Nursing Compilation of Questions June2019

Domain 3: Nursing Practice and Decision Making (Lecturer’s Copy)

Answer: c – Pain is the most common presenting symptom in arterial disease with or without an ulcer.

Multiple Choice Practice Questions 4) 1)

Equipment, age and pressure

Encourage the patient to express her feelings about the job loss

Moisture, pressure and diabetes

Contact social services to assist the patient with accessing available resources

Pressure, shear and friction

Evaluate Mrs X’s understanding of her wound management

Pressure, moisture and age

Explain to Mrs X that she can no longer be seen at the clinic without a job

Answer: c – pressure, shear and friction 5)

Sharp debridement may cause trauma to underlying structures, the procedure should only be carried out by:

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: a.

Consider individual wound management priorities

Review the patient’s treatment plan

Determine the locations of the wounds

Verify the types of cancer

A health care assistant on working full time

A qualified nurse with at least 3 years experience

A doctor of any type of speciality

A qualified healthcare professional with appropriate training

Answer: d – Sharp debridement carries some risk to the patient and should only be carried out by a healthcare professional with the appropriate education and training. 6)

Mrs X has been ordered 100 ml to be infused over 45 minutes via a 20 drops/ml giving set. What drip rate should be set?

Answer: a – The nurse must consider what issues are important to each patient in order to improve compliance to treatment. 3)

Answer: a and b – job loss and subsequent loss of income can be an important factor in non-concordance with wound management, which can lead to delayed wound healing. Understanding how the patient feels about this is an important step in helping them manage the issues. 2)

External factors which increase the risk of pressure damage are:

Mrs X informs the nurse that she has lost her job due to excessive absences related to her wound. (2 correct answers) The nurse should:

Which sign or symptom is a key indication of progressive arterial insufficiency?

50 drops per minute

44 drops per minute

41 drops per minute

52 drops per minute

Oedema

Hyperpigmentation of the skin

Answer: b

Pain

Volume x drop factor = drops per minute

Cyanosis

Time in minutes (100 ml x 20 drops) / 45 minutes = 44.44 drops per minute

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A patient has been prescribed 1L of a saline solution. The rate is set at 150 ml/hr. How long will the infusion take? a.

5 hours and 20 minutes

4 hours and 40 minutes

6 hours and 10 minutes

6 hours and 36 minutes

Answer – d - Speech and language therapists (SLT) assess and treat speech, language and communication problems in people of all ages to help them better communicate. They also work with people who have eating and swallowing problems. 10) 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?

Answer: d Time = volume(mL) / rate(mL/hr)

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

1000(mL) / 150(mL/hr) = 6.66 hours or 6 hours and 36 minutes 8)

Mrs X has been admitted in the hospital due to Oedema of her thighs. One of her medications was Furosemide 40 mg tablets to be administered once daily. What should be done prior to administering Furosemide? a.

Check patient’s blood pressure, and withhold Furosemide if it is low

Check patient’s pupils, and withhold Furosemide if it is constricted

Swab your patient’s wound and send the sample to pathology

Assess each of your patient’s thighs by measuring its girth

Answer: a – Margaret needs support from the people around her, and being there for her is one way to relieve her anxiety. The nurse may also involve Margaret’s family to make decisions regarding her wellbeing. 11) Mrs X has developed Stevens - Johnson syndrome whilst on Carbamazepine. She is now being transferred from the ITU to a bay in a Medicine Ward. Which patients can Mrs X share a bay with? a.

A patient with MRSA

Answer: a – Furosemide is a diuretic used to treat fluid build up among patients with Congestive Heart Failure, Liver Cirrhosis or Kidney Disease. Blood pressure needs to be assessed prior to administering Furosemide. Medication needs to be withheld if BP is low.

A patient with diarrhoea

A patient with fever of unknown origin

A patient who has had Parkinson’s Disease for 7 years has been experiencing aphasia. Which health professional should you make a referral to with regards to his aphasia?

A patient with Stevens-Johnson Syndrome

Occupational Therapist

Community Matron

Psychiatrist

Speech and Language Therapist

Answer: d – Patients with SJS is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. 12) As the nurse on duty, you have noted that there has been an increasing number of cases of pressure sored in your nursing home. Which of the following is the best intervention?

Collaboration with the Multidisciplinary Team

Patient Advocacy

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Reduce fragmentation and costs

Tissue Viability Nurse

Identify opportunities and develop policies to improve nursing practice

Social Worker

Physiotherapist

Answer: d – Quality improvement – implementation of policies and procedures to improve healthcare delivery will help in reducing the number of pressure sore cases. 13) Fiona, 70 years old, has recently been diagnosed with Type 2 Diabetes. You have devised a care plan to meet her nutritional needs. However, you have noted that she has poorly fitting dentures. Which of the following is the least likely risk to the service user?

Answer: b – The Tissue Viability Nurse specialises in chronic and complex wound management, and provides advice and support for patients with complex tissue viability needs. Medicated dressings will have to be prescribed by the TVN for a patient with Grade 4 Pressure Sore. 16) A resident is due for discharge from your nursing home. You have been his keyworker for the last five years, and his family has been appreciative of the care you have provided. One of the relatives has offered you cash in an envelope after saying goodbye. What should you do?

Malnutrition

Hyperglycemia

Dehydration

Say thank you, but refuse the offer politely.

Hypoglycemia

Say thank you and accept the offer.

Accept the offer, and share it to your colleagues.

Accept the offer and keep it to yourself.

Answer: b – Hyperglycaemia is more likely to occur. Having denture problems will cause your patients to tolerate only fluids or pureed foods eaten slowly. This may also decrease the patient’s nutritional intake. 14) You are dispending Morphine Sulphate in the treatment room, which has been witnessed by another qualified nurse. Your patient refuses the medication when offered. What will you do next?

Answer: a 17) 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?

Go back to the treatment room and write a line across your documentation on the CD book; sign it as refused

Dispose the medication using the denaturing kit, document as refused and disposed on the MARS, and write it on the nurse’s notes.

If the dressings are intact, document it on the nursing notes and indicate that the dressings need to be changed after 48 hours.

Dispose the medication and document it on the patient’s care plan

Change the dressings if they look soiled and document this on the wound assessment form.

Store the medication in the CD pod for an hour, and then ask your patient again if he/she wants to take his medication

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

Answer: b – Refused controlled drugs should be disposed using the denaturing kit. Then this should be documented on the MARS, logbook and nurse’s notes.

All of the above.

15) Mr Smith has been diagnosed with Multiple Sclerosis 20 years ago. Due to impaired mobility, he has developed a Grade 4 pressure sore on his sacrum. Which health professional can provide you prescriptions for his dressing? a.

Answer: c – On admission or transfer, the nurse should carry out the necessary assessment of the service user’s skin integrity. One should check the wound bed tissue by removing the dressing and keeping records of the assessment made. A wound photograph needs to be attached with the skin inspection record.

Dietician

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18) You have answered a phone call after receiving handover. The person you were talking to has explained that he needs to find out about his sister’s condition. What should you initially do?

None of the above.

Answer – b – An initial intervention is to allow Mrs X to express her fears and anxiety. A nurse should be able to practice methods of therapeutic communication, which can help reassure patients and allow them to communicate their feelings.

Discuss about his sister’s condition and provide treatment options such as access to other resources in the community.

Check the patient’s record and verify the caller’s identity.

Refuse to divulge any information to the caller.

You must do the physical observations and notify the General Practitioner.

Discuss about his sister’s condition and book an appointment for him to attend care plan reviews.

You must ring the General Practitioner and request for a home visit.

You must administer medication from the Homely Remedy Pod after having spoken to the General Practitioner.

You must observe your patient until the General Practitioner arrives at your nursing home.

21) After having done your medication rounds, you have realised that your patient has experienced the adverse effect of the drug. What will be your initial intervention?

Answer: b – One needs to verify the caller’s identity and check it on the patient’s record. NMC Code of Conduct – Confidentiality. 19) A carer has reported that she has seen a resident fall off his bed. What initial assessment should be done? a.

Check the patient’s Early Warning Score along with the Glasgow Coma Scale immediately.

Ask the patient if he is in pain; if so, administer painkillers immediately.

Dial 999 and request for an ambulance to take your patient to the hospital.

Contact the out-of-hours GP and request for a home visit.

Answer - a – Standard 25-NMC Medicines Management – As a registrant, if a patient experiences an adverse drug reaction to a medication, you must take any action to remedy harm caused by the reaction. You must record this in the patient’s notes, notify the prescriber and notify via the Yellow Card Scheme immediately. 22) 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?

Answer: a – The Early Warning Score and Glasgow Coma Scale are used in acute healthcare settings and have been proven to be effective in the early detection of physical deterioration. 20) 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? a.

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.

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.

Answer - c – Risk assessments for pressure sores should take place within 6 hours at the start of admission. This should be done by somebody who has undergone appropriate and adequate training to recognise the risk factors contributing to pressure sores. If considered not at risk on initial assessment, reassessments should be done if there is a change on the individual’s condition. (RCN, 2001).

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23) You were on the phone with a family member, and one of the carers has reported that one of your residents has stopped breathing and turned blue. What should you do first? a.

End your conversation with the family member, attend to your patient and do the CPR.

End your conversation with the family member, go to your patient’s bedroom and assess for airway, breathing and circulation.

End your conversation with the family member, and dial 999 to request for an ambulance.

Dial 111, and request for an urgent visit from the General Practitioner.

Answer – b – Urinalysis for patients with UTI usually indicates blood in the urine. The presence of bacteria in the urine can indicate a bacterial infection of the urinary tract. Increased WBC count indicates inflammation. 26) A patient with a nutritional deficit and a MUST Score of 2 and above is of high risk. What should be done?

Answer: b – Basic Life Support – Initial assessment should be done prior to doing the Cardiopulmonary Resuscitation. One should check for Airway, Breathing and Circulation. 24) Mr Smith has just been certified dead by the General Practitioner. However, no arrangements have been made by the family. What should you do first? a.

Check patient’s records for the next of kin details, and contact them to discuss about funeral services.

Ring the co-operative and arrange for the undertaker to pick up Mr Smith as soon as possible.

Contact the GP and discuss about how to deal with Mr Smith.

Contact your manager and enquire about dealing with Mr Smith.

Assess his blood pressure.

Take a urine sample and send it to the lab.

Do the buccal swab and send the specimen to the lab.

Refer the patient to the dietician, the Nutritional Support Team and implement local policy.

Observe and document dietary intake for three days.

Repeat screening weekly or monthly depending on the patient’s food intake during the last 72 hours.

All of the above.

Answer – a – MUST Management Guidelines; Nutritionally high risk patients need to be treated as soon as possible. They will need referral to a dietician or the Nutritional Support Team. Goals need to be set and overall nutritional intake has to be increased. Care plans also need to be monitored and reviewed regularly. 27) According to the National Institute for Health and Care Excellence (NICE) Guidelines, examples of the Personal Protective Equipment are:

Answer – a – One should verify the next of kin’s details on the patient’s records, and contact them to discuss about the funeral services. Some family members have the power of attorney to make decisions in behalf of the patient. Sometimes the patient makes a request to donate his/her organs for study/research. In this case, documentation should be available in patient’s records. 25) Mr Marriott, 21 years old, has been complaining of foul smelling urine, pain on urination and night sweats. What further assessment should be done to check if he has Urinary Tract Infection?

Check his prothrombin time and signs of bleeding.

Tunic top, vascular access devices, surgical scissors

Gloves, aprons, face mask and goggles

Gloves, cannula, aprons and syringes

All of the above

None of the above

Answer – b – Personal Protective Equipment are equipment that are intended to be worn or held by a person to protect them from risks to health and safety while at work. Examples are gloves, aprons, and eye and face protection. 28) Based on the National Institute for Health and Care Excellence (NICE) Guidelines, which of the following is incorrect about sharps container? a.

It must be located in a safe position and height to avoid spillage.

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It should be temporarily closed when not in use.

It must not be filled above the fill line.

It must not be filled below the fill line.

31) In a nursing and residential home setting, how will you manage your time and prioritise patients’ needs whilst doing your medication rounds in the morning? a.

Start administering medications from the patient nearest to the treatment room.

Answer – c – The sharps container must not be filled above the fill line to avoid the overflow and spillage of sharps in a clinical setting/treatment room.

Start administering medications to patients who are in the dining room, as this is where most of them are for breakfast.

29) How do you prevent the spread on infection when nursing a patient with long term urinary catheters?

Check the list of patients and identify the ones who have Diabetes Mellitus and Parkinson’s disease.

All of the above.

Patients and carers should be educated about and trained in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital.

Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor.

Bladder instillations or washouts must not be used to prevent catheterassociated infections.

All of the above.

Answer – c – Patient’s needs have to be prioritised whilst doing medication rounds. In this case, one should check the BMs of the ones who are diabetic prior to administering insulin. Patients with Parkinson’s disease should take their medications on time to promote consistent therapeutic blood levels and prevent disabling symptoms. 32) Your patient has been recently prescribed with PEG feeding with a resting period of 4 hours. After two weeks of starting the routine, he has been having episodes of loose stool. What could be done?

Answer – d – All of the above. Healthcare professionals need to be educated with regards to preventing the spread of infection among patients on long term urinary catheter. Aseptic technique should be practiced at all times. Gloves should be worn when emptying urine bags and taking samples from the sampling port. 30) Mrs Hannigan has been assessed to be on nutritional deficit with a MUST Score of 1, which means that she is on medium risk. One of your interventions is to modify her diet for her to meet her nutritional needs. What should you consider?

Refer him to a dietician and review for a longer resting period between feeds.

Refer him to the tissue viability nurse for his peg site.

Examine his abdomen and assess for lumps.

Examine his peg site, and apply metronidazole ointment if swollen.

Answer – c – Continuous feeding needs a break of at least 4 hours in a 24 hour-period. This will allow the stomach to re-acidify. Low stomach acid can cause diarrhoea.

Mrs Hannigan’s meal preferences.

Mrs Hannigan’s intake and output records.

Mrs Hannigan’s x-ray results.

Different IV solutions are packaged similarly

A and B

The label contains the expiration date of the IV fluid

B and C

A and B

A only

33) It is important to read the label on every IV bag because:

Answer – d – One should practice according to the service user’s best interest. Mrs Hannigan needs to be asked of her meal preferences before modifying her diet, as healthy options will be available to meet her preferences. Dietary intake needs to be documented for 3 days, and screening needs to be repeated in regular intervals.

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Answer – c – IV labels need to be checked in accordance to the NMC Safe Drug Administration Guidelines. 34) You have noticed that the management wants all residents to be up and about by 8:30 am, so they can be ready for breakfast. Mrs X has refused to get up at 8 am, and she wants to have a bit of a lie in, but one of the carers insisted to wash and dress her, and took her to the dining room. What type of abuse in in place?

Latent TB Infection

Whether the client has been infected with TB bacteria

Answer: d – A Tuberculin Skin Test is performed to determine if a person has ever had TB. 37) You have discovered that the last dose of intravenous antibiotic administered to service user was the wrong dose. Which of the following should you do?

Financial Abuse

Psychological Abuse

Document the event in the service user’s medical record only.

Sexual Abuse

Institutional Abuse

File an incident report, and document the event in the service user’s medical record.

Document in the service user’s medical record that an incident report was filed.

File an incident report, but don’t document the even on the service user’s record, because information about the incident is protected.

Answer – d – Institutional Abuse - the mistreatment of people brought about by poor or inadequate care or support, or systematic poor practice that affects the whole care setting. It occurs when the individual's wishes and needs are sacrificed for the smooth running of a group, service or organisation.

35) You are preparing a client with Acquired Immunodeficiency Syndrome (AIDS) for discharge to home. Which of the following instructions should the nurse include?

