Nursing Care and

Responsibilities
Total points19/114

The nursing process involves the following:

0/1
Assessment, diagnosis, planning, intervention and evaluation
Assessment, differentiation, planning, intervention, evaluation
Assessment, planning, intervention, evaluation
Assessment, planning, referring, evaluation

Correct answer
Assessment, diagnosis, planning, intervention and evaluation

What are the steps of the nursing process?

0/1
Assessing, diagnosing, planning, implementing, and evaluating
Assessing, planning, implementing, evaluating, documenting
Assessing, observing, diagnosing, planning, evaluating
Assessing, reacting, implementing, planning, evaluating

Correct answer
Assessing, diagnosing, planning, implementing, and evaluating

When do you see problems or potential problems?

0/1
Assessment
Planning

Implementation
Evaluation
Correct answer
Assessment
A walk-in client enters into the clinic with a chief
complaint of abdominal pain and diarrhea. The nurse
takes the client's vital sign thereafter. What phrase of
nursing process is being implemented here by the
nurse?
0/1
Assessment
Diagnosis
Planning
Implementation

Correct answer
Assessment

Constipation needs to be sort out during:

0/1
Planning
Assessment
Implementation
Evaluation

Correct answer
Assessment

At what stage of the nursing process does the revision

of the care plan occur?
0/1
Assessment

Planning
Implementation
Evaluation
Correct answer
Evaluation
When do you plan a discharge?
0/1
24 hours within admission
72 hours within admission
48 hours within admission
12 hours within admission

Correct answer
24 hours within admission

Hospital discharge planning for a patient should start:

0/1
When the patient is medically fit

On the admission assessment

When transport is available

Correct answer
On the admission assessment

Which statement is not correct about the nursing

process?
0/1
An organised, systematic and deliberate approach to nursing
with the aim of improving standards in nursing care

It uses a systematic, holistic, problem solving approach in

partnership with the patient and their family

It is a form of documentation

It requires collection of objective data

Correct answer
It requires collection of objective data
What is comprehensive nursing assessment?
0/1
It provides the foundation for care that enables individuals to
gain greater control over their lives and enhance their health
status

An in-depth assessment of the patient’s health status, physical

examination, risk factors, psychological and social aspects of
the patient’s health that usually takes place on admission or
transfer to a hospital or healthcare agency

An assessment of a specific condition, problem, identified

risks or assessment of care; for example, continence
assessment, nutritional assessment, neurological assessment
following a head injury, assessment for day care, outpatient
consultation for a specific condition

It is a continuous assessment of the patient’s health status

accompanied by monitoring and observation of specific
problems identified

Correct answer
An in-depth assessment of the patient’s health status, physical
examination, risk factors, psychological and social aspects of
the patient’s health that usually takes place on admission or
transfer to a hospital or healthcare agency

Nursing process is best illustrated as:

1/1
Patient with medical diagnosis
Task oriented care
Individualised approach to care

All of the above

Which of the following descriptors is most appropriate to
use when stating the "problem" part of a nursing
diagnosis?
0/1
Grimacing
Anxiety
Oxygenation saturation 93%

Output 500 mL in 8 hours

Correct answer
Anxiety

To prepare a client for discharge home from an acute

care facility, a nurse knows that the planning process
must begin at what point?
0/1
The night before discharge

Upon admission to the hospital

Prior to discharge
When the client indicates the readiness for discharge planning
and teaching

Correct answer
Upon admission to the hospital

Making sure that people are involved in and central to

their care is now recognised as a key component of
developing high quality health care. This is because it is
hoped that putting people at the centre of their care
will:
0/1
  Help people get the care they wanted when they are
enrolled in the NHS
 Help improve the quality of the services available
 Help people be more active in looking for health care
providers themselves
 Help reduce some of the pressures on providing social
services

Correct answer
Help improve the quality of the services available

As a nurse, you make sure that the patient and public

safety is protected. Thus, you work within the limits of
your competence, exercising your professional 'duty of
candour' and raising concerns immediately whenever
you come across situations that put patients or public
safety at risk. Which is the least effective way to protect
a patient's safety?
0/1
 Support the exchange of information at all levels without
fear and against authority gradients - is known to be
associated with constant awareness to the possibility of
hazard or harm

 Support for continual learning, growth and adaptation

even under stress by valuing relevant knowledge, skills
and observations even at the lowest levels of hierarchy

 Support the willingness and capacity to look beyond first

impressions, labels and old beliefs - organisations must
remain closely in touch with activities and facts on the
ground in the daily operations

 Support the openness culture that encourages clear lines

to report concerns and reinforces the attitudes that
 prevent safeguarding concerns from scrutiny where staff
at all levels feel confident that they can voice their
concerns without fear of victimization

Correct answer
Support the openness culture that encourages clear lines to
report concerns and reinforces the attitudes that prevent
safeguarding concerns from scrutiny where staff at all levels
feel confident that they can voice their concerns without fear
of victimisation

The nurse wants to involve a patient in a programme of

care geared towards the patient to quit smoking. The
nurse should make use of which of the following in
communicating to or involving patient in the plan of
care:
0/1
National nursing database
Ehealth services

Nicotine replacement therapy

Core care plans

Correct answer
Core care plans

One of the principal responsibilities of a nurse is to

educate patients, however, time and work-related
constraints can interfere with the provision of patient
education. Which of the following is most crucial and
can influence the patient's ability to retain pre-operative
information?
0/1
Timing of the education
Educational level of the patient and family
The information is appropriate for the patient's understanding
All of the options above

Correct answer
Timing of the education

Who should be responsible in proper disposal of sharps

0/1
Healthcare assistant
Doctor
Registered Nurse
The professional who used the sharp

Correct answer
The professional who used the sharp

Who is responsible in disposing sharps?

0/1
Registered nurse

Nurse assistant
Whoever used the sharps
Whoever collects the garbage

Correct answer
Whoever used the sharps

How can risks be reduced in the healthcare setting?

1/1
 By adopting a culture of openness and transparency and
exploring the root causes of patient safety incidents

 Healthcare will always involve risks so incidents will

always occur; we need to accept this
  Healthcare professionals should be encouraged to fill in
incident forms; this will create a culture of ‘no blame’

 By setting targets which measure quality

All but one describes holistic care:

1/1
 A system of comprehensive or total patient care that
considers the physical, emotional, social, economic, and
spiritual needs of the person; his or her response to
illness; and the effect of the illness on the ability to meet
self-care needs

 It embraces all nursing practice that has enhancement of

healing the whole person from birth to death as it’s goals

 An all nursing practice that has healing the person as its

goal

 It involves understanding the individual as a unitary whole

in mutual process with the environment

Adam, 46 years old is of Jewish descent. As his nurse,

how will you plan his dietary needs?
0/1
Assume he strictly needs Jewish food

Ask relatives to bring food from kosher market

Ask a rabbi to help you plan
Ask the patient about his diet preferences

Correct answer
Ask the patient about his diet preferences

Patient-centred care is best defined as:

0/1
Care is focused on the doctor

Care is focused on the health team

Care is focused on the patient
Care is focused on the environment

Correct answer
Care is focused on the patient

Which of the following is not a component of end of life

care?
0/1
Resuscitation and defibrillation
Reduce pain
Maintain dignity

Provide family support

Correct answer
Resuscitation and defibrillation

Mr. James, 72 years old, is a registered blind admitted

on your ward due to dehydration. He is encouraged to
drink and eat to recover. How will you best manage this
plan of care?
1/1
 Ask the patient the assistance he needs

 Delegate someone to feed him

 Ask the relatives to assist in feeding him
 Look for volunteer to assist with his needs

The rehabilitation nurse wishes to make the following

entry into a client's plan of care: "Client will reestablish
a pattern of daily bowel movements without straining
within two months." The nurse would write this
statement under which section of the plan of care?
0/1
 Long-term goals
 Short-term goals
 Nursing orders
 Nursing diagnosis/problem list

Correct answer
Long-term goals

After instructing the client on crutch walking technique,

the nurse should evaluate the client's understanding by
using which of the following methods?
0/1
Have client explain produce to the family
Achievement of 90 on written test
Explanation
Return demonstration

Correct answer
Return demonstration

A nurse should be able to show awareness of his/her

role in health promotion and supporting a healthy
lifestyle. Whilst providing health education to a group of
patients with cancer about management of their non-
healing wounds, it is important for one to:
0/1
Consider individual wound management priorities
Review the patient’s treatment plan
Determine the locations of the wounds
Verify the types of cancer
Correct answer
Consider individual wound management priorities

It is important to read the label on every IV bag

because:
0/1
Different IV solutions are packaged similarly

The label contains the expiration date of the IV fluid

A and B
A only

Correct answer
A and B

Julie, 50 years old, was admitted to the hospital with

gastrointestinal bleed presumed to be oesophageal
varices. It has been recommended that she needs to be
transfused with blood; however, due to her religious and
personal beliefs, she needed volume expanding agents.
Unfortunately, she died a few hours after admission.
Before dying, she said that it was God’s will, which she
believed was right. Which of the following statements is
false?
0/1
 Health professionals should be aware of imposing one’s
world view upon others and strive to be more receptive
and sensitive to the needs of others

 Individual choice, consent and the right to refuse

treatment is important
  It is important for all health professionals to do any
means to keep a patient alive regardless of traditions and
beliefs

 None of the Above

Correct answer
It is important for all health professionals to do any means to
keep a patient alive regardless of traditions and beliefs

Pauleena, 57 years old, suffered from a very dense left

sided Cerebrovascular Accident / Stroke. She was
unconscious and unresponsive for several days with IV
fluids for hydration. Since her recovery from stroke, she
has been prescribed to commence enteral feeding
through a fine bore nasogastric tube, in which she
signed her consent in front of her who have always been
supportive of her decisions. However, she tends to pull
out her NGT when she is by herself in her room. She died
of malnutrition after a few days. Which of the following
statements is true?
0/1
 Nurses should have the empathy to listen to more than
just the spoken word

 Nurses should practice in accordance to Pauleena’s best

interest while providing support to the family and
listening to their concerns and wishes

 Pauleena needs to be supported with questions related to

mortality and meaning of life Therapautic communication
is also essential

 All of the above

Correct answer
All of the above

Which of the following sets of needs should be included

in your service user’s person centred care plan?
0/1
 Social, spiritual and academic needs

 Medical, psychological and financial needs

 Physical, medical, social, psychological and spiritual

needs

 A and B only

 All of the above

Correct answer
Physical, medical, social, psychological and spiritual needs

What is likely to be true of a nurse's duties when she

acts as a case manager providing community-based
nursing services to a specific group of individuals?
0/1
 The nurse will care for clients at the center, in their
homes, and in the hospital

 The nurse sees only clients who come to the office

 The nurse works independently of other health care

professionals
  The nurse will not continue client care if it involves long-
term needs

Correct answer
The nurse will care for clients at the center, in their homes,
and in the hospital

A client is to be discharged home from a hospital using

crutches or a wheelchair. The client lives alone with
three cats. Which assessment parameter is most
important on the initial home visit?
0/1
 Whether the client will be able to keep medical
appointments

 Whether the client desires spiritual counseling

 Whether the home has stairs and/or throw rugs

 Whether the client has financial resources for payment

Correct answer
Whether the home has stairs and/or throw rugs

To provide effective feedback to a client, the nurse will

focus on:
0/1
 The present and not the past
 Making inferences of the behaviors observed
 Providing solutions to the client
 The client

Correct answer
The present and not the past
Which of the following actions jeopardise the
professional boundaries between patient and nurse
0/1
 Focusing on social relationship outside working
environment

 Focusing on needs of patient related to illness

 Focusing on withholding value opinions related to the

decisions

Correct answer
Focusing on social relationship outside working environment

In using social media like Facebook, these are the best

way to adhere to your Code of Conduct as a nurse,
except?
1/1
 Never have relationship with previous patient
 Never post pictures concerning your practice
 Never tell you are a nurse

 Always rely solely in your FBs privacy setting

The worst advice you can give a student nurse with

regards to the use of social networking sites like
Facebook?
1/1
 Do not identify yourself as a nurse

 Do not engage in a personal discussion or relationship

with a patient or former patient
 Do not post a picture of a patient's child even if they allow
you to
 You can rely on the sites privacy settings
As an RN in charge you are worried about a nurse's act
of being very active on social media site, that it affect
the professionalism. Which one of these is the worst
advice you can give her?
1/1
 Do not reveal your profession of being a Nurse on social
site

 Do not post any pictures of client's even if they have

given you permission
 Do not involve in any conversions with client's or their
relatives through a social site
 Keep your profile private

Nurses assume responsibility on patient with cane.

Which of the following is the nurse’s topmost priority in
caring for a patient with cane?
0/1
 Mobility
 Safety
 Nutrition

 Rest periods

Correct answer
Safety

In the context of assessing risks prior to moving and

handling, what does T-I-L-E stand for?
0/1
 Task – individual – lift – environment
 Task – intervene – load – environment
 Task – intervene – load – equipment
  Task – individual – load – environment

Correct answer
Task – individual – load – environment

Barbara, a 75-year old patient from a nursing home was

admitted on your ward because of fractured neck of
femur after a trip. She will require an open-reduction and
internal fixation (ORIF) procedure to correct the injury.
Which of the following statements will help her
understand the procedure?
0/1
 You are going to have an ORIF done to correct your
fracture

 Some metal screws and pins will be attached to your hip

to help with the healing of your broken bone

 The operation will require a metal fixator implanted to

your femur and adjacent bones to keep it secured

 The ORIF procedure will be done under general

anaesthesia by an orthopaedic surgeon

Correct answer
Some metal screws and pins will be attached to your hip to
help with the healing of your broken bone

Lisa, a working mother of 3, has approached you during

a recent attendance of her daughter in Accident and
Emergency because of an acute asthma attack about
smoking cessation. What is your most appropriate
response to her?
1/1
  Smoking cessation will help prevent further asthma
attack

 Referral can be made to the local NHS Stop Smoking

Service

 Discuss with her the NICE recommendations on smoking

cessation

 It is not common for people like her to stop smoking

A nurse finds it very difficult to understand the needs of

a child with learning disability. She goes to other nurses
and professionals to seek help. How you interpret this
action
0/1
 The nurse is short of self confidence

 A nurse, who is well aware of her limitations sought help

from others She worked within her competency

 She doesn’t have the kind of courage a nurse should have

Correct answer
A nurse, who is well aware of her limitations sought help from
others She worked within her competency

Monica is going to receive blood transfusion. How

frequently should we do her observation?
0/1
Temperature and pulse before the blood transfusion begins,
then every hour, and at the end of bag/unit
Temperature, pulse, blood pressure and respiration before the
blood transfusion begins, then after 15 min, then as indicated
in local guidelines, and finally at the end of bag/unit

Temperature, pulse, blood pressure and respiration and

urinalysis before the blood transfusion, then at end of bag

Pulse, blood pressure and respiration every hour, and at the

end of the bag

Correct answer
Temperature, pulse, blood pressure and respiration before the
blood transfusion begins, then after 15 min, then as indicated
in local guidelines, and finally at the end of bag/unit

During blood transfusion, a patient develops pyrexia,

and loin pain. Nurse interprets the situation as
0/1
 Common reaction to transfusion
 Adverse reaction to blood transfusion
 Patient has septicaemia

Correct answer
Adverse reaction to blood transfusion

A nurse explains to a student that the nursing process is

a dynamic process. Which of the following actions by
the nurse best demonstrates this concept during the
work shift?
1/1
 Nurse and client agree upon health care goals for the
client
 Nurse reviews the client's history on the medical record
 Nurse explains to the client the purpose of each
administered medication
  Nurse rapidly reset priorities for client care based on a
change in the client's condition

Nursing care should be:

0/1
 Task oriented
 Caring medical and surgical patient

 Patient oriented, individualistic care

 All

Correct answer
Patient oriented, individualistic care

How the nurse assesses the quality of care given?

