Chapter 1:

A group of students are discussing the impact of non-nursing theories in clinical practice. The
students would be correct if they chose which theory to prioritize patient care?
Maslow’s Hierarchy of Needs

A nursing student is preparing study notes from a recent lecture in nursing history. The student
would credit Florence Nightingale for which definition of nursing?
The imbalance between the patient and the environment decreases the capacity for health.

Which nurse established the American Red Cross during the Civil War?
Clara Barton

The nurse is caring for a patient who refuses two units of packed red blood cells. The nurse
notifies the health care provider of the patient’s decision. The nurse is acting in the role of the:
Advocate.

A newly licensed registered nurse is curious about the scope of care that she has in caring for
patients undergoing conscious sedation. Which would be the best source of information?
Nurse Practice Act

Which statement contributes to the understanding that nursing is considered a profession? (Select
all that apply.)
Nursing requires specialized training.
Nursing has a specialized body of knowledge.
Nurses make independent decisions within their scope of practice.

Chapter 26:
The nurse administers an immunization consisting of antibodies against hepatitis B. The nurse
knows this is a form of what type of immunity?
Artificially acquired passive

The nurse is explaining to the patient why she is receiving antibiotics. Her answer would be
correct if she stated antibiotics are effective against which microorganism?
Bacteria

The nurse correctly identifies that the most effective method to prevent hospital-acquired
infections is:
Handwashing

The nurse correctly identifies which patient as having the greatest risk for infection?
An 80-year-old male with an enlarged prostate

The nurse is preparing to perform suctioning on a new tracheostomy with the potential for
forceful expulsion of secretions. What PPE should be worn?
Eyewear, mask, gown, gloves
The patient has hepatitis A. Which isolation precaution is correctly implemented?
Contact
The patient has pertussis. What isolation precaution is correctly implemented?
Droplet

Chapter 5:
The nursing process is the foundation of professional nursing practice. As such, the nursing
process can be defined as:
The framework that nurses used to provide care.

The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The
health history is conducted in which step of the nursing process?
Assessment

The nurse is assisting a patient to bed when the patient says, “My chest hurts and my left arm
feels numb. What’s wrong with me?” What is the type and source of data obtained from the
patient’s complaint?
Subjective data from a primary source

Which of the following is a correctly written nursing diagnosis appropriate for a patient’s plan of
care?
Ineffective airway clearance related to excessive secretions as evidenced by diminished breath
sounds.

A patient with a congenital heart defect is admitted for further testing. The nurse observes the
patient has increased shortness of breath and is restless. The nurse is demonstrating which phase
of the nursing process?
Assessment

During a patient’s bath, the nurse observes the patient having a tonic clonic seizure. The nurse
immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of
the nursing process?
Implementation

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify
interventions to address the patient goals?
Planning

The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal
that contains all of the necessary elements is:
The patient will walk to the bathroom without experiencing shortness of breath within 48 hours
after surgery.

A new community health nurse observes that a patient has generalized itching and a red rash
after touching a latex glove. The nurse asks the manager if there is a document written by the
physician for this type of reaction. The nurse is referring to a:
standing order.
The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a
patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?
Implementation

Which of the following statements would be considered objective data? (Select all that apply.)
“Blood pressure 90/68, apical pulse 102, skin pale and moist.”
“Lung sounds clear bilaterally, diminished in right lower lobe.”

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that
nursing diagnoses: (Select all that apply.)
identify actual or potential problems as well as responses to a problem.
require naming patient problems using nursing diagnostic labels.

Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that
apply.)
discussion with the patient.
collaboration with other members of health care team.
coordination of care as collaborative care.

Chapter 6: Assessment
The patient interview consists of three phases: orientation (introductory), working, and
termination. Each phase contributes to the development of trust and engagement between the
nurse and the patient. During the orientation phase of the interview, the nurse should:
establish the name by which the patient prefers to be addressed.

A nurse is conducting a health interview on a newly admitted patient. To establish a trusting

relationship with the patient, the nurse:
sits close and leans in slightly toward the patient.

The triage nurse in a hospital emergency department is determining the order of care for several
patients. Which of the following would the nurse consider as having the highest priority?
A 14-year-old patient having respiratory distress and increasing anxiety

The nurse is documenting data collected during a health assessment interview. Which statement
indicates subjective data?
“My last bowel movement was 4 days ago.”

