hand hygiene
D. Medical asepsis
18. How long should the nurse perform hand hygiene before beginning care of a patient?
A. 5 minutes
B. 2 minutes
C. 1 minute
D. 30 seconds
19. A nurse is observing isolation precautions by wearing a mask while performing complex
patient care. How often should the nurse change masks?
A. 5-10 minutes
B. 10-20 minutes
C. 20-30 minutes
D. 30-40 minutes
20. A major threat to health care workers is blood-contaminated sharps. What should the nurse
use to discard the used syringe?
A. Wastebasket
B. Sink
C. Puncture-proof container
D. Disinfecting soap
21. The nurse is transporting a patient in respiratory isolation to the radiology department. What
intervention should the nurse implement?
A. Cover the patient with a sheet
B. Take the patient down the service elevator
C. Apply a mask to the patient
D. Call x-ray to come and get the patient
22. The patient in isolation may experience psychological or emotional deprivation. What
should the nurse do to help minimize these feelings?
A. Be cheerful
B. Spend extra time with the patient
C. Protect the patient from additional infection
D. Answer the call light quickly
23. The infection control officer has is observing hospital staff for appropriate use of aseptic
technique. What observation demonstrates the need for more instruction on surgical asepsis?
A. Facing the sterile field
B. Placing a sterile dressing on a sterile field
C. Touching the edges of the sterile field with sterile gloves
D. Keeping gloved hands above the waist
24. The nurse is pouring a sterile solution from a bottle. What direction should the label on the
bottle be in for appropriate technique?
A. Facing outward
B. Covered
C. Facing downward
D. In the palm of the hand
25. What is a method used to kill all microorganisms, including spores?
A. Disinfecting
B. Using an antiseptic
C. Using chlorine bleach
D. Sterilizing
26. The nurse accidently spills blood from a specimen container. The first action the nurse takes
is to don gloves. What should the nurse then spray the fluid with?
A. Liquid detergent
B. 20% bleach solution
C. 10% bleach solution
D. Warm soapy water
27. When assessing a patient for signs of an infection, the nurse recognizes which laboratory
result as indicative of an infection?
A. Lowered red blood cell count
B. Increased white blood cell count
C. Lowered white blood cell count
D. Increased red blood cell count
28. What can result from the nurse consistently performing hand hygiene and using sterile
supplies when caring for patients in the hospital setting?
A. Hospital stay is shortened
B. Sense of self-worth is improved
C. Risk of infection is reduced
D. Nursing care needed is reduced
29. Recognizing the stages of an infection assists the nurse in identifying the progression of an
infection. What is the nonspecific to specific symptom stage of an infection?
A. Convalescent
B. Illness
C. Prodromal
D. Incubation
30. What is the most dependable and practical method to use when sterilizing instruments for
the operating room?
A. Chemical solution
B. Boiling water
C. Steam under pressure
D. Dry heat
31. What contribution did Joseph Lister introduce to medical practice?
A. Isolation of infected patients
B. Iodine and alcohol use as disinfectants
C. The autoclave
D. Aseptic technique
32. The nurse is providing instruction to an anxious mother of a child with Rocky Mountain
spotted fever. When discussing this diagnosis what information will the nurse relay about this
disease?
A. It is extremely contagious among humans.
B. It is contracted from handling unvaccinated animals.
C. It is a hemolytic B Streptococcus infection spread by droplet transmission.
D. It is a serious disease contracted from the bite of a tick
33. The emergency department nurse is assessing a puncture wound of the foot. What is the
most likely type of infection in this wound?
A. Aerobic bacterial infection
B. Anaerobic bacterial infection
C. Viral infection
D. Fungal infection
34. The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be
transmitted?
A. From person to person
B. Through microscopic skin punctures
C. Through inhalation of the spores
D. By exposure to animals that have anthrax
35. The nurse is providing teaching to elementary students regarding vectors. What example will
the nurse provide as an example of a vector?
A. Child with measles giving it to his sister
B. Tick whose bite causes Lyme disease
C. Woman with syphilis infecting her partner
D. Dog whose bite causes rabies
36. What type of organism causes malaria?
A. Bacterium
B. Virus
C. Protozoan
D. Fungus
37. A nurse is performing an admission assessment on a patient with suspected tuberculosis.
What assessment findings by the nurse are consistent with tuberculosis?
A. Hemoptysis
B. Weight gain
C. Night terrors
D. Hypothermia
38. A nurse is performing an admission assessment on a patient with suspected tuberculosis.
What is the greatest risk of exposure to tuberculosis?
A. After a diagnosis is made
B. Before a diagnosis is made
C. After the patient has begun medication therapy
D. After implementation of isolation precautions
39. A person can spread a bacterial infection by which actions? (Select all that apply.)
A. Kissing others
B. Sneezing at work
C. Donating blood
D. Coming in contact with blood products
E. Leaving used tissue on the lavatory
40. What are some characteristics of microorganisms? (Select all that apply.)
A. Involved in a life process of their own
B. Pathogens that cause disease
C. Nonpathologic organisms that cause disease
D. May be infectious
E. Can enter the body via skin, air, or blood
41.Which numbered portion of the illustration below depicts the bacterial class bacilli?
A. 1
B. 2
C. 3
D. 4
E. 5
42. A patient is distressed that an antibiotic has not been effective for the control of the
infection. The nurse explains that some bacteria are capable of defending against antibiotics by
the formation of a _______.
Answer: Capsule
43. The nurse reminds a group of nursing students that the type of asepsis that destroys all
microorganisms and their spores is _____ asepsis.
Answer: Surgical
44. What is the most important reason for a nurse to understand pathogenic microorganisms?
A. To prevent the spread of diseases caused by microorganisms
B. To know which microorganisms cause which infectious diseases
C. To classify different microorganisms based on their characteristics
D. To identify genus and species of different microorganisms
45. What type of microorganism causes athlete's foot infections?
A. Algae
B. Fungi
C. Yeast
D. Mold
46. A nurse is caring for a client with an infection. Which intervention will have the greatest impact on
preventing the transmission of pathogens?
