Question 1

A nurse is teaching a patient about the care of a female newborn. It is a priority to teach the patient to notify the health care provider if which of the following is noted in the infant?
A)Vomiting after feeding
B)More than four bowel movements per day
C)Vaginal discharge
D)Fever above 100°F

Accepted Answer

It is a priority to teach the patient to notify the health care provider if a fever above 100°F is noted in the infant. Even slight elevation of temperature in a newborn indicates acute infection. This situation needs to be reported to a health care provider.

Question 2

A newly hired charge nurse assesses the staff nurses as competent individually, but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A)Unhappiness about the change in leadership
B)Unexpected feeling and emotions among the staff
C)Fatigue from overwork and understaffing
D)Failure to incorporate staff in decision making

Accepted Answer

In addressing her concern, the charge nurse should understand that the usual reason for such a situation is unexpected feelings and emotions among the staff. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they're less likely to be the cause.

Question 3

A nurse is aware that the guidelines for writing an appropriate nursing diagnosis include all of the following except:
A)State the diagnosis in terms of a problem, not a need
B)Use nursing terminology to describe the patient's response
C)Use statements that assist in planning independent nursing interventions
D)Use medical terminology to describe the probable cause of the patient's response

Accepted Answer

A nurse is aware that the guidelines for writing an appropriate nursing diagnosis include all of the above except to use medical terminology to describe the probable cause of the patient's response. A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never a part of the nursing diagnosis. An appropriate nursing diagnosis would be an ineffective breathing pattern related to chest pain, rather than ineffective breathing pattern caused by angina.

Question 4

A nurse manager notices that one of the staff nurses is always twenty to thirty minutes late. When the nurse manager discusses the problem with her, the nurse says that she has been late because her daughter's nursery school does not open until 7:30 AM. The nurse manager should respond by telling her to:
A)Ask one of the night nurses to cover for her
B)See if a neighbor can take the child to school
C)Find out if other schools open earlier
D)Find some way to solve the problem and be on time

Accepted Answer

The nurse manager should respond by telling her to find some way to solve the problem and be on time. It is the staff nurse's responsibility to be on time. The nurse manager should not assume a responsibility that belongs to the nurse.

Question 5

Nurse Janina observes a dazed and apparently confused co-worker taking two diazepam tablets by mouth, as the co-worker is about to pour medications. What should Nurse Janina do?
A)Call the nurse supervisor immediately before the co-worker pours and administers the medications
B)Pour the medications for the co-worker while she goes for a cup of coffee
C)Report the co-worker to hospital security because she may be addicted to drugs
D)Watch the co-worker closely and report the incident to the nurse supervisor at the end of the day

Accepted Answer

Nurse Janina should call the nurse supervisor immediately before the co-worker pours and administers the medications. The patient's safety is the major concern in this situation. According to the International Council of Nurses' Code for Nurses: "The nurse [should] take appropriate action to safeguard the individual when his or her care is endangered by a co-worker or any other person." In this case, talking with the head nurse immediately would be the best way to safeguard the patient's safety. The nurse isn't necessarily an addict; she may be abusing a prescription medication.

Question 6

A one-month-old patient presents with nasal flaring, intercostal and substernal retractions, and a respiratory rate of 50. What is the most appropriate nursing diagnosis?
A)Ineffective individual coping
B)Knowledge deficit
C)Ineffective breathing pattern
D)High risk for altered body temperature; hyperthermia

Accepted Answer

The most appropriate nursing diagnosis is ineffective breathing pattern. The findings on assessment suggest respiratory distress. Ineffective breathing pattern is an appropriate diagnosis with the information now available.

Question 7

Which of the following strategies would a nurse manager include in a plan to assist an impaired colleague?
A)Promote professional isolation
B)Appoint a team to confront the colleague
C)Initiate termination of the colleague
D)Provide covert support of the substance abusing behavior

Accepted Answer

A strategy that a nurse manager would include in a plan to assist an impaired colleague is to appoint a team to confront the colleague. The nurse manager needs to assist an impaired nurse in obtaining treatment for his/her substance abuse. This can be initiated when a team of colleagues confronts the nurse and offers him/her assistance in seeking treatment.

Question 8

A nurse is part of a multi-disciplinary team discussing a newborn patient's plan of care. The nurse recognizes that her role on the team is to:
A)Work with other team members to achieve a mutually agreed upon outcome
B)Serve as the group facilitator
C)Identify team members who don't understand the nursing role
D)Assure that her recommendations are adopted in the plan of care

Accepted Answer

The nurse recognizes that her role on the team is to work with other team members to achieve a mutually agreed upon outcome. The healthcare team consists of nurses, physicians, allied health professionals, and specialists. The nurse is most often responsible for coordinating and integrating services because the nurse has the opportunity to interact with all team members.