0/1
 Reflective process
 Clinical bench marking
 Peer and patient response

 All the above

Correct answer
All the above

A patient doesn't take a tablet which is prescribed by

the doctor. Which action by the nurse would be most
appropriate?
0/1
 Report the incident to senior nurse or ward in charge

 Inform the pharmacist

 Do nothing and respect the patients choice

  Routinely document this in the medicine chart and also
record it in the nurses notes

Correct answer
Routinely document this in the medicine chart and also record
it in the nurses notes

After the death of a 46-year-old male client, the nurse

approaches the family to discuss organ donation
options. The family consents to organ donation and the
nurse begins to process. Which of the following would
be most helpful to the grieving family during this difficult
time?
1/1
Calling the client, a donor
Provide care to the deceased client in a careful and loving way

Encourage the family to make a quick decision

Tell them that there is no time to all other family members for
advice

While providing care to a terminally ill client, the nurse

has asked questions about death. Which of the following
would be beneficial to support the client’s spiritual
needs?
0/1
 Nothing

 Ask if they want to die

 Ask if they want anything special before they die
 Provide support, compassion, and love

Correct answer
Provide support, compassion, and love
Under the Yellow Card Scheme you must report the
following except:
0/1
 Faulty brakes on a wheelchair
 Suspected side effects to blood factor, except
immunoglobulin products
 Counterfeit or fake medicines or medical devices

Correct answer
Suspected side effects to blood factor, except immunoglobulin
products

Mrs X informs the nurse that she has lost her job due to
excessive absences related to her wound. The nurse
should:
1/1
 Encourage the patient to express her feelings about the
job loss

 Contact social services to assist the patient with

accessing available resources
 Evaluate Mrs X’s understanding of her wound
management
 Explain to Mrs X that she can no longer be seen at the
clinic without a job

Margaret has been diagnosed with Hepatic Adenoma.

Her results are as follows – benign tumor as shown on
triphasic CT Scan and alpha feto proteins within normal
range. She is asymptomatic and does not appear
jaundice, but she appears to be very anxious. As a
nurse, what will you initially do?
0/1
  Sit down with Margaret and discuss about her fears; use
therapeutic communication to alleviate anxiety

 Refer her to a psychiatrist for treatment

 Discuss invasive procedure with patient, and show her

videos of the operation

 Take her to the surgeon’s clinic and discuss about

consent for invasive procedure

Correct answer
Sit down with Margaret and discuss about her fears; use
therapeutic communication to alleviate anxiety

One of your residents has been transferred from the

hospital to your nursing home after having been
admitted for a week due to a chest infection. On
transfer, you have noted that he had several dressings
on his thighs, which he has not had before. What should
you do?
0/1
 If the dressings are intact, document it on the nursing
notes and indicate that the dressings need to be changed
after 48 hours

 Change the dressings if they look soiled and document

this on the wound assessment form

 Remove the dressings whether they are intact or not,

assess the wounds, document this on the wound
assessment form and redress the wounds

 All of the above

Correct answer
Remove the dressings whether they are intact or not, assess
the wounds, document this on the wound assessment form and
redress the wounds

During your medical rounds, you have noted that Mrs X

was upset. She has verbalised that she misses her
family very much, and that no one has been to visit
lately. What would likely be your initial intervention?
1/1
 Contact Mrs X’s family and encourage them to visit her
during the weekend

 Sit next to Mrs X and listen attentively Allow her to talk

about things that cause her anxiety

 Collaborate with the GP for a care plan review and

request for antidepressants to be prescribed

 All of the above

 None of the above

On admission of a service user, you have done an

informal risk assessment for pressure sores, and you
have noted that the patient is currently not at risk. What
will be your next step?
0/1
 Include the Repositioning Chart on your patient’s daily
notes, and instruct your carers/HCA’s to turn your patient
every two hours

 Alert the General Practitioner about your patient’s

condition
  Reassess your patient on a regular basis and document
your observations

 Modify your patient’s diet to maintain intact skin integrity

Correct answer
Reassess your patient on a regular basis and document your
observations

You were on your rounds with one of the carers. You

were turning a patient from his left to his right side.
What would you do?
0/1
 Both of you can stay on one side of the bed as you turn
your patient

 You go on the opposite side of the bed and use the bed
sheet to turn your patient

 You keep the bed as low as possible because the patient

might fall

 You go on the opposite side and grab the slide sheet to

use

Correct answer
You go on the opposite side and grab the slide sheet to use

The nurse is preparing to move an adult who has right

sided paralysis from the bed into a wheel chair. Which
statement describes the best action for the nurse to
take?
0/1
 Position the wheel chair on the left side of the bed
 Keep the head of the bed elevated 10 degree
  Protect the client’s left arm with a sling during the
transfer
 Bend at the waist while helping the client into a standing
position

Correct answer
Position the wheel chair on the left side of the bed

A client with a right arm cast for fractured humerus

states, “I haven’t been able to straighten the fingers on
the right hand since this morning.” What action should
the nurse take?
0/1
 Assess neurovascular status to the hand
 Ask the client to massage the fingers

 Encourage the client to take the prescribed analgesic

 Elevate the arm on a pillow to reduce oedema

Correct answer
Assess neurovascular status to the hand

As a nurse you are responsible for looking after patient’s

nutritional needs and to maintain good weight during
hospitalization. How would you achieve this?
1/1
 Providing all clients with liquid nutritional supplements
 Assessing all patients using MUST screening tool and by
taking patients preferences into consideration
 Checking daily weigh and documenting
 Assessing nutritional status, client preferences and
needs, making individual food choices available, checking
daily weight and documentation
One of your young patient displayed an overt sexual
behaviour directly to you. How will you best respond to
this?
0/1
 Talk to the patient about the situation, to re- establish
and maintain professional boundaries and relationship

