SESSION 9

1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the
process of:
- data collection.
2. The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need
to incorporate nursing process and:
- interview process.
3. A patient is suffering from shortness of breath. The correct goal statement would be written as:
- the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.
4. When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform
nursing diagnoses and nursing interventions by developing a:
- concept map.
5. Consultation occurs most often during which phase of the nursing process?
- Planning
6. Concept mapping is one way to:
- all of the above.
7. For a student to avoid a data collection error, the student should:
- assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.
8. The nurse in charge identifies a patient’s responses to actual or potential health
problems during which step of thenursing process?
- Diagnosis
9. The nurse performs an assessment of a newly admitted patient. The nurse
understands that this admission assessment is conducted primarily to:
- Identify important data
10. The guidelines for writing an appropriate nursing diagnosis include all of the
following except:
- Use medical terminology to describe the probable cause of the patient's response

SESSION 10
1. Nurse-initiated interventions are
- determined by state Nurse Practice Act
2. You are writing a care plan for a newly admitted patient. Which one of these
outcome statements is written correctly?
- The patient will identify the need to increase dietary intake of fiber by June 5.
3. Your patient has met the goals set for improvement of ambulatory status. You would now:
- discontinue the care plan.
4. Which of the following is an end result that translates into observable patient behaviors that are measurable and
desirable?
- Expected outcome
5. You have finished with several nursing interventions. To evaluate interventions, you need to examine the:
- appropriateness of the interventions and the correct application of the implementation process.
6. Information regarding a patient’s health status may not be released to non–health care team members because:
- legal and ethical obligations require health care providers to keep information strictly confidential.
7. A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission
paperwork, the nurse needs to record:
- objective data that are observed.
8. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of:
- narrative charting.
9. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident
report is to:
- aid in the hospital’s quality improvement program.
10. Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact
that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative
measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally.
This scenario is an example of which implementation skill?
- Cognitive

SESSION 11
1. While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother
states that:
- a 3-year-old can safely sit in the front seat of the car.
2. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing
interventions to prevent a fall for this patient would include:
- use an electronic bed monitoring device.
3. A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as:
- a procedure-related accident.
4. A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer’s disease and has
been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as:
- Foley catheter bag.
5. You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound
looks red and swollen. The patient’s WBCs are elevated. You should:
- notify the provider.
6. An athletic young woman has just fractured her leg while training for a marathon. The use of meditation has many
physiological properties that will help the young woman to:
- lower muscle tension.
7. You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment
when administering medications because this patient may experience problems with:
- excretion.
8. A postoperative patient is receiving morphine sulfate via patient-controlled analgesia (PCA). The nurse assesses that the
patient’s respirations are depressed.
The effects of the morphine sulfate can be classified as:
- toxic.
9. Nurses are legally required to document medications that are administered to patients. The nurse is mandated to
document which of the following?
- Medication after administering it.
10. If a nurse experiences a problem reading a physician’s medication order, the most appropriate action will be to:
- call the physician to verify order.
SESSION 12
1. You are caring for a non–English-speaking male patient. When preparing to assisthim with personal hygiene, you should:
- ensure that culture and ethnicity influence hygiene practices.
2. A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be:
- braiding the hair to reduce tangles.
3. The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will
reply that a wound heals by primary intention when the skin edges:
- are approximated.
4. A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment,you
note an elevated temperature. An indication that
the wound is infected would be:
- it shows purulent drainage coming from the incision site.
5. A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides:
- moisture needed for wound healing.
7. Which of the following are measures to reduce tissue damage from shear? (Select
all that apply.)
a. Use a transfer device (e.g., transfer board)
c. Have head of bed flat when repositioning patient
e. Raise head of bed 30 degrees when patient positioned supine
8. When obtaining a wound culture to determine the presence of a wound infection,
from where should the specimen be taken?
- Cleansed wound
9. What is the correct sequence of steps when performing wound irrigation to large open wounds?
-use slow continuous pressure to irrigate wounds
- attach 19-gauge angiocatheter to syringe
- fill syringe with irrigation fluid
-Place a waterproof bag near bed
-Position angiocatheter over wound
10. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent
edema formation, control bleeding, and anesthetize the body part?
- Ice bag
11. You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with:
-atelectasis
- atelectasis.
12. During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift.
This condition is known as:
- sleep apnea.
13. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be:
- maintaining the child’s home sleep routine.
14. A patient suffers from sleep pattern disturbance. To promote adequate sleep, most important nursing intervention is:
- synchronizing the medication, treatment, and vital signs schedule.
15. A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get
tosleep. What is the nurse's best response?
- “Antihistamines should not be used because they can cause confusion and increase your risk of falls.”
16. The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which
points should be included in the education?
(Select all that apply.)
Go to bed at the same time each night.
Avoid drinking coffee or soda before bedtime.
Turn off your cellphone at bedtime.
17. Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? (Select all that apply.)
Giving the patient a backrub
Turning on quiet music
Dimming the lights in the patient's room
18. Which statement made by the parent of a school-age child requires follow-up by the nurse?
-- I“Iencourage
encourageevening
eveningexercise
exerciseabout
aboutan
anhour
hourbefore
beforebedtime
bedtime.”
19. The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is
appropriate to include on the plan?
- Elevate head of bed and assume a side or prone position.
20. The effects
Thrombus of immobility on the cardiac system include which of the following? (Select all that apply.)
formation
Thrombus formation
Orthostatic hypotension
Increased cardiac workload