Question 9

To which of the following nursing diagnoses would a nurse manager give priority when an impaired nurse returns to work?
A)Ineffective individual coping
B)Growth and development, altered
C)Situational low self-esteem
D)Ineffective family coping; compromised

Accepted Answer

A nursing diagnosis that a nurse manager would give priority to when an impaired nurse returns to work is ineffective individual coping. The impaired nurse has difficulty in coping with stress and has abused substances as a means to reduce stress and anxiety.

Question 10

Which of the following actions may be delegated by the nurse to a licensed practical nurse (LPN)?
A)Administering oral medications
B)Developing the nursing care plan
C)Teaching the patient and family to administer insulin
D)Evaluating the ability of the patient to perform 3 point crutch walking

Accepted Answer

The action that may be delegated by the nurse to a licensed practical nurse (LPN) is administering oral medications. Assessment, evaluation, and nursing judgment are responsibilities of a nurse and may not be delegated to an LPN.

Question 11

A staff nurse on the neonatal intensive care unit tells the nurse in charge that he does not want to care for dying patients. The nurse in charge initially should:
A)Tell the staff nurse that he should request a transfer to another unit
B)Ask the nurse to discuss the reason for his statement
C)Send the staff nurse to meet the spiritual advisor of the institution
D)Not assign the staff nurse to care for dying patients

Accepted Answer

The nurse in charge initially should ask the nurse to discuss the reason for his statement. Before problem-solving can occur, perceptions must be clarified. Asking, which is central to problem-solving, identifies issues and examines reasoning.

Question 12

A charge nurse notes that four staff nurses are arguing about their patient care assignments. Using the democratic style of leadership, the charge nurse should:
A)Ignore the situation
B)Meet with each staff nurse at the end of his/her shift
C)Tell the staff nurses to work out their differences on their own
D)Facilitate a discussion of which staff nurse does what tasks

Accepted Answer

Using the democratic style of leadership, the charge nurse should facilitate a discussion of which staff nurse does which tasks. The democratic type of leadership encourages staff participation indecision-making and involves the staff in planning and developing.

Question 13

After completion of an incident report, the nurse places the document in the patient's chart. The nurse should understand that incident reports:
A)Should be reviewed by the patient prior to discharge
B)Will prevent legal action against the nurse
C)Are maintained by the hospital and used as a staff evaluation tool
D)not considered legal documents, but a risk management tool

Accepted Answer

The nurse should understand that incident reports are not considered legal documents, but are a risk management tool. The document is used as a risk management tool, but does not become part of the patient's legal document.

Question 14

When planning teaching for parents of a baby with tetralogy of fallot, who are both employed full time, the nurse should:
A)Schedule a whole evening for teaching
B)Insist both parents attend the teaching sessions
C)Provide written and oral information in short sessions
D)Explain the specific problems when they are visiting the baby

Accepted Answer

When planning teaching for parents of a baby with tetralogy of fallot who are both employed full time, the nurse should provide written and oral information in short sessions. The parents will probably be anxious and benefit most from short teaching sessions and written material to review at their leisure.

Question 15

On a visit to an older adult who has a chronic heart failure, the nurse observes that the infant lies quietly in a crib and barely has basic needs attended. The older adult is the primary caregiver to the infant. The nurse should:
A)Advise purchasing appropriate toys designed for this age level
B)Inform the older adult that the infant will be retarded if not stimulated
C)Explain the need for the family to hire a mother's helper for the home
D)Initiate a referral to an appropriate agency to assess the need for a home health aide

Accepted Answer

The nurse should initiate a referral to an appropriate agency to assess the need for a home health aide. This will ensure that a thorough assessment of the family's needs is made and the appropriate assistance is initiated.

Question 16

A clinical nurse specialist is interacting with a patient from a different cultural background. Which of the following nursing implementations would a nurse use to provide sensitive care?
A)Confronting issues of noncompliance
B)Use of therapeutic silence
C)Use of therapeutic touch
D)Validation of communication

Accepted Answer

Nursing implementation that a nurse would use to provide sensitive care is validation of communication. It is important for the nurse to frequently validate nurse-patient communication to prevent cultural misunderstanding.

Question 17

A nurse manager assigned a staff nurse to do a home visit for a patient. A spiritual healer from the family's cultural group is present in the home and indicates the desire to work with the patient and the family. Which of the following actions would be most appropriate?
A)The nurse explains that the healer's efforts would be incompatible with medical care
B)The nurse proceeds with data collection only after requesting a private interview with the patient
C)The nurse plans to collaborate with the healer in provision of care to the patient and family
D)The nurse refuses to continue with the patient and family and contacts the nurse manager

Accepted Answer

The most appropriate action is that the nurse plans to collaborate with the healer in provision of care to the patient and family. The nurse providing culturally sensitive care will respect the patient and family's beliefs and collaborate with the spiritual healer.