A. Limiting contact with the client
B. Admitting the client to a private room
C. Appropriate hand washing
D. Using gloves when providing client care
47. A disease-producing agent is known as which of the following?
A. Microorganism
B. Microbe
C. Pathogen
D. Endemic organisms
48. Portals of exit for transmission of the infection are the following except:
A. Urine
B. Blood
C. Feces
D. A cut in the skin
49. Which intervention should the nurse implement to break the infection chain at the vehicle of
transmission level?
A. Carefully cover all infected wounds
B. Remove linens and shake them properly
C. Avoid reuse of equipment and supplies
D. Recap the needles carefully after use
50. Which diagnostic test can identify the pathogenic microorganism responsible for client’s urinary tract
inflection?
A. Complete blood count
B. Urinalysis
C. Gram stain
D. Culture and sensitivity test
51. A nurse is teaching nursing students about the chain of transmission of infection. What basic
healthcare worker procedure should the nurse emphasize as most important in breaking this cycle?
A. Wearing gloves
B. Hand washing
C. Monitoring vital signs
D. Properly caring for lines
52. The nurse is preparing to perform a dressing change for a client who has an open surgical wound of
the abdomen. What is the most appropriate action by the nurse when finding the seal on the sterile 4x4
dressing package broken?
A. Discard the 4x4 closest to the broken seal and the use the others.
B. Proceed with using the 4x4’s
C. Discard them and obtain a new package
D. Use them for the outside of the dressing only.
53. A nurse reinforces teaching nursing students on the following measures to implement infection
precaution except
A. Avoid crowded places
B. Avoid associating with individuals who are sick
C. Avoid receiving fresh flowers
D. Avoid eating fresh fruits but can have vegetable salad
E. Avoid consuming raw fish
54. A nurse reinforces teaching nursing students with which of the following is the cheapest method of
sterilization?
A. Steam with pressure
B. Ethylene Oxide
C. Chemical
D. Radiation
55. What phase is a wound in when blood and fluid flow into the vascular space and produce edema,
erythema, heat, and pain?
A. Healing
B. Inflammation
C. Reconstruction
D. Maturation
56. A nurse reinforces teaching nursing students with which of the following is the stage in infection
immediately after contact with a pathogen?
A. Incubation period
B. Prodromal stage
C. Acute stage
D. Recovery stage
Chapter 8 Body Mechanics
1. The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for
this instruction?
A. Workers' compensation claims will be prevented
B. Big muscles work more effectively
C. It guarantees no muscle strain
D. It distributes workload more evenly
2. What should the nurse do to reduce the effort of moving a heavy object?
A. Bring the feet close together and flex the knees
B. Keep the back straight and bend at the waist
C. Widen the base of support in the direction of movement
D. Broaden the base of support and twist toward the direction of movement
3. What should the nurse do to protect his or her back when lifting or moving a patient?
A. Lowering the height of the bed
B. Holding the back straight with locked knees
C. Bending knees and hips
D. Getting the patient to the side of the bed
4. Where should the nurse place the load when carrying heavy objects?
A. In a low position
B. To the side of the body
C. Close to the body midline
D. With another's assistance
5. The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal
physiological activities. What will the nurse relay as a requirement?
A. Strength
B. Wellness
C. Alertness
D. Mobility
6. The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures.
What will the nurse be sure to include when counseling this patient?
A. The need for additional calcium
B. The need for additional protein
C. The need for some type of exercise
D. The need for a special protective bed
7. What is the term for range of motion (ROM) when it is performed by the patient?
A. Assisted
B. Passive
C. Active
D. Coordinated
8. The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the
joint through ROM?
A. The fullest extent
B. Place the joint in normal position
C. The point of pain
D. Relax the patient
9. How should the nurse assist the patient with moving when pain is anticipated?
A. Be supportive
B. Apply heat before moving them
C. Administer medication before ambulation
D. Obtain assistance if the patient is heavy
10. The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may
safely lift by herself?
A. 158.75 lb.
B. 168.75 lb.
C. 178.75 lb.
D. 188.75 lb.
11. What is the site of the most common strain injury acquired by the nurse when working?
A. Trapezius muscle group
B. Thoracic muscle group
C. Lumbar muscle group
D. Thigh muscle group
12. What implementation might the nurse use to improve safety during a transfer?
A. Weighing the patient first
B. Using a transfer belt
C. Putting shoes on the patient
D. Supporting a flaccid arm
13. What is considered to be the minimum number of hours of daily activity necessary to prevent the
negative consequences of immobility?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
14. The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury.
What is the number of times the nurse should move each joint when performing passive range-of-motion
(ROM) exercises?
A. Three
B. Four
C. Five
D. Six
15. What profession has the highest workers' compensation claim rates of any occupation or industry?
A. Firefighters
B. Truck drivers
C. Law enforcement
D. Nursing personnel
16. A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse
intervene when observing the nursing assistant perform a return demonstration?
A. The nursing assistant is using simple language.
B. The nursing assistant is avoiding jerky movements.
C. The nursing assistant is avoiding sudden movements.
D. The nursing assistant is pulling the patient across bed linens.
17. The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would
indicate that this patient is in the correct position?
A. Patient is leaning over the bedside table
B. Head of bed is at a 30-degree angle
C. Knee is drawn toward the chest
D. Arms are flexed toward the head
18. A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term
care facility. What information will be included regarding considerations of mobility and the older adult?
(Select all that apply.)
A. The skin of older adults is more fragile and susceptible to injury.
B. Always support older adults under the soft tissue when moving them in bed.
C. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest.