A patient is transported to the emergency room from a local skilled nursing facility and admitted
for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate
that the patient has dementia. The nurse contacts the patient’s son for additional health history
information. Information provided by the son would be considered:
secondary, subjective data.
 An in-depth health history: (Select all that apply.)
includes demographic data.
lists the patient’s allergies.
contains the family history of diseases.
explains the patient’s health promotion practices.

Chapter 7: Nursing Diagnosis

1. The nurse completes a health and physical assessment on a patient admitted with a fractured
pelvis. Which of the following tasks should the nurse do next?
Analyze and cluster the assessment information.

2. A group of patients in a community center attend a nursing-led information session on the risks
of contracting tuberculosis. After the presentation several patients ask the nurse for additional
web-based resources regarding the lung disease. Which type of nursing diagnosis would the
nurse choose for the community care plan?
Health-promotion

3. A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the
pericardium. Which diagnosis written on the plan indicates a need for further instruction on
using the nursing process?
Pericarditis

15. The nursing student submits a care plan to the nursing instructor for a review prior to
implementing the nursing interventions. Which of the following nursing diagnostic statements is
written incorrectly?
Insomnia and knowledge deficit related to stress as evidenced by patient report of difficulty
sleeping and lack of energy.

16. When creating a nursing diagnosis, the related factor:

is the underlying etiology of the patient’s situation.

4. A group of nursing students is discussing the importance of accurately selecting nursing

diagnoses. Which of the following are reasons for choosing the diagnoses carefully? (Select all
that apply.)
Patient satisfaction
Positive patient outcomes
Quality patient care
Determine appropriate interventions

Chapter 8: Planning
1. The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior
to surgery that “I don’t think I’ll be able to handle this if I get a colostomy. I wouldn’t know how
to manage it.” There is no “next of kin” listed in the patient’s record. The patient is complaining
of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first?
Pain
 2. Setting priorities among identified nursing diagnoses is the first step in the planning process. The
nurse is responsible for:
monitoring patient responses.

5. The nurse has a thorough understanding of the planning phase of the nursing process when
stating:
“Patients should be included in the planning process.”

6. Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
are mutually acceptable to the nurse, patient, and family.

7. In developing the nursing care plan, the nurse creates goals:

with the patient and possibly the family.

9. Which of the following is a correctly written example of a short-term goal?

With diet and exercise, the patient will lose 1 lb this week.

10. Which goal is written correctly for the nursing diagnosis of activity intolerance related to
imbalance between oxygen supply and demand?
Patient will ambulate 100 feet with no shortness of breath on third day after treatment.

11. The nurse recognizes which of the following as a barrier to achieving goals?
The effects of pain and/or clinical depression

14. The nurse is formulating the patient’s care plan. In determining when to evaluate the patient’s
progress, the nurse is aware that evaluations:
depend on intervention and patient condition.

17. Medication administration is what type of nursing intervention?

Dependent

18. Dependent nursing interventions include:

administer antipyretic medications as appropriate.

20. Discharge planning begins:

upon admission.

21. The nurse is accurate when stating that adequate discharge planning:
“May decrease the incidence of patients required to return to the hospital.”

1. The significance of developing organized plans of care for patients cannot be stressed enough. In
the planning phase, the nurse must take seriously the responsibility of: (Select all that apply.)
prioritizing patient needs.
developing mutually agreed-on goals.
determining outcome criteria.
identifying interventions.
 2. The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the
nurse: (Select all that apply.)
prioritizes nursing diagnoses.
determines short and long-term goals.
identifies outcome indicators.
lists nursing interventions.

3. Patients should be included in the planning process. Involving patients in planning their care
helps them to: (Select all that apply.)
be aware of identified needs.
embrace mutually agreed-on goals.
feel a sense of empowerment.

4. Measurable goals are: (Select all that apply.)

specific
concrete
easy to judge

Chapter 9: Implementation and Evaluation

1. Which of the following is a direct care intervention?
Administration of an injection

4. After the nurse completes a patient’s initial assessment and develops a plan of care:
continual reassessment of the patient is required.

6. The nurse is providing care for a patient of the Jehovah’s Witness faith. Based on the nurse’s
knowledge of the patient’s religious beliefs, the nurse would question which of the following
orders?
Infuse 1 unit packed red blood cells

8. The registered nurse is providing an independent nursing intervention when:

providing emotional support.

10. The nurse is learning to identify readiness to learn in patients. Which one of the following
patients would the nurse identify correctly as ready to learn?
The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged
in 2 days

11. The nurse is considering asking the patient for permission to involve the patient’s family
members in the teaching plan for the patient. Which of the following is the best rationale to
support this involvement?
Involving the family in effective teaching empowers the patient and their support system.

