Test Bank For Fundamental Nursing Care, 2nd Edition
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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A graduate practical/vocational nurse has downloaded a copy of the NCLEX-PN® test plan fromthe National Council of State Boards of Nursing website. The nurse notes that information isincluded under a section entitled Integrated Processes. What is the most helpful understanding bythe nurse of the relevance of these integrated processes into the licensing examination questions?1)A)They are used as a guideline in every question that is included in the licensing examination.B)The include all of the steps in the nursing process.C)They are mainly important when the question is of a cultural nature.D)They test the licensure candidate's awareness of legal and ethical aspects of nursing.Answer:AExplanation:A)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationB)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationC)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplication1
ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A graduate practical/vocational nurse has downloaded a copy of the NCLEX-PN® test plan fromthe National Council of State Boards of Nursing website. The nurse notes that information isincluded under a section entitled Integrated Processes. What is the most helpful understanding bythe nurse of the relevance of these integrated processes into the licensing examination questions?1)A)They are used as a guideline in every question that is included in the licensing examination.B)The include all of the steps in the nursing process.C)They are mainly important when the question is of a cultural nature.D)They test the licensure candidate's awareness of legal and ethical aspects of nursing.Answer:AExplanation:A)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationB)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplicationC)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplication1
D)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplication2)A graduate nurse has been preparing for the NCLEX-PN® is and scheduled to take theexamination in 3 weeks. As the licensure candidate reviews, she is aware of an increase in herself-confidence as well as in her accuracy in answering questions. She is beginning to think aboutrescheduling the examination for an earlier date if one is available. She decides to use the nursingprocess to help in reaching a decision. What is an appropriate initial action by this graduate nurse?2)A)Keep the scheduled appointment time and continue to review as planned.B)Ask several nursing instructors what they would recommend.C)Answer a set of 205 questions within a 5-hour time period with 90 percent accuracy.D)Call the testing center to see if an earlier appointment time is available.Answer:DExplanation:A)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplicationB)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplication2
D)The Integrated Processes used in developing the current NCLEX-PN® test planare those concepts identified as fundamental to the practice of practical/vocationalnursing and are incorporated throughout the client needs categories andsubcategories. These processes include the Clinical Problem-Solving Process(Nursing Process), Caring, Communication and Documentation, and Teaching andLearning. Including all of the steps of the nursing process addresses only oneaspect of this. Legal and ethical aspects of nursing are tested in the client needcategory of Safe, Effective Care Environment. Cultural influence in nursing care istested in the client need category of Psychosocial Integrity.ImplementationSafe, Effective Care Environment-Coordinated CareApplication2)A graduate nurse has been preparing for the NCLEX-PN® is and scheduled to take theexamination in 3 weeks. As the licensure candidate reviews, she is aware of an increase in herself-confidence as well as in her accuracy in answering questions. She is beginning to think aboutrescheduling the examination for an earlier date if one is available. She decides to use the nursingprocess to help in reaching a decision. What is an appropriate initial action by this graduate nurse?2)A)Keep the scheduled appointment time and continue to review as planned.B)Ask several nursing instructors what they would recommend.C)Answer a set of 205 questions within a 5-hour time period with 90 percent accuracy.D)Call the testing center to see if an earlier appointment time is available.Answer:DExplanation:A)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplicationB)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplication2
C)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplicationD)If an earlier appointment time is not available, then the reviewer does not need tokeep thinking about it and can proceed to decide what and how she will continueto review. Another call can always be made to the testing site to see if the situationhas changed. A test date can be changed once (earlier or later). Additional changeswill incur a charge. Plan to gather objective information initially, then evaluateongoing feelings about taking the exam earlier. Keeping the scheduledappointment time and continuing to review as planned is a do-nothing choice.Asking several nursing instructors what they would recommend seeks evaluationfrom people other than the test-taker herself. Answering 205 questions in 5 hourswith 90 percent accuracy may be something the test-taker decides to do as part ofgathering information about readiness to test.PlanningSafe, Effective Care Environment-Coordinated CareApplication3)A student nurse who is doing a clinical practicum on a nursing unit approaches a staff licensedpractical/vocational nurse and asks the nurse to read the PPD that the student received yesterday.What is the most appropriate response by the staff nurse at this time?3)A)"The earliest the test can be read is after 48 hours."B)"What observations have you made about the results?"C)"Okay. Let me finish what I'm doing and I will meet you at the nurse's station."D)"It's not within my scope of practice to read PPD tests. A registered nurse has to do that."Answer:AExplanation:A)A tuberculin test is most correctly read between 48 and 72 hours afteradministration, by measuring the degree of induration (not redness). Saying thatnurse will finish what she is doing and then meet the LPN at the nurse's station isnot within the correct time limits. Although asking the LPN/LVN whatobservations have been made about the results may be interesting information toobtain, it is not the most appropriate response. LPN/LVNs can read tuberculintests.AssessmentHealth Promotion and MaintenanceApplication3