Answer: b – The event should be recorded using an incident report, and written on the service user’s nursing notes. 38) There has been a bomb threat at the medical centre. The emergency response team informs the staff that the threat is legitimate and that service users should start being evacuated. Which of the following should you do?

Avoid sharing things such as razors and toothbrushes.

Do not share eating utensils with family members.

Ambulatory Patients

Limit the time you spend in public places.

Bedridden Patients

Avoid eating food from serving dishes shared with others.

ITU Patients

Infants

Answer: a – The Human Immunodeficiency Virus (HIV), which causes AIDS, is concentrated mostly in blood and semen. The client should not share articles that may be contaminated with blood, such as razors and toothbrushes. 36) You are preparing to administer a Tuberculin (Mantoux) Skin Test to a client suspected of having tuberculosis (TB). The nurse knows that the test will reveal which of the following? a.

How long the client has been infected with TB

Active TB Infection

Answer: a – Ambulatory patients have the potential to wander and end up in an unsafe place if not directed correctly. 39) A patient with a Bipolar Disorder makes a sexually inappropriate comment to the nurse. One should take which of the following actions?

Ignore the comment because the client has a mental health disorder and cannot help it.

Report the comment to the nurse manager.

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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.

Call for help immediately

Press the emergency call button immediately

Check the patient for injuries and transfer him to the wheelchair

Answer: d – The nurse should notify the client that this is inappropriate behaviour and set up appropriate boundaries.

Answer: a - It is of importance and highest priority to assess the patient first before calling for help. Patient should be immobilised to prevent further injuries.

40) You are nursing an adult patient with a long-bone fracture. You encourage your patient to move fingers and toes hourly, to change positions slightly every hour, and to eat high-iron foods as part of a balanced diet. Which of the following foods or beverages should you advise the client to avoid whilst on bed rest?

43) A patient with Leukaemia was about to receive a transfusion of blood platelets. The experiences nurse on duty in the ward noticed small clumps visible in the platelet pack and questions whether the transfusion should proceed. What should the nurse do?

Fruit juices

Proceed with platelet transfusion and monitor for signs of rejection

Large amounts of milk or milk products

Withhold platelet transfusion and document it on the patient’s chart

Cranberry juice cocktail

Ring the blood bank and enquire about the platelet pack received

No need to avoid any foods while on bed rest

All of the above

Answer: b – Too much milk increases the demand on the kidneys to excrete calcium and can lead to kidney stones.

Answer: C – Supplier of blood/platelets need to be informed about the changes noted, or anything that is unusual. Platelet pack may be contaminated by microorganisms such as E Coli, which may lead to death.

41) The nurse is preparing to make rounds. Which client should be seen first? a.

1 year old with hand and foot syndrome

69 year old with congestive heart failure

40 year old resolving pancreatitis

56 year old with Cushing’s disease

44) You are about to administer Morphine Sulfate to a paediatric patient. The information written on the controlled drug book was not clearly written – 15 mg or 0.15 mg. What will you do first?

CHF patient? – read about cushings, and hand and foot syndrome 42) The nurse sat an older man on the toilet in a six-bed hospital bay. Using her judgement, she recognised that he was at risk of falling and so left the toilet door ajar. In the meantime, the nurse went to make his bed on the other side of the bay. On turning around, she noticed that the patient had fallen onto the toilet floor. What should be her initial intervention? a.

Immobilise the patient and conduct a thorough assessment, checking for injuries

Not administer the drug, and wait for the General Practitioner to do his rounds

Administer 0.15 mg, because 15 mg is quite a big dose for a paediatric patient

Double check the medication label and the information on the controlled drug book; ring the chemist to verify the dosage

Ask a senior staff to read the medication label with you

Answer: C – NMC Safe Medicines Management; If you are not sure about the dose for the medication to administer, it is advised that you should have the dosage verified both on records and by the chemist.

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45.) Mr Smith is 89 years old with Prostate Cancer. He was advised that the only treatment available for him was palliative care after Transurethral Resection of the Prostate. What is your main task as a coordinator of care in the multidisciplinary team? a.) One should be able to organise the services identified in the care plan and across other agencies. b.) Assess the patient for respiratory complications caused by gas exchange alterations due to old age.

Answer: C – Abuse can be due to poor practice. It might be – the person does not know how to deal with the situation, has not been trained, or thinks he/she is doing the best thing for the patient. 48.) Which of the following statements is false? a.) Abuse mostly happens in nursing and residential homes. b.) Abuse can take place anywhere there is a vulnerable adult.

c.) Sit down with the patient and ask for the frequency of his bowel elimination

c.) Abuse can take place in a day care centre.

d.) Document the patient’s capability of self-care activities and the support he needs to carry out activities of daily living.

d.) Abuse can be carried out by anyone – doctors, nurses, carers and even family members.

Answer: A – One should collaborate effectively with the multidisciplinary team by organising how the patient’s needs can be met. One way is to liaise with McMillan Nurses and the Palliative Care Team to achieve the aims and goals of care.

Answer: B – Abuse can take place anywhere there is a vulnerable adult. Any person over the age of 18 who is unable to look after oneself or is at a high risk of harm, with a disability whether mental or physical are more vulnerable to being harmed than other adults.

46.) A diabetic patient with suspected Liver Tumor has been prescribed with Triphasic CT Scan. Which medication needs to be on hold after the scan? a.) Furosemide

a.) Physical Abuse

b.) Metformin

b.) Psychological Abuse

c.) Docusate Sodium

c.) Emotional Abuse

d.) Paracetamol Answer: B – Metformin should be on hold after the triphasic ct scan due to the fact that the contrast media used for the triphasic ct scan will react to met formin causing lactic acidosis with signs and symptoms of muscle pain or weakness, numbness of limbs, breathing problems, nausea and vomiting, slow heart rate and dizziness. 47.) Which of the following statements is true?

49.) During the day, Mrs X was sat on a chair and has a table put in front of her to stop her getting up and walking about. What type of abuse is this?

d.) Discriminatory Abuse Answer: A – This can include hitting, pushing, pulling hair, rough handling, misuse of medication, or inappropriate use of restraint. 50.) Michael feels very uncomfortable when the carer visiting him always gives him a kiss and holds him tightly when he arrives and leaves his home. What type of abuse is this?

a.) Someone is only an abuser if they deliberately intend to cause harm.

a.) Emotional Abuse

b.) Abuse only happens to children.

b.) Psychological Abuse

c.) Only people over 70 can be vulnerable.

c.) Discriminatory Abuse

d.) Abuse can occur unintentionally without the person meaning to cause harm.

d.) Sexual Abuse

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Answer: D – Sexual abuse can include rape, sexual assault, being forced to look at sexual images or any sexual activity that is not freely consensual.

Answer: C - Sexual abuse can include rape, sexual assault, being forced to look at sexual images or any sexual activity that is not freely consensual.

51.) Anna has been told that unless she does what the ward staff tell her, the consultant will stop her family from visiting. What type of abuse is this?

54.) An 82 year old lady was admitted to the hospital for assessment of her respiratory problems. She has been a long term smoker in spite of her daughter advising her to stop. Based on your assessment, she has lost a substantial amount of weight. How will you assess her nutritional status?

a.) Psychological Abuse

a.) Check her height and weight, so you can determine her BMI, BMI Score and Nutritional Care Plan

b.) Discriminatory Abuse c.) Institutional Abuse

b.) Use the respiratory and perfusion assessment chart on admission

d.) Neglect Answer: A – Psychological Abuse can include name calling, bullying, treating someone like a child, being shouted at, verbal abuse, threats, intimidation and coercion. 52.) Christine cannot get herself a drink because of her disability. Her carers only give her drinks three times a day so she does not wet herself. What type of abuse is this? a.) Physical Abuse

c.) Neglect d.) Sexual Abuse Answer: C – Neglect can include ignoring medical needs, not providing personal care or withholding necessities such as food, drink, medication or heating. 53.) Gabriella is 26 year old woman with severe learning disabilities. She is usually happy and outgoing. Her mobility is good, her speech is limited but she is able to be involved if carers take time to use simple language. She lives with her mother, and is being assisted with personal care. Her home care worker has noticed bruising on upper insides of her thighs and arms. The genital area was red and sore. She told the care worker that a male care worker is her friend and he has been cuddling her but she does not like the cuddling because it hurts. What could possibly be the type of abuse Gabriella is experiencing?

b.) Financial Abuse c.) Sexual Abuse d.) Institutional Abuse

d.) All of the above Answer: A – To assess your patient’s nutritional status, you will need her height, weight, BMI scores. This will help you plan your patient’s nutritional care plan throughout admission and discharge. 55.) John, 26 years old, was admitted to the hospital due to multiple gunshot wounds on his abdomen. On nutritional assessment in the ICU, the patient’s height and weight were estimated to be 1.75 m and 75 kg, respectively, with a normal body mass index (BMI) of 24.5 kg/m2. He was started on Parenteral Nutrition support on day one post admission. Postoperatively, the patient developed worsening renal function and required dialysis. In critical care, what would be most likely recommended for him to meet his nutritional need?

b.) Institutional Abuse

a.) Discriminatory Abuse

c.) Check if she is struggling to chew and swallow, and make a referral to the Speech and Language Therapist

a.) Starting Parenteral Nutrition early in patients who are unlikely to tolerate enteral intake within the next three days b.) Starting with a slightly lower than required energy intake (25 kCal/kg) c.) A range of protein requirements (1.3-1.5 g/kg) d.) All of the above e.) None of the above Answer: D – All of the above are recommended to meet the nutritional needs of the ICU patient as discussed. 56.) You are currently working in a nursing home. One of the service users is struggling to swallow or chew his food. To whom do you make a referral to? a.) Tissue Viability Nurse

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b.) Social Worker

59.) Which of the following is not a criteria for anaphylactic reaction:

c.) Speech and Language Therapist

a.) sudden onset and rapid progression of symptoms

d.) Care Manager

b.) life-threatening airway and/or breathing and/or circulation problems

Answer: C – Speech and Language Therapists (SALT) assess and treat speech, language and communication problems in people of all ages to help them better communicate. They'll also work with people who have eating and swallowing problems.

c.) skin and/or mucosal changes (flushing, urticarial and angioedema)

57.) What are the six physiological parameters incorporated into the National Early Warning Scores? a.) Respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate and level of consciousness b.) Biomarkers, oxygen saturation, temperature, systolic blood pressure, pulse rate and level of consciousness c.) Oxygen saturation, temperature, systolic blood pressure, pulse rate, level of consciousness and oedema d.) Temperature, systolic blood pressure, pulse rate, level of consciousness, oedema and pupillary reaction

d.) skin and mucosal changes only e.) A and B only f.) all of the above e.) A, B and C Answer: E – A single set of criteria will not identify all anaphylactic reactions. There is a range of signs and symptoms, none of which are entirely specific for anaphylactic reactions. However, certain combinations of signs make the diagnosis of an anaphylactic reaction more likely. 60.) Mrs X was taken to the Accident and Emergency Unit due to anaphylactic shock. The treatment for Mrs X will depend on the following except: a.) Location

e.) all of the above Answer: A - Respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate and level of consciousness; these are all readily measures in patients, either in the prehospital or hospital setting and can be repeatedly measured to document trends and assess changes in illness severity. 58.) Mr C’s mother was admitted to hospital following a fall at home and it was clearly documented that his mother suffered from diabetes. Mr C contacted the Trust concerning the Trust’s failure to make adequate discharge arrangements for his mother including the necessary arrangements to ensure that his mother would be provided with insulin following her discharge. What needs to be implemented to avoid such concern/complaint in the future? a.) Diabetic Liaison Nurse to work with service users in the community

b.) Number of Responders c.) Equipment and Drugs available d.) Triage system in the A&E Answer: D – The specific treatment of an anaphylactic reaction depends on location, training and skills of rescuers, number of responders, and equipment and drugs available. 61.) Mark, 48 years old, has been exhibiting signs and symptoms of anaphylactic reaction. You want to make sure that he is in a comfortable position. Which of the following should you consider?

b.) On-line training for blood glucose monitoring introduced within the Trust

a.) Mark should be sat up if he is experiencing airway and breathing problems.

c.) Diabetics to have their blood sugar recorded within four hours prior to discharge

b.) Mark should be lying on his back if he is assessed to be breathing and unconscious.

d.) A and C only

c.) Mark should be sat up if his blood pressure is too low.

e.) all of the above

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d.) Mark should be encouraged to stand up if he feels faint.

Answer: B – Resuscitation Council (UK) recommends adrenaline not to be administered intramuscularly when on cardiac arrest after anaphylactic reaction.

Answer: A – All patients should be placed in a comfortable position. The following factors should be considered: Patients with airway or breathing problems may prefer to sit up as this will make breathing easier. Lying flat with or without leg elevation is helpful for patients with low blood pressure. If the patient feels faint, do not sit or stand them up – may cause cardiac arrest. Patients who are breathing and unconscious should be placed on their side (recovery position).

a.) 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. b.) Individual choice, consent and the right to refuse treatment is important. c.) It is important for all health professionals to do any means to keep a patient alive regardless of traditions and beliefs.

Pregnant patients should lie on their left side to prevent caval compression. 62.) The following are ways to remove factors that trigger anaphylactic reaction except for one. a.) It is not recommended to make the patient should not be forced to vomit after food-induced anaphylaxis. b.) Definitive treatment should not be delayed if removing a trigger is not feasible. c.) Any drug suspected of causing an anaphylactic reaction should be stopped. d.) After a bee sting, do not touch the stinger for about a maximum of 3 hours. Answer: D – Removing the trigger for an anaphylactic reaction is not always possible. Any intravenous transfusion or antibiotic causing anaphylaxis should be discontinued. Stinger should be removed immediately after a bee sting. 63.) Mrs Smith has been assessed to have a cardiac arrest after anaphylactic reaction to a medication. Cardiopulmonary Resuscitation (CPR) was started immediately. According to the Resuscitation Council UK, which of the following statements is true? a.) Intramuscular route administration of adrenaline is always recommended during cardiac arrest after anaphylactic reaction. b.) Intramuscular route for adrenaline is not recommended during cardiac arrest after anaphylactic reaction. c.) Adrenaline can be administered intradermally during cardiac arrest after anaphylactic reaction. d.) None of the Above

64.) 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?

d.) None of the Above Answer: C - This case study raises some important issues about the relationship between personal beliefs and professional practice. We should be aware of imposing our views upon others and strive to be more sensitive of their needs. Patients have the right to refuse treatment and inform health professionals involved of their preferences in care. 65.) 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? a.) Nurses should have the empathy to listen to more than just the spoken word. b.) Nurses should practice in accordance to Pauleena’s best interest while providing support to the family and listening to their concerns and wishes. c.) Pauleena needs to be supported with questions related to mortality and meaning of life. Therapautic communication is also essential. d.) All of the above Answer: D – all of the above 66.) An adult patient with Nasogastric Tube died in a medical ward due to aspiration of fluids. Staff nurse on duty believes that she has flushed the tube and believed it is patent. What should NOT have been done?

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a.) Nothing should be introduced down the tube before gastric placement is confirmed.

69.) Population groups at higher risk of having a low vitamin D status include the following except:

b.) Internal guidewires should not be lubricated before gastric placement is confirmed.

a.) People who have darker skin

c.) Auscultate the patient’s stomach as you push some air in, and if you cannot hear anything, flush it.

b.) People who have high exposure to the sun

d.) It is important to check the position of the tube by measuring the pH value of stomach contents. Answer: C – Bowel sounds and pH of contents need to be checked to confirm if the tube is in place. Otherwise, this may lead to harmful flushing of the NGT.

c.) People who have low exposure with the sun d.) People who cover their skin for cultural reasons Answer: B – Population groups at higher risk of having a low vitamin D status include: All pregnant and breastfeeding women, particularly teenagers and young women

67.) The following are ways to assess a patient’s fluid and electrolyte status except:

Infants and children under 5 years

a.) pulse, blood pressure, capillary refill and jugular venous pressure

People over 65 years old

b.) presence of pulmonary or peripheral oedema

People who have low exposure to the sun.

c.) presence of postural hypertension

People with darker skin

d.) biomarkers

70.) Which of the following is considered a medication?