Question 18

A nurse is working with a neonatal patient who originated from a culture that uses the services of a special healer. The grandparents requested this service when the baby was admitted in the NICU. What nursing intervention is congruent with culturally sensitive nursing care?
A)Refer the grandparents to the physician
B)Explain that it is inappropriate in a hospital setting
C)Facilitate the request
D)Reflect that this means an unhealthy reliance on magical healing

Accepted Answer

Nursing intervention that is congruent with culturally sensitive nursing care is to facilitate the request. The request is congruent with cultural beliefs and should be honored. Avoid any statement that has a value judgment. The family has the right to practice religious and cultural beliefs.

Question 19

Betty, a clinical nurse specialist, is caring for a neonate who is admitted for seventy-two -hours after a traumatic delivery. The father, who is a citizen of Laos, says "yes" whenever Betty explains the nursing care plan to him. As a culturally sensitive nurse, Betty should:
A)Continue in explaining and performing procedures
B)Try to talk to the patient's mother to hear a different response
C)Validate an understanding of communication
D)Consult another staff nurse and request to evaluate the effectiveness of explanation

Accepted Answer

As a culturally sensitive nurse, Betty should validate an understanding of communication. It is essential for the nurse to frequently validate nurse-patient and family communication to avoid cultural misunderstanding. People from Laos often say "yes" as an indication that they understand what is being said, but it doesn't necessary mean that they agree with it; therefore, it is best to validate communication.

Question 20

A patient is admitted to the NICU due to a recurrent medical problem. During admission, the nurse identifies expected outcomes. The nurse understands that expected outcomes are:
A)Clinical pathways
B)Measurable realistic goals
C)Variance of care
D)Long-term objectives

Accepted Answer

The nurse understands that expected outcomes are measurable realistic goals. Expected outcomes are the desirable projected responses to therapeutic interventions that consider the patient's present and potential capabilities; they are measurable and realistic.

Quiz 2: Neonatal

A nurse is teaching a patient about the care of a female newborn. It is a priority to teach the patient to notify the health care provider if which of the following is noted in the infant?

A newly hired charge nurse assesses the staff nurses as competent individually, but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:

A nurse is aware that the guidelines for writing an appropriate nursing diagnosis include all of the following except:

Nurse Janina observes a dazed and apparently confused co-worker taking two diazepam tablets by mouth, as the co-worker is about to pour medications. What should Nurse Janina do?

A one-month-old patient presents with nasal flaring, intercostal and substernal retractions, and a respiratory rate of 50. What is the most appropriate nursing diagnosis?

Which of the following strategies would a nurse manager include in a plan to assist an impaired colleague?

A nurse is part of a multi-disciplinary team discussing a newborn patient's plan of care. The nurse recognizes that her role on the team is to:

To which of the following nursing diagnoses would a nurse manager give priority when an impaired nurse returns to work?

Which of the following actions may be delegated by the nurse to a licensed practical nurse (LPN) ?

A staff nurse on the neonatal intensive care unit tells the nurse in charge that he does not want to care for dying patients. The nurse in charge initially should:

A charge nurse notes that four staff nurses are arguing about their patient care assignments. Using the democratic style of leadership, the charge nurse should:

After completion of an incident report, the nurse places the document in the patient's chart. The nurse should understand that incident reports:

When planning teaching for parents of a baby with tetralogy of fallot, who are both employed full time, the nurse should:

On a visit to an older adult who has a chronic heart failure, the nurse observes that the infant lies quietly in a crib and barely has basic needs attended. The older adult is the primary caregiver to the infant. The nurse should:

A clinical nurse specialist is interacting with a patient from a different cultural background. Which of the following nursing implementations would a nurse use to provide sensitive care?

A nurse manager assigned a staff nurse to do a home visit for a patient. A spiritual healer from the family's cultural group is present in the home and indicates the desire to work with the patient and the family. Which of the following actions would be most appropriate?

A nurse is working with a neonatal patient who originated from a culture that uses the services of a special healer. The grandparents requested this service when the baby was admitted in the NICU. What nursing intervention is congruent with culturally sensitive nursing care?

Betty, a clinical nurse specialist, is caring for a neonate who is admitted for seventy-two -hours after a traumatic delivery. The father, who is a citizen of Laos, says "yes" whenever Betty explains the nursing care plan to him. As a culturally sensitive nurse, Betty should:

A patient is admitted to the NICU due to a recurrent medical problem. During admission, the nurse identifies expected outcomes. The nurse understands that expected outcomes are: