Foundation Online Question

Questions and Answers
 1.
What is the "Nursing Process"? Select all that apply
o A.
Organizational framework for the practice of Nursing
o B.
Systematic method by which nurses plan and provide care for

patients
o C.
The application of the nursing process only applies to RN's

and not LPN's
o D.
The Nursing Scope and Standards of Practice of the ANA

outlines the steps of the nursing process
Correct Answer(s)
A. Organizational framework for the practice of Nursing
B. Systematic method by which nurses plan and provide care
for patients
D. The Nursing Scope and Standards of Practice of the ANA
outlines the steps of the nursing process
Explanation
page 121
 2.
ANA defines it as a"systematic dynamic process by which the
nurse, through interaction with the client, significant others and
health care providers collect and analyzes data about the client
o A.
Physical Check-up
o B.
Hospital evaluation
o C.
Assessment
o D.
Analysis
Correct Answer
C. Assessment
Explanation
page 122
 3.
Which of the following is not true about Focused ASSESSMENT
o A.
When patient is critically ill or disoriented
o B.
When patient is unable to respond

o C.
Preferably early in the morning before breakfast.
o D.
When drastic changes are happening to a patient.

 Correct Answer
C. Preferably early in the morning before breakfast.
Explanation
page 122
 4.
A synonym for significant data that usually demonstrate an
unhealthy response.
o A.
Cue
o B.
Objective
o C.
Subjective
o D.
Interpretative
Correct Answer
A. Cue
Explanation
page 122
 5.
Headache, itchiness, warmth
o A.
Symptoms
o B.
Signs
o C.
Feelings
o D.
Emotions
Correct Answer
A. Symptoms
Explanation
page 122
 6.
Secondary Source of Data. (Select all that apply)
o A.
Diagnostic procedures
o B.
Medical record
o C.
Personal interview
o D.
Significant other
Correct Answer(s)
A. Diagnostic procedures
B. Medical record
D. Significant other
Explanation
page 123
 7.
Which of the following is not a method of data collection?
o A.
Interview
o B.
Biographic data
o C.
Social media
o D.
Health history
Correct Answer
C. Social media
Explanation
page 123
 8.
If the first method of data collection is to conduct an interview,
what is the second method?
o A.
Laboratory work
o B.
Diagnostic Tests
o C.
Evaluation
o D.
Performance of a physical examination

Correct Answer
D. Performance of a physical examination
Explanation
page 123
 9.
After establishing a database and before the identification of
nursing diagnosis, what does a nurse do?
o A.
Documentation of database
o B.
Analysis of database
o C.
Filing of database
o D.
Acquiring a database of information

Correct Answer
B. Analysis of database
Explanation
page 123
 10.
Data Clustering
o A.
Analyzing signs and symptoms
o B.
Identifying patient statements
o C.
Grouping related cues together

o D.
Entering patient data in the computer

Correct Answer
C. Grouping related cues together
Explanation
page 123
 11.
Deficient Fluid Volume (Select all that apply)
o A.
Thirst
o B.
Dry skin and dry oral mucous
o C.
Decreased urine output
o D.
Nystagmus
Correct Answer(s)
A. Thirst
B. Dry skin and dry oral mucous
C. Decreased urine output
Explanation
page 123 - The answers, when clustered are all signs and
symptoms of deficient fluid volume.
 12.
Which of the following refers to the definition of a Nursing
Problem?
o A.
Nurse overload and nurse burnout
o B.
When the nurse calls in sick
o C.
Any health care condition that requires diagnostic,

therapeutic, or educational actions.
o D.
Lose of employment
Correct Answer
C. Any health care condition that requires diagnostic, therapeutic,
or educational actions.
Explanation
page 123
 13.
Clinical judgment
o A.
Diagnosis
o B.
Job description of a clinical nurse
o C.
Data collection
o D.
Health intervention
Correct Answer
A. Diagnosis
Explanation
page 123
 14.
Components of a Nursing Diagnosis. Select all that apply
o A.
Nursing diagnosis title or label
o B.
Definition of the title or label
o C.
Data clustering
o D.
Contributing, etiologic or related factors

o E.
Defining characteristics
Correct Answer(s)
A. Nursing diagnosis title or label
B. Definition of the title or label
D. Contributing, etiologic or related factors
E. Defining characteristics
Explanation
page 124
 15.
Which of the following are true regarding nursing diagnosis?
o A.
A nursing diagnosis is any problem related to the health of

a patient
o B.
When writing a nursing diagnosis, place the adjective

before the noun modified
o C.
A nursing diagnosis is usually the etiology of the disease
o D.
Both medical and nursing diagnosis can be converted into

a nursing intervention.
Correct Answer
B. When writing a nursing diagnosis, place the adjective before the
noun modified
Explanation
page 124 - All other statements are false.
 16.
Clear, precise description of a problem
o A.
Definition
o B.
Intervention
o C.
Etiology
o D.
Diagnosis
Correct Answer
A. Definition
Explanation
page 125
 17.
Risk factors
o A.
Description of a problem
o B.
Analysis of a health issue
o C.
Possible illness
o D.
Circumstances that increase the susceptibility of a patient

to a problem
Correct Answer
D. Circumstances that increase the susceptibility of a patient to a
problem
Explanation
page 125
 18.
Clinical cues, signs, symptoms that furnish evidence that the
problem exists.
o A.
Risk factors
o B.
Defining characteristics
o C.
Description of a problem
o D.
Nursing diagnosis
Correct Answer
B. Defining characteristics
Explanation
page 125
 19.
How cues, signs and symptoms identified in patient's assessment
are written
o A.
Diagnosed by
o B.
Explained by
o C.
Manifested by
o D.
Caused by
Correct Answer
C. Manifested by
Explanation
page 126
 20.
"Constipation related to insufficient fluid intake manifested by
increased abdominal pressure". What is the defining
characteristic?
o A.
Constipation
o B.
Insufficient fluid
o C.
Increased abdominal pressure
o D.
Related to
Correct Answer
C. Increased abdominal pressure
Explanation
page 126 - Defining characteristics are cues, signs and symptoms.
It normally follows the phrase "manifested by" or "as evidenced
by". In this case, increased abdominal pressure comes immediately
after "manifested by" and is a sign of constipation.
 21.
What is RISK NURSING DIAGNOSIS as described by
NANDA-I? Select all that apply
o A.
Human responses to health conditions/life processes that

may develop in a vulnerable individual/family
o B.
Describes the symptoms of the disease
o C.
Supported by risk factors that contribute to increased

vulnerability
o D.
Proof that the person is suffering from an illness

Correct Answer(s)
A. Human responses to health conditions/life processes that may
develop in a vulnerable individual/family
C. Supported by risk factors that contribute to increased
vulnerability
Explanation
page 126
 22.
How many parts does a RISK NURSING DIAGNOSIS have?
o A.
o B.
o C.
2
o D.
None
Correct Answer
C. 2
Explanation
page 126
 23.
Which of the following is a Risk Nursing Diagnosis statement?
o A.
Risk for falls related to unstable balance
o B.
Constipated because of fecal impaction
o C.
Risk for Diarrhea
o D.
Constipation related to dehydration

Correct Answer
A. Risk for falls related to unstable balance
Explanation
page 126
 24.
Syndrome Nursing Diagnosis
o A.
An isolated disease with numerous symptoms
o B.
Numerous symptoms describing a single disease
o C.
Used when a cluster of actual or risk nursing diagnosis are

predicted to be present
o D.
Numerous symptoms leading to an idiopathic disorder

Correct Answer
C. Used when a cluster of actual or risk nursing diagnosis are
predicted to be present
Explanation
page 126
 25.
Wellness Nursing Diagnosis
o A.
Absence of illness
o B.
Not strictly a diagnosis
o C.
Human responses to levels of good health in an individual,
family or community
o D.
All of the above

Correct Answer
C. Human responses to levels of good health in an individual,
family or community
Explanation
page 126
 26.
Certain Physiologic complications that nurses monitor to detect
their onset or changes in the patient's status.
o A.
Variance
o B.
Collaborative problems
o C.
Clustered Syndrome
o D.
Signs of death
Correct Answer
B. Collaborative problems
Explanation
page 126
 27.
Potential complications: hypoglycemia. This is a sample of
what?
o A.
Syndromatic pathology
o B.
Definite Variance
o C.
Collaborative problem
o D.
Idiopathic etiology
Correct Answer
C. Collaborative problem
Explanation
page 126
 28.
Identification of a disease or condition by a scientific evaluation
of physical signs, symptoms, history, laboratory test and
procedures.
o A.
Health Analysis
o B.
Nursing Problem
o C.
Medical Diagnosis
o D.
All of the above

Correct Answer
C. Medical Diagnosis
Explanation
page 126
 29.
Difference between Medical and Nursing Diagnoses
o A.
Medical is etiology; Nursing is human response
o B.
Medical is disease; Nursing is the cause of disease
o C.
Medical is illness; Nursing is illness too
o D.
Medical is to heal the disease: Nursing is to discover the
disease
Correct Answer
A. Medical is etiology; Nursing is human response
Explanation
page 127
 30.
Difference between a goal statement and an outcome statement
o A.
A good outcome statement is specific to the patient
o B.
Goals are general deadlines that are to be met
o C.
An outcome statement refers to what the nurse will do
o D.
Goals and Statements are practically the same

Correct Answer
A. A good outcome statement is specific to the patient
Explanation
page 127
 31.
The purpose to which an effort is directed
o A.
Goal
o B.
Outcome
o C.
Intervention
o D.
Evaluation
Correct Answer
A. Goal
Explanation
page 127
 32.
Which of the following statements describe a well-written
patient outcome statement? Select all that apply.
o A.
Uses a measurable verb
o B.
Focuses on the completion of nursing interventions
o C.
Does not interfere with the medical care plan

o D.
Includes a time frame for patient reevaluation

Correct Answer(s)
A. Uses a measurable verb
C. Does not interfere with the medical care plan
D. Includes a time frame for patient reevaluation
Explanation
page 127 - always patient centered, never focused on what the
nurse would do
 33.
A common framework that helps guide the prioritization of
nursing tasks during the process of planning
o A.
Ericsson's psychosocial development
o B.
Maslow's hierarchy
o C.
Glasgow Scale
o D.
Bernoulli principle
Correct Answer
B. Maslow's hierarchy
Explanation
page 128
 34.
Nursing interventions
o A.
Depend on the tasks delegated by the nursing supervisor
o B.
A sequence of prioritized tasks that describe a nurse's job
o C.
Activities that promote the achievement of the desired

patient outcome
o D.
An act of taking care of the sick

Correct Answer
C. Activities that promote the achievement of the desired patient
outcome
Explanation
page 129
 35.
Which of the following is not a Physician Prescribed
intervention?
o A.
Ordering diagnostic tests

o B.
Drug administration
o C.
Performing wound care
o D.
Elevating an edematous leg

Correct Answer
D. Elevating an edematous leg
Explanation
page 129
 36.
Which of the following is not a nurse-prescribed intervention?
o A.
Turning the patient every two hours
o B.
Providing a back massage
o C.
Offering a vitamin supplement
o D.
Monitoring a patient for complications

Correct Answer
C. Offering a vitamin supplement
Explanation
page 129
 37.
Which of the following statements about the nursing process is
true.
o A.
A nursing process is written together with a nursing care

plan
o B.
A nursing care plan is a product of the nursing process
o C.
Both the nursing process and the nursing care plan are
purely critical thinking strategies
o D.
The nursing process is not an accurate clinical theory

Correct Answer
B. A nursing care plan is a product of the nursing process
Explanation
page 130
 38.
IN which of the following scenarios would a standardized
nursing care plan be appropriate?
o A.
Trauma center
o B.
Center for infection control
o C.
Intensive care unit
o D.
Maternity floor without a single Cesarean delivery

Correct Answer
D. Maternity floor without a single Cesarean delivery
Explanation
page 130 - Know what standardized nursing care plan is. They
apply to patient populations with the same routinary and expected
care requirements
 39.
Prioritization of tasks belongs to which phase of the Nursing
Process?
o A.
Assessment
o B.
Diagnosis
o C.
Planning
o D.
Implementation
o E.
Evaluation
Correct Answer
D. Implementation
Explanation
page 131
 40.
Documentation is a vital component of which phase of the
nursing process?
o A.
Assessment
o B.
Diagnosis
o C.
Planning
o D.
Implementation
o E.
Evaluation
Correct Answer
D. Implementation
Explanation
page 131
 41.
Validation of patient outcome and goals
o A.
Assessment
o B.
Planning
o C.
Intervention
o D.
Evaluation
Correct Answer
D. Evaluation
Explanation
page 131
 42.
Evidence based practice
o A.
Past educational knowledge
o B.
Theoretical research
o C.
Expertise of specialists
o D.
Integration of research and clinical experience

Correct Answer
D. Integration of research and clinical experience
Explanation
page 131
 43.
Which of the following is not considered a standardized
language in nursing?
o A.
NIC
o B.
ANA
o C.
NOC
o D.
NANDA
Correct Answer
B. ANA
Explanation
page 132
 44.
Variance
o A.
A research method
o B.
Patient does not achieve expected outcome
o C.
Similar to zoning
o D.
Not the same

Correct Answer
B. Patient does not achieve expected outcome
Explanation
page 133
 45.
Which of the following is not the role of the LPN/LVN in the
nursing process?
o A.
Suggest interventions
o B.
Gather further data to confirm problems
o C.
Discuss details of the disease as part of patient education
o D.
Observe and report signficant cues

Correct Answer
C. Discuss details of the disease as part of patient education
Explanation
page 133
 46.
Which of the following are functions of managed care? Select all
that apply.
o A.
Provides control over health care services
o B.
Standardized diagnosis and treatment
o C.
Control Cost
o D.
Primary resource for patient advocacy

Correct Answer(s)
A. Provides control over health care services
B. Standardized diagnosis and treatment
C. Control Cost
Explanation
page 133
 47.
Clinical pathway
o A.
Nursing career development plan
o B.
Multidisciplinary action
o C.
A concept map for care plans
o D.
Specific location in a healthcare facility

Correct Answer
B. Multidisciplinary action
Explanation
page 133
 48.
A reflective reasoning process that guides a nurse in generating,
implementing and evaluating approaches for dealing with client
care and professional concerns
o A.
Nursing process
o B.
Critical thinking
o C.
Nursing care plan
o D.
Nursing logic
Correct Answer
B. Critical thinking
 1.
The systematic problem-solving approach towards providing
individualized nursing care is known as
___________________.
o A.
Nursing care plan
o B.
Nursing process
o C.
Nurses practice act
o D.
Nursing method
Correct Answer
B. Nursing process
Explanation
The nursing process is a systematic problem-solving approach that
nurses use to provide individualized nursing care. It involves
assessing the patient's needs, formulating a nursing diagnosis,
planning interventions, implementing those interventions, and
evaluating the outcomes. This process helps nurses to prioritize
and organize their care, ensuring that each patient receives the
appropriate and personalized care they need. The nursing process
is a fundamental framework in nursing practice and is essential for
delivering high-quality patient care.
 2.
Name the association established to develop, refine, and
promote the taxonomy of nursing diagnostic terminology
used by nurses.
o A.
North American Nursing Diagnosis Association
International
o B.
American nurses association
o C.
Ethical Nursing Association
o D.
Humane Nursing Association

Correct Answer
A. North American Nursing Diagnosis Association International
Explanation
The correct answer is North American Nursing Diagnosis
Association International. This association was established to
develop, refine, and promote the taxonomy of nursing diagnostic
terminology used by nurses. It is responsible for providing a
standardized language for nurses to communicate and document
patient care, improving the quality and safety of nursing practice.
 3.
This step of the nursing process includes the systematic
collection of all subjective and objective data about the client
in which the nurse focuses holistically on the client- physical,
psychological, emotional, sociocultural, and spiritual. Name
this step.
o A.
Assessment
o B.
Planning
o C.
Implementation
o D.
Diagnosis
Correct Answer
A. Assessment
Explanation
The step of the nursing process that involves the systematic
collection of all subjective and objective data about the client,
focusing on the client's physical, psychological, emotional,
sociocultural, and spiritual aspects is called assessment. In this
step, the nurse gathers information through interviews,
observations, and physical examinations to gain a comprehensive
understanding of the client's health status and needs. This
information forms the basis for the subsequent steps of the nursing
process, such as planning, implementation, and diagnosis.
 4.
What is the name of the assessment that focuses on past
medical history, family history, the reason for admission,
medications currently taking, previous hospitalization,
surgeries, psychosocial assessment, nutrition, complete
physical assessment?
o A.
Initial assessment
o B.
Focus assessment
o C.
Emergency assessment
o D.
Comprehensive assessment
Correct Answer
A. Initial assessment
Explanation
The correct answer is initial assessment. The initial assessment is a
comprehensive evaluation of a patient's medical history, family
history, reason for admission, current medications, previous
hospitalizations, surgeries, psychosocial assessment, nutrition, and
complete physical assessment. It is typically conducted upon a
patient's admission to a healthcare facility to gather essential
information for the development of a care plan. This assessment
helps healthcare professionals understand the patient's overall
health status and identify any immediate needs or concerns.
 5.
Name the assessment process that collects data about a
problem that has already been identified and determines if
the problem still exists or any changes.
o A.
Focus assessment
o B.
Initial assessment
o C.
o D.
Non-invasive assessment
Correct Answer
A. Focus assessment
Explanation
A focus assessment is a process that collects data about a problem
that has already been identified and determines if the problem still
exists or any changes. This type of assessment is focused on a
specific problem or area of concern and is conducted to gather
more detailed information about the problem. It helps in evaluating
the effectiveness of interventions or treatments and making
necessary adjustments to the care plan.
 6.
Complete the sentence- A ________________________ is
performed to identify a life-threatening problem (choking,
stab wound, heart attack).
o A.
Initial assessment
o B.
Focus assessment
o C.
o D.
Critical assessment
Correct Answer
C. Emergency assessment
Explanation
An emergency assessment is performed to identify a life-
threatening problem such as choking, stab wound, or a heart attack.
This type of assessment is done quickly and efficiently to
determine the severity of the situation and to provide immediate
care and intervention. It involves assessing vital signs, conducting
a brief physical examination, and gathering relevant information to
make quick decisions and initiate appropriate emergency
treatments.
 7.
Information verbalized or stated by the client is called
____________.
o A.
Objective data
o B.
Subjective data
o C.
Integral data
o D.
Holistic data
Correct Answer
B. Subjective data
Explanation
Subjective data refers to information that is based on personal
opinions, feelings, or experiences of the client. It is the client's own
interpretation or perception of their condition or situation. This
type of data is important in healthcare as it provides insights into
the client's perspective and helps healthcare professionals
understand their needs and preferences. Objective data, on the
other hand, refers to measurable and observable facts or findings.
Integral data and holistic data are not commonly used terms in
healthcare and do not accurately describe the concept of
information verbalized by the client.
 8.
Observable and measurable information is known as
__________________.
o A.
Objective data
o B.
Subjective data
o C.
Visible data
o D.
Obscured data
Correct Answer
A. Objective data
Explanation
Observable and measurable information refers to data that can be
perceived and quantified without any personal bias or
interpretation. It is based on facts and evidence that can be verified
by multiple observers. Therefore, the correct answer is "objective
data."
 9.
What are the 4 types of nursing diagnosis?
o A.
Actual
o B.
Risk
o C.
Health promotion
o D.
Wellness
o E.
Safety
Correct Answer(s)
A. Actual
B. Risk
C. Health promotion
D. Wellness
Explanation
The correct answer for the question is Actual, Risk, health
promotion, and wellness. These are the four types of nursing
diagnosis. Actual nursing diagnosis refers to the current health
problems that the patient is experiencing. Risk nursing diagnosis is
used when there is a potential for the patient to develop a health
problem. Health promotion nursing diagnosis focuses on
improving the patient's overall health and well-being. Wellness
nursing diagnosis is used when the patient is in a state of optimal
health. Safety nursing diagnosis is used to address potential risks
and hazards to the patient's safety.
 10.
What are the 3 parts of the nursing diagnosis (PES)?
o A.
Patient
o B.
Problem
o C.
Signs and symptoms
o D.
Physical assessment
o E.
Etiology
Correct Answer(s)
B. Problem
C. Signs and symptoms
E. Etiology
Explanation
The nursing diagnosis (PES) consists of three parts: problem, signs
and symptoms, and etiology. The problem refers to the health issue
or concern that the patient is experiencing. Signs and symptoms
are the observable and subjective manifestations of the problem.
Etiology, on the other hand, refers to the underlying cause or
contributing factors of the problem. By considering these three
components, nurses can accurately identify and address the
patient's health needs.
 11.
This is the step of the nursing process where you do the PES.
o A.
Planning
o B.
Implementation
o C.
Assessment
o D.
Diagnosis
Correct Answer
D. Diagnosis
Explanation
The nursing process involves a series of steps that nurses follow to
provide care to their patients. The step mentioned in the question is
the one where the nurse performs the PES, which stands for
Problem, Etiology, and Signs/Symptoms. This step is known as the
diagnosis, where the nurse analyzes the patient's assessment data to
identify the health problems and their underlying causes. It is
during this step that the nurse formulates nursing diagnoses, which
guide the planning and implementation of care for the patient.
 12.
In this step of the nursing process, you prioritize the
diagnosis in order of importance and figure out what
nursing interventions need to take place to accomplish these
as well as goals to achieve your care plan.
o A.
Planning
o B.
Implementation
o C.
Assessment
o D.
Evaluation
Correct Answer
A. Planning
Explanation
In the planning step of the nursing process, the nurse prioritizes the
diagnosis based on their importance and determines the necessary
nursing interventions to address them. This step also involves
setting goals and developing a care plan to achieve those goals. It
is a crucial step as it helps the nurse outline the specific actions and
interventions that need to be implemented to provide effective care
to the patient.
 13.
This step begins after the care plan has been made and is
recognized as the step where the nurse performs the
interventions to achieve goals.
o A.
Planning
o B.
Assessment
o C.
Diagnosis
o D.
Implementation
Correct Answer
D. Implementation
Explanation
Implementation is the correct answer because it refers to the step in
the nursing process where the nurse carries out the interventions
that were planned in the care plan. This step involves putting the
plan into action and providing the necessary care and treatments to
the patient. It is during this step that the nurse actively works
towards achieving the goals and outcomes identified in the care
plan.
 14.
Name the stage where you determine if the patient has
achieved the expected outcomes.
o A.
Implementation
o B.
Evaluation
o C.
Assessment
o D.
Diagnosis
Correct Answer
B. Evaluation
Explanation
Evaluation is the stage where healthcare professionals determine if
the patient has achieved the expected outcomes. This involves
assessing the effectiveness of the interventions and treatments
provided to the patient. During evaluation, healthcare professionals
analyze the patient's progress and compare it to the expected
outcomes to determine if any adjustments or modifications to the
care plan are necessary. This stage is crucial in ensuring that the
patient receives appropriate and effective care.
 15.
What purpose does the nursing process serve?
o A.
Assisting family members in making important healthcare

decisions
o B.
Providing nurses with a framework to aid them in

delivering comprehensive care
o C.
Help other healthcare professionals know what is going on

with the client
o D.
Organize information so the doctor knows what is wrong

with the client
Correct Answer
B. Providing nurses with a framework to aid them in delivering
comprehensive care
Explanation
The nursing process serves the purpose of providing nurses with a
framework to aid them in delivering comprehensive care. This
process helps nurses assess the client's needs, diagnose health
problems, develop a care plan, implement interventions, and
evaluate the outcomes. It guides nurses in providing individualized
and holistic care to their patients, ensuring that all aspects of the
patient's health are addressed. By following the nursing process,
nurses can effectively plan and deliver care that is tailored to each
patient's unique needs and promote optimal health outcomes.
 16.
Which could be considered objective data from the
following?
o A.
A temperature of 100.1 degrees Fahrenheit
o B.
A patient’s report of moderate pain
o C.
Complaints of nausea
o D.
Feelings of sleepiness
Correct Answer
A. A temperature of 100.1 degrees Fahrenheit
Explanation
Objective data refers to measurable and observable information
that is not influenced by personal opinions or feelings. A
temperature of 100.1 degrees Fahrenheit is an objective data
because it can be measured using a thermometer and is not subject
to interpretation or bias. It provides concrete information about the
patient's body temperature, which can be useful for medical
diagnosis and treatment.
 17.
Which nursing diagnosis should receive the highest priority
in the case of a female patient who is diagnosed with deep
vein thrombosis?
o A.
Impaired gas exchange relating to an increased blood flow
o B.
Fluid volume excess relating to peripheral vascular disease
o C.
Risk of injury from edema
o D.
Altered peripheral tissue perfusion related to venous

congestion
Correct Answer
D. Altered peripheral tissue perfusion related to venous congestion
Explanation
The highest priority nursing diagnosis in the case of a female
patient diagnosed with deep vein thrombosis is "Altered peripheral
tissue perfusion related to venous congestion." Deep vein
thrombosis can lead to impaired blood flow and venous
congestion, which can result in compromised tissue perfusion. This
can lead to tissue damage, necrosis, and other complications.
Therefore, addressing and managing altered peripheral tissue
perfusion is crucial in preventing further complications and
promoting the patient's overall well-being.
 18.
From the following, which independent nursing intervention
can a nurse include in the plan of care for a patient with a
fractured tibia?
o A.
Administer aspirin 325 mg every 4 hours as needed
o B.
Apply a cold pack to the tibia
o C.
Perform a range of motion to right leg every 4 hours
o D.
Elevate the leg 5 inches above the heart

Correct Answer
D. Elevate the leg 5 inches above the heart
Explanation
Elevating the leg 5 inches above the heart is an independent
nursing intervention that can be included in the plan of care for a
patient with a fractured tibia. Elevating the leg helps to reduce
swelling and promote venous return, which can aid in the healing
process and prevent complications such as deep vein thrombosis.
This intervention does not require a physician's order and can be
implemented by the nurse without the need for assistance or
supervision.
 19.
To participate in goal setting clients must be:
o A.
Ambulatory and mobile
o B.
Able to read and write
o C.
Alert and have some degree of independence
o D.
Be able to talk
Correct Answer
A. Ambulatory and mobile
Explanation
To participate in goal setting, clients must be ambulatory and
mobile. This means they should be able to move around and have
the physical ability to engage in activities related to goal setting.
Being ambulatory and mobile is important as it allows clients to
actively participate and take necessary actions towards achieving
their goals.
 20.
A client-centered goal is a specific and measurable behavior
or response that reflects a client’s:
o A.
Highest possible level of wellness and independence in

function
o B.
Response when compared to another client with a like

problem
o C.
Physician’s goal for the specific client
o D.
Desire for specific health care interventions