D. Aging tends to result in loss of flexibility and joint mobility.
E. Older adults sometimes become fearful when hydraulic lifts are used for transfers.
19. The nurse receives a patient from the recovery room following total hip replacement surgery. What
will the nurse include when assessing neurovascular status on this patient? (Select all that apply.)
A. Pupils
B. Pain
C. Sensation
D. Color
E. Skin temperature
20. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the
nurse to ______ and lift at the same time.
ANS: twist
21. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of
_____times the length of the nurse's shoe.
ANS: 1.5
22. When a fall occurs, the nurse should document the incident and initiate a(n) ____report.
ANS: incident
23. ______machines flex and extend joints to mobilize them passively without the strain of active
exercises.
ANS: Continuous passive motion (CPM)
24. The nurse points to the X in the illustration below and describes this point as the____ of _____.
ANS: center, gravity
25. Place the nursing activities in priority order for the preparation of a patient to ambulate. Put a comma
and space between each answer choice (A, B, C, D, etc.). ANS: DEABC
A. Dangle the patient at the side of the bed
B. Apply a gait belt
C. Assist the patient to stand
D. Inform the patient of activity
E. Roll up the head of the bed
26. Place the initial nursing activities in priority order for preparing to move a patient. Put a comma and
space between answer choice. (A, B, C, D, etc.).
A. Explain procedure
B. Perform hand hygiene
C. Prepare patient
D. Introduce self
E. Identify patient
27. A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should
the nurse perform first?
A. Determine if the client can bear weight.
B. Place a transfer belt on the client.
C. Position the bed at an appropriate height.
D. Assist the client to a seated position.
28. A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the
following methods should the nurse plan to use?
A. One nurse lifting as the clients pushes with his feet.
B. Two nurses lifting the client under the shoulders.
C. One nurse lifting the client's legs as the client uses a trapeze bar.
D. Two nurses using a friction reduction device.
29. A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the
following terms should the nurse document when the client brings her fingers together, closing the spaces
between them?
A. Abduction
B. Flexion
C. Adduction
D. Extension
30. A nurse is assisting a client with range-of-motion exercises of the thumbs. Which of the following
terms should the nurse document when the client moves his thumb across the palm of his hand?
A. Flexion
B. Abduction
C. Opposition
D. Adduction
31. An older adult client in a tong-term care facility had a stroke 4 weeks ago and has been unable to
move independently since that time. The nurse caring for her should observe for which of the following
findings that indicates a complication of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities
D. Difficulty hearing some types of sounds
32. A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The
client spends most of his day in a reclining chair. Which of the following physiological responses to
prolonged immobility should the nurse expect?
A. Increased insulin production
B. Decreased RBC production
C. Decreased sodium excretion
D. Increased calcium excretion
33. A nurse is assisting a client with range-of-motion exercises of the elbows. When instructing the client
in the essential motions to use when exercising her elbows, the nurse should explain that she can
remember these motions by recalling that the elbow is which of the following types of joints?
A. Hinge
B. Saddle
C. Gliding
D. Ball and socket
34. A client is recovering from a cerebrovascular accident (CVA). Which of the following information
should the nurse include when teaching family members about repositioning? (Select all that apply.)
A. Remove pillows prior to repositioning.
B. Elevate the bed to waist height.
C. Position the client towards the edge of bed with a foam wedge.
D. Stand with feet wide apart.
E. Face the direction of movement when positioning the client.
35. A nurse is monitoring a client for complications of immobility. Which of the following does the nurse
expect to find? (Select all that apply.)
A. Contractures of extremities
B. Decreased pain
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers
36. A nurse is talking with an older adult client who has osteoarthritis about joint protection strategies.
Which of the following recommendations should the nurse reinforce?
A. Jog or run three times a week.
B. Decrease the use of caffeine.
C. Maintain the recommended body weight.
D. Reduce the amount of purine in the diet.
Chapter 10 Safety
1. The nurse manager is providing an in-service regarding a "safe hospital environment." What will this
education mainly focus on preventing?
A. Falls
B. Exposure to contaminants
C. Injury
D. Electrical hazard
2. What is important for the nurse to determine in order to decrease the risk for injury to a patient?
A. If patient can read English
B. If patient is left-handed
C. If patient is able to eat unassisted
D. If patient can dress independently
3. What skills should health care workers frequently attend in-services about to ensure that staff has
competent skills and risk for falls can be decreased?
A. Bathing
B. Feeding
C. Transferring
D. Ambulating
4. What important safety precaution should the home health nurse teach parents in order to prevent burns
to small children?
A. Never leave them unattended
B. Turn pot handles on stoves away from reach
C. Turn hot water on first when filling the bathtub
D. Keep side rails up on the crib
5. What must the nurse do before applying a safety reminder device (SRD)?
A. Get permission from the family
B. Assess patient's skin condition
C. Get a physician's order
D. Explain the SRD to the patient
6. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?
A. Give the patient a straw
B. Dilute the coffee with cold water
C. Fill the cup half full
D. Offer a bib or an apron
7. What type of fire extinguisher should the nurse use when the oxygen concentrator machine
malfunctions and causes an electrical fire?
A. Type A
B. Type B
C. Type C
D. Type D
8. A disaster situation occurs and involves an explosion in a hospital laundry. What would this be
classified as?
A. Active
B. External
C. Life-threatening
D. Internal
9. The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive
the best assistance for dealing with this victim?
A. American Red Cross
B. Fire department paramedics
C. Poison control center
D. Civil defense office
10. A nurse instructs a nursing assistant about the proper use of a gait belt and is observing a return
demonstration. What action by the nursing assistant should cause the nurse to intervene?
A. Nursing assistant is walking on the patient's strong side
B. Nursing assistant is walking to the side of the patient
C. Nursing assistant is securing the gait belt securely around the patient's waist
D. Nursing assistant is grasping the handles of the gait belt while the patient ambulates
11. What should a nurse do when encountering a mercury spill?
A. Vacuum the spill
B. Open interior doors
C. Close all outside windows
D. Open any outside windows
12. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse
take? (Select all that apply.)
A. Walk on the patient's right side
B. Keep the patient away from heavy furniture
C. Hold the patient's arm securely
D. Keep the leg nearest the patient behind the patient's knee
E. Use a gait belt
13. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may
increase because of the use of SRDs? (Select all that apply.)
A. Immobility
B. Lethargy
C. Risk for impaired circulation
D. Risk for skin impairment
E. Incontinence
14. A long-term care facility is committing to a restraint-free environment. What will the health care
workers implement to encourage this environment? (Select all that apply.)
A. Frequent orientation to surroundings
B. Explain all procedures and treatments
C. Discourage visitors
D. Maintain toileting routines
E. Minimize exercise and ambulation
15. ______ is a violent or dangerous act used to intimidate or coerce a person or government to further a
political or social agenda.
ANS: Terrorism
Terrorism is a violent or dangerous act used to intimidate or coerce a person or government to further a
political or social agenda.
16. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the
final "S" stands for _______.
ANS: sweep
The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep.
17. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as
weapons. An agent that does not seriously damage or kill the target population but only impairs it is
classified as________.
ANS: incapacitating
The agent that only impairs the target rather than killing or seriously damaging it is classified as an
incapacitating agent.
18. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of
Gy an individual may absorb before becoming ill with radiation syndrome is ______.
ANS: 0.75
The amount of radiation absorbed is measured by the Gy. 1 Gyis equal to 100 rad. Absorption of 0.75 Gy
will cause the individual to develop acute radiation syndrome.
19. A nurse is assisting a client who has generalized weakness out of bed to a wheelchair. Which of the
following actions should the nurse take?
A. Place the wheelchair at a 90° angle to the bed.
B. Lock the wheels of the bed and the wheelchair.
C. Get the help of several staff members to lift the client.
D. Elevate the bed to a position of comfort for the nurse.
20. A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick
injuries. Which of the following actions should the nurse recommend?
A. Place uncapped needles in a puncture-proof container after use.
B. Do not recap the needle on an ABG specimen.
C. Recap needles and place them in a wastebasket.
D. Break needles in half before putting them in the sharps disposal box.
21. A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her
throat with her hands, and cannot talk. Which of the following actions should the nurse take?
A. Assist the guest to the floor and begin mouth-to-mouth resuscitation.
B. Observe the quest before taking further action.
C. Perform the Heimlich maneuver on the guest.
D. Slap the guest on the back several times.
22. A nurse notes that a client's IV tubing has disconnected frowine I catheter, resulting in the client’s
blood spilling onto the sides of the bed and the floor. Which of the following solutions should the nurse
use to disinfect the spill?
A. Isopropyl alcohol
B. Chlorine bleach solution
C. Soap and water
D. Chlorhexidine
23. A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific
exercises for him. Which of the following activities should the nurse suggest?
A. Tennis
B. Canoeing
C. Swimming
D. Archery
24. A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Which
of the following interventions should the nurse contribute to the client's care plan? (Select all that apply.)
A. Document restraint checks every 2 hr.
B. Educate the client's family about restraint use.
C. Obtain the provider's prescription renewal every 72 hr.
D. Implement passive range-of-motion exercises.
25. A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to
determine the client's level of strength?
A. Ask the client how strong she feels today.
B. Ask the client if she has been out of bed today.
C. Check the client's pedal pulses and feet for edema.
D. Ask the client to push her legs and feet against the nurse's palms.
26. A nurse is caring for a client whose hand movement is limited. Which of the following actions should
the nurse take to assist the client with feeding?
A. Place the client in a lateral position.
B. Provide an adaptive feeding device for the client.
C. Initiate a liquid diet for the client.
D. Arrange the food groups clockwise on the plate.
27. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for
an escharotomy and wants to know what the procedure involves. Which of the following statements is
appropriate for the nurse to make?
A. "It surgically removes dead tissue.
B. "Puncture holes will be made in the skin to allow drainage of fluids
C. "A piece of skin will be removed and grafted over the burned area.
D. "Large incisions will be made in the burned tissue to improve circulation.”
28. A nurse is collecting data on the depth and extent of a client who has severe burns to the face, neck,
and upper extremities. Which of the following factors is the first priority when assessing the severity of
the burn?
A. Age of the client
B. Associated medical history
C. Location of the burn
D. Cause of the burn
29. Nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred
speech. Which of the following are appropriate actions by the nurse?
A. Obtain the number of the client's provider.
B. Find a location for the client to sit.
C. Call emergency management services.
D. Drive the client to the nearest emergency treatment
30. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a
stroke. Which of the following actions should the nurse take?
A. Instruct the client to tilt her head back when she swallows.
B. Place food on the left side of the client's mouth.
C. Add thickener to fluids.
D. Serve food at room temperature.
31. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and
chest. The nurse should recognize which of the following is the priority risk to the client?
A. Airway obstruction
B. Infection
C. Fluid imbalance
D. Contractures
32. A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on
the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom,
using an IV pole for support. Which of the following actions should the nurse take?
A. Walk the client back to bed immediately and get the client a bedpan.
B. Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
C. Warn the client she might have to be restrained if she gets up without assistance.
D. Keep the bathroom door open to ensure the client is okay.
33. A nurse is reinforcing teaching nursing students with which is the IV solution of choice for fluid
resuscitation in patients with burns?
A. Dextrose 5% in water
B. Dextrose 5% in Lactated Ringers
C. Normal saline solution
D. Dextrose 10 % in water
34. A nurse is reinforcing teaching nursing students with which of the following is the most common
cause of death in the first 24 hours of patients with severe burns?