Answers: D – Biomarkers are used to assess the severity of a disease entity.

a.) whole blood 68.) Mrs X is 89 years old and very frail. She has renal impairment and history of myocardial infarction. She needs support from staff to meet her nutritional needs. Which IV fluids are recommended for Mrs X?

b.) albumin c.) blood clotting factors d.) antibodies

a.) consider prescribing less fluid

Answer: Blood is not classified as a medicinal product although some blood components are. Products derived from the plasma component of blood such as blood clotting factors, antibodies and albumin are licensed and classified as considered to be medicinal products.

b.) consider prescribing more fluid c.) either of the above d.) none of the above Answer: A – Less fluids are prescribed to patients who are older/frail, have renal impairment or cardiac failure, are malnourished and at risk of refeeding syndrome.

71.) You were running a shift and a pack of controlled drugs were delivered by the chemist/pharmacist whilst you were giving the morning medications. What would you do first? a.) keep the controlled drugs in the trolley first, then store it after you have done morning drugs b.) Count the controlled drugs, store them in controlled drug cabinet and record them on the controlled drug book

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c.) Count the controlled drugs, store them in the medication trolley and record them on the controlled drug book d.) Record them in the controlled drug book and delegate one of the carers to store them in the controlled drug cabinet Answer: B – On receipt of controlled drugs from the pharmacy, one should count the stocks received with a witness, store them in the controlled drug cabinet, then record it on the controlled drug book and Medication Administration Record Sheet. 72.) One of the following is not true about a delegation responsibility of a medication registrant:

The cupboard must be dedicated to the storage of controlled drugs. No other medicines or items may be stored in the controlled drug cupboard. Controlled drugs must be locked away when not in use. 74.) You were on a night shift in a ward and has been allocated to dispose controlled medications. Which of the following is correct? a.) Controlled drugs destruction and pharmacy stock check should be done at different times. b.) Controlled drugs should be destroyed with the use of the Denaturing Kit.

a.) Nurses are accountable to ensure that the patient, carer or care assistant is competent to carry out the task.

c.) Excessive quantities of controlled drugs can be stored in the cupboard whilst awaiting for destruction.

b.) Nurses can delegate medication administration to student nurses / nurses on supervision.

d.) None of the Above

c.) Nurses can delegate medication administration to unregistered practitioners to assist in ingestion or application of the medicinal product. d.) All of the above Answer: B – Student nurses are not considered as registrants until they receive their NMC pins. They should be under the direct supervision of a sign off mentor. Qualified nurses are allowed to delegate to someone who has been trained to do medications, such as senior carers and support workers. 73.) General guidance for the storage of controlled drugs should include the following except: a.) cupboards must be kept locked when not in use

Answer: B – Controlled drugs disposal and destruction Destruction on ward may take place at the same time as a pharmacy stock check. CDs should be destroyed in such a way that the drug is denatured or destroyed so that it cannot be retrieved, reconstituted or used. Destruction must occur in a timely fashion, so that excessive quantities are not stored awaiting destruction. All destruction must be documented in the appropriate section of the register, it must be witnessed by a second competent professional. 75.) You were assigned to change the dressing of a patient with diabetic foot ulcer. You were not sure if the wound has sloughy tissues or pus. How will you carry out your assessment?

b.) keys must only be available to authorised member of staff c.) regular drugs can also be stored in the controlled drug storage

a.) Sloughy tissue is a mass of dead tissues in your wound bed, while pus is a thick yellowish/greenish opaque liquid produced in an infected wound.

d.) the cupboard must be dedicated to the storage of controlled drugs

b.) Sloughy tissues are exactly the same as pus, and they both have a yellowish tinge.

Answer: General guidance for the storage of controlled drugs should include the

c.) Sloughy tissues and pus are similar to each other; both are found on the wound bed tissue and indicative of a dying tissue.

Cupboards must be kept locked when not in use

d.) The presence of sloughy tissues and pus are an indication of non-surgical debridement.

following:

The lock must not be common to any other lock in the hospital

e.) All of the above

Keys must only be available to authorised members of staff

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f.) None of the above

Answer: c

Answer: a

79.) Which of the following is an open ended question?

76.) Annie, one of the residents in the nursing home, has not yet had her mental capacity assessment done. She has been making decisions that you personally think are not beneficial for her. Which of the following should not be implemented?

a.) Do you enjoy the activities in this care home? b.) Do you like the food in the ward?

a.) Force her to change her mind every time she makes a decision

c.) Would you like me to take you out for a walk in the garden?

b.) Explain the benefits of making the right decision

d.) What are your favourite activities in the home?

c.) Allow her to make her own decision, as she still has mental capacity

Answer: d

d.) All of the above

80.) Adam has not been able to communicate with the nurses on duty. Using nonverbal communication and gestures to help one identify a service user’s needs is important because:

Answer: a – A person who has not yet been assessed as unable to make decisions is still considered to have his or her mental capacity. Hence, Annie’s decision should be respected, and she should be allowed to make decisions for herself. Staff’s preconception and prejudices should be set aside, so this will not affect the care delivered.

a.) the ability to communicate may be affected by illness b.) It saves time and makes one more efficient.

77.) A complaint has been raised by one of the service user’s relatives. Which of the following should you not document?

c.) the service user may be distracted and might not enjoy talking to staff d.) all of the above

a.) the person’s name Answer: a

b.) the date and time of complaint made

81.) Which of the following tasks is crucial in therapeutic communication?

c.) the complaint itself

a.) Listening attentively to a service user’s story

d.) the person’s country of origin

b.) Assessment of signs and symptoms

Answer: d

c.) Documenting an incident report

78.) Which of the following sets of needs should be included in your service user’s person centred care plan?

d.) All of the other answers

a.) social, spiritual and academic needs

Answer: d

b.) medical, psychological and financial needs

82.) Mr Z called for your assistance and wanted you to sit with him for a bit. He has disclosed confidential information about his personal life. Which of the following should you urgently deal with?

c.) physical, medical, social, psychological and spiritual needs d.) a and b only

a.) history of gall stones

e.) all of the above

b.) presence of pacemaker

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c.) suicidal connotations

Answer: c

d.) loss of appetite due to depression

86.) Alan Smith has a history of Congestive Heart Failure. He has also been complaining of general weakness. After taking his physical observations, you have noticed that he has pitting oedema on both feet. Which of the following is incorrect?

Answer: c – The service user’s safety is a priority at all times. He should be observed for the signs and symptoms of a suicidal patient. 83.) You were on duty, and you have noticed that the syringe driver is not working properly. What should you do?

b.) Lasix can be prescribed for the pitting oedema.

a.) ask someone to fix it

c.) Furosemide and Digoxin can be combined for patients with CHF.

b.) report this to your supervisor immediately

d.) Furosemide will increase Alan’s blood pressure, and lessen pitting oedema.

c.) leave this for the senior staff to sort out

Answer: d – Furosemide / Lasix, which is also known as the water pill is usually prescribed for patients with CHF. This is used to manage pitting edema, and manage fluid retention; hence, the bool pressure will be lowered. Digoxin is usually combined with Furosemide in different doses.

d.) recommend a person to repair it Answer: b – Any faulty equipment should be reported to the supervisor/person in charge so this can be dealt with and sent for maintenance. 84.) A patient in one of your bays has called for staff. She needed assistance with “spending a penny”. What will you do?

buy

a.) The Water Pill can be prescribed to manage fluid retention.

87.) Maisie is 86 years old, and has been in the nursing home for 5 years now. She has been complaining of burning sensation in her chest and sour taste at the back of her throat. What would she most likely to be prescribed with? a.) Ranitidine

a.) Ask her if she wants a hot or cold drink, and give her one as requested

b.) Zantac

b.) Assist her to walk to the vending machine, and let her choose what she wants to

c.) Paracetamol d.) Levothyroxine

c.) Assist her to walk to the toilet, and provide her with some privacy

e.) a and b

d.) Help her find her purse, and ask her what time she will be ready to go out

f.) b and d

Answer – c 85.) 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? a.) Give her wet wipes for her hands before dinner b.) Disregard the cardigan and take her to the dining room c.) Ask her what she means by a cardigan

Answer: e – Maisie will be most likely prescribed with Zantac (Ranitidine). This is used to treat hyperacidity in her stomach. It blocks the action of histamine in the stomach, reduces the acid the stomach makes. 88.) Mrs A is 90 years old and has been admitted to the nursing home. The staff seem to have difficulty dealing with her family. One day, during your shift, Mrs A fell off a chair. You have assessed her, and no injuries have been noted. Which of the following is a principle of the Duty of Candour? a.) You will not ring the family since there is no injury caused by the fall.

d.) Make her comfortable in a wheelchair, and cover her legs with a blanket

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b.) You have liaised with the lead nurse, and she decided not to ring the family due to no harm.

91.) You were a new nurse in a geriatric ward. The son of one of your patients discussed that he has noticed his mother is not being treated well in the ward, and that she looks very dehydrated and malnourished. How do you deal with the scenario?

c.) Observe the patient, take her physical observations, and ask if you must call the family.

a.) Do not do anything, because it is not much of a concern

d.) All of the above

b.) Discuss the case with a colleague

e.) None of the above

c.) Report this to your supervisor

Answer: e – Duty of Candour - openness and honesty as a professional duty when things go wrong 89.) Maggie has been very physically and verbally aggressive towards other patients and staff for the last few weeks. She is now on one-to-one care, 24 hours a day. According to her person centred care plan, the nurses are looking after her very well preventing her from causing any harm. Behaviour has been discussed with the social worker, and clinical lead has applied for DoLS. Which of the following is correct?

d.) Make a decision not to intervene – it will be dealt with by management Answer: c 92.) Documentation confirms that Amy has MRSA. You walked into her bedroom with coffee and biscuits on a tray. Which of the following is incorrect? a.) Put the coffee and biscuits on her bedside table and leave the tray on the other table

a.) DoLS will allow staff to intervene depriving Maggie from doing something to hurt herself, other residents, and staff

b.) Wash your hands thoroughly before leaving her room

b.) DoLS refers to protecting the other patients only from Maggie’s destructive behaviour.

c.) Dispose your gloves and apron before washing your hands

c.) DoLS protects the nurses and doctors only when providing care for Maggie.

d.) Use the alcohol gel on Amy’s bedside before leaving her room

d.) DoLS protects Maggie only from committing suicide.

Answer: d

Answer: a

93.) Which of the following is the most important in infection control and prevention?

90.) 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?

a.) Wearing gloves and apron at all times b.) Hand washing c.) immediate prescription of antibiotics

a.) Ask her what she prefers; show her the clothes and let her choose

d.) Use of hand rubs in the bedside

b.) Let Mrs X wear her trousers c.) Explain to her that the dress is so difficult to put on d.) Tell her that the trousers will make her more comfortable if she chooses it Answer: a

Answer: b 94.) There has been an outbreak of the Norovirus in your clinical area. Majority of your staff have rang in sick. Which of the following is incorrect? a.) Do not allow visitors to come in until after 48h of the last episode b.) Tally the episodes of diarrhoea and vomiting

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c.) Staff who has the virus can only report to work 48h after last episode

e.) None of the above

d.) Ask one of the staff who is off-sick to do an afternoon shift on same day

Answer: d

Answer: d 95.) Mrs X is diabetic and on PEG feed. Her blood sugar has been high during the last 3 days. She is on Nystatin Oral Drops QID, regular PEG flushes and insulin doses. Her Humulin dose has been increased from 12 iu to 14 iu. The nurse practitioner has advised you to monitor her BM’s for the next two days. What will be your initial intervention if her BM drops to 2.8 mmol after 2 morning doses of 14 iu?

98.) Mrs Z has been very chesty the last few days. She has been having difficulty with breathing. You have referred her to the GP, and requested for a home visit. What would probably be prescribed by the GP? a.) Stalevo 200 b.) Digoxin 40 mg

a.) Offer her a chocolate bar and a glass of orange juice

c.) Trimethoprim 100 mg

b.) Flush glucose syrup through her PEG Tube

d.) Simvastatin 100 mg

c.) Ring the nurse practitioner and ask if the insulin dose can be dropped to 12 iu

Answer: c

d.) Contact the General Practitioner and request for a visit

99.) Cherry has been prescribed with Estradiol tablet to be inserted twice a week at night. You entered her bedroom and noticed she is fast asleep. What would you do?

Answer: b a.) Try to gently wake her up and insert her vaginal tablets.

96.) 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?

b.) Allow her to get some sleep and try to insert the vaginal tablet on your next turn rounds.

a.) Document the incident and speak to your Manager

c.) Speak to her and ask her to spread her legs, so you can insert her vaginal tablet.

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

d.) Document that the tablet cannot be administered at all because the patient has refused.

c.) Find out what the whistle blowing policy is about d.) Ask the qualified nurse to sign it on handover if it is definitely been administered

Answer: b 100.) You are the night nurse in a nursing home. Maxine, 81 years old, has been prescribed with Lorazepam PRN. You have assessed her to be wandering and talking to staff. When do you administer the Lorazepam?

Answer: a 97.) Alan appears to be very confused today. He seems to be quite verbally aggressive towards staff. His urine has also got a bit of foul smell. How would you assess this resident?

a.) Immediately due to wandering

a.) Check his papillary response to light

b.) As soon as possible so she can go to bed

b.) Collect a urine sample for MSU

c.) When you see signs of confusion

c.) Carry out the urine dipstick

d.) When you see signs of agitation

d.) b and c

Answer: d

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101.) Mr Jones has been having Type 6 and 7 stools today. As you are doing his medications, which of the following would you not omit?

c.) Check bowel charts and cancel Macrogol on MARS if bowels are fine. d.) Change the prescription to PRN.

a.) Docusate Sodium 2 Capsules Answer: b

b.) Lactulose 5 mL

105.) Maria has ran out of Cavilon Cream. You have noted that her groins are very red and sore. You can see that David has spare Cavilon tubes after checking the stocks. What will you do?

c.) Senna 10 mL d.) Simvastation 100 mg

a.) Borrow a tube from David’s stock as Maria’s groins are red and sore

Answer: d

b.) Use Canesten for now and apply Cavilon once stock has arrived

102.) 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?

c.) Request for a repeat prescription from the GP, and have the stock delivered by the chemist

a.) Ring the family and find out what happened to the resident

d.) Ring the GP and ask him to see Maria’s groins, then prescribe Cavilon.

b.) Speak to your manager and tell her about it

Answer: c

c.) Ring the ward and request for an update from the nurse on duty

106.) Manu is in persistent pain and has Oromorph PRN. All your carers are on their rounds, and you are about to administer this drug. What would you do?

d.) Document that the resident is still in the hospital

a.) Dispense 10 mL Oromorph and administer immediately to relieve pain

Answer: c

b.) Dispense 10 mL Oromorph and call one of the carers to witness

103.) One of your residents in the nursing home has requested for a glass of whiskey before she goes to bed. What would you do?

c.) Call one of the carers to witness dispensing and administering the drug

a.) Refuse to give it / ignore the request

d.) Administer the drug and ask one of the carers to sign the book after their pad rounds

b.) Explain that the whiskey will cause her harm Answer: c c.) Give her a shot of whiskey, as requested

107.) 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?

d.) Give her a glass of apple juice and tell her it is whiskey Answer: c

a.) Both of you can stay on one side of the bed as you turn your patient

104.) The MARS says that Benedict is on TID Macrogol. You have notice that the nurses have been writing “A” for refused. What do you do?

b.) You go on the opposite side of the bed and use the bed sheet to turn your patient c.) You keep the bed as low as possible because the patient might fall

a.) Write “A” on the MARS, because Benedict is expected to refuse it.

d.) You go on the opposite side and grab the slide sheet to use

b.) Offer the Macrogol, and write “A” if the patient refuses it. Answer: d

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108.) You were on your medication rounds and the emergency alarm goes off. What will you do first? a.) Lock your trolley

1) You are assisting a doctor who is trying to assess and collect informaation from a child who does not seem to understand all that the doctor is telling and is restless.What will be your best response: 

stay quite and remain with the doctor

c.) Check first if everyone had their meds



Interrupt the doctor and ask the child the questions

d.) a and c



Remain with the doctor and try to gain the confidence of the child and politely assess the child's level of understandng and help the doctor with the information he is looking for

b.) Rush to your patient’s bedroom

Answer: a 109.) Your patient has has Diverticulitis for about a decade now. You have assessed her to be having soft stools of Type 4/5. Which of the following will need urgent intervention? a.) She is losing a lot of electrolytes in her body, and this needs to be replaced. b.) There is no urgency in this case, because patients with Diverticulitis are expected to have soft to loose stools.