Correct Answer
A. Highest possible level of wellness and independence in function
Explanation
A client-centered goal is a specific and measurable behavior or
response that reflects a client's highest possible level of wellness
and independence in function. This means that the goal should
focus on helping the client achieve the best possible state of well-
being and the ability to function independently. It should not be
compared to another client with a similar problem, be based on the
physician's goal, or solely based on the client's desire for specific
health care interventions. The emphasis is on the client's well-
being and ability to function at their best.
b
A patient 1 day postoperative after abdominal surgery has
incisional pain, 99.5°F temperature, slight erythema at the incision
margins, and 30 mL serosanguinous drainage in the Jackson-
Pratt drain. Based on this assessment, what conclusion would the
nurse make?
a. the abdominal incision shows signs of infection

b. the patient is having a normal inflammatory response
c. the abdominal incision shows signs of impending dehiscence
d. the patient's physician must be notified about her condition
b
The nurse assessing a patient with a chronic leg wound finds
local signs of erythema and the patient complains of pain at the
wound site. What would the nurse anticipate being ordered to
assess the patient's systemic response?
a. serum protein analysis

b. WBC count and differential
c. punch biopsy of center of wound
d. culture and sensitivity of the wound
b
A patient in the unit has a 103.7°F temperature. Which
intervention would be the most effective in restoring normal body
temperature?
a. using a cooling blanket while the patient is febrile
b. administer antipyretics on an around-the-clock schedule
c. provide increased fluids and have the UAP give sponge baths
d. give prescribed antibiotics and provide warm blankets for
comfort
b
A nurse is caring for a patient who has a pressure ulcer that is
treated with debridement, irrigations, and moist gauze dressings.
How should the nurse anticipate healing to occur?
a. tertiary intention
b. secondary intention
c. regeneration of cells
d. remodeling of tissues
b
A nurse is caring for a patient with diabetes who is scheduled for
amputation of his necrotic left great toe. The patient's WBC count
is 15.0 X 10^6/µL, and he has coolness of the lower extremities,
weighs 75 lbs. more than his ideal body weight, and smokes two
packs of cigarettes a day. Which priority nursing diagnosis
addresses the primary factor affecting the patient's ability to heal?
a. imbalanced nutrition: obesity related to decreased blood flow
secondary to diabetes and smoking
b. impaired tissue integrity related to decreased blood flow
secondary to diabetes and smoking
c. ineffective peripheral tissue perfusion related to narrowed blood
vessels secondary to diabetes and smoking
d. ineffective individual coping related to indifference and denial of
long-term effects of diabetes and smoking
c
Which one of the orders should a nurse question in the plan of
care for an elderly immobile stroke patient with a stage III
pressure ulcer?
a. pack the ulcer with foam dressing

b. turn and position the patient every hour
c. clean the ulcer every shift with Dakin's solution
d. assess for pain and medicate before dressing change
a
An 85 year old patient is assessed to have a score of 16 on the
Braden scale. Based on this information, how should the nurse
plan for this patient's care?
a. implement a 1 hr turning schedule with skin assessment

b. place DuoDerm on the patient's sacrum to prevent breakdown
c. elevate the head of bed to 90 degrees when the patient is
supine
d. continue with weekly skin assessments with no special
precautions
b
c
A 65 year old stroke patient with limited mobility has a purple area
of suspected deep tissue injury on the left greater trochanter.
Which nursing diagnoses are the most appropriate? (Select all
that apply)
a. acute pain related to tissue damage and inflammation
b. impaired skin integrity related to immobility and decreased
sensation
c. impaired tissue integrity related to inadequate circulation
secondary to pressure
d. risk for infection related to loss of tissue integrity and under-
nutrition secondary to stroke
e. ineffective peripheral tissue perfusion related to arteriosclerosis
and loss of blood supply to affected area
c
An 82 year old man is being cared for at home by his family. A
pressure ulcer on his right buttock measures 1 X 2 X 0.8 cm in
depth, and pink subcutaneous tissue is completely visible on the
wound bed. Which stage would the nurse document on the wound
assessment form?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
d
In a patient with leukocytosis with a shift to the left, what does the
nurse recognize as causing this finding?
a. the complement system has been activated to enhance

phagocytosis
b. monocytes are released into the blood in larger-than-normal
amounts
c. the response to cellular injury is not adequate to remove
damaged tissue and promote healing
d. the demand for neutrophils causes the release of immature
neutrophils from the bone marrow
c
What does the mechanism of chemotaxis accomplish?
a. causes the transformation of monocytes into macrophages

b. involves a pathway of chemical processes resulting in cellular
lysis
c. attracts the accumulation of neutrophils and monocytes to an
area of injury
d. slows the blood flow in a damaged area, allowing migration of
leukocytes into tissue
d
What effect does the action of the complement system have on
inflammation?
a. modifies the inflammatory response to prevent stimulation of

pain
b. increases body temperature, resulting in destruction of
microorganisms
c. produces prostaglandins and leukotrienes that increase blood
flow, edema, and pain
d. increases inflammatory responses of vascular permeability,
chemotaxis, and phagocytosis
c
Key interventions for treating initial soft tissue injury and resulting
inflammation are remembered using the acronym RICE. What are
the most important actions for the emergency department nurse
to do for the patient with an ankle injury?
a. reduce swelling, shine light on wound, control mobility, and get
the history of the injury
b. rub the wound clean, immobilize the area, cover the area
protectively, and exercise the leg
c. rest with immobility, apply a cold compress and/or a
compression bandage, and elevate the ankle
d. rinse the wounded ankle, get x-rays of the ankle, carry the
patient, and extend the ankle with a splint
b
What is characteristic of chronic inflammation?
a. it may last 2-3 weeks

b. the injurious agent persists or repeatedly injures tissue
c. ineffective endocarditis is an example of chronic inflammation
d. neutrophils are the predominant cell type at the site of
inflammation
a
During the healing phase of inflammation, which cells would
be most likely to regenerate?
a. skin
b. neurons
c. cardiac muscle
d. skeletal muscle
c
What is the primary difference between healing by primary
intention and healing by secondary intention?
a. primary healing requires surgical debridement for healing to

occur
b. primary healing involves suturing two layers of granulation
tissue together
c. presence of more granulation tissue in secondary healing
results in a larger scar
d. healing by secondary intention takes longer because more
steps in the healing process are necessary
b
A patient had abdominal surgery 3 months ago and calls the clinic
with complaints of severe abdominal pain and cramping, vomiting,
and bloating. What should the nurse most likely suspect as the
cause of the patient's problem?
a. infection
b. adhesion
c. contracture
d. evisceration
d
A patient had a complicated vaginal hysterectomy. The student
nurse provided perineal care after the patient had a bowel
movement. The student nurse tells the nurse there was a lot of
light brown, smelly drainage seeping from the vaginal area. What
should the nurse suspect when assessing this patient?
a. dehiscence
b. hemorrhage
c. keloid formation
d. fistula formation
c
Which nutrients aid in capillary synthesis and collagen production
by the fibroblasts in wound healing?
a. fats
b. proteins
c. vitamin c
d. vitamin a
d
What role do the B-complex vitamins play in wound healing?
a. decrease metabolism
b. protect protein from being used for energy
c. provide metabolic energy for the inflammation process
d. coenzymes for fat, protein, and carbohydrate metabolism
c
The patient is admitted from home with a clean stage II pressure
ulcer. What does the nurse expect to observe when she does her
wound assessment?
a. adherent gray necrotic tissue

b. clean, moist granulating tissue
c. red-pink wound bed, without slough
d. creamy ivory to yellow-green exudate
a
What type of dressing will the nurse most likely use for the
patient with a clean stage II pressure ulcer, with a red-pink wound
bed, without slough?
a. hydrocolloid
b. transparent film
c. absorptive dressing
d. negative pressure wound therapy
c
The patient's wound is not healing, so the HCP is going to send
the patient home with negative pressure wound therapy. What will
the caregiver need to understand about the use of this device?
a. the wound must be cleaned daily

b. the patient will be placed in a hyperbaric chamber
c. the occlusive dressing must be sealed tightly to the skin
d. the diet will not be as important with this sort of treatment
d
During care of patients, what is the most important precaution for
preventing transmission of infections?
a. wearing face and eye protection during routine daily care of the
patient
b. wearing nonsterile gloves when in contact with body fluids,
excretions, and contaminated items
c. wearing a gown to protect the skin and clothing during patient
care activities likely to soil clothing
d. hand washing after touching fluids and secretions, removing
gloves, and between patient contacts
c
Which patient is at the greatest risk for developing pressure
ulcers?
a. a 42 year old obese woman with type 2 diabetes
b. a 78 year old man who is confused and malnourished
c. a 30 year old man who is comatosed following a head injury
d. a 65 year old woman who has urge and stress incontinence
b
What is the most important nursing intervention for the
prevention and treatment of pressure ulcers?
a. using pressure-reduction devices
b. repositioning the patient frequently
c. massaging pressure areas with lotion
d. using lift sheets and trapeze bars to facilitate patient movement
d
The patient is transferring from another facility with the description
of a sore on her sacrum that is deep enough to see the muscle.
What stage of pressure ulcers does the nurse expect to see on
admission?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
c
A patient's documentation indicates he has a stage III pressure
ulcer on his right hip. What should the nurse expect to find on
assessment of the patient's right hip?
a. exposed bone, tendon, or muscle

b. an abrasion, blister, or shallow crater
c. deep crater through subcutaneous tissue to fascia
d. persistent redness (or bluish color in darker skin tones)
d
e
Which nursing interventions for a patient with a stage IV sacral
pressure ulcer are most appropriate to assign or delegate to a
licensed practical/vocational nurse? (Select all that apply)
a. assess and document wound appearance
b. teach the patient pressure ulcer risk factors
c. choose the type of dressing to apply to the ulcer
d. measure the size (width, length, depth) of the ucler
e. assist the patient to change positions at frequent intervals
c
d
A nurse is teaching a patient how to promote healing following
abdominal surgery. What should be included in the
teaching (select all that apply.)?
a. Take the antibiotic until the wound feels better.
b. Take the analgesic every day to promote adequate rest for
healing.
c. Be sure to wash hands after changing the dressing to avoid
infection.
d. Take in more fluid, protein, and vitamins C, B, and A to
facilitate healing.
e. Notify the health care provider of redness, swelling, and
increased drainage.
c
A patient arrives in the emergency department reporting fever for
24 hours and lower right quadrant abdominal pain. After
laboratory studies are performed, what does the nurse determine
indicates the patient has a bacterial infection?
a. Increased platelet count

b. Increased blood urea nitrogen
c. Increased number of band neutrophils
d. Increased number of segmented myelocytes
b
A patient had abdominal surgery last week and returns to the
clinic for follow-up. The nurse assesses thick, white, malodorous
drainage. How should the nurse document this drainage?
a. Serous
b. Purulent
c. Fibrinous
d. Catarrhal
c
A patient has been provided with a compression dressing in an
attempt to facilitate rapid healing of an ankle sprain. What is
a priority nursing assessment?
a. Frequent examination of the character and quantity of exudate
b. Monitoring for signs and symptoms of local or systemic
infections
c. Assessment of the patient’s circulation distal to the location of
the dressing
d. Assessment of the range of motion of the ankle and the
patient’s activity tolerance
b
A patient is ordered to receive acetaminophen 650 mg per rectum
every 6 hours as needed for fever greater than 102°F. Which
parameter would the nurse monitor, other than temperature, if the
patient requires this medication?
a. Pain level
b. Intake and output
c. Oxygen saturation
d. Level of consciousness
d
A patient is postoperative after a breast reduction and arrives for
a follow-up appointment at the clinic. The nurse assesses excess
soft pink tissue from the surgical incision site. What complication
of wound healing does the nurse recognize this to be?
a. Adhesion
b. Contractions
c. Keloid formation
d. Excess granulation tissue
b
A patient is seen in the emergency department for a sprained
ankle. What initial interventions should the nurse teach the
patient for treatment of this soft tissue injury?
a. Warm, moist heat and massage
b. Rest, ice, compression, and elevation
c. Antipyretic and antibiotic drug therapy
d. Active movement and exercise to prevent stiffness
b
A patient with pneumonia has a fever of 103°F. What nursing
actions will assist in managing the patient's febrile state?
a. Administer aspirin on a scheduled basis around the clock.