A. Acute kidney failure
B. Hypovolemic shock
C. Sepsis
D. Hypoglycemia
35. A nurse is reinforcing teaching nursing students with which of the following is the total surface area
burned for a client who burned his whole head, the anterior chest, the left upper extremity and half of the
right upper extremity?
A. 27
B. 31.5
C. 36
D. 27.5
36. A nurse is reinforcing teaching nursing students with which of the following is the total surface area
burned for a client who burned his anterior trunk, the genital, the whole left lower extremity and the right
anterior thigh?
A. 37.5
B. 41.5
C. 32.5
D. 46
37. A nurse is reinforcing teaching nursing students with which of the following is the most fatal type of
burns?
A. Radiation
B. Chemical
C. Electrical
D. Combustible
38. A nurse is reinforcing teaching nursing students with which of the following is the type of burn that
the patient will not feel any pain?
A. First degree
B. Second degree
C. Third degree
D. All degrees have pain
39. A nurse is reinforcing teaching nursing students with which of the following is the type of bum is a
blister?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
40. A nurse is reinforcing teaching nursing students with which of the following is the type of burn that
involves all the layers of the skin?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
41. A nurse delegates the application of wrist restraints for a client who is confused to an assistive
personnel (AP). The AP padded the wrist restraints and secured the straps to the bed frame with a double
knot. Which of the following actions should the nurse take?
A. Retie the restraint straps with a slipknot.
B. Check that three fingers will fit beneath the restraints.
C. Retie the restraint straps to the side rails.
D. Remove the padding under the wrist restraints.
42. A nurse is caring for a client when the safety on the bed plugs electrical outlet pops and begins to
smoke. Which of the following actions is the nurse’s priority?
A. Use a fire extinguisher on the outlet.
B. Activate the fire alarm.
C. Close the fire doors on the unit.
D. Move any clients in the immediate vicinity
43. A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the
floor. Which of the following actions should the nurse take first?
A. Assist the client back into bed.
B. Inform the client's family member.
C. Notify the client's provider.
D. Obtain the client's vital signs.
44. A nurse is caring for a client who is confused and has pulled out his peripheral IV catheter three
times. Which of the following actions should the nurse consider?
A. Administer a mild sedative to the client.
B. Place mitt restraints on the client's hands.
C. Reorient the client to time, place, and person.
D. Move the client close to the nurses' station.
45. A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls.
Which of the following actions should the nurse contribute to the plan? (Select all that apply)
A. Keep a night light on the client’s room and bathroom
B. Keep the bed at a comfortable working height.
C. Lock the wheels on beds and wheelchairs during transfers.
D. Place the bedside table within the client's reach.
E. Administer a sedative at bedtime.
46. A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the
safest method of transfer, which of the following is most important for the nurse to determine?
A. The client's ability to communicate
B. The client's current weight-bearing status
C. The client's activity tolerance
D. The type of equipment the staff used to transfer the client in the past
47. A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the
following statements should the nurse identify as an indication that the client understands the
instructions?
A. "I will keep my walker at the end of my bed."
B. "I will keep the fluorescent ceiling light on in my room at night."
C. "I will place an area rug at the entry of my bathroom."
D. "I will place a bath seat in my shower to use when I bathe."
48. A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the
following methods should the nurse plan to use?
A. One nurse lifting as the client pushes with his feet
B. Two nurses lifting the client under the shoulders
C. One nurse lifting the client's legs as the client uses a trapeze bar
D. Two nurses using a friction-reducing device
49. A nurse is working a night shift and caring for several clients at risk for falls. Which of the following
actions should the nurse take? (Select all that apply.)
A. Keep the clients' rooms dark.
B. Instruct the clients to use the call light.
C. Move overbed tables away from the bed.
D. Place a fall risk wristband on each of the clients.
E. Perform client checks every 4 hr
50. A nurse reinforces teaching nursing students with which of the following nursing interventions is
done to determine adequate fluid resuscitation in patients with severe burns?
A. Insertion of a foley catheter
B. Insertion of nasogastric tube
C. Insertion of a tracheostomy tube
D. Insertion of a gastrostomy tube
Chapter 19 Nutrition
1. The nurse makes nutrition a focus in the care plan. Where does nutrition play the most important role?
A. Weight control
B. Sustained Appetite
C. Building Strong Bones
D. Health maintenance
2. The nurse is explaining the activity recommendations from the USDA's new MyPlate plan. What is the
minimum amount of moderate weekly exercise needed to balance nutritional intake?
A. 15 minutes
B. 1 hour and 15 minutes
C. 2 hours and 30 minutes
D. D. 60 minutes
3. What are elements that are found in food and necessary for good health but that the body cannot make?
A. Important nutrients
B. Life-saving nutrients
C. Essential Nutrients
D. Necessary nutrients
4. To demonstrate the energy-producing potential of different foods, the nurse explains that 3 g of lean
meat produces 12 kcal/g. How many kcal/g does 3 g of fish oil produce?
A. 6 kcal/g
B. 15 kcal/g
C. 21 kcal/g
D. 27 kcal/g
5. What has replaced the USDA's Recommended Dietary Allowance (RDA)?
A. Nutrition Recommended Allowance (NRA)
B. National Bionutritional Allowance(NBA)
C. Dietary Reference Intake (DRI)
D. Dietary Guidelines for Americans (DGA)
6. How many kcal/g does 1 g of alcohol provide?
A. 4 kcal/g
B. 5 kcal/g
C. 6 kcal/g
D. 7 kcal/g
7. The nurse is educating a group of high school students regarding nutrition. How should the nurse
respond when the students ask what occurs when protein, mineral, iron, and fat combine?
A. Body processes are regulated
B. Energy is provided
C. Tissue is built and repaired
D. Body function is restored
8. When reviewing a patient's dietary intake, the nurse recommends that sugar consumption be reduced to
the recommended daily level. What is this level?