12. Change of shift report, collaboration with other health care members, and ensuring availability of
needed equipment are examples of:
indirect care.
14. In implementing research-based interventions, the nurse realizes that:
nurses must read recent literature and remain current in practice

15. The nurse has many roles. One is to support and work on behalf of patients for whom he/she has
concern. This role is known as:
advocate.

16. Which of the following cannot be delegated?

Assessment of lung sounds

17. The five rights of delegation include:

right task, right circumstance, right person, right direction, and right supervision

18. Repositioning a patient, providing hygiene, and active listening are examples of:
independent nursing interventions.

Chapter 27: Hygiene and Personal Care

1. The nurse knows that which of the following statements is true regarding the importance of
hygiene?
The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary
systems during the bath.

2. Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this,
what is the most applicable nursing diagnosis for a patient with excessively dry skin?
Risk for infection

7. The nurse is preparing to give a patient a complete bed bath. What area of the body should be
bathed first?
Eyes

8. The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is
appropriate?
To promote circulation

11. Which member of the collaborative team is most appropriate to cut the toenails of a diabetic
patient?
Podiatrist

19. The nurse and UAP are making an occupied bed together. Which action by the nurse is
incorrect?
The nurse rolls dirty linens to the side then places the linens on the floor while finishing.

Chapter 4: Critical Thinking in Nursing

11. The nurse is planning care for a group of patients. Which of the following activities may be
delegated to unlicensed assistive personnel?
Morning vital signs, height, and weight.
16. A patient, frequently admitted to the hospital for chronic back pain, asks the medication nurse for
additional pain medication. The nurse has seen patients like this before, and “knows” that the
only reason that these people come to the hospital is to get their pain medication. The nurse is
demonstrating:
a bias.

2. Professional nursing requires a commitment to lifelong learning because: (Select all that apply.)
treatment modalities and technology continue to advance.
nurses are expected to update and maintain competency.
critical thinking is essential in nursing.

Chapter 14: Health and Literacy and Patient Education

1. In addressing patient education, the nurse recognizes that patient education is a process
involving: (Select all that apply.)
assessment.
diagnosis.
planning.
implementation and evaluation.

3. In preparing to teach the patient, the nurse must consider: (Select all that apply.)
background.
pain level.
emotional status.
readiness to learn.

Chapter 11: Ethical and Legal Considerations

2. The nurse is providing patient care and pays special attention to meeting the needs of the patient
while maintaining the patient’s right to privacy, confidentiality, autonomy, and dignity. This
nurse is applying what ethical theory?
Deontology

3. The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate
in a new chemotherapy trial. How would the nurse respond if working under the ethical principle
of utilitarianism?
“You should do this because many could benefit from it.”

4. The nurse realizes that a medication error has been made. The nurse then reports the error and
takes responsibility to ensure patient safety despite personal consequences. This nurse has
exhibited:
accountability.

5. The nurse is providing care for a patient who has had a stroke recently and has multiple self-care
deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of
needed equipment. What ethical concept is being applied?
Advocacy
 6. A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift
report, the nurse asks, “Why was the man convicted and imprisoned?” Another nurse responds
that this is not important since nurses are required to provide compassionate care for all people in
all circumstances. The responding nurse has displayed what concept?
Beneficence

7. The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and
promptly administers the ordered analgesics as promised to the patient. This nurse has applied:
fidelity.

8. “First, do no harm” defines what ethical principle?

Nonmaleficence

11. Which of the following statements indicates an appropriate understanding by the student nurse
(SN)?
“I will be held to the same ethical standards as professional nurses.”

14. The nurse is providing end-of-life care. It is essential for the nurse to:
offer unconditional support for the patient and family.

16. In the nursing profession, ethical issues:

have required The Joint Commission to mandate ethics committees.

17. Each state has a nurse practice act that establishes the standards of care required for legal nursing
practice. In order to protect herself/himself from litigation, the nurse should understand that:
keeping current with changing laws can protect the nurse.

23. State legislatures give authority to administrative bodies, such as state boards of nursing, to:
establish regulatory laws.

24. Which of the following nurses has committed a serious documentation error?
Susan documents all medications for her patients prior to administration.

3. Health care providers are required to supply patients with written information regarding their
rights to make medical decisions and implement advance directives, which consist of three
documents. Which of the following are considered “advanced directives”? (Select all that apply.)
Living will
Durable power of attorney
Health care proxy