b. Provide acetaminophen every 4 hours to maintain consistent
blood levels.
c. Administer acetaminophen when the patient's oral temperature
exceeds 103.5°F.
d. Provide drug interventions if complementary and alternative
therapies have failed.
b
Rationale: Custard contains milk, egg, sugar, and vanilla. These
contain calcium, vitamin A, and zinc, which are needed for wound
healing
A postoperative patient is now able to eat and is requesting a
snack. What snack should the nurse recommend for the patient
that will facilitate wound healing?
a. Apple
b. Custard
c. Popsicle
d. Potato chips
a
After the unlicensed assistive personnel (UAP) bathed the patient,
she then told the nurse about a reddened area on the patient's
coccyx. After assessing the area, what should be included in the
plan of care?
a. Reposition every 2 hours.

b. Measure the size of the reddened area.
c. Massage the area to increase blood flow.
d. Evaluate the area later to see if it is better.
c
An older adult patient is transferred from the nursing home with a
black wound on her heel. What immediate wound therapy does
the nurse anticipate providing to this patient?
a. Dress it with an absorbent dressing for exudate.
b. Handle the wound gently and let it dry out to heal.
c. Debride the nonviable, eschar tissue to allow healing.
d. Use negative-pressure wound (vacuum) therapy to facilitate
healing.
d
The nurse is caring for a patient who is immunocompromised
while receiving chemotherapy for advanced breast cancer. What
signs and symptoms will the nurse teach the patient to report that
may indicate an infection?
a. Fever and chills

b. Increased blood pressure
c. Increased respiratory rate
d. General malaise and fatigue
c
The nurse is providing care to a patient with an open abdominal
wound after surgery. What teaching should the nurse provide to
the patient regarding the healing process?
a. The wound will be stapled together until it heals.

b. The healing will contract the area to close the wound.
c. The wound will be left open and heal from the edges inward.
d. The wound will be sutured after the current infection is
controlled.
a
The nurse observes a patient experiencing chills related to an
infection. What is the priority action by the nurse?
a. Provide a light blanket.
b. Encourage a hot shower.
c. Monitor temperature every hour.
d. Turn up the thermostat in the patient’s room.
b
The patient has inflammation and reports tiredness, nausea, and
anorexia. The nurse explains to the patient that these
manifestations are related to inflammation in what way?
a. Local response
b. Systemic response
c. Infectious response
d. Acute inflammatory response
c
The unlicensed assistive personnel (UAP) is assisting the patient
with Crohn’s disease with perineal care. The UAP tells the nurse
that the patient had feces coming from the vagina. What is
the priority action by the nurse?
a. Notify the health care provider.
b. Document the fistula formation.
c. Assess the patient and vaginal drainage.
d. Have the UAP apply a dressing to the vagina.
a
To which patient should the nurse plan to administer around-the-
clock antipyretic drugs?
a. A 76-yr-old patient with bacterial meningitis and a temperature

of 104.2°F
b. An 82-yr-old patient after hip replacement surgery and a
temperature of 100.4°F
c. A 14-yr-old patient with infectious mononucleosis and a
d. A 59-yr-old patient with an acute myocardial infarction and a
c
When assessing a patient who is receiving cefazolin for the
treatment of a bacterial infection, which data suggest that
treatment has been effective?
a. White blood cell (WBC) count of 8000/ìL; temperature of 101°F

b. White blood cell (WBC) count of 4000/ìL; temperature of 100°F
c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4°F
d. White blood cell (WBC) count of 16,500/ìL; temperature of
98.8°F
b
Which intervention should the nurse include in the plan of care for
a patient who is paraplegic with a stage III pressure ulcer?
a. Keep the pressure ulcer clean and dry.

b. Maintain protein intake of at least 1.25 g/kg/day.
c. Use a 10-mL syringe to irrigate the pressure ulcer.
d. Irrigate the pressure ulcer with hydrogen peroxide.
a
Which patient is most at risk for the development of a pressure
ulcer?
a. An older patient who is septic, bedridden, and incontinent
b. An obese woman with leukemia who is receiving chemotherapy
c. A middle-aged thin man in a halo cast after a motor vehicle
accident
d. An adult with type 1 diabetes mellitus admitted in diabetic
ketoacidosis
a
A basic principle of wound management for all open wounds is to
a. Protect new granulation and epithelial tissue.

b. Apply topical antimicrobials to prevent wound infection.
c. Remove wound exudate with frequent dressing changes.
d. Use occlusive dressings to prevent wound contamination.
A nurse is assessing a patient's skin and notes a 3 cm shallow

crater on the patient's buttocks. The patient winces when the area
is palpated. How should the nurse stage this wound?
A. stage 1 pressure ulcer
B. stage 2 pressure ulcer
C. stage 3 pressure ulcer
D. stage 4 pressure ulcer
B. Stage 2 pressure ulcer
Which of the following are functions of dressings? (select all that
apply)
A. promote hemostasis
B. keep wound bed dry
C. wound debridement
D. prevent contamination
E. increase circulation
A. promote hemostasis
C. wound debridement
D. prevent contamination
We don't want to keep the wound bed dry and dressings don't
increase circulation
Which of the following patients would be expected to benefit from
a moist to dry dressing (mechanical debridement)? (select all that
apply)
A. 24 year old with an open infected wound from a spider bite
B. 7 year old with an abrasion on bilateral knees
C. 50 year old with a post operative knee replacement incision
D. 30 year old who had a large cyst removed and now has some
necrotic tissue present in the crater type wound
A. 24 year old with an open, infected wound from a spider bite.
D. 30 year old who had a large cyst removed and now has some
necrotic tissue present in the crater type wound.
Which of the following devices should be used to ensure the
appropriate amount of irrigation pressure during a wound
irrigation?
A. 10 mL syringe with a 19 gauge needle
B. 35 mL syringe with a 19 gauge needle
C. steady flow of fluid from a height of 12 inches above the wound
D. steady but gentle squirt of irrigant through a catheter irrigating
system
B. 35 mL syringe with a 19 gauge needle
The nurse is caring for a patient who had knee replacement
surgery 5 days go. The patient's knee appears red and warm to
the touch and patient is requesting increased pain medication.
What complication should the nurse be concerned about?
A. nothing, this is expected post operatively
B. patient is becoming dependent on pain medication
C. post operative wound dehiscence
D. post operative wound infection
D. post operative wound infection
Which of the following may indicate internal hemorrhage? (select
all that apply)
A. distention or swelling of the affected body part.
B. elevated WBC
C. decrease in blood pressure and increase in pulse
D. change in the type and amount of drainage.
A. Distention or swelling of effected body part
C. decrease in blood pressure and increase in pulse
Which of the following are common sites for development of
pressure ulcers? (select all that apply)
A. sternum
B. heels
C. sacrum
D. ears
E. lateral malleoli
F. trochanters
G. tip of great toe
B. heels
C. sacrum
D. ears
E. lateral maleoli
F. trochanters
When educating a patient about wound healing the nurse should
include what in the teaching?
A. inadequate nutrition delays wound healing and increases risk
of infection.
B. chronic wounds heal better in a dry, open environment so
leave them open to air.
C. fat tissue heals more rapidly because there is less
vascularization.
D. long term steroid use diminishes the inflammatory response
and speeds up wound healing
A. inadequate nutrition delays wound healing and increases risk
of infection
What strategies should be included in pressure ulcer prevention
(select all that apply)
A. use moisture barrier ointment with incontinence
B. reposition immobile patients every 4 hours
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
E. maintain bed at 45 degree angle
F. massage reddened bony prominences
G. oral nutrition supplement should be used when
undernourished.
A. use moisture barrier ointment with incontinence
C. when patient in side lying position ensure HOB <30 degrees
D. place patient on pressure reducing support surface
G. oral nutrition supplement should be used when
undernourished.
Why does a wound bed need to stay moist?
A. to support healing by enabling granulation tissue to grow.
B. to prevent excessive fluid loss from the body
C. to determine if the area has reactive hyperemia
D. to decrease patient discomfort
A. to support healing by enabling granulation tissue to grow.
Which of the following characteristics are most likely that of a
stage 4 pressure ulcer?
A. eschar
B. blister
C. shallow crater
D. nonblanchable redness
A. eschar
What evaluation criteria are included in the Braden Risk
assessment? (select all that apply)
A. sensory perception
B. medications
C. mobility
D. friction and shear
E. mental status
F. moisture
A. sensory perception
C. mobility
D. friction and shear
F. moisture
What term refers to pale, red and watery drainage from a wound?
A. serous
B. sanguineous
C. serosanguineous
D. purulent
C. serosanguineous
serous - clear, watery, plasma

sanguineous - bright red, active bleeding
purulent - thick, yellow, green, tan or brown (pus)
A nurse is caring for a patient with a pressure ulcer. What type of
healing process will occur with this wound?
A. primary intention
B. secondary intention
C. tertiary intention
B. secondary intention
A patient has a new abdominal wound. The wound has stopped
bleeding and clots are beginning to form. What phase of healing
is identified?
A. remodeling phase
B. proliferative phase
C. inflammatory phase
D. hemostasis phase
D. hemostasis phase
 1.
These are surgical wounds in which the respiratory, alimentary,
genital, or urinary tract has been entered:
o A.
Clean wounds
o B.
Clean-contaminated wounds
o C.
Contaminated wounds
o D.
Dirty or infected wounds
Correct Answer
B. Clean-contaminated wounds
 2.
Wounds are left open for 3-5 days for edema, infection, or
exudate to drain.
o A.
Primary healing
o B.
Secondary healing
o C.
Tertiary healing
o D.
Quaternary healing
Correct Answer
C. Tertiary healing
 3.
This exudate is hemorrhagic, contains a large number of RBCs,
and shows severe damage to capillaries.
o A.
Serous
o B.
Purulent
o C.
Sanguineous
o D.
None
Correct Answer
C. Sanguineous
 4.
Wounds must be cleaned before applying ointments.
o A.
True
o B.
False
Correct Answer
A. True
 5.
For pressure ulcers, which of these are risk factors?
o A.
Decreased mental status

o B.
Fecal and urinary incontinence
o C.
Soft bed
o D.
Excessive body heat
o E.
Cold body
Correct Answer(s)
A. Decreased mental status
B. Fecal and urinary incontinence
D. Excessive body heat
 6.
Full-thickness skin loss involving damage or necrosis of
subcutaneous tissue
o A.
Stage I
o B.
Stage II
o C.
Stage III
o D.
Stage IV
Correct Answer
C. Stage III
 7.
Wounds on the hard parts don't require ointments.
o A.
True
o B.
False
Correct Answer
B. False
 8.
Which of these are ways to prevent pressure ulcers?
o A.
Give supplements to increase caloric intake.
o B.
Massage the area
o C.
Decrease humidity
o D.
Frequent toileting
Correct Answer(s)
A. Give supplements to increase caloric intake.
D. Frequent toileting
 9.
Which are methods to apply moist cold?
o A.
Cold pack
o B.
Compress
o C.
Ice bag
o D.
Cooling sponge bath

Correct Answer
B. Compress
 10.
This phase of healing increases from day 3 or 4 until day 21 and
then injury. Collagen extends in the area. Capillaries go across
the wound.
o A.
Inflammatory phase
o B.
Proliferative phase
o C.
Maturation phase
o D.
None of these
Correct Answer
B. Proliferative phase
The nurse is attending to a client who was diagnosed with heart failure.
During the examination, the nurse observes that the client is dyspneic
with crackles upon auscultation. Which symptoms would manifest for a
client with excess fluid volume?
 A. Decreased central venous pressure

 B. Flat neck and hand veins
 C. Hypertension
 D. Weight loss
Show Rationale
Correct:
C. Hypertension is a sign of fluid volume excess or fluid overload. The

increase in fluid volume causes an increase in blood pressure
Incorrect:
A., B., D. Decreased central venous pressure, flat neck and hand veins,
and weight loss are all signs of fluid volume deficit.
2. Question
During the client’s medical records review, what condition can put the
client at risk for developing hypokalemia?
 A. Has a history of Addison’s disease

 B. Nasogastric suction
 C. Burn
 D. Uric acid level of 10.2 mg/dL (59.48 µmol/L)
Show Rationale
3. Question
The nurse analyzes the electrolyte test results for a client and notes that
the potassium level is 2.2 mEq/L (2.2 mmol/L). Based on the laboratory
result, which ECG pattern is not expected?
 A. Absent P waves
 B. Depressed ST segment
 C. Inverted T waves
 D. Presence of U waves
Show Rationale
4. Question
An intravenous dose of potassium chloride is prescribed for a client with

hypokalemia. Which action of the nurse indicates a need for further
teaching in the preparation and administration of potassium?
 A. Administer potassium through IV bolus.

 B. Check if the label of the bag indicates the volume of the
potassium in the solution.
 C. Infuse potassium through an intravenous (IV) infusion pump.
 D. Monitor urine output during infusion.
Show Rationale
5. Question
A client with hypoparathyroidism is suspected of having hypocalcemia.

Upon assessment, the nurse notes which clinical symptom would
indicate hypocalcemia.
 A. Diminished deep tendon reflexes

 B. Hypoactive bowel sounds
 C. Negative Trousseau’s sign
 D. Twitching
Show Rationale
6. Question
A client diagnosed with Crohn’s disease has a calcium level of 7 mg/dL

(1.75 mmol/L). Which ECG patterns would the nurse monitor?
 A. Peaked T wave
 B. Prolonged QT interval
 C. Prominent U wave
 D. Widened T wave
Show Rationale
7. Question
A client diagnosed with Cushing’s disease has a potassium level of 2.3

mEq/L (2.3 mmol/L). Based on the result, which pattern would the nurse
be monitoring for on the cardiac monitor?
 A. Prolonged ST segment
 B. Prominent U wave
 C. ST elevation
 D. Tall peaked T waves
Show Rationale
8. Question
Which client will most likely experience a serum sodium concentration

of 127 mEq/L (127 mmol/L)?
 A. A client who has Cushing’s syndrome

 B. A client who has hyperaldosteronism
 C. A client who is taking thiazide diuretics
 D. A client who uses corticosteroids
Show Rationale
9. Question
The client was diagnosed with heart failure and is currently taking high
doses of diuretics. During the assessment, the nurse noted generalized
weakness, flat neck veins, and diminished deep tendon reflexes. Which
of the following symptoms would indicate that the client has
hyponatremia?
 A. Decreased urinary output

 B. Hyperactive bowel sounds
 C. Increased urine specific gravity
 D. Tremors
Show Rationale
10. Question
After the nurse reviewed the client’s lab results, the client’s serum
phosphorus (phosphate) level was found to be at 1.8 mg/dL (0.58
mmol/L) level. What condition is most likely to cause the serum
phosphorus level?
 A. Hypoparathyroidism
 B. Kidney failure
 C. Malnutrition
 D. Tumor lysis syndrome
Show Rationale
11. Question
After reading the doctor’s progress reports, the nurse plans to monitor
the client, which states that the patient has “insensible fluid loss of
approximately 800 mL daily.” The nurse is aware that one way
insensible fluid loss happens is through which form of excretion?
 A. Gastrointestinal tract
 B. Sweat
 C. Urinary output
 D. Wound drainage
Show Rationale
12. Question
The nurse reviewed the medical records of the four clients assigned to
her. Which client has the highest risk for a fluid volume deficit?
 A. A client with an ileostomy

 B. A client with heart failure
 C. A client on long-term corticosteroid therapy
 D. A client with SIADH
Show Rationale
13. Question
A client diagnosed with heart failure has been receiving intravenous (IV)
diuretics. Which finding would the nurse expect to assess from this
client suspected of experiencing fluid volume deficit?
 A. Decreased hematocrit
 B. Increased blood pressure
 C. Lung congestion
 D. Poor skin turgor
Show Rationale
14. Question
Which client is at risk for fluid volume excess?
 A. The client with intermittent gastrointestinal suctioning

 B. The client who is on diuretics and has skin tenting
 C. The client with an ileostomy from a recent abdominal surgery
 D. The client with kidney disease developed as a complication of
diabetes mellitus
Show Rationale
15. Question
Which client is most likely to develop a potassium level of 6.2 mEq/L

(6.2 mmol/L)?
 A. The client who abuses laxatives

 B. The client who had a traumatic burn
 C. The client with colitis
 D. The client with Cushing’s syndrome
Show Rationale
16. Question
Immunosuppression is noted in the client. Which WBC value would

cause the nurse to consider using neutropenic precautions?
 A. 2000 mm3 (2.0 × 109/L)
 B. 5800 mm3 (5.8 × 109/L)
 C. 8400 mm3 (8.4 × 109/L)
 D. 9,500 mm3 (9.5 × 109/L)
Show Rationale
17. Question
The client’s blood has a platelet count of 300,000 mm3 (300 x 109/L).
What should the nurse do when she receives this laboratory result?
 A. Advise the primary healthcare provider about the unusually

increased value.
 B. Document the report as normal in the client’s medical file.
 C. Notify the primary healthcare provider about the unusually
decreased value.
 D. Put the client on platelet boosting medication.
Show Rationale
18. Question
After undergoing abdominal perineal excision for a colon tumor, a 55-

year-old male patient is admitted for colostomy placement. The nurse
will evaluate the newly inserted colostomy. Which of the following
assessments indicates a functional colostomy?
 A. Absent bowel sounds upon auscultation

 B. Bloody drainage coming out of the colostomy drainage
 C. Presence of flatus
 D. Client’s food tolerance
Show Rationale
19. Question
The nurse observes the stoma to be red and edematous. Based on this
finding, what should the nurse do?
 A. Immediately apply ice.

 B. Record the findings.
 C. Elevate the client’s buttocks.
 D. Notify the primary healthcare provider.
Show Rationale
20. Question
The client started passing foul-smelling flatus from the colostomy stoma
after two days of the insertion. What is the correct interpretation for the
nurse?
 A. It is a sign of ischemic bowel disease.

 B. The client’s nasogastric tube should stay inserted with the
client.
 C. It is an expected outcome.
 D. The intestinal preparation before surgery is not adequate.
Show Rationale
21. Question
Which of the following findings must be immediately reported to the

primary healthcare provider?
 A. Beefy red and shiny stoma.

 B. Excoriation of the skin around the stoma
 C. A semi-formed stool in the ostomy.
 D. The stoma is purple in appearance.
Show Rationale
22. Question
A nosocomial infection of Methicillin-resistant Staphylococcus aureus
was detected in the client, who has been put on contact precautions as a
result (MRSA). What protective equipment should a nurse prepare
before providing colostomy care?
 A. Gloves and gown

 B. Gloves and goggles
 C. Gloves, gown, and shoe protectors
 D. Gloves, gown, goggles, and a mask or face shield
Show Rationale
23. Question
The responsibility of taking a 47-year-old female client’s vital signs who

was diagnosed with right breast cancer post-mastectomy has been
assigned to the newly graduated nurse. Which of the following vital sign
procedures should be considered?
 A. Attaching pulse oximeter on the left index finger.

 B. Attaching pulse oximeter on the right index finger.
 C. Taking BP on the left arm.
 D. Taking BP on the right arm.
Show Rationale
24. Question
The nurse is preparing to give a bed bath to a client diagnosed with

tuberculosis. Which equipment should the nurse include when
administering this procedure?
 A. Particulate respirator and protective eyewear
 B. Particulate respirator, gown, and gloves
 C. Surgical mask and gloves
 D. Surgical mask, gown, and protective eyewear
Show Rationale
25. Question
The client is getting ready for a thoracentesis. Which position should the
client be placed in for the procedure?
 A. Lie on the affected side

 B. Lay on the unaffected side.
 C. Prone with the head turned to the side with a pillow supporting
the head
 D. Sims’ position with the head flat on the bed
Show Rationale
 Tasks that facilitate the passage from grief to closure. Select all
that apply:
o A.
Accepting the reality of the loss
o B.
Finding new ways to transition to a lifestyle of mourning.
o C.
Experiencing the pain of grief
o D.
Adjusting to an environment that no longer includes the

lost person, object, or aspect of self.
o E.
Removing emotional energy into new relationships

 Correct Answer(s)
A. Accepting the reality of the loss
C. Experiencing the pain of grief
D. Adjusting to an environment that no longer includes the lost
person, object, or aspect of self.
E. Removing emotional energy into new relationships
 Explanation
p. 220
 2.
"Sense of Presence." Select all that apply:
o A.
Individuals who have experienced a loss sometimes have a

non-threatening comforting perception that the deceased is
present.
o B.
Varies from general feelings of deceased's presence to

having actual sensory experiences
o C.
It is considered an abnormal form of mental and

personality disorder.
o D.
Sometimes they manifest as dreams or conversations;

sometimes, they involve senses and include vision,
hallucinations, or the perception of voices, smells, or
touch.
o E.
A sense of presence is thought to be a form of searching

behavior, a means of consciously or unconsciously
denying the reality of a loss.
Correct Answer(s)
A. Individuals who have experienced a loss sometimes have a non-
threatening comforting perception that the deceased is present.
B. Varies from general feelings of deceased's presence to having
actual sensory experiences
D. Sometimes they manifest as dreams or conversations;
sometimes, they involve senses and include vision, hallucinations,
or the perception of voices, smells, or touch.
E. A sense of presence is thought to be a form of searching
behavior, a means of consciously or unconsciously denying the
reality of a loss.
Explanation
p. 221
 3.
"Grief Attacks." Select all that apply:
o A.
The involuntary and unexpected appearance of emotions

and behaviors associated with grief
o B.
Occurs in response to routine events and sometimes
results in emotional outbursts
o C.
Sometimes, it is triggered by the experiences shared with

the deceased such as music or places.
o D.
Sometimes, it is an unrelated event such as a death that

took place in a movie.
o E.
Grief attacks are consistent with the normal growth pattern

of an individual
Correct Answer(s)
A. The involuntary and unexpected appearance of emotions and
behaviors associated with grief
B. Occurs in response to routine events and sometimes results in
emotional outbursts
C. Sometimes, it is triggered by the experiences shared with the
deceased such as music or places.
D. Sometimes, it is an unrelated event such as a death that took
place in a movie.
Explanation
p. 221
 4.
A risk that nurses experience as a result of multiple losses in the
course of work with a failure to adequately process them.
o A.
Grief overload
o B.
Loss overload
o C.
Bereavement overload
o D.
Burnt out overload

Correct Answer
C. Bereavement overload
Explanation
p. 222
 5.
The study of dying and death
o A.
Ontology
o B.
Eschatology
o C.
Pathophysiology
o D.
Gerontology
o E.
Thanatology
Correct Answer
E. Thanatology
Explanation
p. 222
 6.
James went to a funeral for the third time this month. He is quite
depressed that most of his friends are dying. He is also very
much afraid of getting sick for a long period of time to the extent
that he sees his doctor at least once a week and calls him up
every other day. When talking with his brother, James expresses
that when death comes, he will be free from pain, and he will
meet his friends once more. What is Mr. James' age group?
Select the best answer
o A.
45 to 65 years
o B.
65 + years
o C.
18 to 45 years
o D.
12 to 18 years
Correct Answer
B. 65 + years
Explanation
p. 223
 7.
Which of the following are descriptions of complicated grief?
Select all that apply:
o A.
It is the same as "unresolved grief."
o B.
It is also called "dysfunctional grieving."
o C.
It is a delayed or exaggerated response to a perceived,

actual, or potential loss.
o D.
It is the direct opposite of simple grief.

Correct Answer(s)
A. It is the same as "unresolved grief."
B. It is also called "dysfunctional grieving."
C. It is a delayed or exaggerated response to a perceived, actual, or
potential loss.
Explanation
p. 224
 8.
When providing nursing care during the dying and grieving
process, nursing interventions should target the following: Select
all that apply.
o A.
Energy conservation
o B.
Pain-reduction techniques
o C.
Comfort measures
o D.
Increase self-esteem through cosmetic improvements
o E.
Promotion of sleep and rest

Correct Answer(s)
A. Energy conservation
B. Pain-reduction techniques
C. Comfort measures
E. Promotion of sleep and rest
Explanation
p. 224 - Increase self-esteem through body image acceptance
 9.
When providing supportive care for the dying or grieving
patient, which of the following assessments should be
considered? Select all that apply:
o A.
Physical assessment
o B.
Emotional assessment
o C.
Intellectual assessment
o D.
Sociocultural assessment
o E.
Philosophical assessment
Correct Answer(s)
A. Physical assessment
B. Emotional assessment
C. Intellectual assessment
D. Sociocultural assessment
 10.
What are the roles of the LPN/LVN in the nursing process of
Loss and Grief? Select all that apply:
o A.
Participate in planning care for patients based on patient

needs
o B.
Review patient's plan of care and recommend revisions as

needed
o C.
Review and follow defined prioritizations for patient care
o D.
Use clinical pathways, care maps, or care plans to guide

and review patient care.
o E.
Participate with patient's religious and cultural practices to

build rapport
Correct Answer(s)
A. Participate in planning care for patients based on patient needs
B. Review patient's plan of care and recommend revisions as
needed
C. Review and follow defined prioritizations for patient care
D. Use clinical pathways, care maps, or care plans to guide and
review patient care.
Explanation
p. 229
 11.
Interpretation of a loss varies greatly with a person's cultural and
ethnic backgrounds. The following are examples. Select all that
apply:
o A.
In the Western tradition, the grieving process is usually

personal and private with emotional restraint
o B.
Grief is expressed in a basic and universal expression

across cultures and traditions
o C.
The Northern tradition of people belonging to the upper

hemisphere of the globe is related to climate changes
o D.
In Eastern nations, respect for the dead is shown by loud

wailing, and physical demonstration of grief for a
specified period
Correct Answer(s)
A. In the Western tradition, the grieving process is usually personal
and private with emotional restraint
D. In Eastern nations, respect for the dead is shown by loud
wailing, and physical demonstration of grief for a specified period
Explanation
p. 229
 12.
Which of the following is NOT a NANDA-I approved nursing
diagnoses related to grieving?
o A.
Grieving related to potential loss of physiopsychosocial

well being
o B.
Complicated grieving related to loss of significant other
o C.
Despair related to cultural discrepancies and dysfunctions
o D.
Hopelessness related to failing or deteriorating

physiologic condition
o E.
Interrupted family process related to situational transition