 Ignore the behaviour as this is part of the development

process

 Report the patient to their relatives

 Inform line manager of the incident

Correct answer
Talk to the patient about the situation, to re- establish and
maintain professional boundaries and relationship

The patient under a nurse's care is showing sexual

behaviours toward him/her, what should the nurse do?
0/1
 File an incident report, do not care for the patient
anymore

 Write the patient's behaviour on the patient's chart

 This is normal as the patient is sick, later as the

medication kicks off it will soon be over
 Talk to the patient about the behaviour, attempt to re-
establish professional relationship, talk to the line
manager

Correct answer
Talk to the patient about the behaviour, attempt to re-establish
professional relationship, talk to the line manager
Post surgery, the doctor tells the patient that treatment
is not working. The doctor instructed the nurse to stay
with the patient until the nurse specialist arrive. What
should the nurse do?
1/1
 Document outcomes in the patient's chart
 Sit silently with patient until nurse specialist arrives
 Ask the patient if he wants to discuss what the doctor
said

 Do not leave the patient unattended and try to answer his

questions

A registered nurse is new to the diagnosis of her patient.

What is the best response of the nurse?
0/1
 The nurse should come early for her shift and spend more
time to care for the patient

 The nurse should spend an hour in library, learn about the

new diagnosis and then take care of the patient

 The nurse should clarify her doubts with her senior on

duty and with the doctors about the diagnosis and plan
nursing care accordingly

 The nurse should request the other staff to continue with

the shift as she lacks knowledge about the diagnosis

Correct answer
The nurse should clarify her doubts with her senior on duty and
with the doctors about the diagnosis and plan nursing care
accordingly
A client diagnosed of cancer visits the OPD and after
consulting the doctor breaks down in the corridor and
begins to cry. What would the nurses best action?
0/1
 Ignore the client and let her cry in the hallway

 Inform the client about the preparing to come forth next

appointment for further discussion on the treatment
planned

 Take her to a room and try to understand her worries and

do the needful and assist her with further information if
required

 Explain her about the list of cancer treatments to survive

Correct answer
Take her to a room and try to understand her worries and do
the needful and assist her with further information if required

A patient has sexual interest in you. What would you do?

0/1
 Just avoid it, because the problem can be the
manifestation of the underlying disorder, and it will be
resolved by its own as he recovers

 Never attend that patient

 Try to re-establish the therapeutic communication and

relationship with patient and inform the manager for
support

 Inform police

Correct answer
Try to re-establish the therapeutic communication and
relationship with patient and inform the manager for support

A client is diagnosed with cancer and is told by surgery

followed by chemotherapy will be necessary, the client
states to the nurse, "I have read a lot about
complementary therapies. Do you think I should try it?".
The nurse responds by making which most appropriate
statement?
0/1
 It is a tendency to view one's own ways as best

 You need to ask your physician about it

 I would try anything that I could if I had cancer

 There are many different forms of complementary

therapies, let's talk about these therapies

Correct answer
There are many different forms of complementary therapies,
let's talk about these therapies

An antihypertensive medication has been prescribed for

a client with hypertension. The client tells the clinic
nurse that they would like to take an herbal substance
to help lower their blood pressure. The nurse should
take which action?
0/1
 Tell the client that herbal substances are not safe and
should never be used

 Teach the client how to take their BP so that it can be

monitored closely
  Encourage the client to discuss the use of an herbal
substance with the health care provider

 Tell the client that if they take the herbal substance they
will need to have their BP checked frequently

Correct answer
Encourage the client to discuss the use of an herbal substance
with the health care provider

Mrs. A is posted for CT scan. Patient is afraid cancer will

reveal during her scan. She asks "why is this test". What
will be your response as a nurse?
0/1
 Tell her that you will arrange a meeting with a doctor
after the procedure

 Give a health education on cancer prevention

 Ignore her question and take her for the procedure

 Understand her feelings and tell the patient that it is

normal procedure

Correct answer
Understand her feelings and tell the patient that it is normal
procedure

A patient with a Bipolar Disorder makes a sexually

inappropriate comment to the nurse. One should take
which of the following actions?
0/1
 Ignore the comment because the client has a mental
health disorder and cannot help it
  Report the comment to the nurse manager

 Ignore the comment, but tell the incoming nurse to be

aware of the client’s propensity to make inappropriate
comments

 Tell the client that is it inappropriate for clients to speak

to any nurse that way

Correct answer
Tell the client that is it inappropriate for clients to speak to
any nurse that way

Betty has been assessed to be very confused and with

impaired mobility. She wants to go to the dining room for
her meal, but she wants a cardigan before doing so.
What will you do?
0/1
 Give her wet wipes for her hands before dinner
 Disregard the cardigan and take her to the dining room

 Ask her what she means by a cardigan

 Make her comfortable in a wheelchair, and cover her legs

with a blanket

Correct answer
Ask her what she means by a cardigan

You were assisting Mrs X with personal care and

hygiene. She has been assessed to have mental
capacity. In her wardrobe, you have seen a dress that is
quite difficult to wear and a pair of trousers, which is
quite easy to put on. You are trying to make a decision
which one to put on her. Which of the following is a
person centred intervention?
0/1
 Ask her what she prefers; show her the clothes and let
her choose

 Let Mrs X wear her trousers

 Explain to her that the dress is so difficult to put on

 Tell her that the trousers will make her more comfortable
if she chooses it

Correct answer
Ask her what she prefers; show her the clothes and let her
choose

One of your residents in the nursing home has requested

for a glass of whiskey before she goes to bed. What
would you do?
0/1
 Refuse to give it / ignore the request

 Explain that the whiskey will cause her harm

 Give her a shot of whiskey, as requested

 Give her a glass of apple juice and tell her it is whiskey

Correct answer
Give her a shot of whiskey, as requested

A client, who has had visitors the last two evenings

during the unit's regular evening visitors hours, 6:00 p.m.
to 8:00 p.m., asks, "What time can I have visitors this
evening?" Which of the following would be the best
response to this question?
0/1
 "Don't you remember what time you visitor have been
coming?"

 You are worried about visiting hours

 You want to know when you can have visitors?

 Visiting hours are from 6:00 pm to 8:00 pm

Correct answer
Visiting hours are from 6:00 pm to 8:00 pm

A critically ill client asks the nurse to help him die.

Which of the following would be an appropriate response
for the nurse to give this client?
0/1
 "Tell me why you feel death is your only option"
 "How would you like to do this?"
 "Everyone dies sooner or later"

 "Assisted suicide is illegal in this country"

Correct answer
"Tell me why you feel death is your only option"

The 4-year-old son of a deceased male is asking

questions about his father. Which of the following
activities would be beneficial for this young child to
participate in?
0/1
 Nothing because he is too young to understand death
  Tell him his father has gone away, never to return

 Tell him his father is sleeping

 Explain that his father has died and give him the option of
attending the funeral

Correct answer
Explain that his father has died and give him the option of
attending the funeral

A young woman has suffered fractured pelvis in an

accident, she has been hospitalized for 3 days, when
she tells her primary nurse that she has something to
tell her but she doesnot want the nurse to tell anyone.
She says that she had tried to donate blood and tested
positive for HIV. What is best action of the nurse to
take?
0/1
 Document this information on the patient’s chart

 Tell the patient’s physician

 Inform the healthcare team who will come in contact with

the patient

 Encourage the patient to disclose this information to her

physician

Correct answer
Encourage the patient to disclose this information to her
physician

The nurse is admitting a client, on initial assessment the

nurse tries to inquire the patient if he has been taking
alternative therapies and OTC drugs but the client
becomes angry and refuses to answer saying the nurse
is doing so because he belongs to an ethnic minority
group, what is the nurse’s best response?
0/1
 The nurse will stop asking questions as it is upsetting to
the patient
 Wait and give some time for the client to get adjusted to
modern ways of hospitalization

 The nurse will politely explain to the patient about

alternative therapies such as St Johns Wort which
interact with drugs

 The nurse will assign another nurse to ask questions

Correct answer
The nurse will politely explain to the patient about alternative
therapies such as St Johns Wort which interact with drugs

Which is the most appropriate phrase to communicate?

0/1
 "I'm sorry, your mother died"
 "I'm sorry, your mother gone to heaven"

 "I'm sorry, your mother is no longer with us"

 "I'm sorry, your mother passed away"

Correct answer
"I'm sorry, your mother died"

One of your patient has challenged your recent practice

of administering a subcutaneous low-molecular weight
heparin (LMWH) without disinfecting the injection site.
The guidelines for nursing procedures do not
recommend this method. Which of the following
response will support your action?
1/1
 "We were taught during our training not to do so as it is
not based on evidence"

 "Our guidelines, which are based on current evidence,

recommends a non-disinfection method of subcutaneous
injection"

 "I am glad you called my attention I will disinfect your

injection site next time to ensure your safety and peace
of mind"

 "Disinfecting the site for subcutaneous injection is a thing

of the past We are in an evidence-based practice now"

A nurse is caring for clients in the mental health clinic.

A women comes to the clinic complaining of insomnia
and anorexia. The patient tearfully tells the nurse that
she was laid off from a job that she had held for 15
years. Which of the following responses, if made by the
nurse, is most appropriate?
0/1
 "Did your company give you a severance package?"

 "Focus on the fact that you have a healthy, happy family"

 "Losing a job is common nowadays"

 "Tell me what happened"

Correct answer
"Tell me what happened"
When do we need to document?
0/1
 As soon as possible after an event has happened to
provide current up to date information about the care and
condition of the patient or client

 Every hour

 When there are significant changes to the patient’s

condition

 At the end of the shift

Correct answer
As soon as possible after an event has happened to provide
current up to date information about the care and condition of
the patient or client

In a patient with hourly monitoring, when does a nurse

formally document the monitoring?
0/1
 Every hour

 When there are significant changes to the patient’s

condition
 At the end of the shift

 Mid of shift

Correct answer
Every hour

NMC defines record keeping as all of the following

except:
0/1
  Helping to improve advocacy

 Showing how decisions related to patient care were made

 Supporting effective clinical judgements and decisions

 Helping in identifying risks, and enabling early detection

of complication

Correct answer
Helping to improve advocacy

You are transcribing the patient's medications to the

discharge letter. What should you ensure before the
letter is sent?
1/1
 The next of kin's details are included in the letter
 The letter is checked by a registered practitioner for
accuracy
 It cannot be sent because transcription is not allowed in
any circumstances
 The letter is signed off by the nurse-in-charge

A nurse documented on the wrong chart. What should

the nurse do?
0/1
 Immediately inform the nurse in charge and tell her to
cross it all off
 Throw away the page

 Write line above the writing; put your name, job title, date,
and time
 Ignore the incident
Correct answer
Write line above the writing; put your name, job title, date, and
time

When is the time to take the vital signs of the patients?

Select which does not apply:
0/1
 At least once every 12 hours, unless specified otherwise
by senior staff

 When they are admitted or initially assessed

 On transfer to a ward setting from critical care or transfer

from one ward to

 Every four hours

Correct answer
Every four hours

All should be seen in a good documentation except:

0/1
 Legible handwriting

 Name and signature, position, date and time

 Abbreviations, jargon, meaningless phrases, irrelevant

speculation and offensive subjective statements

 A correct, consistent, and factual data

Correct answer
Abbreviations, jargon, meaningless phrases, irrelevant
speculation and offensive subjective statements
Taking a nursing history prior to the physical
examination allows a nurse to establish a rapport with
the patient and family. Elements of the history include
all of the following except:
0/1
 The client’s health status
 The course of the present illness

 Social history

 Cultural beliefs and practices

Correct answer
The client’s health status

Adequate record keeping for a medical device should

provide evidence of:
0/1
 A unique identifier for the device, where appropriate

 A full history, including date of purchase and where

appropriate when it was put into use, deployed or
installed

 Any specific legal requirements and whether these have

been met
 Proper installation and where it was deployed

 Schedule and details of maintenance and repairs

 The end-of-life date, if specified

 All of the above

Correct answer
All of the above

A registered nurse had a very busy day as her patient

was sick, got intubated and had other life saving
procedures. She documented all the events and by the
end of the shift recognized that she had documented in
other patient's record. What is best response of the
nurse?
0/1
She should continue documenting in the same file as the
medical document cannot be corrected
She should tear the page from the file and start documenting
in the correct record

She should put a straight cut over her documentation and

write as wrong, sign it with her NMC code, date and time

She should write as wrong documentation in a bracket and

continue

Correct answer
She should put a straight cut over her documentation and
write as wrong, sign it with her NMC code, date and time

A patient in one of your bays has called for staff. She

needed assistance with “spending a penny”. What will
you do?
0/1
 Ask her if she wants a hot or cold drink, and give her one
as requested
 Assist her to walk to the vending machine, and let her
choose what she wants to buy
 Assist her to walk to the toilet, and provide her with some
privacy
  Help her find her purse, and ask her what time she will be
ready to go out

Correct answer
Assist her to walk to the toilet, and provide her with some
privacy

You are working in a nursing home (morning shift), and

one of your residents is still in the hospital. Nothing has
been documented since admission. What would you do?
0/1
 Ring the family and find out what happened to the
resident
 Speak to your manager and tell her about it
 Ring the ward and request for an update from the nurse
on duty
 Document that the resident is still in the hospital

Correct answer
Speak to your manager and tell her about it

After the handover, you noticed that the outgoing nurse

documented an intervention on a wrong patient chart.
What should you do to correct it, maintain safety and
continuation of care?
0/1
 Discard the paper/ document

 Cross the wrong entry with a line, indicated it is an error,

write the date, time, name and signature, document the
care correctly

 Leave it, never alter patient record

  Inform the nurse manager, let her draw a line on the entry
and place her name and signature

The nurse suspects that a client is withholding health-

related information out of fear of discovery and possible
legal problems. The nurse formulates nursing diagnoses
for the client carefully, being concerned about a
diagnostic error resulting from which of the following?
0/1
 Incomplete data
 Generalise from experience
 Identifying with the client
 Lack of clinical experience

After finding the patient, which statement would be

most appropriate for the nurse to document on a
datix/incident form?
0/1
 "The patient climbed over the side rails and fell out of
bed"
 "The use of restraints would have prevented the fall"

 "Upon entering the room, the patient was found lying on

the floor"
 "The use of a sedative would have helped keep the
patient in bed"

Correct answer
"Upon entering the room, the patient was found lying on the
floor"

A nurse documents vital signs without actually

performing the task. Which action should the charge
nurse take after discussing the situation with the nurse?
0/1
 Charge the nurse with malpractice
 Document the incident
 Notify the board of nursing

 Terminate employment

Correct answer
Document the incident

The nurse has made an error in documenting client care.

Which appropriate action should the nurse take?
0/1
 Draw a line through error, initial, date and document
correct information

 Document a late addendum to the nursing note in the

client’s chart

 Tear the documented note out of the chart

 Delete the error by using whiteout

Correct answer
Draw a line through error, initial, date and document correct
information

Which of the following items of subjective client data

would be documented in the medical record by the
nurse?
0/1
 Client's face is pale
 Cervical lymph nodes are palpable
 Nursing assistant reports client refused lunch
 Client feel nauseated
Correct answer
Client feel nauseated

Annie is on Cefalexin QID. You were working on a night

shift and have noticed that the previous nurse has not
signed for the last two doses. What should you do?
0/1
Document the incident and speak to your Manager

Check the rota, find out when he is back and leave a note on
the MARS for him to sign

Find out what the whistle blowing policy is about

Ask the qualified nurse to sign it on handover if it is definitely

been administered

Correct answer
Document the incident and speak to your Manager

Providing patient centred nursing care is an expectation

for all nurses. For a patient with pyrexia, which of the
following is the ritual nursing intervention?
0/1
 Administer antipyretics