2) You are nurse at the community care centre and an elderly complaints to you that hisneighbouris stealing money from him.He sends hisforshopping and sometimes the neighbour does not shop and keeps the money with him .You will: 

Confront the neighbour when he visits you next time



Remain quite and ignore the complaint



request the elderly to talk to the hospital chaplin for further assisitance



Raise a complaint in the incident report form and investigate the matter and inform the concerned

c.) She needs to be prescribed with fluid retention pills. d.) There is no urgency in this case because the stool is quite hard, and it should be fine. Answer: b 110.) One of your health care assistants came to you saying that she could not continue with her rounds due to a bad back. What will you do first?

Answer: c

3)You are training the staffs on mediaction errors.Which is the most common error that occurs due to streesful clinical environment?

a.) Document the incident and report to the manager.



Wrong dose and identity

b.) Ring for agency staff to cover the shift.



failure to capture allergies

c.) Assess your colleague’s back and administer pain killers.



Wrong contraindications

d.) Send her home and cover her work yourself to help the team.



Wrong constitution of drug

4) A client wants to leave thehospital. The medical team is not happy withh his clinical condition and judgement as per the mental health act.What willyou do ? 

let the client leave the hospital as he does not posses any threat to the public or is visibly ill

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

inform the security to hold the patient and not let him go away



Hypotension ,smoker,DM,obese men with ,non sedentry lifestyle



inform the police



hypertention ,smoker,obese men ,sedentry lifestyle



counsel the patient to stay back in the hospital for his betterment

9 )A client with CVA is foun to have difficulty in swallowing.Whom do you think should be informed for further assessment :

5) What is the purpose of clinical audit 

it helps to understand the functioning and effectiveness of nursing activities



helps to understand the outcomes and processesfor medical and surgical procedures



helps to identify areas of improvement in the system pertaining to Nursing and medical personnel



helps to understand medical outcomes and processes only



neurological physiotherapist



occupatoinal physiotherapist

1.last sense lost of a dying pt?

6)while brushhing the teeth the nurse observes bleeding gums in the client . The nurse understands that the probable cause for this gingivitis is:

ans.hearing 2.hollistic care ?



Poor diet



Poor flossing



Poor tarter removal



Infection

Person centred care with dignity and respect 3.adverse reaction repoting -yellow card 4.old copd pt in home care ,dysonea,anxious?

7) 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?

-administer oramorph



Ignore the client and let her cry in the hllway

5.clinical benchmaking ?



Inform the client about the preparing to come forthe next appointment for further discussion on the treatment planned

-to improve standards in health care



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

8) Who among the list below are more prone to coronary artery disease: 

Hypotension,smoker,DM, obese women , non sedentry life style

-a new initiate in health care system 6.contolled drug usage in home care setup ? -stict to local policies and guidelines -dont give rest of the mediacation to relatives

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dontleavebalanceofmediactioninhome

12.in a queue pt collapses ?

7.nurse and collegue found a discrepency of controlled drug.how to report ?

-run to bring AED

-inform police

-shout for help

-inform pharmacy

-asses for response

-recheck,infom incharge,if not found inform senior nurse

13.compassionate care ?

8.while mentoring a final year student dispensing medication .nurse role ?

Ans: Deep awareness of the suffering of another coupled with the wish to relieve it.

-direct supervision

14.primary care ?

-before delegating find out he is competemnt

-care provided in acute settings

-ask himt to tell after the administration is complete

-first hand care appoach made by pt

9.electonic data transfer is more these days, which of the report is not suitable to sent to a discharged client ?

15.why old people afebrile even if they are infected ? -immature mast T- lymphocYtes

-confusing blood report interuuption of non adrenaline activity -smoking caessation policy 16.postrual hypotension? Hypotension when standing 10.not a sign of ectopic pregnancy ? 17.inter mediate care ? -vaginal bleed Operative care begning from4-12hrs -shoulder pain 18.pt suspected of UTI? -dysuria -ask doctors to wea gloves ,gown -positive pregnancy test -use PPE while dealing with body fluids 11.not a sign of meconium aspiration syndrome ? use PPE and act as an infection control link nurse -baby crying -review antimicobials daily and report health care team -floppy appeaance 19.a pt who attempted suicide is at high risk when ? -dark greenish appearance -he appears happy

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20.you saw a pt unhappy who has been admitted in hospital for more than one week, you ask him whether he is ok ,he aswers he is ok .you response?

27.1 gm paracetamol advised .500 mg tab available ? ans-2

-accept it 28.40 mg adviced.2.5 mg available -you dont seem to be ok .are you sure you are ok -ans 16 1.speed shock complication? 29.125 mg available in 5ml 50 mg to be given ? 22.clostridium defficile pt discharged,which measures is ineffective ? ans2ml -alcohol hand rub useage 30.6 year old child who is dyspagic restless,visiting hours over your role ? 23.motion mixed with blood and mucous,which condition does not show this as a sign ? -allow mother to stay -hashimotors syndrome -tell her visiting hour is over -ulcerative colitis -tell her you will take care of the child -pseudo membaneous colitis 31.removing plaster cast of a child who is not co-operating? -cronhs disease -explain to him accoding to his own understanding in age appropriate language 24.dehydration in old adult ? -force fully remove -skin turgour 32.when can you disclose information of pt? -elasticity -public interest and law and order 25.dehydration ? -law and order -skin turgour 33.when confidentiality can be revealed 26.which drug causes fall in elderly? -puts any one at risk or harm -loop diuretics 34.nmc stands for ?nmc stands code and conduct for nurses -beta blockers 34.steps in nursing process ? -nsaids -assesment,planning,implementation,evaluation -hypnotics -assesment,planning,audit

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35.after completion of nursing notes ,nurse should?

-double bag it

-sign,printed name,designation,time,date

-use gloves

-sign,designation,time,date

-inform lab before transfering

-sign,time,date of bith

44.how to check position of enteric tube ?

36.during shift change nurse gets over from incharge of an infected pt ,your role?

ans.aspirate and check ph

-using ppe

45.national early warning score ?

37.correct pocedure to get infomed consent from pt sheduled for surgery?

ans- helps nurses to early asses any deterioration of physiological features in pts

ans.explain to him details of evething and makes sure his participation in the process

46.heart rate below 50?

-get consent on the day of surgery

ans.bradycardia

40.registered RN role ,while administering medicine ?

47.while using crutches where to give weight

-should know about all medications

-arms of chair and stand up

-should know about medicines,explain to pt to make them understand why they are taking them

48.proper technique to use walke?.

-for giving iv medicines get help of other nurse

-move frame, 10 feet, take small steps

41.while putting iv line doctor leaves to emergency,you have not done it before

-move 10feet,take large wide steps

-dont insert as you are incompetent

-move 12feet

42.you noticed medical equipment not working while you joined a new team and the team members are not using it.your role?

-tansform weight to walker and walk 49.which step is not right to follow while using walker?

-during audit raise your concern -use outside -inform in written to management -use only while standing -inform nmc -when getting up raise from chair by pushing with palms on armrest -take photograph 50.digoxin administation,heart rate 58,your role ? 43.bio hazard label on a bottle in nursing counter? -inform docto

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ans.omit dose,record,raise your concern

ans.pevent pneumothoacx

51.atrial arrythimias in ecg

59.leg stockings used.why?

ans.atrial fibrilation

ans.promote venous return

52.an old admitted patient comes up with a new confusion ?

60.when to keep pts privacy and diginity?

-alzhimers

-under all circumstances

-dementia

-not in emergency

-normal ageing

61.poliferative phase in wound healing,how long ?

- UTI

ans.3 to 2 days

53.advice for a dementia patient while giving discharge teaching ?

62.ideal wound dressing characteristics?

-predictable environment

-gaseous exchange,adherance,insulation,low humidity,high humidity,anaerobic

54.while iv administration finds swelling and redness

63.ideal site for IM INJECTIONS in buttocks region ?

ans.remove the cannula

ans.upper outer quadrant

55.old dysphagic pt,orders by doctors and therapist does not include ?

64.after abdominal surgery.pt complains of pain even after administration of analgesics little ago?

-giving water to drink re administer analgesics 56.why pts kept on npo -apply heat -prevent reflux and inhalation of gastric content -position to 45 degree angle -prevent vomitting 65.pt bring own medication to hospital and wants to self administer.your role ? 57.poper way to remove vaccum drainage ? -allow him -release vaccum and remove -give medications back to relatives to take back to home -pullout -keep it in locker,use from medication trolly -get doctor to do it -explain to pt about medication before he administer it 58.why double clamp applied to remove chest drainage ?

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66.after LP pt becomes unconcious .reason?

73.how nurse should improve his practice ?

-csf lealkage

-experience

-headache

-feedback

-herniation

-reflection

67.not a policy in palliative care ?

ans-all of above

-pain relief

74.while formulating and giving advices nurse is performing which role ?

-CPR

-advocate

68.pt fequentlY urinates in night

-educator

Ans; polyuria

-healthcarer

69.accountability means ?

-researcher

-rensponsible

75.advocacy means?

-responsive

-act as a liasion between pt and health care team

70.tibia ,fibula fracture correction done,which sign and symptom

-help pt to make informed decisions

leads to the suspicion that it is leading to compartment syndrome ?

76.pt states "i hate cancer"according to kobler theory this is

-pain not relieved by analgesics

-anger

-numbness and tingling sensation

-denial

71.a pts relative is seen praying in a dark place,your role ?

-acceptance

-complaint to security that the chaplin is not open

77.proper method to collect urine sample?

-povide him a peaceful place

ans.clean meatus and collect midstream

-tell him it is aganist the rule

78.needle stick injury proper way to report ?

72.after laminectomy how to turn patient ?

the incharge and infection control nurse

-as a unit

79.how frequent vitals must be recorded?

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ans.during admission and then plan is made how fequently it should be measured

89.potassium sparing diuretic

80.a nurse is adviced one hour vital charting of a pt,how frequently it should be recorded?

-spirinolactone

-every one hour

90.after iv dose pt develops,rashes,itching,flushed skin

-whenever the vital signs shows deviation from normal

-septecimia

81.when discharge should be planned ?

-adverse reaction

ans.within 24 hours of admission

91.indication of chest tube drainage

82.oxygen administratio order should include ?

-pneumothorax

ans.initiation time,device,route,litre,how long etc

92.health care assistant task delegation criteria?

-no need to write order

-make sure he is competent

83.one the day of discharge spouse of a pt is tensed about discharge ?

-make sure he is experienced

-cancel discharge

-confirm that he is a staff having same designation

-fix time for consultation

-he is an employee of the same institution

84.cancer pt nsheduled for CT ,worried.your role ?

93.a pt had complained several times,now that pt register a new complainat about your collegue,your role ?

ans.encouraging him to tell about how he feels and about his fears -tell staff members to be careful to avoid mistakes in future 85.movement away from midline ? -be honest and impartial and complete investigation -abduction 94.acute illness ? 86.where to asses edema ? 95.positive fluid balance ? ans.ankles ans.intake greater than output 87.in which type of wound,wound care plan to be implemented ? 96.paracentesis position .how to position client? -all type of wounds -head end elevation to 45 degree 88.how to asses respiratory status ? -ease,rate,rhytm,,pattern

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97when can we perform LP?

104.when can we realise actual and potential poblems of a pt ?

-icp normal

-assesment

98.how can we identify health poblems of a patient ?

105.pt comes to emegency in shock,signs ?

-lifestyle

-tachycardia,hypotension

-medical notes

-tachycardia,hypertension

-discussion

-bradycardia,hypotension

-interview

106.pt centred care,who is the centre of approach ?

99.how to collect details of a pt ?

-pt

-open ended questions

107.signs of infection?

-listen to their concerns

-WBC raised,blood sugar low

-ask relatives

-tachy cardia,shivering,temp 38.6 c

100.while dealing with a pt,sexuality aganist nurses belief ?

-temp 36 c

ans.acceptance

108.nursing home bill doesnot include ?

101.when you provide care for a pt of different culture ?

-laundry

-whenever possible provide sensible care

-food

102.haemorrhoids risk factor?

-social activities

-straining of stools

119.head injury pt,unequal pupils ?

-veg diet

-consider this as an emergency,follow ABCDE approach

-fibre rich food

110.iv administration benefit ?

-non -processed food

-fast acting

103.comprehensive nursing care ?

111.after nj feeding how to position the client

Critical nd advanced care

-fowlers

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C. D.

-head turned to side

Speak to the client & family together Stand close to the client & speak loudly

112.criteria to base while giving care ? -allcriteria

113.while in outside setup what care will you give if exposed to a situation ? -keeping up to professional standards -above what is expected

-no involvement 114.measures to prevent fall in an unconcious pt in bed -side rails -call bell

115.how to act in an emergency -according to our competence -according to situation 6.

The code is concerned about focusing on which of the following criteria A – Clinical expertise B – Conduct, behavior, ethics & professionalism C - Hospital policies D – Disciplinary actions When communicating with a client who speaks a different language , which best practice should the nurse implement? A. Speak loudly & slowly B. Arrange for an interpreter to translate

A nurse is not trained to do the procedure of IV cannulation , stil she tries to do the procedure . You are the colleague of this nurse . what will be your action ? A – You should tell that nurse to not to do this again B – You should report the incident to someone in authority C – you must threaten the nurse, that you will report this to the authority D – you should ignore her act An antihypertensive medication has been prescribed for a client with HTN. The client tells the clinic nurse that they would like to take an herbal substance to help lower their BP . The nurse should take which action? A. Tell the client that herbal substances are not safe & should never be used. B. Teach the client how to take their BP so that it can be monitored closely C. Encourage the client to discuss the use of an herbal substance with the health care provider D. Tell the client that if they take the herbal substance they will need to have their BP checked frequently Which professional organizations are responsible for establishing the code? A. NHS B. NMC C. American Nurses Association, National League of Nursing, and American Association of Nurse Executives D. State Boards of Nursing, state and national organizations, and specialty organizations Nurses who seek to enhance their cultural-competency skills and apply sensitivity toward others are committed to which professional nursing value? A. Autonomy B. Strong commitment to service C. Belief in the dignity and worth of each person D. Commitment to education

When trying to make a responsible ethical decision , what should the nurse understand as the basis for ethical reasoning ? A. Ethical principles & code B. The nurse’s experience C. The nurse’s emotional feelings D. The policies & practices of the institution

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A fully alert & competent 89 year old client is in end stage liver disease . The client says , “I’m ready to die,” & refuses to take food or fluids . The family urges the client to allow the nurse to insert a feeding tube. What is the nurses moral responsibility ? A. The nurse should obtain an order for a feeding tube B. The nurse should encourage the client to reconsider the decision C. The nurse should honor client’s decision D. The nurse must consider that the hospital can be sued if she honors the client’s request

A mentally competent client with end stage liver disease continues to consume alcohol after being informed of the consequences of this action. What action best illustrates the nurse’s role as a client advocate? A. Asking the spouse to take all the alcohol out of the house B. Accepting the patient’s choice & not intervening C. Reminding the client that the action may be an end-of life decision D. Refusing to care for the client because of the client’s noncompliance

10. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? 1) Reverse isolation 2) Respiratory isolation 3) Standard precautions 4) Contact isolation 11. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? 1) A diagnosis of AIDS and cytomegalovirus 2) A positive PPD with an abnormal chest x-ray 3) A tentative diagnosis of viral pneumonia 4) Advanced carcinoma of the lung 12. A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? 1) “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.” 2) “If any healed areas break open I should first cover them with a sterile dressing and then report it.” 3) “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”

“I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.” 13. Contact precautions are initiated for a client with a health care associated infection caused by MRSA. Which protective equipments the nurse should wear while providing colostomy care? 1) Gloves & gown 2) Gloves & goggles 3) Gloves, gowm & shoe protecters 4) Gloves , gown , goggle & face shield 14. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: 1) interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. 2) congratulate the nurse on the use of good technique. 3) discuss dressing change technique with the nurse at a later date. 4) interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves. 15. The Nurse is caring for a patient with heart failure . On Assessment , the nurse notes that the patient is dyspnoiec & crackles are audible on auscultation . What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss B. Flat neck & hand veins C. An increase in BP D. Decreased central venous pressure (CVP) 16. The nurse is preparing to care for a patient with a potassium deficit. The nurse reviews the patient’s record & determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires nasogastric suction C. Has a history of Addison’s disease D. Is taking a potassium –retaining diuretic 17. A 27- year old adult male is admitted for treatment of Crohn’s disease . Which information is most significant when the nurse assesses his nutritional health? A. Anthropometric measurements B. Bleeding gums

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18.

19.

20.

21.

C. Dry skin D. Facial rubor An adult woman is admitted with metabolic acidosis . Which set of arterial blood gases should the nurse expect to find in a client with metabolic acidosis? A. Ph 7.28 ; pCO2 -55; HCO3 -26 B. Ph 7.50 ; pCO2 -40 ; HCO3 -31 C. Ph 7.48 ; pCO2 -30 ; HCO3 -22 D. Ph 7.30 ; pCO2 -36 ; HCO3 -18 The nurse is assigned to care for a group of patients. On review of the patient’s medical records the nurse determines that which patient is at risk for fluid volume excess? A. The patient taking diuretics B. The patient with kidney disease C. The patient with an ileostomy D. The patient who requires gastrointestinal suctioning An adult who has gastroenteritis & is on digitalis has lab values of ; K 3.2 mEq/L , Na 136 mEq/L, Ca 4.8 mEq/L , & Cl 98 mEq/L. The nurse puts which of the following on patient’s plan of care? A. Monitor for hyperkalemia B. Avoid foods rich in potassium C. Observe for digitalis toxicity D. Observe for Trousseau’s & Chvostek’s signs The nurse is reading a health care provider’s ( HCP) progress notes in the patient’s record & reads that the HCP has documented “ insensible fluid loss of approx 800 ml daily” . The nurse interprets that this type of fluid loss can occur through which route? A. The skin B. Urinary output C. Wound drainage D. The gastrointestinal tract

22. The nurse is preparing to change the parenteral nutrition (PN) solution bag & tubing . The patient’s central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? A. Breathe normally B. Turn the head to the right C. Exhale slowly & evenly D. Take a deep breath, hold it ,& bear down 23. Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1) Walking without shoes

2) Sitting in Fowler's position 3) Lying supine in bed 4) Using a heating pad 24. The client at greatest risk for postoperative wound infection is: 1) A 3-month-old infant postoperative from pyloric stenosis repair 2) A 78-year-old postoperative from inguinal hernia repair 3) An 18-year-old drug user postoperative from removal of a bullet in the leg 4) A 32-year-old diabetic postoperative from an appendectomy 25.

Black wounds are treated with debridement. Which type of debridement is most selective and least damaging? 1) Debridement with scissors 2) Debridement with wet to dry dressings 3) Mechanical debridement 4) Chemical debridement 26. A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: 1) Sanguineous 2) Serous-sanguineous 3) Serous 4) Purulent 27. The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a: 1) Transparent film 2) Hydrogel dressing 3) Collogenase dressing 4) Wet to dry dressing 28. A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes: 1) Cleaning the skin and wound with betadine 2) Removing all traces of residues for the old dressing 3) Choosing a dressing no more than quarter-inch larger than the wound size 4) Holding in place for one minute to allow it to adhere

29.

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A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as: 1) Abrasion 2) Unapproximated 3) Laceration 4) Eschar 30. TRUE/FALSE 1. Standard precautions are the daily practices (e.g. hand washing, use of personal protective equipment, cleansing of equipment) that will reduce the transmission of infections. 2. Gowns and gloves should not be worn in common use areas such as nursing stations, eating areas, and elevators. 3. Masks and goggles must be worn for care activities such as care of patients who have a cough or are vomiting. 4. The use of gloves is an effective substitute for hand washing. 5. You must wash your hands after removing your gloves. 6. In a hospital, routine precautions are the responsibility of doctors and nurses only. MULTIPLE CHOICE – Choose the MOST CORRECT response. 31. . The objective of standard precautions is to prevent the spread of infection within the health care institution: a. From patient to patient. b. From patient to staff. c. From staff to patient. d. From staff to staff. e. All of the above. 32.

The most important procedure for the prevention of infection from germs and viruses is: a. Wearing gloves. b. Properly bagging used linen. c. Effective hand washing.

d. Wearing protective eyewear. 33. Which of the major theories of aging suggests that older adults may decelerate the aging process? 1) Disengagement theory 2) Activity theory 3) Immunology theory 4) Genetic theory 34. Which of the following is a guiding principle for the nurse in distinguishing mental disorders from the expected changes associated with aging? 1) A competent clinician can readily distinguish mental disorders from the expected changes associated with aging. 2) Older people are believed to be more prone to mental illness than young people. 3) The clinical presentation of mental illness in older adults differs from that in other age groups. 4) When physical deterioration becomes a significant feature of an elder’s life, the risk of comorbid psychiatric illness rises. 35. A normal sign of aging in the renal system is 1) Intermittent incontinence 2) Concentrated urine 3) Microscopic hematuria 4) A decreased glomerular filtration rate 36. A 76 year old man who is a resident in an extended care facility is in the late stages of Alzheimer’s disease . He tells his nurse that he has sore back muscles from all the construction work he has been doing all day . Which response by the nurse is most appropriate ? 1) “ you know you don’t work in construction anymore” 2) “ what type of motion did you do to precipitate this soreness?” 3) “ you’re 76 years old & you’ve been here all day. You don’t work in construction anymore.” 4) “would you like me to rub your back for you?” 37. An 86 year old male with senile dementia has been physically abused & neglected for the past two years by his live in caregiver . He has since moved & is living with his son & daughter-in-law. Which response by the client’s son would cause the nurse great concern? 1) “ How can we obtain reliable help to assist us in taking care of Dad? We can’t do it alone.” 2) “ Dad used to beat us kids all the time . I wonder if he remembered that when it happened to him?” 3) “I’m not sure how to deal with Dad’s constant repetition of words.”

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“I plan to ask my sister & brother to help my wife & me with Dad on the weekends.” 38. Knowing the difference between normal age- related changes & pathologic findings , which finding should the nurse identify as pathologic in a 74 year old patient? 1) Increase in residual lung volume 2) Decrease in sphincter control of the bladder 3) Increase in diastolic BP 4) Decreased response to touch , heat & pain . 39. Convert 40mg into gram 40. Digoxin 400 mcg is prescribed, the ampule of digoxin is labeled 250mcg/ml. How many mls will you draw up . 41. Which of the following is an important principle of delegation? 1) No transfer of authority exists when delegating. 2) Delegation is the same as work allocation. 3) Responsibility is not transferred with delegation 4) When delegating, you must transfer authority. 42. A staff nurse has delegated the ambulating of a new post-op patient to a new staff nurse. Which of the following situations exhibits the final stage in the process of delegation? 1) Having the new nurse tell the physician the task has been completed 2) Supervising the performance of the new nurse 3) Telling the unit manager the task has been completed 4) Documenting that the task has been completed 43. Which of the following is a specific benefit to an organization when delegation is carried out effectively? 1) Delegates gain new skills facilitating upward mobility 2) The client feels more of their needs are met. 3) Managers devote more time to tasks that cannot be delegated. 4) The organization benefits by achieving its goals more efficiently 44. To prepare a client for discharge home from an acute care facility, a nurse knows that the planning process must begin at what point? 1) The night before discharge. 2) Upon admission to the hospital. 3) Prior to discharge. 4) When the client indicates the readiness for discharge planning and teaching. 45. 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?

The nurse will care for clients at the center, in their homes, and in the hospital. 2) The nurse sees only clients who come to the office. 3) The nurse works independently of other health care professionals. 4) The nurse will not continue client care if it involves long-term needs. 46. 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? 1) Whether the client will be able to keep medical appointments 2) Whether the client desires spiritual counseling 3) Whether the home has stairs and/or throw rugs 4) Whether the client has financial resources for payment 47. A nurse demonstrates patient advocacy by becoming involved in which of the following activities? 1) Taking a public stand on quality issues and educating the public on "public interest" issues 2) Teaching in a school of nursing to help decrease the nursing shortage 3) Engaging in nursing research to justify nursing care delivery 4) Supporting the status quo when changes are pending 48. In the role of patient advocate, the nurse would do which of the following? 1) Emphasize the need for cost-containment measures when making health care decisions 2) Override a patient's decision when the patient refuses the recommended treatment. 3) Support a patient's decision, even if it is not the decision desired by the nurse. 4) Foster patient dependence on health care providers for decision making. 49. A patient is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet . The patient is looking forward to the diet change because he has been “bored “ with the clear liquid diet. The nurse should offer which full liquid item to the patient? 1) Tea 2) Gelatin 3) Custard 4) Ice pop 50. Before administering a tube feeding the nurse knows to perform which of the following assessments? 1) The gastrointestinal tract , including bowel sounds ,last BM , & distention. 2) The client’s neurologic status , especially gag reflex 3) The amount of air in stomach 4) That the formula is used directly from the refrigerator

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51. 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? 1) "Don't you remember what time you visitor have been coming?" 2) "You are worried about visiting hours." 3) "You want to know when you can have visitors?" 4) "Visiting hours are from 6:00 p.m. to 8:00 p.m." 52. A client breathes shallowly and looks upward when listening to the nurse. Which sensory mode should the nurse plan to use with this client? 1) Auditory 2) Kinesthetic 3) Touch 4) Visual 53. A nurse has been told that a client's communications are tangential. The nurse would expect that the clients verbal responses to questions would be 1) long and wordy 2) loosely related to the questions. 3) rational and logical 4) simplistic, short, and incomplete. 54. Which of the following statements by a nurse would indicate an understanding of intrapersonal communications? 1) "Intrapersonal communications occur between two or more people." 2) "Intrapersonal communications occurs within a person" 3) "Interpersonal communications is the same as intrapersonal communications." 4) "Nurses should avoid using intrapersonal communications." 55. According to the therapeutic communication theory, what criteria must be met for successful communication? 1) The communication needs to be efficient, appropriate, flexible, and include feedback. 2) The individuals communicating with each other must share a similar perception of the conversation. 3) The communication must be intrapersonal, interpersonal, group, or societal in nature. 4) Nonverbal communication is consistent with verbal communication. 56. The nonverbal communication that expresses emotion is: 1) Body positioning. 2) Eye contact 3) Cultural artifacts. 4) Facial expressions.

57. The nurse is interacting with a client and observes the client’s eyes moving from side to side prior to answering a question. The nurse interprets this behavior as: 1) The client being bored with the interaction. 2) The client processing auditory information. 3) The client engaging in intrapersonal communication. 4) The client responding to auditory hallucinations 58. To provide effective feedback to a client, the nurse will focus on: 1) The present and not the past. 2) Making inferences of the behaviors observed. 3) Providing solutions to the client. 4) The client. 59. 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 the process. Which of the following would be most helpful to the grieving family during this difficult time? 1) calling the client a "donor" 2) provide care to the deceased client in a careful and loving way 3) encourage the family to make a quick decision 4) tell them that there is no time to call other family members for advice 60. . 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? 1) tell me why you feel death is your only option 2) how would you like to do this 3) everyone dies sooner or later 4) assisted suicide is illegal in this state

61. A 42 year old female has been widowed for 3 years yet she becomes very anxious, sad, and tearful on a specific day in June. Which of the following is this widow experiencing? 1) preparatory depression 2) psychological isolation 3) acceptance 4) anniversary reaction 62. 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? 1) nothing because he is too young to understand death 2) tell him his father has gone away, never to return 3) tell him his father is sleeping

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63.

64.

65.

66.

67.

68.

explain that his father has died and give him the option of attending the funeral The hospice nurse has been working for two weeks without a day off. During this time, she has been present at the deaths of seven of her clients. Which of the following might be beneficial for this nurse? 1) Nothing 2) provide her with an assistant 3) suggest she take a few days off 4) assign her to clients that aren't going to die for awhile The wife of a recently deceased male is contacting individuals to inform them of her husband's death. She decides, however, to drive to her parent's home to tell them in person instead of using the telephone. Of what benefit did this communication approach serve? 1) she needed to get out of the house 2) for the family to gain support from each other 3) no benefit 4) she was having a pathological grief response While providing care to a terminally ill client, the nurse is asked questions about death. Which of the following would be beneficial to support the client's spiritual needs? 1) Nothing 2) ask if they want to die 3) ask if they want anything special before they die 4) provide support, compassion, and love An emergency room nurse is working when an Amtrak train derails. The emergency room nurse knows that reverse triage may need to be instituted. What is the rationale for using reverse triage? 1) Mass casualty is an event with greater than 20 victims 2) A very basic reverse triage system is to categorize or label victims needing the most support and emergency care as red. 3) Victims most likely to survive are color coded as black. 4) Reverse triage works on the principle of the greatest good for the greatest number. Which of the following would be an appropriate strategy in reorienting a confused patient to where her room is? 1) Place pictures of her family on the bedside stand 2) Put her name in large letters on her forehead 3) Remind the patient where her room is 4) Let the other residents know where the patient’s room is Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife or I take it out on the

1) 2) 3) 4)

kids." Nurse: "I notice that you are smiling as you talk about this physical violence." Encouraging comparison Exploring Formulating a plan of action Making observations

69. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." 1) Restatement 2) Offering general leads 3) Focusing 4) Accepting 70. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" 1) Reflecting 2) Making observations 3) Formulating a plan of action 4) Giving recognition 71. The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a "general lead"? 1) "Do you know why you are here?” 2) "Are you feeling depressed or anxious?" 3) "Yes, I see. Go on." 4) "Can you chronologically order the events that led to your admission?" 72. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1) S 2) O 3) L 4) E 5) R 73. What is the purpose of a nurse providing appropriate feedback? 1) To give the client good advice 2) To advise the client on appropriate behaviors

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3) 4)

To evaluate the client's behavior To give the client critical information

74. Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? 1) "We've discussed past coping skills. Let's see if these coping skills can be effective now." 2) "Please tell me in your own words what brought you to the hospital." 3) "This new approach worked for you. Keep it up." 4) "I notice that you seem to be responding to voices that I do not hear." 75. During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? 1) "Don't worry. Everything will be alright." 2) "You appear uptight." 3) "I notice you have bitten your nails to the quick." 4) "You are jumping to conclusions." Answer key 1. 2.