or crisis
Correct Answer
C. Despair related to cultural discrepancies and dysfunctions
Explanation
p. 229
 13.
The following are the most frequent symptoms experienced by
the dying older adult. Select all that apply:
o A.
Pain
o B.
Euphoria
o C.
Respiratory distress
o D.
Confusion
Correct Answer(s)
A. Pain
C. Respiratory distress
D. Confusion
Explanation
p. 231
 14.
When providing supportive care for perinatal or pediatric death,
which of the following is not an appropriate intervention?
o A.
When possible, allow parents to see, touch and hold the

infant, so that they can face the reality of the situaion and
resolve their grief
o B.
Be aware of how children view or understand death, both
of their own and that of others.
o C.
During a still birth, it is not recommended to show the

dead child to prevent complicated grieving
o D.
Refer to the baby as "your baby", "your son", or "your

daughter" or use the given name to reinforce that the baby
was indeed a unique individual who was loved and will be
missed
Correct Answer
C. During a still birth, it is not recommended to show the dead
child to prevent complicated grieving
Explanation
pages 231-232
 15.
Which of the following are basic guidelines to follow while
providing care for a child who is dying or experiencing the death
of a loved one? Select all that apply:
o A.
Allow young children to visit a dying parent or

grandparent if all parties agree.
o B.
Respect the family's wishes in how and what to tell

children about serious illness, dying and death
o C.
Treat the family and child as a unit.
o D.
Parents should be encouraged to leave the dying child

alone to rest
o E.
Understand that decisions to end treatment can be more

difficult when children are involved
Correct Answer(s)
A. Allow young children to visit a dying parent or grandparent if
all parties agree.
B. Respect the family's wishes in how and what to tell children
about serious illness, dying and death
C. Treat the family and child as a unit.
E. Understand that decisions to end treatment can be more difficult
when children are involved
Explanation
p. 232- Parents should be allowed to stay with a child at any time
of day or night.
 16.
Suicide will sometimes result in what kind of grief to a loved
one? Select the best answer
o A.
Delayed
o B.
Complicated
o C.
Disenfranchised
o D.
Masked
Correct Answer
C. Disenfranchised
Explanation
p. 233 - Suicide is usually considered not acceptable and therefore
is difficult to acknowledge publicly. Hence, a disenfranchised grief
 17.
A deliberate action taken with the purpose of shortening life to
end suffering or to carry out the wishes of a terminally ill
patient.
o A.
Suicide
o B.
Euthanasia
o C.
Coupe-du-grace
o D.
Coupe-de-fille
Correct Answer
B. Euthanasia
Explanation
p. 233
 18.
Permitting the death of a patient by withholding treatment that
might extend life, such as medication, life-support systems, or
feeding tubes
o A.
Euthanasia
o B.
Passive euthanasia
o C.
Active euthanasia
o D.
Suicide
Correct Answer
B. Passive euthanasia
Explanation
p. 233
 19.
DNR. Select all that apply
o A.
Do not resuscitate
o B.
No code
o C.
Withhold other care
o D.
May be indicated in patient's living will

Correct Answer(s)
A. Do not resuscitate
B. No code
D. May be indicated in patient's living will
Explanation
p. 234
 20.
Signed and witnessed documents providing specific instructions
for healthcare treatment in the event that a person is unable to
make those decisions personally at the time they are needed.
o A.
Advanced directives
o B.
Power of attorney
o C.
Living will
o D.
Health document
Correct Answer
A. Advanced directives
Explanation
p. 234
 21.
Two basic types of advanced directives. Select all that apply:
o A.
Living wills
o B.
Death will
o C.
Estate planning
o D.
Durable powers of attorney

Correct Answer(s)
A. Living wills
D. Durable powers of attorney
Explanation
p. 234
 22.
Written document that directs treatment in accordance with a
patient's wishes in the event of a terminal illness or condition
o A.
Dying will
o B.
Living will
o C.
Inheritance will
o D.
Health will
Correct Answer
B. Living will
Explanation
p. 234
 23.
A homeless patient who is terminally ill requested her night shift
nurse to witness her "living will" documents. Which of the
following are applicable to the statement? Select all that apply
o A.
If a health care worker follows the direction of the living

will, they are immuned from liability
o B.
At night, the patient coded. The nurse should use the best
intervention before considering the "living will"
o C.
Considering that the nurse is not a physician or a relative

of the patient, he/she can witness the document
o D.
Since the patient is homeless, she does not have the

benefit of having a living will
Correct Answer(s)
A. If a health care worker follows the direction of the living will,
they are immuned from liability
C. Considering that the nurse is not a physician or a relative of the
patient, he/she can witness the document
Explanation
p. 234
 24.
What is the ethical doctrine of autonomy? Select the best answer
o A.
The patient's right to refuse treatment
o B.
The patient's right to be left alone
o C.
The patient's right to select his/her treatment
o D.
The patient's right to select a nurse

Correct Answer
A. The patient's right to refuse treatment
Explanation
p. 234
 25.
Durable power of attorney
o A.
Agent, surrogate or proxy that makes decisions on

patient's behalf based on patient's wishes
o B.
Agent, surrogate or proxy that makes health interventions

on patient's needs based on patient's wishes
o C.
Agent, surrogate or proxy to make health care decisions
on patient's behalf based on patient's wishes
o D.
Agent, surrogate or proxy who counsels the patient to

make health care decisions based on patient's wishes
Correct Answer
C. Agent, surrogate or proxy to make health care decisions on
patient's behalf based on patient's wishes
Explanation
p. 234
 26.
Which of the following statements regarding organ donations are
true? Select all that apply
o A.
A person's organs can be donated by a family member for

a fee with or without the patient's consent
o B.
The Uniform Anatomical Gifts Act stipulates that the

physician who certifies death shall not be involved in
removal or transplantation of organs.
o C.
Legally competent people are free to donate their bodies

or organs for medical use
o D.
In many states, it is possible for adults to request organ
donation by signing the back of their driver's license
Correct Answer(s)
B. The Uniform Anatomical Gifts Act stipulates that the physician
who certifies death shall not be involved in removal or
transplantation of organs.
C. Legally competent people are free to donate their bodies or
organs for medical use
D. In many states, it is possible for adults to request organ donation
by signing the back of their driver's license
Explanation
p. 235
 27.
Which of the following statements is not part of the "Dying
Patient's Bill of Rights"?
o A.
I have the right to be treated as a living human being until

I die
o B.
I have a right not to die alone
o C.
I have a right to choose the way I die
o D.
I have a right to be free from pain

o E.
I have a right that the sanctity of the human body will be

respected after death
Correct Answer
C. I have a right to choose the way I die
Explanation
p. 236
 28.
Which of the following is NOT APPROPRIATE when
communicating with a dying patient?
o A.
Therapeutic communication requires that the nurse pays

careful attention to what the patient expresses verbally and
nonverbally
o B.
One of the most important task of the bedside nurse is to

empower patients and families to participate in the final
act of living.
o C.
It is vitally important to remember that there is always a

way for you to "solve" the problem of dying
o D.
When appropriately used, touching is a highly effective

means of communication
Correct Answer
C. It is vitally important to remember that there is always a way for
you to "solve" the problem of dying
Explanation
p. 237 - It is vitally important to remember that there is no way for
you to "solve" the problem of dying
 29.
Which of the following statements about PALLIATIVE CARE
is true and applicable? Select all that apply
o A.
The goal of palliative care is prevention, relief, reduction

or soothing of symptoms of disease or disorders without
effecting a cure
o B.
Allows patients to make more informed choices
o C.
Palliative care and Hospice care are one and the same
o D.
Allows patients to achieve better alleviations of symptoms
o E.
Palliative care offers a support system to help families

cope during a patient's illness and their own bereavement.
Correct Answer(s)
A. The goal of palliative care is prevention, relief, reduction or
soothing of symptoms of disease or disorders without effecting a
cure
B. Allows patients to make more informed choices
D. Allows patients to achieve better alleviations of symptoms
E. Palliative care offers a support system to help families cope
during a patient's illness and their own bereavement.
Explanation
p. 238
 30.
Which of the following are clinical signs of death? Select all that
apply
o A.
Skin is cool, clammy and with profuse diaphoresis
o B.
Cheyne-stokes respiration
o C.
Slow, weak, and thready pulse; lowered blood pressure
o D.
Absence of apical pulse, no reflexes, detached look in the

eye
o E.
Diminished libido
Correct Answer(s)
A. Skin is cool, clammy and with profuse diaphoresis
B. Cheyne-stokes respiration
C. Slow, weak, and thready pulse; lowered blood pressure
D. Absence of apical pulse, no reflexes, detached look in the eye
Explanation
p. 240
 31.
Resolution of grief has begun when after the loss, the grieving
person or family can complete the following tasks. Select all that
apply:
o A.
Have positive interactions with others
o B.
Purchases a funeral plan and detailed description of

mourning rituals
o C.
Participate in support groups with others who are similarly

bereaved to articulate loss together and offer
companionship
o D.
Establish goals and works to achieve them
o E.
Discuss the meaning of the loss and its effect on the
survivor's life
Correct Answer(s)
A. Have positive interactions with others
C. Participate in support groups with others who are similarly
bereaved to articulate loss together and offer companionship
D. Establish goals and works to achieve them
E. Discuss the meaning of the loss and its effect on the survivor's
life
Explanation
p. 244
1. A nurse midwife is assisting a patient to deliver a full-term
baby. The patient is firmly committed to natural childbirth and has
attended each natural childbirth class in preparation for labor and
delivery. A cesarean delivery becomes necessary when her fetus
displays signs of distress. Inconsolable, the patient cries and calls
herself a failure as a mother. The nurse notes that the patient is
experiencing what type of loss? Select all that apply.
a. Actual
b. Perceived
c. Psychological
d. Anticipatory
e. Physical
f. Maturational
a. Actual
b. Perceived
c. Psychological
2. A nurse who cared for a dying patient and his family documents
that the family is experiencing a period of mourning. Which
behaviors would the nurse expect to see at this stage? Select all
that apply.
a. The family arranges for a funeral for their loved one.
b. The family arranges for a memorial scholarship for their loved

one.
c. The coroner pronounces the patient's death.
d. The family arranges for hospice for their loved one.
e. The patient is diagnosed with terminal cancer.
f. The patient's daughter writes a poem expressing her sorrow.

a. The family arranges for a funeral for their loved one.
b. The family arranges for a memorial scholarship for their loved

one.
f. The patient's daughter writes a poem expressing her sorrow.

3. A nurse interviews an 82-year-old resident of a long-term care
facility who says that she has never gotten over the death of her
son 20 years ago. She reports that her life fell apart after that and
she never again felt like herself or was able to enjoy life. What
type of grief is this woman experiencing?
a. Abbreviated
b. Anticipatory
c. Dysfunctional
d. Inhibited
c. Dysfunctional
4. A home health care nurse has been visiting a patient with AIDS
who says, "I'm no longer afraid of dying. I think I've made my
peace with everyone, and I'm actually ready to move on." This
reflects the patient's progress to which stage of death and dying?
a. Acceptance
b. Anger
c. Bargaining
d. Denial
a. Acceptance
5. A nurse is visiting a male patient with pancreatic cancer who is
dying at home. During the visit, he breaks down and cries and
tells the nurse that it is unfair that he should have to die now when
he's finally made peace with his family and wants to live. Which
response by the nurse would be most appropriate?
a. "You can't be feeling this way. You know you are going to die."
b. "It does seem unfair. Tell me more about how you are feeling."
c. "You'll be all right; who knows how much time any of us has"
d. "Tell me about your pain. Did it keep you awake last night?"
b. "It does seem unfair. Tell me more about how you are feeling."
6. A nurse is caring for a terminally ill patient during the 11 PM to
7 AM shift. The patient says, "I just can't sleep. I keep thinking
about what my family will do when I am gone." What response by
the nurse would be most appropriate?
a. "Oh, don't worry about that now. You need to sleep."
b. "What seems to be concerning you the most?"
c. "I have talked to your wife and she told me she will be fine."
d. "I have to go and give medicines, you should discuss this with
your wife."
b. "What seems to be concerning you the most?"
7. A patient tells a nurse that he has no one he trusts to make
health care decisions for him should he become incapacitated.
What should the nurse suggest he prepare?
a. Combination advance medical directive
b. Durable power of attorney for health care
c. Living will
d. Proxy for health care

c. Living will
8. A hospice nurse is caring for a patient who is terminally ill and
who is on a ventilator. After a restless night, the patient hands the
nurse a note with the request: "Please help me end my suffering."
Which response by a nurse would best reflect adherence to the
position of the American Nurses Association regarding assisted
suicide?
a. The nurse promises the patient that he or she will do everything

possible to keep the patient comfortable but cannot administer an
injection or overdose to cause the patient's death.
b. The nurse tells the patient that under no condition can he be

removed from the ventilator because this is active euthanasia and
is expressly forbidden by the Code for Nurses.
c. After exhausting every intervention to keep a dying patient

comfortable, the nurse says, "I think you are now at a point where
I'm prepared to do what you've been asking me. Let's talk about
when and how you want to die."
d. The nurse responds: "I'm personally opposed to assisted