SESSION 13
1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbormis
conceptions about the patient's pain. Which of the following is true?
- Patients are the best judges of their pain.
2. A patient who has just undergone recommendation would be an appendectomy. When discussing with the patientseveral
pain-relief interventions, the most appropriate
- PCA pain management.
3. A postoperative patient is using PCA. You will evaluate the effectiveness of the
medication when:
- you compare assessed pain w/baseline pain.
4. A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct
quantities of nutrients. Which statement reflects that she understands the dietary
guidelines?
- “I am making eating choices according to the recommended dietary allowances.”

5. You receive an order to begin enteral tube feedings. The first step is to:
- introduce a small amount of fluid into the tube before feeding.
6. A patient with a long-standing history of diabetes mellitus is voicing concerns about
kidney disease. The patient asks the nurse where urine is formed in the kidney. The
nurse’s response is the:
- nephron.
7. A health care provider may suspect that a patient is experiencing urinary retention
when the patient has:
- small amounts of urine voided two to three times per hour.
8. A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding:
- in the presence of a person other than one of their parents.
9. A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and
hard to pass. This type of bowel pattern is consistent with:
- constipation.
10. To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour
after meals because:
- mass colonic peristalsis occurs at this time.

SESSION 14
1. A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac—rather than respiratory
or gastrointestinal—when it:
- does not occur with respiratory variations.
2. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the
nurse includes:
- tracheal suctioning.
3. When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would
be to:
- place the device below the patient’s chest.

4. A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of:
- sensible water loss.
5. The body’s fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements
shows an understanding of this mechanism?
- “The pituitary gland secretes antidiuretic hormone.”
6. A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the
nursing assistant understands the task of I&O when the nursing assistant states,
- “I will record the amount of all voided urine.”

SESSION 15
1. You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has
been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting:
- an increased heart rate.
2. A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the
chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can
be classified as
- situational.
3. You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess
this type of depression as:
- maturational loss.
4. As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you
will want to:
- develop a personal understanding of your own feelings about grief and death.

SESSION 16
1. An elderly patient who lives in an adult assisted-living facility mentions that he is experiencing hearing and vision
changes. During your assessment, you would associate this type of sensory deprivation with:
- altered perception.
2. A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve
home safety, the nurse tells the family to:
- install extra incandescent lighting.
3. Which of the following populations have the highest incidence of STI? (Select all that apply.)
Hispanic women age 15 to 24 years
African-American men age 15 to 24 years
4. Upon admission, when gathering a patient’s sexual history, nurses should:
- include questions related to sexual function.
5. When caring for patients, the nurse must understand the difference between
religion and spirituality. Religious care helps individuals:
- maintain their belief systems and worship practices.
6. To assess, evaluate, and support a patient’s spirituality, the best action a nurse can take is to:
- determine the patient’s perceptions and belief system
7 . A couple comes to the family planning clinic and ask about sterilization procedures. Which question by the nurse should
determine whether this method of family planning would be most appropriate?
-”Do you plan to have any other children?”
8 A 55-year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse’s best
response?
-”Please share with me more about your concerns.”
9 The nurse notes that the primary health provider has documented a diagnosis of presbycusis on a client’s chart. Based on
this information, what action should the nurse take?
-Speak at normal tone and pitch, slowly and clearly
10 A clientt’s vision is tested with a Snellen Chart. The results of the test are documented 20/60. What action should the
nurse implement based on this finding?
-Instruct the client that he may need glasses when driving.