A. No more than 24% of total daily kilocalories
B. No more than 16% of total daily kilocalories
C. No more than 8% of total daily kilocalories
D. No more than 4% of total daily kilocalories
9. What is the body's storage form of carbohydrates, usually found in the liver with some storage in the
muscles?
A. Sugar
B. Glucose
C. Lipids
D. Glycogen
10. What is the term for stored fat that insulates the body and serves as a cushion to protect organs?
A. Subcutaneous tissue
B. Adipose tissue
C. Cohesive tissue
D. Lipid tissue
11. The nurse is providing information about high cholesterol levels. What is the rationale for avoiding
saturated fats?
A. They block absorption of nutrients
B. They interfere with metabolism
C. They increase blood cholesterol
D. They must be hydrogenated
12. When discussing the digestion and metabolism of fat, the nurse tells the patient who has a history of
cholecystitis and who is on a low-fat diet that fat must be emulsified to be digested. What is the substance
necessary for emulsification?
A. Sugar
B. Cholesterol
C. Bile
D. Protein
13. The body uses 22 common amino acids, but 9 of them must be obtained from protein in the diet. What
are these proteins considered?
A. Essential
B. Basic
C. Fundamental
D. Primary
14. The nurse is educating a patient on a vegan diet. What supplement will the nurse encourage this
patient to take to avoid a deficiency?
A. B6
B. B12
C. K
D. D
15. A fit, young woman was at zero nitrogen balance. The nurse discovers that this patient is now
pregnant with her first child. For what is this patient at risk?
A. Embolism
B. Anabolism
C. Catabolism
D. Metabolism
16. The nurse explains that a patient with a heart problem should follow a decreased sodium diet. What
will this diet help reduce the risk for or prevent?
A. Stroke
B. Fluid excretion
C. Heart attacks
D. Obesity
17. The patient complains to the nurse that he feels terrible since he has been taking several different
kinds of vitamin preparations. What should the nurse assess for indications of vitamin toxicity?
A. Edema
B. Hypertension
C. Fatigue
D. Diarrhea
18. The nurse cautions a patient with a pancreatic disorder that will interfere with the digestion of fats and
may lead to a clotting disorder. What is the cause of these potential problems?
A. Inability to use vitamin B
B. Inability to use vitamin C
C. Inability to use vitamin D
D. Inability to use vitamin K
19. The home health nurse is caring for a patient that has undergone removal of a part of the stomach. For
what should the nurse carefully assess this patient?
A. A stomach ulcer
B. Digestive problems
C. Pernicious anemia
D. Malabsorption
20. A patient taking a diuretic is assessed by the nurse as having an erratic pulse and muscle weakness.
What should the nurse suspect is deficient?
A. Sodium
B. Potassium
C. Chloride
D. Iron
21. A patient who has hypertension is complaining about the lack of taste with the low- sodium diet that
has been prescribed. What should the nurse emphasize that sodium may do?
A. Contribute to hypertension
B. Interfere with blood clotting
C. Produce stomach ulcers
D. Decrease calcium in the bones
22. The young woman who is breastfeeding will need an increase of calories and protein. What foods
should the nurse suggest as sources of protein?
A. Green, leafy vegetables
B. Citrus Fruits
C. Asparagus
D. Nuts
23. At approximately 4 to 6 months of age, solid food is introduced to a baby. What foods with high iron
content should be recommended by the nurse?
A. Pureed fruit
B. Fortified cereals
C. Fruit juice
D. Rice
24. A school nurse is teaching a group of adolescents about adequate nutrition. What increased intake
should the nurse encourage?
A. Potassium and sodium
B. Chloride and magnesium
C. Iron and calcium
D. Vitamins and minerals
25. A nurse caring for a patient who is prescribed a full-liquid diet recognizes that this diet lacks some
nutrients. What nutrients are lacking?
A. Fat-soluble vitamins
B. Potassium
C. Iron and fiber
D. Water-soluble vitamins
26. The nurse has assessed a patient's body mass index (BMI) to be 19.6. This assessment of weight
versus height indicates that this patient's weight category is in which category?
A. Low health risk
B. Overweight
C. Obese
D. Morbidly obese
27. What eating disorder is characterized by body image distortion, excessive exercise, and vicarious
enjoyment of food?
A. Self-fasting
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating
28. The nurse is counseling a patient about the difference between type 1 and type 2 diabetes. What
should the nurse stress that patients with type 2 diabetes are required to receive on a daily basis?
A. Regular carbohydrate-controlled meals
B. Oral hyperglycemic agents
C. Insulin injections
D. Stringent low-calorie diets
29. Careful attention to carbohydrate consumption can improve metabolic control of diabetes. The nurse
teaches a meal planning approach that focuses on the total amount of carbohydrates eaten at a meal. What
is this meal planning approach called?
A. Carbohydrate splitting
B. Reduced caloric intake
C. Carbohydrate counting
D. Carbohydrate balancing
30. The patient who had a gastrostomy complains to the nurse about frequent episodes of dumping
syndrome. What can the nurse recommend to this patient to decrease this problem?
A. Eat small, frequent meals
B. Include more fiber in meals
C. Increase seasoning on food
D. Limit intake to semi-liquids
31. The nurse reminds the male patient with lactose intolerance that he can avoid the unpleasant
symptoms of nausea, bloating, flatulence, and diarrhea, if he will avoid certain foods. What product
should the patient be instructed to avoid?
A. Soy beans
B. Rice
C. Milk
D. High fiber
32. A patient diagnosed with renal failure is unable to excrete protein waste products and develops a
condition that requires a protein-restricted diet. The nurse instructs the patient that azotemia can be
diminished by substituting other food groups for protein. What is an example of a food that this patient
can substitute for protein?