suicide, but I'll find you a colleague who can help you."
a. The nurse promises the patient that he or she will do everything
possible to keep the patient comfortable but cannot administer an
injection or overdose to cause the patient's death.
9. A patient diagnosed with breast cancer who is in the end
stages of her illness has been in the medical intensive care unit
for 3 weeks. Her husband tells the nurse caring for the patient that
he and his wife often talked about the end of her life and that she
was very clear about not wanting aggressive treatment that would
merely prolong her dying. The nurse and husband both agree that
this seems to be all that therapy is now doing for her. The nurse
would suggest that the husband speak to his wife's physician
about which type of order?
a. Comfort-measures-only
b. Do-not-hospitalize
c. Do-not-resuscitate
d. Slow-code-only
a. Comfort-measures-only
10. A nurse is preparing a family for a terminal weaning of a loved
one. Which nursing actions would facilitate this process? Select
all that apply.
a. Participate in the decision-making process by offering the

family information about the advantages and disadvantages of
continued ventilatory support.
b. Explain to the family what will happen at each phase of the

weaning and offer support.
c. Check the orders for sedation and analgesia, making sure that
the anticipated death is comfortable and dignified.
d. Tell the family that death will occur almost immediately after the
patient is removed from the ventilator.
e. Tell the family that the decision for terminal weaning of a

patient must be made by the primary care provider.
f. Set up mandatory counseling sessions for the patient and family

to assist them in making this end-of-life decision.
a. Participate in the decision-making process by offering the
family information about the advantages and disadvantages of
continued ventilatory support.
b. Explain to the family what will happen at each phase of the

weaning and offer support.
c. Check the orders for sedation and analgesia, making sure that
the anticipated death is comfortable and dignified.
11. All of the following diagnoses may apply to a young couple
who gave birth to a premature infant with serious respiratory
problems who has been in the neonatal intensive care unit for the
last 3 months. The couple has a 22-month-old son at home.
Which diagnosis would be most appropriate based on the
following assessment data: report of chronic fatigue and
decreased energy, guilt about neglecting son at home, shortness
of temper with one another, and apprehension about continued
ability to go on this way?
a. Grieving
b. Ineffective Coping
c. Caregiver Role Strain
d. Powerlessness
c. Caregiver Role Strain
12. A nurse is caring for terminally ill patients in a hospital setting.
Which example describes appropriate end-of-life care?
a. To eliminate confusion, taking care not to speak too much

when caring for a comatose patient
b. Sitting on the side of the bed of a dying patient, holding the

patient's hand, and crying with the patient
c. Referring to a counselor the daughter of a dying patient who is

complaining about the care associated with artificially feeding her
father
d. Telling a dying patient to sit back and relax and performing

patient hygiene for the patient because it is easier than having the
patient help
b. Sitting on the side of the bed of a dying patient, holding the
patient's hand, and crying with the patient
13. A nurse is providing postmortem care. Which nursing action
violates the standards of caring for the body after a patient has
been pronounced dead and is not scheduled for an autopsy?
a. The nurse places the patient in a sitting position while the

family visits.
b. The nurse places identification tags on both the shroud and the
ankle.
c. The nurse removes soiled dressings and tubes.
d. The nurse makes sure a death certificate is issued and signed.

a. The nurse places the patient in a sitting position while the
family visits.
14. The family of a patient who has just died asks to be alone with
the body and asks for supplies to wash the body. The nurse
providing care knows that the mortician usually washes the body.
Which response would be most appropriate?
a Inform the family that there is no need for them to wash the
body since the mortician typically does this.
b. Explain that hospital policy forbids their being alone with the
deceased patient and that hospital supplies are to be used only
by hospital personnel.
c. Give the supplies to the family but maintain a watchful eye to

make sure that nothing unusual happens.
d. Provide the requested supplies, checking if this request is

linked to their religious or cultural customs and asking if there is
anything else you can do to help.
d. Provide the requested supplies, checking if this request is
linked to their religious or cultural customs and asking if there is
anything else you can do to help.
15. A 70-year-old female patient who has had a number of
strokes refuses further life-sustaining interventions, including
artificial nutrition and hydration. She is competent, understands
the consequences of her actions, is not depressed, and persists
in refusing treatment. Her doctor is adamant that she cannot be
allowed to die this way, and her daughter agrees. An ethics
consult has been initiated. Who would be the appropriate decision
maker?
a. Patient
b. Daughter
c. Doctor
d. Ethics consult team

a. Patient
 List the four rules when collecting specimens:

o A.
Right specimen, time, amount and container
o B.
Temperature, state and amount
o C.
Amount, money, etc
o D.
All of the above

 Correct Answer
A. Right specimen, time, amount and container
 2.
When collecting a specimen, when should you wash your
hands?
o A.
Only before
o B.
Before and after
o C.
Only after
o D.
None of the above

Correct Answer
B. Before and after
 3.
When should you put on gloves?
o A.
Before only touching the specimen
o B.
Before touching bedpan, patient, or specimen
o C.
Before only touching the patient
o D.
None of the above
Correct Answer
B. Before touching bedpan, patient, or specimen
 4.
What information must be put on the specimen label?
o A.
Type of specimen
o B.
Client's name & address
o C.
Date & Time
o D.
All of the above

Correct Answer
D. All of the above
 5.
A routine specimen should be collected:
o A.
At 7 a.m.
o B.
First thing when the client awakens
o C.
Before a meal
o D.
Anytime
Correct Answer
D. Anytime
 6.
When collecting a 24-hour urine specimen: What is done
with the urine collected at 7 a.m. on the first day?
o A.
Time
o B.
Discard
o C.
Scale
o D.
None of the above

Correct Answer
B. Discard
 7.
When collecting a 24-hour urine specimen: What is done
with the urine collected at 7 a.m. on the last day?
o A.
Saved
o B.
Discarded
o C.
Dilute
o D.
None of the above

Correct Answer
A. Saved
 8.
When collecting a 24-hour urine specimen: Where must the
urine for a 24-hour specimen be stored?
o A.
Mix it with another specimen
o B.
Boil it
o C.
Discard
o D.
Refrigerator or on ice
Correct Answer
D. Refrigerator or on ice
 9.
When collecting a 24-hour urine specimen: What is a midstream
clean catch urine specimen?
o A.
Area is cleaned and wound is sterilized
o B.
Area is cleaned off and specimen is saved after a small

amount has been voided
o C.
Area is shaved and cleaned and then specimen given
o D.
None of the above

Correct Answer
B. Area is cleaned off and specimen is saved after a small amount
has been voided
 10.
When collecting a 24-hour urine specimen: What is a major
potential problem with collecting urine from an indwelling
Foley catheter?
o A.
Urinary infection from contamination
o B.
Incorrect dilution of the specimen
o C.
Incorrect amount of specimen collected
o D.
None of the above

Correct Answer
A. Urinary infection from contamination
 11.
The amount of stool needed for a specimen is
________________.
o A.
2g
o B.
2 ml
o C.
1-2 tbsp.
o D.
2 kg
Correct Answer
C. 1-2 tbsp.
 12.
A stool that is black in color might indicate the presence of
_____________ or ____________.
o A.
Pus and blood
o B.
Tissue clots and phosphorus
o C.
Blood or Iron
o D.
None of the above

Correct Answer
C. Blood or Iron
 13.
The best time to collect a sputum specimen is
__________________.
o A.
First thing in morning
o B.
After dinner
o C.
Before the lunch
o D.
There is no specific time

Correct Answer
A. First thing in morning
 14.
A sputum specimen is collected to determine problems in the
___________system.
o A.
Cardiac
o B.
Reproductive
o C.
Respiratory or pulmonary
o D.
None of the above
Correct Answer
C. Respiratory or pulmonary
 1.) You are taking care of a patient with severe COPD. What type
of diet would best suit this patient's needs?*
o Cut apples, fresh broccoli, and grilled chicken
o Green beans, boiled carrots, and steamed fish
o Pureed sweet potatoes, ground turkey & gravy with mash

potatoes
o Fried chicken, French fries, and pudding
 1.
You have been instructed to administer oral medication
(Ranitidine 150mg) to a patient. What is the minimum of
times the nurse should check the medication label before
administering this drug?
o A.
o B.
o C.
o D.
4
Correct Answer
C. 3
Explanation
The nurse should check the medication label at least three times
before administering the drug. This is important to ensure that the
correct medication is being given to the patient and to prevent any
medication errors. Checking the label multiple times helps to
confirm the medication name, dosage, and any special instructions.
It is a crucial step in medication administration to ensure patient
safety.
 2.
Which of the following is NOT a common route for
administering medication?
o A.
Oral
o B.
Intramuscular
o C.
Intravenous
o D.
Intraosmolar
Correct Answer
D. Intraosmolar
Explanation
Intraosmolar is not a common route for administering medication.
The common routes for administering medication include oral,
intramuscular, and intravenous. Intraosmolar administration refers
to the injection of medication directly into the osmolar space,
which is not a commonly used method.
 3.
1. The route describes how the medication is actually given to

or taken by the patient. Which of the following is true
regarding the medication routes
o A.
Most medications administered by the nurse are by

injection.
o B.
Drugs administered by the sublingual route have a

relatively slow absorption rate.
o C.
All tablets are administered by the oral route.
o D.
The route can be determined by the nurse.

 Correct Answer
B. Drugs administered by the sublingual route have a relatively
slow absorption rate.
 Explanation
The correct answer is "Drugs administered by the sublingual route
have a relatively slow absorption rate." This means that when
medication is placed under the tongue and absorbed through the
sublingual glands, it takes a longer time for the medication to be
absorbed into the bloodstream compared to other routes of
administration. This is because the sublingual route bypasses the
digestive system and allows the medication to directly enter the
bloodstream.
 4.
The six rights for medication administration
o A.
Right medication, right route, right date, right

documentation, right dose, right time.
o B.
Right patient, right medication, right time, right

prescription, right date, and documentation.
o C.
Right dose, right route, right date, right symptoms, right

document, right medication.
o D.
Right dose, right patient, right formulation, right

documentation, and right medication.
Correct Answer
A. Right medication, right route, right date, right documentation,
right dose, right time.
Explanation
The answer "Right medication, right route, right date, right
documentation, right dose, right time" is correct because these are
the six essential rights for medication administration. It is crucial
to administer the correct medication to the right patient, using the
appropriate route and dose, at the correct time. Documentation is
necessary to ensure accurate record-keeping and accountability.
The right date ensures that the medication is not expired or
outdated.
 5.
To ensure that key steps are followed during administering
medication, the nurse should
o A.
Verify the date the prescription was written.
o B.
Verify the amount of medication that has already been

used.
o C.
Check for discoloration and expiration of the drug.
o D.
Confirming with the patient’s physician that he issued the

prescription.
Correct Answer
C. Check for discoloration and expiration of the drug.
Explanation
To ensure the safety and effectiveness of the medication, the nurse
should check for discoloration and expiration of the drug.
Discoloration may indicate that the drug has degraded or become
contaminated, making it unsafe for administration. Expired drugs
may have lost their potency or could potentially cause harm.
Therefore, it is crucial for the nurse to visually inspect the
medication for any signs of discoloration and to check the
expiration date before administering it to the patient. This step
helps to prevent the administration of ineffective or harmful
medication.
 6.
What is used to minimize local skin irritation by sealing the
medication in muscle tissue?
o A.
Z-track method
o B.
As you prepare it
o C.
Some combined with steroids
o D.
Right drug
Correct Answer
A. Z-track method
Explanation
The Z-track method is used to minimize local skin irritation by
sealing the medication in muscle tissue. This technique involves
pulling the skin to one side, administering the medication deep into
the muscle, and then releasing the skin. By creating a zig-zag path,
the medication is effectively sealed in the muscle tissue, preventing
it from leaking back into the subcutaneous tissue and causing
irritation. This method is commonly used for intramuscular
injections of medications that are known to cause skin irritation or
discoloration.
 7.
Name the calibrated cylinder that holds medication.
o A.
Solution
o B.
Adverse reaction
o C.
15-30 seconds
o D.
Barrel
Correct Answer
D. Barrel
 8.
Name the part of a syringe that is pushed to move the fluid out.
o A.
Barrel
o B.
Otic drugs
o C.
Plunger
o D.
Delivered at 45-degree angle