 Remove heavy blankets

 Direct fan therapy
 Indirect fan therapy

Correct answer
Direct fan therapy
You are taking the rectal temperature of an elderly
patient when it is registered moderate hypothermia of
34 degrees Celcius. What should be the most
appropriate action by the nurse?
1/1
 Programme the reheating device to increase temperature
as fast as possible
 Programme the reheating device to register the
temperature to 36 degrees
 Programme the reheating device to increase temperature
2 degrees per hour
 Programme the reheating device to register the
temperature to increase at 0.5 to 1 degree per hour

When do you consider using clean gloves acceptable as

methods for preventing infection?
0/1
 Dressing a necrotic wound

 Assessing IV insertion site

 Obtaining urine sample
 Accessing a central venous device

Correct answer
Accessing a central venous device

To address individual and family responses to health

problems, theory-based nursing practice is important for
designing and implementing nursing interventions.
Dorothea Orem identified a theory of nursing practice.
Which of the following statements best exemplify
Orem's theory?
0/1
  Promotes nursing care that increases a patient's self-care
abilities

 Helps nurses provide culture-specific care that assists

patients to achieve and maintain health

 Assists nurses to identify behaviours associated with

various stages of coping with death and dying

 Facilities identification of a child's stage of development

so that appropriate nursing care is planned

Correct answer
Promotes nursing care that increases a patient's self-care
abilities

Which nursing action is associated with Faye Glenn

Abdellah's Patient-Centred Approach to Nursing?
1/1
 The nurse identifies that although the patient has a
serious chronic illness, the patient states that he feels
healthy because he can meet the responsibilities required
of him as a husband and a father

 The nurse collects data about a patient and organises it

into overt and covert problems as addressing the covert
problems may solve the overt problems as well

 The nurse plots a patient's health status in the quadrant

of poor health with a very unfavourable environment

 The nurse determines that the patient's need for oxygen

is the priority with reference to the 21 nursing problems
Which statement by a nurse meets Virginia Henderson's
Principles and Practice of Nursing?
0/1
 I see that you have applied makeup today for the first
time since your surgery.

 I am your nurse for the next 12 hours. You can use your
call bell to page me when you need assistance.

 Your wife can visit everyday between 10 in the morning

and 8 at night.

 A physical therapist will be in today to complete an

evaluation so we can start planning your care.

Correct answer
I am your nurse for the next 12 hours. You can use your call
bell to page me when you need assistance.

A nurse is caring for an older adult newly admitted to

the hospital. The nurse understands the importance of
organising data and then prioritising needs based on
Roper-Logan-Tierney Model for Nursing. Based on the
collected data, which nursing action addresses the
basic assumptions related to this theory?
0/1
 Encourage the patient to increase oral fluid intake

 Seek an order for oxygen via nasal cannula

 Activate the bed alarm on the patient's bed
 Take vital signs every four hours

Correct answer
Seek an order for oxygen via nasal cannula
The nurse is conducting a patient-centred interview on a
teenager who conveys that she is not getting relief from
shortness of breatheven if she uses the prescribed
inhaler. The nurse then decides to ask the patient to
demonstrate how she uses the inhaler and what she
does when she gets no relief. On the basis of Gordon's
Functional Health Patterns, which pattern is the nurse
assessing?
0/1
 Health perception-health management pattern
 Value-belief pattern

 Cognitive-perceptual pattern
 Coping-stress tolerance pattern

Correct answer
Health perception-health management pattern

The nurse reviewed the patient's clinical record and

assessed the patient. Which statement by the patient
indicates the conflict of ego integrity versus despair
according to Erik Erikson's Theory of Development?
1/1
 I really don't trust any of my doctors and their treatment
plan.
 I don't care what the doctor says, I will do it my war or no
way.
 I hope that in my next lifetime I get the chance to become
a doctor.

 I feel that I will never get better because nothing ever

goes well for me.
Which statement is accurate in relation to the concepts
of health and wellness indicated in the presented
theoretical framework?
0/1
 Implies that people are unhealthy if they are unable to
fulfill their roles in society

 Promotes meeting basic-level needs first and then

progressing to higher level needs

 Supports teaching about how to alter internal and

external factors to facilitate adaptations

 Facilitates prediction of whether patients will likely

improve in health or experience a decline based on level
of support

Correct answer
Facilitates prediction of whether patients will likely improve in
health or experience a decline based on level of support

A nurse is evaluating patient outcomes associated with

learning about hypertension and self-care. Which
outcome indicates success in the utilisation of the role-
modeling theory?
0/1
 Patient explains how to interpret the serving size on a
food label to calculate the caloric value of the nutrient

 Patient is able to identify five foods high in salt that

should be avoided when receiving a low sodium diet

 Patient is able to assess that his blood pressure is within

normal limits after accurately obtaining a blood pressure
reading using a sphygmomanometer
  Patient adheres to a weight-reduction diet, as evidenced
by a weekly 2-lb weight loss

Correct answer
Patient is able to assess that his blood pressure is within
normal limits after accurately obtaining a blood pressure
reading using a sphygmomanometer

Which is an example of an independent nursing

intervention?
0/1
 Administering enema
 Changing a soiled dressing

 Delegating the giving of bath to an unregistered

practitioner
 Assisting a patient with a transfer from a bed to a chair

Correct answer
Assisting a patient with a transfer from a bed to a chair