B- Conduct, behavior, ethics & professionalism {refer to the code} B- Arrange for an interpreter to translate { arranging a interpreter would be the best practice when communicating with a client who speaks a different language . Options A & D are inappropriate & are ineffective ways to communicate. Option C violates privacy & does not ensure correct answer } 3. B- You should report the incident to someone in authority{refer to the code} 4. C- Encourage the client to discuss the use of an herbal substance with the health care provider { herbal substance may have some beneficence , not all herbs are safe to use . Clients with conventional therapy should be encouraged to avoid herbal substance with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects} 5. B- NMC 6. C - Belief in the dignity and worth of each person 7. A - Ethical principles & code 8. C - The nurse should honor client’s decision { refer revised code } 9. B - Accepting the patient’s choice & not intervening { revised code 10. Answer 4 . Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient”s sputum is expected. A private room and BSI, along

with good hand washing techniques, are the best defense against the spread of MRSA pneumonia. 11. Answer 2 . The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion. 12. Answer 2. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately. 13. Answer 4 . there is a possibility of splashes ofbody secretions therefore a nurse must wear goggles , gown & face shield Reference: pgno, 1120q no. 968, saundersbasedon6thedition 14.

Answer 4 . Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this

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can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not

22.

doing this compromises client safety and should be brought to the immediate attention of the nurse. 15. C - An increase in BP Rationale- A fluid volume excess is also known as overhydration or fluid overload & occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea , crackles, tachypnea, tachycardia, elevated BP, bounding pulse, elevated CVP , weight gain , edema , neck & hand vein distention, altered level of consciousness & decreased hematocrit. 16. B - Requires nasogastric suction Rationale – potassium rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. 17. A- Anthropometric measurements Rationale –anthropometric measurements are the prime parameters used to evaluate fat & muscle stores in the body. Bleeding gums & dry skin are associated several systemic problems & can be signs of micronutrient deficiencies as well. Facial rubor is not a parameter used to evaluate nutritional health. 18. D - Ph 7.30 ; pCO2 -36 ; HCO3 -18 Rationale- the ph is below the normal range of 7.35- 7.45. The pCO2 is within normal range 35-45 & HCO3 is below normal limits of 21-28. These values indicate a metabolic problem because the pCO2 is within normal limits.& acidosis because the ph is below normal 19. B - The patient with kidney disease Rationale- A fluid volume excess is also known as overhydration or fluid overload & occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function , heart failure, use of hypotonic fluids to replace isotonic fluid losses , excessive irrigation of wounds & body cavities & excessive ingestion of sodium. 20. C - Observe for digitalis toxicity Rationale- hypokalemia enhances digitalis toxicity & must be observed carefully 21. A- The skin

23.

24. 25.

26. 27. 28.

29. 30.

31. 32. 33.

Rationale- insensible loss may occur without the person’s awareness . Insensible losses occur daily through the skin & the lungs. Sensible losses are those of which the person’s aware , such as through urination , wound drainage, & gastrointestinal tract losses. D- Take a deep breath, hold it ,& bear down Rationale- The client should be asked to perform the valsalva maneuver during tubing changes . This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath , hold it, & bear down . Answer 2. Rationale: None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position. Answer 3. Rationale: All are at risk for infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is at great risk for immune deficiency. Answer 4. Rationale: Chemical debridement is either done with enzyme agents or autolytic agents. Answer 1 is a type of sharp debridement. Answers 2 and 3 are mechanical and less precise than chemical Answer 4. Rationale: Drainage is described as purulent. Sanguineous and Seroussanguineous contain blood. Serous is clear and watery. Answer 1. Rationale: Wounds in the regeneration phase of healing need to be protected as new tissue grows. Answers 2, 3, and 4 are dressings used to remove nonviable tissue. Answer 4. Rationale: The skin is cleansed with normal saline or a mild cleanser. Residue of old dressings will dissolve. The dressing size is to be 3-4 cm (1.5 inches) larger than the size of the wound. Answer 3. Rationale: Laceration best describes the wound, because skin is ripped off. An abrasion is a scrape.Unapproximated is a general term for a wound that is not closed. Eschar is a scab-like covering over a wound 1- true 2- true 3- true 4- false 5 – true 6- false Answer e Answer c Answer: 2. Rationales: 1. Disengagement theory. In contrast to activity theory, disengagement theory views withdrawal from social contact and responsibilities as an inevitable and deliberate process. First proposed in the 1960s, this theory is not supported by the current trend for many older adults to remain engaged and responsible into later life. 2. Activity theory. This theory proposes that the way to age successfully is to stay active

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34.

35.

36.

37.

and involved. Activity theory focuses on the current behavior of the older adult. 3. Genetic theory. According to genetic theory, an individual’s lifespan is predetermined and people’s aging experience is programmed by their genetic makeup. 4. Immunology theory. According to this theory, the body misidentifies older cells as foreign bodies, rendering them vulnerable to attack by the immune system. This theory implies that care of the cells over the lifespan is of primary importance if the individual is to decelerate the aging process. Answer: 3. Rationales: 1. The clinical presentation of mental illness in older adults differs from that in other age groups. Currently, there are few age-specific descriptors or criteria. However, research and identification of diagnostic criteria in children experiencing bipolar disorder is likely to appear in a future edition of the DSM, suggesting that specific criteria for older adults may appear in future editions as well. 2. Older people are believed to be more prone to mental illness than young people. This belief is an example of an ageist attitude that blurs important distinctions. It is the oldold group that tends to have the greatest incidence of depression, dementia, delirium, and other chronic disabling conditions. 3. When physical deterioration becomes a significant feature of an elder’s life, the risk of comorbid psychiatric illness rises. This statement will not assist the nurse in distinguishing mental disorders from the expected changes associated with aging. It may, however, provide a rationale for the ageist observation, as most individuals’ physiological needs become more complex as they age. 4. A competent clinician can readily distinguish mental disorders from the expected changes associated with aging. Even expert clinicians experience difficulty in distinguishing mental illness from age-related changes. Answer 4. The GFR is decreased dramatically in the elderly due to changes in the renal tubules Reference : ques no. 52, pg no. 183, NCLEX – RN review 5th edition NSNA Answer 4. In the late stages of alzheimer’s disease , it is better to go along with the client’s reality rather than confront him with logic & reasoning . Asking close-ended , simple questions that relate to his reality is nonthreatening & calming . Note that the nurse responds in a way that is congruent with his main concern , which is his sore back. Reference : ques no. 63, pg no. 184, NCLEX – RN review 5th edition NSNA Answer 2 . This statement is a cause for concern . Victims of abuse may alternate between generations . Abusive patterns are highly likely to be passed from parents to children . when children grow up & move into positions where they are caring for their aged parents ( role reversal ) , the abusive behavior can surface. Reference : ques no.64, pg no. 184, NCLEX – RN review 5th edition NSNA

38. Answer 3. A modest increase in systolic blood pressure , not diastolic BP , is an expected age-related change due to an increase in vascular resistance & vessel rigidity. An increase in diastolic BP , however , is not an expected age-related change . it is pathologic & needs to be monitored. Reference : ques no.58, pg no. 184, NCLEX – RN review 5th edition NSNA 39. 1 mg = 0.001 gm 40 mg = 0.04 gm 40. 1.6 ml 41. Answer 4. Along with responsibility, one must transfer authority when delegating 42. Answer 2. Monitoring performance and providing feedback is the final stage of effective delegation. 43. Answer 4. 44. Answer 2. Rationale: Discharge planning should begin when the client is admitted to the acute care facility. With the admissions process, the nurse can begin to assess the home environment, family and community support, as well as the client’s readiness to be in the home. The process can be multifaceted and involve collaboration; therefore the earlier the process begins, the better prepared the health care team and client are for a successful transition to the home. 45. Answer 1. Rationale: The case manager in a community-based nursing service will see clients in all settings. The case manager often is involved in wellness care, acute care, long-term care, hospice services, etc. The community-based case manager often consults with other health care professionals 46. Answer 3. Rationale: Safety comes first in this case. Stairs and/or throw rugs while using a wheelchair or crutches are safety hazards. The other items are important, but are not most important on initial contact with the client. 47. Answer 1. Nurses need to advocate for public policy that promotes and protects the health of the public by taking public stands on quality care issues and educating the public on "public interest" issues. 48. Answer 3. An important component of advocacy is supporting the patient's decision, which might not be the decision the nurse desires but must be supported. 49. Answer 3. Rationale: full liquid food items include items such as plain ice cream , sherbet, breakfast drinks, milk, pudding, & custard , soups, that are starined , refined cooked cereals & strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids. Reference : ques no. 84, pg no. 136, saunders comprehensive review for nclex –RN exam . based on 6th edition 50. Answer 1. Rationale : the GI tract should be assessed before each feeding to ensure functioning & minimal problems. Reference : ques no. 21, pg no. 171, NCLEX RN review, 5th edition NSNA

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51. Answer 4. Reference : www.wps.prenhall.com Location on Site:

Home > Therapeutic Communication > NCLEX Review

52. Answer 4. Shallow breathing and looking upward reflect the visual mode. Nurses should attempt to use a client's preferred sensory style during communications. Reference : www.wps.prenhall.com

indicative of auditory hallucination. 2. The client processing auditory information. An individual processing auditory information usually moves the eyes from side to side. 3. The client being bored with the interaction. Rolling of the eyes is typically observed in an individual who is bored with a situation. 4. The client engaging in intrapersonal communication. A person engaging in intrapersonal communication usually focuses the eyes down in the direction of the nondominant hand. Reference : www.wps.prenhall.com Location on Site:

Location on Site:

Home > Therapeutic Communication > NCLEX Review

53. Answer 2. Tangential responses disregard important content and are related to incidental aspects of the conversation. Reference : www.wps.prenhall.com Location on Site:

Home > Therapeutic Communication > NCLEX Review

54. Answer 2. Intrapersonal communication occurs when people communicate within themselves. Reference : www.wps.prenhall.com

Chapter 10 > NCLEX® Review Questions

58. Answer 1. The present and not the past Rationale: 1. The client. To provide nonthreatening feedback, the focus should be on the behavior and not the client. 2. The present and not the past. Focusing on the here and now makes the feedback more meaningful. Feedback should be given as soon as it is appropriate to do so. 3. Providing solutions to the client. Assisting the client with identifying possible alternatives or goals for a problem is more effective than giving the client the answers. Providing solutions to the client gives the message that the client is not capable of doing so. 4. Making inferences of the behaviors observed. Inferences imply conclusions and assumptions and don’t give the client an opportunity to explain a situation. Reference : www.wps.prenhall.com Location on Site:

Chapter 10 > NCLEX® Review Questions

Location on Site:Home > Therapeutic Communication > NCLEX Review 59. Answer 2. provide care to the deceased client in a careful and loving way Reference : www.wps.prenhall.com 55. Answer 1. The communication needs to be efficient, appropriate, flexible, and include feedback. Reference : www.wps.prenhall.com Location on Site:

Chapter 10 > NCLEX® Review Questions

Location on Site: Chapter 15 > NCLEX Multiple Choice Questions 60. Answer 1. tell me why you feel death is your only option Reference : www.wps.prenhall.com Location on Site:

56. Answer 4. Facial expressions Reference : www.wps.prenhall.com

Chapter 15 > NCLEX Multiple Choice Questions

61. Answer 4. anniversary reaction Reference : www.wps.prenhall.com

Location on Site: Chapter 10 > NCLEX® Review Questions 57. Answer 2. The client processing auditory information Rationale: 1. The client responding to auditory hallucinations. Eye movement side to side is an example of eyes accessing cues to an individual’s thinking process and is not necessarily

Location on Site:

Chapter 15 > NCLEX Multiple Choice Questions

62. Answer 4. explain that his father has died and give him the option of attending the funeral

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Reference : www.wps.prenhall.com Location on Site:

technique of making observations encourages the client to compare personal perceptions with those of the nurse. Reference : www.quizlet.com 2204 therapeutic communication 69. ANS: 1 The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client's statement has been heard and understood. Reference : www.quizlet.com 2204 therapeutic communication

Chapter 15 > NCLEX Multiple Choice Questions

63. Answer 3. suggest she take a few days off Reference : www.wps.prenhall.com Location on Site:Chapter 15 > NCLEX Multiple Choice Questions

70. ANS: 3 The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client's poor coping choice, may serve to prevent anger or anxiety from escalating. Reference : www.quizlet.com 2204 therapeutic communication

64. Answer 2. for the family to gain support from each other Reference : www.wps.prenhall.com Location on Site:Chapter 15 > NCLEX Multiple Choice Questions 65. Answer 4. provide support, compassion, and love Reference : www.wps.prenhall.com

71. ANS: 3 The nurse's statement, "Yes, I see. Go on." is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information. Reference : www.quizlet.com 2204 therapeutic communication

Location on Site: Chapter 15 > NCLEX Multiple Choice Questions 66. Answer 4. Reverse triage works on the principle of the greatest good for the greatest number. Rationale: During a disaster, nurses may be expected to perform triage. Triage means sorting. # 1 is incorrect because a mass casualty is an event with more than 100 victims. # 2 is incorrect because it describes basic triage and not reverse triage. # 3 is incorrect because victims least likely to survive or are already dead are colorcoded as black. Reference : www.wps.prenhall.com Location on Site:

PART 1: MEDICAL-SURGICAL NURSING PRACTICE > Chapter 7: Nursing Care of Clients Experiencing Disasters > NCLEX® Review

67. Answer 3. The nurse should be someone the patient can turn to for guidance Reference : ques no. 27, pg no. 659, NCLEX –RN review , 5th edition , NSNA 68. ANS: 4 The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The

72. ANS: 2 The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the "O" in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R). 73. ANS: 4 The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors. Reference : www.quizlet.com 2204 therapeutic communication 74. ANS: 1 This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique, the nurse can help the client plan in advance to deal with a stressful situation which may prevent anger and/or anxiety from escalating to an unmanageable level. Reference : www.quizlet.com 2204 therapeutic communication

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ANS:

75. ANS: 1 This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occur when the nurse misjudges the degree of the client's discomfort, thus a lack of empathy and understanding may be conveyed. Reference : www.quizlet.com 2204 therapeutic communication

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 & tested positive for HIV . what is best action of the nurse to take? 1) Document this information on the patient’s chart 2) Tell the patient’s physician 3) Inform the healthcare team who will come in contact with the patient 4) Encourage the patient to disclose this information to her physician A young woman who has tested positive for HIV tells her nurse that she has had many sexual partners. She has been on an oral contraceptive & frequently had not requested that her partners use condoms. She denies IV drug use she tells her nurse that she believes that she will die soon. What would be the best response for the nurse to make. 1) “Where there is life there is hope” 2) “ Would you like to talk to the nurse who works with HIV- positive patient’s ?” 3) “ you are a long way from dying” 4) “ not everyone who is HIV positive will develop AIDS & die” An adult is offered the opportunity to participate in research on a new therapy. The researcher ask thenurse to obtain the patient’s consent. What is most appropriate for the nurse to take? 1) Be sure the patient understands the project before signing the consent form 2) Read the consent form to the patient & give him or her an opportunity to ask questions 3) Refuse to be the one to obtain the patient’s consent 4) Give the form to the patient & tell him or her to read it carefully

before signing it. An adult has signed the consent form for a research study but has changed her mind . The nurse tells the patient that she has the right to change her mind based upon which of the following principles. 1) Paternalism & justice 2) Autonomy & informed consent 3) Beneficence & double effect 4) Competence & right to know 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. 1) Position the wheel chair on the left side of the bed 2) Keep the head of the bed elevated 10 degree 3) Protect the client’s left arm with a sling during the transfer 4) Bend at the waist while helping the client into a standing position An adult has experienced a CVA that has resulted in right side weakness. The nurse is preparing to move the patient right side of the bed so that he may then be turned to his left side. The nurse knows that an important principle when moving the patient is. 1) To keep the feet close together 2) To bend from waist 3) To use body weight when moving objects 4) A twisting motion will save steps An adult has just returned to the unit from surgery . the nurse transferred him to his bed but did not put up the side rails. The client fell and was injured. What kind of liability does the nurse have? 1) None 2) Negligence 3) Intentional tort 4) Assault & battery The nurse is in the hospitals public cafeteria & hears two nursing assistants talking about the patient in 406 . they are using her name & discussing intimate details about her illness which of the following actions id best for the nurse to take? 1) Go over & tell the nursing assistants that their actions are inappropriate especially in a public place 2) Wait & tell the assistants later that they were overheard discussing the patient otherwise they might be embarrassed 3) Tell the nursing assistant’s supervisor about the incident. It is

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the supervisor’s respondibility to address the issue Say nothing . it is not the nurses job , he or she is not responsible for the assistant’s action Which of the following client should the nurse deal with first 1) A client who needs her dressing changed 2) A client who needs to be suctioned 3) A client who needs to be medicated for incisional pain 4) A client who is incontinent & needs to be cleaned

it is attached to her chart.