A. Potatoes
B. Beans
C. Cheese
D. Soy products
33. What is a nursing intervention to decrease the thirst of a patient who is on a fluid restriction?
A. Rinsing the mouth with warm water
B. Sipping carbonated drinks
C. Sucking on occasional ice chips
D. Limiting tooth brushing to once per day
34. The nurse recognizes that when a patient is unable to consume adequate nutrition by mouth, an
alternative route such as a feeding ostomy may be used. What is the proper term for feeding a patient by
this method?
A. Total parenteral nutrition (TPN)
B. Nasogastric
C. Enteral
D. Parenteral
35. The nurse teaches a patient who has a nonfunctioning or dysfunctional GI tract that total parenteral
nutrition (TPN) will be infused. Where will the infusion occur?
A. Through the carotid artery
B. Through the superior vena cava
C. Through the femoral vein
D. Through the inferior vena cava
36. Which are the energy-providing food groups? (Select all that apply.)
A. Carbohydrates
B. Fats
C. Proteins
D. Vitamins
E. Minerals
37. To simplify food values, the measurement of energy obtained by food is defined as the_______.
ANS: kilocalorie
38. The body mass index (BMI) of a man 6 feet tall weighing 250 pounds is _______.
ANS: 33.9
39. ______softens stools, speeds transit of foods through the digestive tract, and reduces pressure in the
colon.
ANS: Insoluble fiber
40. Which of the following organs produce a substance that emulsifies fat?
A. Gallbladder
B. Liver
C. Common bile duct
D. Small intestine
41. The end product of digestion for fat:
A. Amino acid
B. Glycerol
C. Glycogen
D. Sucrose
42. Saliva has a digestive enzyme, amylase, which digests carbohydrates. What is another name, this
enzyme is called?
A. Pepsin
B. Trypsin
C. Ptyalin
D. Gastrin
43. Where in the gastrointestinal tract is complete digestion taking place?
A. Duodenum
B. Jejunum
C. Ileum
D. Large intestine
Chapter 22 Surgical Wound Care
1. The nurse instructs a patient who has a drain in a surgical wound that the wound will heal by:
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Deliberate intention
2. To assist the postoperative patient to cough, the nurse:
A. Supports the patient's back.
B. Offers antitussive.
C. Splints the abdomen with a pillow.
D. Leans patient against the bedside table.
3. The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this
drainage as:
A. Serosanguineous.
B. Sanguineous.
C. Serous.
D. Purulent.
4. The nurse explains that the advantage of an occlusive dressing is that it:
A. Allows air to the incision.
B. Keep the incision moist.
C. Delayed epithelialization.
D. Does not have to be changed.
5. When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should:
A. Call the RN.
B. Gently remove the gauze with sterile forceps.
C. Cover with occlusive dressing.
D. Moisten the dressing with sterile water.
6. The nurse instructs the patient in home wound irrigation to hold the hand-held shower head
approximately ______ inches from the wound.
A. 2.5
B. 6
C. 12
D. D. 18
7. The nurse follows the basic concept of wound irrigation when directing the flow of the irrigate:
A. From the area of least contamination to the area of most contamination.
B. Forcefully into the wound.
C. Gently over the skin into the wound.
D. From a distance of about 12 inches.
8. The nurse observes a loop of bowel protruding from the surgical incision. The nurse's initial
intervention should be to:
A. Call the RN.
B. Cover the bowel with a sterile saline dressing.
C. Turn the patient to the side of the evisceration.
D. Raise the patient up to a high Fowler's position.
9. The nurse is removing every other staple from a surgical wound, which has been closed with 15
staples. If the wound begins to separate after removal of 3 of the 15 staples, the nurse should:
A. Remove 7 more alternate staples and securely tape with Steri-Strips.
B. Cover with moist dressing and apply a binder.
C. Continue to remove staples as ordered because this is an expected outcome.
D. D. Leave the 12 staples in place and record the separation.
10. Because the physician has not ordered a dressing change for a draining wound, the nurse should
assess the amount of drainage by:
A. Weighing the patient to estimate the weight of the saturated dressing.
B. Reinforcing the dressing.
C. Circling and dating the outline of the exudate on the dressing.
D. Counting each dressing as 1 mL of drainage.
11. The Centers for Disease Control (CDC) classifies wounds according to the amount of contamination.
An uninfected surgical wound with less than a 5% chance of becoming infected postoperatively is
classified as a:
A. Dirty wound.
B. Clean-contaminated wound.
C. Contaminated wound.
D. Clean wound.
12. Hemostasis (termination of bleeding) begins as soon as the injury occurs and a clot begins to form.
The substance in the clot that holds the wound together is:
A. Fibrin.
B. Thrombin.
C. Protime.
D. Calcium.
13. When blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain, the
nurse knows that the wound is in which phase?
A. Healing
B. Inflammatory
C. Reconstruction
D. D. Maturation
14. Primary intention has a marked advantage over other phases of wound healing because:
A. Healing is rapid.
B. Healing rarely becomes Infected.
C. Minimal scarring results.
D. Healing is painless.
15. For the first 24 hours following surgery, the nurse assesses for bleeding by observing the dressing and
the area under the patient every:
A. 30 minutes.
B. 60 minutes.
C. 2 to 4 hours.
D. 5 to 8 hours.
16. To keep the patient comfortable during a dressing change, the nurse may administer an analgesic:
A. After the dressing change.
B. At least 15 minutes before the dressing change.
C. At least 30 minutes before the dressing change.
D. At least 1 hour before the dressing change.
17. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying
process causes it to adhere to the wound, which when removed results in:
A. Destruction of tissue.
B. Bleeding.
C. Mechanical debridement.
D. Prevention of infection.
18. During assessment of a postoperative patient, the nurse discovers that the pulse is rapid, blood
pressure has decreased, urinary output has decreased, and the dressing is dry. The nurse recognizes these
findings as indicative of:
A. Pain shock.
B. Pehydration.
C. Internal hemorrhage.
D. D. Acute infection.
19. The usual length of time before suture removal is:
A. 2 to 3 days.
B. 4 to 5 days.
C. 5 to 6 days.
D. 7 to 10 days.
20. The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a
Jackson-Pratt drain. It is considered abnormal if the drainage exceeds:
A. 50 mL.
B. 100mL.
C. 200mL.
D. 300 mL.
21. The nurse recognizes that the Jackson-Pratt drainage removal system is classified as a(n):
A. Sterile drainage system.
B. Closed drainage system.
C. Open drainage system.
D. Self-measuring drainage system.
22. The nurse caring for a patient with a surgical wound promotes healing by:
A. Offering fluids every 4 hours.
B. Encouraging the consumption of large meals.
C. Encouraging up to 1000 mL of daily fluid intake.
D. Encouraging the consumption of small frequent meals.
23. The nurse is instructing a patient about the effects of smoking. What accurate information does the
nurse provide?
A. Smoking increases the amount of tissue oxygenation.
B. Smoking increases the amount of functional hemoglobin in blood.
C. Smoking may decrease platelet aggregation and cause hypercoagulability.
D. Smoking interferes with normal cellular mechanisms that promote release of oxygen
24. The nurse instructing a patient about the effects of diabetes mellitus informs the patient that diabetes
mellitus:
A. Improves overall tissue perfusion.
B. Promotes release of oxygen to tissues.
C. Causes hemoglobin to have a greater affinity for oxygen.
D. Causes hemoglobin to have a decreased affinity for oxygen.
25. The nurse assessing a patient's wound notes a clear watery drainage. The nurse documents this finding
as:
A. Serous drainage.
B. Purulent drainage.
C. Sanguineous drainage.
D. Serosanguineous drainage.
26. The nurse assessing a patient's wound notes thick, yellow drainage. The nurse documents this finding
as:
A. Serous drainage.
27. The nurse assessing a patient's wound notes pale red watery drainage. The nurse documents this
finding as:
A. Serous drainage.
28. The nurse assessing a patient's wound notes bright red drainage. The nurse documents this finding as:
A. Serous drainage.
29. The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling
that his surgical incision has separated. The nurse recognizes this as an indication of:
A. Cellulitis.
B. Dehiscence.
C. Evisceration.
D. Extravasation.
30. The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as
ordered by the health care provider. What is an advantage of gauze bandages?
A. Provision of warmth.
B. Applies strong pressure.
C. Antibacterial effects.
D. Prevents skin maceration.
31. A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a stage 2 foot
injury. The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly
obese. The nurse assesses the injury to be healing, free from signs and symptoms of infection, with a
positive pedal pulse and warm to touch. What patient problem will be identified as a priority?
A. Infection
B. Altered nutrition: more than body requirements
D. Altered peripheral tissue perfusion
32. The nurses employed at a wound therapy clinic are preparing an educational in-service about the
vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in
this in-service? (Select all that apply.)
A. Positive pressure is applied by this device.
B. Healing is facilitated by decrease in drainage.
C. Promotes formulation of granulation tissue.
D. Reduces local and peripheral edema.
E. Drops bacterial level in wound.
33. Which are the phases of wound healing? (Select all that apply.)
A. Reconstruction
B. Hemostasis
C. Inflammatory
D. Granulation
E. Maturation
34. Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.)
A. Normal saline
B. Lactated Ringer's
C. Acetic acid
D. Dakin's
E. Lysol
35. What are the advantages of a transparent dressing? (Select all that apply.)
A. Adheres to undamaged skin.
B. Contains the exudate.
C. Reduces wound contamination.
D. Serves as a barrier to external bacteria.
E. Slows epithelial growth.
36. The nurse assures a patient that the purple, raised, immature scar of his surgical wound is
normal and caused by _______ formation.
ANS: collagen
37. The nurse encourages a patient recovering from a hysterectomy to drink at least _______
mL of fluid a day.
ANS: 2000
38. When preparing to remove a dressing, the nurse should don __________ gloves.
ANS: clean
39. Nurse reinforces teaching nursing students with which of the following is a wound in the nostril for a
rhinoplasty be classified?
A. Clean
B. Clean-contaminated
C. Contaminated
D. Dirty
32. A nurse reinforces teaching nursing students with which of the following is a wound in the uterus in a
caesarean section be classified?
A. Clean
C. Contaminated
D. Dirty
33. A nurse reinforces teaching nursing students with which of the following is a wound in an
appendectomy be classified?
A. Clean
C. Contaminated
D. Dirty
34. A nurse reinforces teaching nursing students with which of the following is a wound with clean-cut
edges be classified?
A. Incision
B. Laceration
C. Punctured wound
D. Abrasion
35. A nurse reinforces teaching nursing students with which of the following is a wound with skin and
part of muscle hanging on the tip of the thumb be classified?
A. Avulsion
B. Laceration
C. Punctured wound
D. Abrasion
36. A nurse reinforces teaching nursing students with which of the following is the the most common
cause of death in the first 24 hours of severely burned patients?
A. Infection
C. Sepsis
D. Neurogenic shock
37. A nurse reinforces teaching nursing students with which of the following is the the most common
cause of death after 48 hours of severely burned patients?
A. Infection
C. Cardiogenic shock
D. Neurogenic shock
38. A nurse reinforces teaching nursing students with which of the following is a wound with perforation
of the large colon caused by a stabbed wound be classified?
A. Clean
C. Contaminated
D. Dirty
39. A nurse reinforces teaching nursing students with which of the following is percentage of potential
infection of a contaminated wound?
A. 5%
B. 11%
C. 22%
D. 40%
40. A client was involved in a fire which burned his whole head, left upper extremity, anterior chest and
the right upper arm. Compute for the total surface areas burned.
A. 27.5
B. 31.5
C. 36
D. 40.5

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Chapter 2 Legal and Ethical Aspects of nursing

1. What is true regarding surgical asepsis?

The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep.

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