Correct Answer
C. Plunger
Explanation
The part of a syringe that is pushed to move the fluid out is called
the plunger. The plunger is typically a long, cylindrical rod that fits
inside the barrel of the syringe. When pressure is applied to the
plunger, it moves forward, forcing the fluid out of the syringe
through the needle.
 9.
Which device attaches the needle to the barrel.
o A.
Sublingual
o B.
Hub
o C.
15-30 seconds
o D.
Right route
Correct Answer
B. Hub
Explanation
The hub is the device that attaches the needle to the barrel. It is the
part of the syringe where the needle is screwed or attached to. The
hub ensures a secure connection between the needle and the barrel,
allowing for accurate and controlled administration of medication
or withdrawal of fluids.
 10.
Name the injection that is given into the subcutaneous tissues for
a sustained release. (insulin)
o A.
Drug-drug interaction
o B.
Vaccines
o C.
Barrel
o D.
Subcutaneous
Correct Answer
D. Subcutaneous
Explanation
Subcutaneous injection is given into the subcutaneous tissues for a
sustained release. This type of injection involves delivering
medication into the fatty layer of tissue just below the skin. It
allows for slow and continuous absorption of the medication into
the bloodstream, providing a sustained release effect. Insulin, a
hormone used to manage diabetes, is commonly administered
through subcutaneous injections to maintain stable blood sugar
levels throughout the day.
1. One registered nurse may be responsible for giving medications,
another nurse for admission and discharges while nursing
attendants change linen, provide hygienic care or do simple
procedures for which they have trained. This model of nursing
practice is called
a. Functional nursing
b. Team nursing
c. Primary nursing
d. Total patient care
2. 2. Which among the following leadership style is most effective
a. Laissez-Faire Leadership
b. Autocratic Leadership
c. Democratic Leadership
d. Bureaucratic Leadership
3. 3. Most commonly used model of care in ICUs
a. Functional nursing
b. Team nursing
c. Primary nursing
d. Total patient care
4. Leadership style adopted to make crucial decisions need to be
made on the spot, when dealing with inexperienced and new team
members and there’s no time to wait for team members to gain
familiarity with their role.
a. Autocratic
b. Authoritative
c. Pacesetting
d. Coaching
5. . Which of the following is considered a traditional charting?
a. Narrative
b. Problem Oriented Medical Record
c. SOAPE
d. DAR
6. 6. Any event that is not consistent with routine patient care and is
used when patient care is not consistent with facility or national
standards of expected care
a. Incident Reports
b. Kardex or Rand System
c. Intervention Guidelines
d. Nursing Care plan
7. 7. This among the following leadership style in nursing is not good

fit for the health sector, which is most often seen in young
inexperienced nurses
a. Autocratic Leadership
b. Democratic Leadership
c. Transformational Leadership
d. Laissez-Faire Leadership
8. 8. When does discharge planning ideally begin?
a. During admission
b. After admission
c. Before admission
d. Without admission
9. 9. Specific instructions regarding the treatment of the condition are

coming under called
10. a. Nursing protocol
b. Nursing research.
c. Code of ethics.
d. Nursing theory
11. 10. The process of negotiation between employers and a

group of employees aimed at agreements to regulate working
salaries, working conditions, benefits, and other aspects of
workers’ compensation and rights for workers.
a. Negotiation
b. Bargaining
c. Collective bargaining
d. Discussion
12. 11. Which of the following is included in the features of

collective bargaining?
a. Group activity
b. Flexibility
c. Building relationship
d. All of the above
13. 12. Which of the following is not a type of standing order?
a. Institutional standing order
b. Specific standing order
c. General standing order
d. Instructional standing order
14. 13. The evaluation of nursing care by examining the records

and charts of discharged patients.
a. Nursing management audit
b. Concurrent audit
c. Retrospective audit
d. General audit
15. 14. The assessment of the quality of nursing care or use of a

record as an aid in evaluating the quality of patient care
a. Nursing audit
b. Nursing evaluation
c. Supervision
d. Guidance
16. 15. Departmental, divisional or sectional heads, and other

executive officers attached to the different departments belong to
which level of management?
a. Top level management
b. Middle level management
c. Supervisory level management
d. None of these
17. 16. Objectives of Nursing supervision includes all except
a. Promote communication
b. Initiate disciplinary actions
c. Promote motivation
d. Evaluate and improve performance
18. 17. Which of the following is not an objective of patient

assignment?
a. To promote good health
b. Good ward management
c. Provide education
d. To develop new services
19. 18. The following steps are involved in communication

process expect:
a. Information source and encoding
b. Channel
c. Decoding and feedback
d. Evaluation
20. 19. The conditions that does not make democratic leadership
successful is
a. Atmosphere of approval.
b. Knowledge and discipline.
c. Right of appeal
d. Right to order.
 You have been instructed to administer oral medication
(Ranitidine 150mg) to a patient. What is the minimum of
times the nurse should check the medication label before
administering this drug?
o A.
1
o B.
o C.
o D.
4
 Correct Answer
C. 3
 Explanation
The nurse should check the medication label at least three times
before administering the drug. This is important to ensure that the
correct medication is being given to the patient and to prevent any
medication errors. Checking the label multiple times helps to
confirm the medication name, dosage, and any special instructions.
It is a crucial step in medication administration to ensure patient
safety.
 2.
Which of the following is NOT a common route for
administering medication?
o A.
Oral
o B.
Intramuscular
o C.
Intravenous
o D.
Intraosmolar
Correct Answer
D. Intraosmolar
Explanation
Intraosmolar is not a common route for administering medication.
The common routes for administering medication include oral,
intramuscular, and intravenous. Intraosmolar administration refers
to the injection of medication directly into the osmolar space,
which is not a commonly used method.
 3.
1. The route describes how the medication is actually given to

or taken by the patient. Which of the following is true
regarding the medication routes
o A.
Most medications administered by the nurse are by

injection.
o B.
Drugs administered by the sublingual route have a

relatively slow absorption rate.
o C.
All tablets are administered by the oral route.
o D.
The route can be determined by the nurse.
 Correct Answer
B. Drugs administered by the sublingual route have a relatively
slow absorption rate.
 Explanation
The correct answer is "Drugs administered by the sublingual route
have a relatively slow absorption rate." This means that when
medication is placed under the tongue and absorbed through the
sublingual glands, it takes a longer time for the medication to be
absorbed into the bloodstream compared to other routes of
administration. This is because the sublingual route bypasses the
digestive system and allows the medication to directly enter the
bloodstream.
 4.
The six rights for medication administration
o A.
Right medication, right route, right date, right

documentation, right dose, right time.
o B.
Right patient, right medication, right time, right

prescription, right date, and documentation.
o C.
Right dose, right route, right date, right symptoms, right

document, right medication.
o D.
Right dose, right patient, right formulation, right
documentation, and right medication.
Correct Answer
A. Right medication, right route, right date, right documentation,
right dose, right time.
Explanation
The answer "Right medication, right route, right date, right
documentation, right dose, right time" is correct because these are
the six essential rights for medication administration. It is crucial
to administer the correct medication to the right patient, using the
appropriate route and dose, at the correct time. Documentation is
necessary to ensure accurate record-keeping and accountability.
The right date ensures that the medication is not expired or
outdated.
 5.
To ensure that key steps are followed during administering
medication, the nurse should
o A.
Verify the date the prescription was written.
o B.
Verify the amount of medication that has already been

used.
o C.
Check for discoloration and expiration of the drug.
o D.
Confirming with the patient’s physician that he issued the
prescription.
Correct Answer
C. Check for discoloration and expiration of the drug.
Explanation
To ensure the safety and effectiveness of the medication, the nurse
should check for discoloration and expiration of the drug.
Discoloration may indicate that the drug has degraded or become
contaminated, making it unsafe for administration. Expired drugs
may have lost their potency or could potentially cause harm.
Therefore, it is crucial for the nurse to visually inspect the
medication for any signs of discoloration and to check the
expiration date before administering it to the patient. This step
helps to prevent the administration of ineffective or harmful
medication.
 6.
What is used to minimize local skin irritation by sealing the
medication in muscle tissue?
o A.
Z-track method
o B.
As you prepare it
o C.
Some combined with steroids
o D.
Right drug
Correct Answer
A. Z-track method
Explanation
The Z-track method is used to minimize local skin irritation by
sealing the medication in muscle tissue. This technique involves
pulling the skin to one side, administering the medication deep into
the muscle, and then releasing the skin. By creating a zig-zag path,
the medication is effectively sealed in the muscle tissue, preventing
it from leaking back into the subcutaneous tissue and causing
irritation. This method is commonly used for intramuscular
injections of medications that are known to cause skin irritation or
discoloration.
 7.
Name the calibrated cylinder that holds medication.
o A.
Solution
o B.
Adverse reaction
o C.
15-30 seconds
o D.
Barrel
Correct Answer
D. Barrel
 8.
Name the part of a syringe that is pushed to move the fluid out.
o A.
Barrel
o B.
Otic drugs
o C.
Plunger
o D.
Delivered at 45-degree angle

Correct Answer
C. Plunger
Explanation
The part of a syringe that is pushed to move the fluid out is called
the plunger. The plunger is typically a long, cylindrical rod that fits
inside the barrel of the syringe. When pressure is applied to the
plunger, it moves forward, forcing the fluid out of the syringe
through the needle.
 9.
Which device attaches the needle to the barrel.
o A.
Sublingual
o B.
Hub
o C.
15-30 seconds
o D.
Right route
Correct Answer
B. Hub
Explanation
The hub is the device that attaches the needle to the barrel. It is the
part of the syringe where the needle is screwed or attached to. The
hub ensures a secure connection between the needle and the barrel,
allowing for accurate and controlled administration of medication
or withdrawal of fluids.
 10.
Name the injection that is given into the subcutaneous tissues for
a sustained release. (insulin)
o A.
Drug-drug interaction
o B.
Vaccines
o C.
Barrel
o D.
Subcutaneous
Correct Answer
D. Subcutaneous
Explanation
Subcutaneous injection is given into the subcutaneous tissues for a
sustained release. This type of injection involves delivering
medication into the fatty layer of tissue just below the skin. It
allows for slow and continuous absorption of the medication into
the bloodstream, providing a sustained release effect. Insulin, a
hormone used to manage diabetes, is commonly administered
through subcutaneous injections to maintain stable blood sugar
levels throughout the day.
21.
Test Bank
Chapter 30: The Experience of Loss, Death, and Grief
MULTIPLE CHOICE
1. A client has a terminal illness and is discussing future treatments with
the nurse. The
nurse notes that he has not been eating and his response to the nurse’s
information is,
“What does it matter?” The most appropriate nursing diagnosis for this
client is:
1. Denial
2. Hopelessness
3. Social isolation
4. Spiritual distress
ANS: 2
A defining characteristic for the nursing diagnosis of hopelessness may
include the client
stating, “What does it matter?” when offered choices or information
concerning
themselves. Also, the client’s behavior of not eating is an indicator of
hopelessness. The
client’s behavior and verbalization do not indicate denial. This is not an
example of
social isolation. The client is not avoiding or restricted from seeing
others. Spiritual
distress is not the most appropriate nursing diagnosis for this client. The
focus needs to be
on the client’s lack of hope.
PTS: 1 DIF: A REF: 470 OBJ:
Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care
Environment
2. One of the benefits of anticipatory grieving to a client or family is that
it can:
1. Be done in private
2. Be discussed with others
3. Promote separation of the ill client from the family
4. Help a person progress to a healthier emotional state
ANS: n is,
“What does it matter?” The most appropriate nursing diagnosis for this
client is:
1. Denial
2. Hopelessness
3. Social isolation
4. Spiritual distress
ANS: 2
A defining characteristic for the nursing diagnosis of hopelessness may
include the client
stating, “What does it matter?” when offered choices or information
concerning
themselves. Also, the client’s behavior of not eating is an indicator of
hopelessness. The
client’s behavior and verbalization do not indicate denial. This is not an
example of
social isolation. The client is not avoiding or restricted from seeing
others. Spiritual
distress is not the most appropriate nursing diagnosis for this client. The
focus needs to be
on the client’s lack of hope.
PTS: 1 DIF: A REF: 470 OBJ:
Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care
Environment
2. One of the benefits of anticipatory grieving to a client or family is that
it can:
1. Be done in private
2. Be discussed with others
3. Promote separation of the ill client from the family
4. Help a person progress to a healthier emotional state
ANS: 4

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Questions and Answers

Organizational framework for the practice of Nursing

Systematic method by which nurses plan and provide care for

The application of the nursing process only applies to RN's

The Nursing Scope and Standards of Practice of the ANA

When patient is critically ill or disoriented

When patient is unable to respond

Preferably early in the morning before breakfast.

When drastic changes are happening to a patient.

Performance of a physical examination

Acquiring a database of information

Analyzing signs and symptoms

Identifying patient statements

Grouping related cues together

Entering patient data in the computer

Dry skin and dry oral mucous

Decreased urine output

Nurse overload and nurse burnout

When the nurse calls in sick

Any health care condition that requires diagnostic,

Job description of a clinical nurse

Nursing diagnosis title or label

Definition of the title or label

Contributing, etiologic or related factors

A nursing diagnosis is any problem related to the health of

When writing a nursing diagnosis, place the adjective

A nursing diagnosis is usually the etiology of the disease

Both medical and nursing diagnosis can be converted into

Analysis of a health issue

Circumstances that increase the susceptibility of a patient

Increased abdominal pressure

Human responses to health conditions/life processes that

Describes the symptoms of the disease

Supported by risk factors that contribute to increased

Proof that the person is suffering from an illness

Risk for falls related to unstable balance

Constipated because of fecal impaction

Risk for Diarrhea

Constipation related to dehydration

An isolated disease with numerous symptoms

Numerous symptoms describing a single disease

Used when a cluster of actual or risk nursing diagnosis are

Numerous symptoms leading to an idiopathic disorder

Not strictly a diagnosis

All of the above

All of the above

Medical is etiology; Nursing is human response

Medical is disease; Nursing is the cause of disease

Medical is illness; Nursing is illness too

A good outcome statement is specific to the patient

Goals are general deadlines that are to be met

An outcome statement refers to what the nurse will do

Goals and Statements are practically the same

Uses a measurable verb

Focuses on the completion of nursing interventions

Does not interfere with the medical care plan

Includes a time frame for patient reevaluation

Ericsson's psychosocial development

Depend on the tasks delegated by the nursing supervisor