(C) The nurse should tell the physician that the patient agrees to have the examination. (D) The nurse should verify that the patient or a family member has signed the consent form.

10. A client on your medical surgical unit has a cousin who is a physician & wants to see the chart . which of the following is the best response for the nurse to take 1) Hand the cousin the client chart to review 2) Ask the client to sign an authorization & have someone review the chart with cousin 3) Call the attending physician & have the doctor speak with the cousin 4) Tell the cousin that the request cannot be granted

11. An adolescent male being treated for depression arrives with his family at the Adolescent Day Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the goals of the family meeting is to encourage the adolescent to: (A) Trust the nurse who will solve his problem.

(A) Raise your voice until the patient is able to hear you. (B) Face the patient and speak quickly using a high voice. (C) Face the patient and speak slowly using a slightly lowered voice. (D) Use facial expressions and speak as you would formally 14. . A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient’s wife comforting other family members. Which of the following interpretations of this behavior is MOST justifiable? (A) She has already moved through the stages of the grieving process. (B) She is repressing anger related to her husband’s death.

(B) Learn to live with anxiety and tension

(D) She is demonstrating resolution of her husband’s death.

(D) Use the members of the therapeutic milieu to solve his problems. 12.

13. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patient’s family to use which of the following approaches when speaking to the patient?

A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of the following statements BEST describes the nurse’s responsibility concerning written consent?

(A) The nurse should explain the procedure to the patient and ask her to sign the consent form.

15. . After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate? (A) The treatment plan is not effective; the patient requires a larger dose of lithium. (B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan.

(B) The nurse should verify that the consent form has been signed by the patient and that

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(C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior. (D) The treatment plan is not effective; the patient requires an antidepressant

19. A client comes to the local clinic complaining that sometimes his heart pounds and he has trouble sleeping. The physical exam is normal. The nurse learns that the client has recently started a new job with expanded responsibilities and is worried about succeeding. Which of the following responses by the nurse is BEST? A. B. C. D.

16. The nurse works on a medical/surgical unit that has a shift with an unusually high number of admissions, discharges, and call bells ringing. A nurse’s aide, who looks

“Have you talked to your family about your concerns? You appear to have concerns about your ability to do your job “You could benefit from counseling. “It’s normal to feel anxious when starting a new job.”

20. Which of the following situations on a psychiatric unit are an example of a trusting patientnurse relationship?

increasingly flustered and overwhelmed with the workload, finally announces “This is impossible! I quit!” and stomps toward the break room. Which of the following statements, if made by the nurse to the nurse’s aide, is BEST? A. Fine, we’re better off without you anyway.” B. “It seems to me that you feel frustrated. What can I help you with to care for our patients?” C. “I can understand why you’re upset, but I’m tired too and I’m not quitting.” D. “Why don’t you take a dinner break and come back? It will seem more manageable with a normal blood sugar.” 17. . A patient with a history of schizophrenia is admitted to the acute psychiatric care unit. He mutters to himself as the nurse attempts to take a history and yells, “I don’t want to answer any more questions! There are too many voices in this room!” Which of the following assessment questions should the nurse ask NEXT? A. “Are the voices telling you to do things? B. “Do you feel as though you want to harm yourself or anyone else?” C. “Who else is talking in this room? It’s just you and me. D. “I don’t hear any other voices”

A. B. C. D.

The patient tells the nurse that he feels suicidal The nurse offers to contact the doctor if the patient has a headache. The nurse gives the patient his daily medications right on schedule. The nurse enforces rules strictly on the unit 24. The client is being involuntarily committed to the psychiatric unit after threatening to kill his spouse and children. The involuntary commitment is an example of what bioethical principle? 1) Fidelity 2) Veracity 3) Autonomy 4) Beneficence

18. The nurse cares for a client diagnosed with conversion reaction. The nurse identifies the client is utilizing which of the following defense mechanisms? A. B. C. D.

21. A client expressed concern regarding the confidentiality of her medical information. The nurse assures the client that the nurse maintains client confidentiality by: 1) Sharing the information with all members of the health care team. 2) Limiting discussion about clients to the group room and hallways. 3) Summarizing the information the client provides during assessments and documenting this summary in the chart. 4) Explaining the exact limits of confidentiality in the exchanges between the client and the nurse. 22. When caring for clients with psychiatric diagnoses, the nurse recalls that the purpose of psychiatric diagnoses or psychiatric labeling is to: 1) Identify those individuals in need of more specialized care. 2) Identify those individuals who are at risk for harming others. 3) Enable the client’s treatment team to plan appropriate and comprehensive care.

Introjection Displacement Identification Repression

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Define the nursing care for individuals with similar diagnoses.

23. The nurse restrains a client in a locked room for 3 hours until the client acknowledges who started a fight in the group room last evening. The nurse’s behavior constitutes: 1) False imprisonment. 2) Duty of care. 3) Standard of care practice. 4) Contract of care 24. A client has been voluntarily admitted to the hospital. The nurse knows that which of the following statements is inconsistent with this type of hospitalization? 1) The client retains all of his or her rights 2) the client has a right to leave if not a danger to self or others 3) the client can sign a written request for discharge 4) the client cannot be released without medical advice 25. A nurse enters a patient’s room & finds that the waste basket is on fire . the nurse immediately assists the patient out of the room. The next nursing action would be 1) Confine the fire by closing the room door 2) Activate the fire alarm 3) Call for help 4) Extinguish the fire 26. A nurse is preparing to initiate an IV line containing high dose of KCL & plans to use an IV infusion pump. The nurse brings the pump to the bedside prepares to plug the pump cord into the wall & notes that no receptacle Is available in the wall socket .which of the following is the most appropriate nursing action? 1) Use an extension cord from nurses lounge for the pump plug 2) Initiate the IV line without the use of a pump 3) Plug in the pump cord in the available plug above the rooms sink 4) Contact the electrical maintenance deptt for assistance 27. A nurse obtains an order from a physician to restraint a client by using a jacket restraint. The nurse instructs nursing assistant to apply the restraint. Which of the following would indicate inappropriate application of the restraint by the nursing assistant. 1) A safety knot in the restraint straps 2) Restraint straps that are safely secured to the side rails 3) The jacket restraint secured such that two fingers can slide easily

between the restraints & the client skin Jacket restraint straps that do no tighten when force is applied against them 28. A mother calls the home care nurse & tells the nurse that her 3 year old child has ingested liquid furniture polish . the home care nurse would direct the mother immediately to 1) Induce vomiting 2) Bring the child to the ER 3) Call an ambulance 4) Call the poison control centre 29. A home care nurse performs a home safety assessment & discovers that a client is using a space heater to heat her apartment . which of the following instructions would the nurse provide to the client regarding the use of the space heater. 1) A space heater shouldnot be used in an apartment 2) Space heater to be placed at least 3 feet from anything that can burn 3) The space heater should be placed in the hallway at night 4) The space heater should be kept at a low setting at all times 30. An emergency room nurse receives a telephone call & is informed that a tsunami has hit a local residential area & that numerous casualties have occurred . the victims will be brought to the ER . the initial nursing action is which of the following 1) Prepare the triage room 2) Obtain additional supplies from the central supply deptt 3) Activate the agency disaster plan 4) Obtain additional nursing staff to assist in treating the casualties 31. Ms. jane is to have a pelvic exam , which of the following should the nurse do first 1) Have the client remove all her clothes , socks & shoes 2) Have the client go to the bathroom & void saving a sample 3) Place the client in lithotomy position on the exam table 4) Assemble all the equipment needed for the examination 32. When prioritizing a client’s plan of care based on Maslow’s hierarchy of needs, nurse Charles first priority would be: 1) allowing the family to see a newly admitted client 2) ambulating the client in the hallway 3) administering pain medication 4) placing wrist restraints on the client 4)

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33. Doctor’s Order: Tylenol supp 1 g pr q 6 hr prn temp > 101; Available: Tylenol supp 325 mg (scored). How many supp will you administer? A. 2 supp B. 1 supp C. 3 supp D. 5 sup 34. Doctor’s Order: Nafcillin 500 mg po pc; Available: Nafcillin 1 gm tab (scored). How many tab will you administer per day? 2.5 tabs B. 2 tabs C. 1.5 tabs D. 1 tab 35. Doctor’s Order: Synthroid 75 mcg po daily; Available: Synthroid 0.15 mg tab (scored). How many tab will you administer? 1 tab B. 0.5 tab C. 2 tabs D. 1.5 tabs 36. Doctor’s Order: Diuril 1.8 mg/kg po tid; Available: Diuril 12.5 mg caps. How many cap will you administer for each dose to a 31 lb child? 2 caps B. 2.5 caps C. 3 caps D. 1.5 caps 37. Doctor’s Order: Cleocin Oral Susp 600 mg po qid; Directions for mixing: Add 100 mL of water and shake vigorously. Each 2.5 mL will contain 100 mg of Cleocin. How many tsp of Cleocin will you administer? 3 tsp B. 5 tsp C. 3.5 tsp D. 1 tsp 38. Doctor’s Order: Sulfasalazine Oral Susp 500 mg q 6 hr; Directions for mixing: Add 125 mL of water and shake well. Each tbsp will yield 1.5 g of Sulfasalazine. How many mL will you give? 5 ml B. 3 ml C. 4 ml

D. 2 ml 39. Your patient has had the following intake: 2 ½ cups of coffee (240 mL/cup), 11.5 oz of grape juice, ¾ qt of milk, 320 mL of diet coke, 1 ¼ L of D5W IV and 2 oz of grits. What will you record as the total intake in mL for this patient? 2,325 ml B. 3,265 ml C. 3,325 ml D. 2,235 ml 40. Your patient has had the following intake: 8 oz glasses of iced tea, 4 oz cartons of grape juice, ¾ pt of ice cream, 32 oz of juice, 1 ½ L of D5W IV and 6 oz of cottage cheese. What will you record as the total intake in mL for this patient? 3,357 ml B. 3,375 ml C. 3,915 ml D. 3,195 ml 41. Doctor’s Order: Kantamycin 7.5 mg/kg IM q 12 hr; Available: Kantamycin 0.35 Gm/mL. How many mL will you administer for each dose to a 157 lb patient? 2 ml B. 1 ml C. 2.5 ml D. 1.5 ml 42. Doctor’s Order: Heparin 7,855 units Sub Q bid; Available: Heparin 10,000 units per ml. How many mL will you administer? 0.79 ml B. 1.79 ml C. 0.17 ml D. 1.17 ml 43. Doctor’s Order: Demerol 50 mg IVP q 6 hr prn pain; Available: Demerol 75 mg/ 1.3mL. How many mL will you administer? 0.87 ml B. 1.87 ml C. 2 ml D. 2.87 ml 44. Doctor’s Order: Streptomycin 1.75 mg/ lb IM q 12 hr; Available: Streptomycin 0.35 g / 2.3 mL. How many mL will you administer a day to a 59 Kg patient? 1.5 ml

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B. 2 ml C. 2.5 ml D. 3 ml 45. Doctor’s Order: Bumex 0.8 mg IV bolus bid; Reconstitution instructions: Constitute to 1000 micrograms/3.1 mL with 4.8mL of 5% Dextrose Water for Injection. How many mL will you administer? 2 ml B. 3.5 ml C. 3 ml D. 2.5 ml 46. Doctor’s Order: Tazidime 0.3 g IM tid; Reconstitution instructions: For IM solution add 1.5 mL of diluent. Shake to dissolve. Provides an approximate volume of 1.8 mL (280 mg/mL). How many mL will you give? 1.9 ml B. 2 ml C. 3 ml D. 1.1 ml 47. Doctor’s Order: Infuse 50 mg of Amphotericin B in 250 mL NS over 4 hr 15 min; Drop factor: 12gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump? 11.8 ml/hr B. 58.8 ml/hr C. 14.1 ml/hr D. 60.2 ml/hr 48. Doctor’s Order: 1 ½ L of NS to be infused over 7 hours; Drop factor: 15 gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump?

49. Doctor’s Order: Mandol 300 mg in 50 mL of D5W to infuse IVPB 15 minutes; Drop factor: 10 gtt/mL. How many mL/hr will you set on the IV infusion pump?

200 ml/hr B. 87.5 ml/hr C. 3.3 ml/hr D. 50 ml/hr

50. Doctor’s Order: Infuse 1200 mL of 0.45% Normal Saline at 125 mL/hr; Drop Factor: 12gtt/min. How many gtt/min will you regulate the IV?

2 gtt/min B. 12 gtt/min

53.6 ml/hr C. 25 gtt/min B. 214.3 ml/hr D. 27 gtt/min C. 35.7 ml/hr 51. Doctor’s Order: Rocephin 0.5 grams in 250 mL of D5W to infuse

D. 142.9 ml/hr

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IVPB 45 minutes; Drop Factor: 12gtt/min. How many gtt/ min will you regulate the IVPB?

6 gtt/min

54. The contingency theory of management moves the manager away from which of the following approaches? 1) No perfect solution 2) One size fits all 3) Interaction of the system with the environment 4) A method or combination of methods that will be most effective in a given situation 55. Transformational leadership is characterized by all of the following elements except: 1) charisma. 2) inspirational leadership 3) intellectual stimulation 4) incentives to promote loyalty and performance.

B. 30 gtt/min C. 67 gtt/min D. 87 gtt/min

52. Doctor’s Order: ¼ L of D5W to infuse over 2 hr 45 min; Drop factor: 60 gtt/mL. How many gtt/min will you regulate the IV?

A. 91 gtt/min B. 96 gtt/min

56. The characteristics of an effective leader include: 1) attention to detail 2) financial motivation 3) sound problem-solving skills and strong people skills 4) emphasis on consistent job performance 57. Which nursing delivery model is based on a production and efficiency model and stresses a task-oriented approach? 1) Case management 2) Primary nursing 3) Differentiated practice 4) Functional method 58. What are essential competencies for today's nurse manager? 1) A vision and goals 2) Communication and teamwork 3) Self- and group awareness 4) Strategic planning and design

C. 125 gtt/min D. 142 gtt/min

59. What is the most important issue confronting nurse managers using situational leadership? 1) Leaders can choose one of the four leadership styles when faced with a new situation. 2) Personality traits and leader's power base influence the leader's choice of style. 3) Value is placed on the accomplishment of tasks and on interpersonal

53. As a nurse manager achieves a higher management position in the organization, there is a need for what type of skills? 1) Personal and communication skills 2) Communication and technical skills 3) Conceptual and interpersonal skills 4) Visionary and interpersonal skills

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relationships between leader and group members and among group members. 4) Leadership style differs for a group whose members are at different levels of maturity. 60. When group members are unable and unwilling to participate in making a decision, which leadership style should the nurse manager use? 1) Participative 2) Authoritarian 3) Laissez-faire 4) Democratic 61. Ms. Castro is newly-promoted to a patient care manager position. She updates her knowledge on the theories in management and leadership in order to become effective in her new role. She learns that some managers have low concern for services and high concern for staff. Which style of management refers to this?

c. Uses visioning as the core of his leadership d. Matches his leadership style to the situation at hand.

64. Which of the following conclusions of Ms. Castro about leadership characteristics is TRUE? a. There is a high correlation between the communication skills of a leader and the ability to get the job done. b. A manager is effective when he has the ability to plan well. c. Assessment of personal traits is a reliable tool for predicting a manager's potential. d. There is good evidence that certain personal qualities favor success in managerial role.

65. She reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory? a. Recognizes staff for going beyond expectations by giving them citations b. Challenges the staff to take individual accountability for their own practice c. Admonishes staff for being laggards. d. Reminds staff about the sanctions for non performance.

a. Organization Man b. Impoverished Management c. Country Club Management d. Team Management

62. Her former manager demonstrated passion for serving her staff rather than being served. She takes time to listen, prefers to be a teacher first before being a leader, which is characteristic of

66. One leadership theory states that "leaders are born and not made," which refers to which of the following theories? a. Trait b. Charismatic c. Great Man d. Situational

a. Transformational leader b. Transactional leader c. Servant leader d. Charismatic leader

67. She came across a theory which states that the leadership style is effective dependent on the situation. Which of the following styles best fits a situation when the followers are self-directed, experts and are matured individuals?

63. On the other hand, Ms. Castro notices that the Chief Nurse Executive has charismatic leadership style. Which of the following behaviors best describes this style?

a. Democratic b. Authoritarian c. Laissez faire d. Bureaucratic

a. Possesses inspirational quality that makes followers gets attracted of him and regards him with reverence b. Acts as he does because he expects that his behavior will yield positive results

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1. 68. She surfs the internet for more information about leadership styles. She reads about shared leadership as a practice in some magnet hospitals. Which of the following describes this style of leadership?

Answer 4 . Encourage the patient to disclose this information to her physician

Rationale : a nurse is legally obliged to protect a client’s right to privacy Reference

a. Leadership behavior is generally determined by the relationship between the leader's personality and the specific situation b. Leaders believe that people are basically good and need not be closely controlled c. Leaders rely heavily on visioning and inspire members to achieve results d. Leadership is shared at the point of care.

69.

Ques no. 1, pg no. 135, NCLEX –RN review , 5th edition , NSNA 2.

Reference : Ques no. 2, pg no. 135, NCLEX –RN review , 5th edition , NSNA

Harry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. Patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest. He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Harry?

a. Call for a staff meeting and take this up in the agenda. b. Seek help from her manager. c. Develop a strategic action on how to deal with these concerns. d. Ignore the issues since these will be resolved naturally After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this? a. Collaboration b. Majority rule c. Dominance d. Compromise

Answer 2. “ Would you like to talk to the nurse who works with HIV- positive patient’s ?” Rationale : this provides the patient with expert care

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Answer 3. Refuse to be the one to obtain the patient’s consent Rationale: the nurse can not obtain consent, they may legally witness consent to medical procedures. Research team is responsible for the consent. Reference : Ques no. 3 , pg no. 135, NCLEX –RN review , 5th edition , NSNA Answer 2. Autonomy & informed consent Rationale: autonomy is the ethical right to decide what treatment you will or will not receive . informed consent can be withdrawn . Reference : Ques no. 4, pg no. 135, NCLEX –RN review , 5th edition , NSNA Answer 1. Position the wheel chair on the left side of the bed

Rationale: Place the wheelchair beside the bed on the patient’s strongest side, so that it faces the foot of the bed

Reference : Ques no. 5 , pg no. 135, NCLEX –RN review , 5th edition , NSNA ANSWER 3. To use body weight when moving objects RATIONALE : OBJECT SHOULD BE pushed or pulled instead of lifted. It prevents strain to muscles & joints . Reference : Ques no. 6 , pg no. 135, NCLEX –RN review , 5th edition , NSNA

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Answer 2, Negligence Rationale : the nurse has been negligent & can be liable for malpractice Reference : Ques no. 18 , pg no. 137, NCLEX –RN review , 5th edition , NSNA Answer 1. Go over & tell the nursing assistants that their actions are inappropriate especially in a public place Rationale : client has a right to confidentiality & her case should not be discussed in a public place Reference : Ques no. 19 , pg no. 137, NCLEX –RN review , 5th edition , NSNA

Answer 2 . A client who needs to be suctioned Rationale : any client with a potential compromise of the airway should be dealt with first Reference : Ques no. 25 , pg no. 137, NCLEX –RN review , 5th edition , NSNA 10. Answer 2. Ask the client to sign an authorization & have someone review the chart with cousin Rationale : the client must agree to & sign an authorization before others can review the chart Reference : Ques no. 21 , pg no. 137, NCLEX –RN review , 5th edition , NSNA 11. the correct answer is C. What is the goal of family therapy? Needed Info: Symptoms of depression: a low self-esteem, obsessive thoughts, regressive behavior, unkempt appearance, a lack of energy, weight loss, decreased concentration, withdrawn behavior. (A) Trust the nurse who will solve his problem — not realistic

12. The correct answer is B. What is your responsibility concerning informed consent? Needed Info: Physician’s responsibility to obtain informed consent. (A) The nurse should explain the procedure to the patient and ask her to sign the consent form — Physician should get patient to sign consent (B) The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart — CORRECT (C) The nurse should tell the physician that the patient agrees to have the examination — Physician should explain procedure and get consent form signed (D) The nurse should verify that the patient or a family member has signed the consent form — must be signed by patient, unless unable to do. REFERANCE: www.kaptest.com quest. 2 Sample NCLEX-RN®* Quiz: Psychosocial Integrity A 13. The correct answer is C. What should you do to communicate with a person with a moderate hearing loss? Needed Info: Presbycusis: age-related hearing loss due to inner ear changes. Decreased ability to hear high sounds. (A) Raise your voice until the patient is able to hear you — would result in high tones patient unable to hear (B) Face the patient and speak quickly using a high voice — usually unable to hear high tones (C) Face the patient and speak slowly using a slightly lowered voice — CORRECT: also decrease background noise; speak at a slow pace, use nonverbal cues (D) Use facial expressions and speak as you would normally —non verbal cues helps but low tones

(B) Learn to live with anxiety and tension — minimizes concerns

REFERANCE: www.kaptest.com quest. 3

Sample NCLEX-RN®* Quiz: Psychosocial Integrity A

(D) Use the members of the therapeutic milieu to solve his problems — must do it himself REFERANCE: www.kaptest.com quest. 1 Sample NCLEX-RN®* Quiz: Psychosocial Integrity A

14. The correct answer is C. What is the reason for the wife’s behavior? Needed Info: Stages of grief: 1) shock and disbelief, 2) awareness of pain and loss,

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3) restitution. Acute period: 4-8 weeks, usual resolution: 1 year. (A) She has already moved through the stages of the grieving process — takes one year (B) She is repressing anger related to her husband’s death — not accurate; second stage: crying, regression (C) She is experiencing shock and disbelief related to her husband’s death — CORRECT: denial first stage; inability to comprehend reality of situation (D) She is demonstrating resolution of her husband’s death — too soon

solve the cause of the problem. REFERANCE:www.freenclexquestion.com quest no:1 17. ANSWER :1 “Are the voices telling you to do things?

RATIONALE: We need to assess for command hallucinations to determine

REFERANCE: www.kaptest.com quest. 4

if this patient is at increased risk for harming himself or others.

Sample NCLEX-RN®* Quiz: Psychosocial Integrity A REFERANCE:www.freenclexquestion.com quest no:2

15. The correct answer is C. Is the depression normal, or something to be concerned about? (A) The treatment plan is not effective; the patient requires a larger dose of lithium — not accurate (B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan — does not address safety needs (C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior — CORRECT: delay of 1-3 weeks before med benefits seen (D) The treatment plan is not effective; the patient requires an antidepressant — normal response

18.

ANSWER:4 Repression

RATIONALE:The patient is repressing their stressful thoughts and converting them into a physical symptom (conversion reaction).

REFERANCE: www.kaptest.com quest. 5

REFERANCE:www.freenclexquestion.com quest no:3

19. ANSWER: 2 You appear to have concerns about your ability to do your job RATIONALE: Use reflection at them, to repeat the patient’s words back

Sample NCLEX-RN®* Quiz: Psychosocial Integrity A

REFERANCE:www.freenclexquestion.com quest no:4 16. Answer: 2 “It seems to me that you feel frustrated. What can I help you with to care for our patients?”

20. ANSWER:1 The patient tells the nurse that he feels suicidal The trusting relationship between the patient and nurse means that the patient

RATIONALE: This statement uses reflection and offers help to a fellow member of the patient care team. Do not refer back to yourself or offer a break. Offer to directly

feels he can express his feelings in a safe environment. REFERANCE:www.freenclexquestion.com quest no:5

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Learning Outcome: Discuss how ethical guidelines can be applied in reconciling crucial ethical dilemmas. 21. Answer 4, Beneficence Rationale: 1. Fidelity. Fidelity refers to the nurse’s loyalty and commitment to clients and remaining faithful to your duties, promises and obligations. 2. Beneficence. Protecting clients from harm because of their thoughts, feelings, and behaviors is an example of beneficence. An involuntary commitment is necessary to protect the client from harming self or others. 3. Veracity. Veracity implies the intention to tell the truth. 4. Autonomy. Autonomy is the freedom to choose a course of action and accept the consequences of the decision. Cognitive Level: Application Client Need: Physical Integrity Nursing Process: Implementation Learning Outcome: Relate the five principles of bioethics to the practice of psychiatric-mental health nursing. www.wps.prenhall.com Chapter 13 > NCLEX® Review Questions Location on Site: 22. Answer 4, Explaining the exact limits of confidentiality in the exchanges between the client and the nurse. Rationale: 1. Sharing the information with all members of the health care team. Nurses attempt to secure client confidentiality by sharing information with only those members of the health care team who have a need to know. 2. Explaining the exact limits of confidentiality in the exchange between the client and the nurse. Client education regarding the exact limits of confidentiality empowers the client. 3. Summarizing the information the client provides during assessments and documenting this summary in the chart. It is essential that the nurse documents information accurately and accurately represents the data the client has communicated. Summarizing the data increases the risk of the nurse losing objectivity. 4. Limiting discussion about clients to the group room and hallways. Discussions of client information should be restricted to private rather than public areas. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation

www.wps.prenhall.com Location on Site:

Chapter 13 > NCLEX® Review Questions

23. Answer 3, Enable the client’s treatment team to plan appropriate and comprehensive care. www.wps.prenhall.com Chapter 13 > NCLEX® Review Questions Location on Site: 24. Answer 1, False imprisonment. Rationale: 1. Standard of care practice. Standards of nursing care dictate that client care should be in the least restrictive environment. Restraining a client in a locked room violates this standard. 2. False imprisonment. False imprisonment is an example of a tort, a wrongful act. The nurse can be held liable for his or her actions. 3. Duty of care. The nurse acting in good faith for the client, with intentions to help the client, is exercising duty of care. 4. Contract of care. A contract of care is established between a client and a nurse once the nurse accepts the assignment. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome: Identify the acts for which psychiatric–mental health nurses can be held legally liable. www.wps.prenhall.com Chapter 13 > NCLEX® Review Questions Location on Site: 25. Andwer 4, the client cannot be released without medical advice Rationale: When a client is involuntarily admitted to the hospital, the client cannot be released without medical advice. The clinet does retain all of his rights, can sign a written request for discharge, and has a right to leave if not a danger to self or others

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www.quizlet.com

26. Answer 2 Activate the fire alarm Rationale : the order of priority in the event of a fire is to rescue the patient who are in danger the next step is to activate the fire alarm. The fire then is confined by closing all the doors & last the fire is extinguished Reference : ques no 1. Pg no. 183, saunders 3rd edition 27. Answer 4. Contact the electrical maintenance deptt for assistance Rationale : the nurse need to use hospital resources for assistance Reference : ques no 4. Pg no. 183, saunders 3rd edition 28. Answer 2 Restraint straps that are safely secured to the side rails Rationale : half bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it & allows quick & easy removal of the restraint in case of emergency . the restraints straps are secured to the bed frame & never to the side rails to avoid accidental injury Reference : ques no 5. Pg no. 183, saunders 3rd edition

32. Answer 2, Have the client go to the bathroom & void saving a sample Rationale : the client should have an empty bladder before the examnation Reference : ques no. 26, pg no, 802, NCLEX RN review , 4 th edition NSNA 33. Answer C. In Maslow’s hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. Reference : www.nclexreviewers.com

SafeandEffectiveCareEnvironmentNCLEXReviewQuestionsAnswersandRationale

Answer: C. 3 supp

1 g = 1000 mg 29. Answer 4 Call the poison control centre Rationale : if poisoning occurs the poisoning control centre should be contacted immediately . vomiting should not be induced if the victim is unconscious & if the substance ingested is a strong corrosive Reference : ques no 8. Pg no. 183, saunders 3rd edition

34.

30. Answer 2. Space heater to be placed at least 3 feet from anything that can burn Rationale : space heater need to be used appropriately because they present a great risk of fire Reference : ques no 3. Pg no. 183, saunders 3rd edition

35. . Answer: C. 1.5 tabs

1 g = 1,000 mg

31. Answer 3 Activate the agency disaster plan Rationale : use the process of elimination to determine the priority action. Note the key word “initial” Reference : ques no 9. Pg no. 183, saunders 3rd edition

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36. Answer: B. 0.5 tab

1 mg = 1,000 mcg 40. Answer: B. 3,265 ml

1 qt = 1,000 ml 1 oz = 30 ml 37. Answer: A. 2 caps 600 ml + 345 ml + 750 ml + 320 ml + 1,250 ml = 3,265 ml (Grits is not liquid at room 31 lbs = 14 kg

temperature, so it is not included when calculating intake.)

1.8 mg/kg x 14 kg = 25.2 mg or 25 mg (per dose) 41. Answer: D. 3,195 ml

1 pt = 500 ml 1 oz = 30 ml 38. Answer: A. 3 tsp

240 ml + 120 ml + 375 ml + 960 ml + 1,500 ml = 3,195 ml (Cottage cheese is not liquid at room temperature, so it is not included when calculating intake.)

42. Answer: D. 1.5 ml 39. Answer: A. 5 ml 157 lbs = 71.36 kg or 71 kg 1 tbsp = 15 ml

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7.5 mg/kg x 71 kg = 532.5 mg

46. . Answer: D 2.5 ml

1 mg = 1,000 mcg

43. Answer: A. 0.79 ml

47. Answer: D. 1.1 ml

44. Answer: A. 0.87 ml

48. Answer: B. 58.8 ml/hr

4 hr 15 min = 4.25 hrs [4 hrs + (15 mins÷60 mins)]

45. . Answer: D. 3 ml

59 kg = 130 lbs

49. Answer: B. 214.3 ml/hr

1.75 mg/lbs x 130 lbs = 227.5 mg

50. Answer: A. 200 ml/hr 1.5 ml x 2 = 3 ml 15 min = 0.25 hr

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