B)A tuberculin test is most correctly read between 48 and 72 hours afteradministration, by measuring the degree of induration (not redness). Saying thatnurse will finish what she is doing and then meet the LPN at the nurse's station isnot within the correct time limits. Although asking the LPN/LVN whatobservations have been made about the results may be interesting information toobtain, it is not the most appropriate response. LPN/LVNs can read tuberculintests.AssessmentHealth Promotion and MaintenanceApplicationC)A tuberculin test is most correctly read between 48 and 72 hours afteradministration, by measuring the degree of induration (not redness). Saying thatnurse will finish what she is doing and then meet the LPN at the nurse's station isnot within the correct time limits. Although asking the LPN/LVN whatobservations have been made about the results may be interesting information toobtain, it is not the most appropriate response. LPN/LVNs can read tuberculintests.AssessmentHealth Promotion and MaintenanceApplicationD)A tuberculin test is most correctly read between 48 and 72 hours afteradministration, by measuring the degree of induration (not redness). Saying thatnurse will finish what she is doing and then meet the LPN at the nurse's station isnot within the correct time limits. Although asking the LPN/LVN whatobservations have been made about the results may be interesting information toobtain, it is not the most appropriate response. LPN/LVNs can read tuberculintests.AssessmentHealth Promotion and MaintenanceApplication4)Several graduate practical/vocational nurses are preparing for the licensing examination, whichthey plan to take in approximately 6 weeks. Each graduate shares one of his or her plans forreviewing. Which plan is the most realistic in relation to the task and time?4)A)"I plan to answer sets of 85 questions, correct, and review the rationales at least three times aweek. I will spend 2 hours doing this."B)"I'm starting at the beginning of the review book I bought and I'll go through it all and answerthe questions. When I finish, I'll do the comprehensive examinations in the book."C)"I'm going to start with mental health because that's my weakest area. I plan to review somecontent and answer NCLEX-PN® style questions for at least 1 hour every day. It will take meabout 2 weeks to review mental health."D)"The only time I have available is on the weekends, so I will review for at least 8 hours everyweekend day. I'm starting with pharmacology."Answer:C4
Explanation:A)It is imperative to plan appropriate and realistic task and timeframes for reviewingfor the NCLEX-PN®. Based on the comments, the graduate who is going to startwith mental health has identified a weaker area and decided to begin with it, andhas a plan to incorporate theory review and assessment (questions). Given thetopic of mental health nursing and the potential of a minimum of 14 hours on thetopic, the goal has a high possibility to be attained. Two hours (120 minutes) is notsufficient time to answer and correct and review rationales of 85 questions withany degree of thoroughness or effectiveness. Two hours is a reasonable time toanswer the questions themselves, with no additional action. Planning to spend 8hours a day focusing on NCLEX-PN® review is a goal that is difficult for manypeople to attain. Retaining information over this length of time is often decreased.Starting at the beginning of the review book and working through the entire bookcan potentially be an effective plan, once timeframes are attached to the activities.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisB)It is imperative to plan appropriate and realistic task and timeframes for reviewingfor the NCLEX-PN®. Based on the comments, the graduate who is going to startwith mental health has identified a weaker area and decided to begin with it, andhas a plan to incorporate theory review and assessment (questions). Given thetopic of mental health nursing and the potential of a minimum of 14 hours on thetopic, the goal has a high possibility to be attained. Two hours (120 minutes) is notsufficient time to answer and correct and review rationales of 85 questions withany degree of thoroughness or effectiveness. Two hours is a reasonable time toanswer the questions themselves, with no additional action. Planning to spend 8hours a day focusing on NCLEX-PN® review is a goal that is difficult for manypeople to attain. Retaining information over this length of time is often decreased.Starting at the beginning of the review book and working through the entire bookcan potentially be an effective plan, once timeframes are attached to the activities.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisC)It is imperative to plan appropriate and realistic task and timeframes for reviewingfor the NCLEX-PN®. Based on the comments, the graduate who is going to startwith mental health has identified a weaker area and decided to begin with it, andhas a plan to incorporate theory review and assessment (questions). Given thetopic of mental health nursing and the potential of a minimum of 14 hours on thetopic, the goal has a high possibility to be attained. Two hours (120 minutes) is notsufficient time to answer and correct and review rationales of 85 questions withany degree of thoroughness or effectiveness. Two hours is a reasonable time toanswer the questions themselves, with no additional action. Planning to spend 8hours a day focusing on NCLEX-PN® review is a goal that is difficult for manypeople to attain. Retaining information over this length of time is often decreased.Starting at the beginning of the review book and working through the entire bookcan potentially be an effective plan, once timeframes are attached to the activities.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis5
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D)It is imperative to plan appropriate and realistic task and timeframes for reviewingfor the NCLEX-PN®. Based on the comments, the graduate who is going to startwith mental health has identified a weaker area and decided to begin with it, andhas a plan to incorporate theory review and assessment (questions). Given thetopic of mental health nursing and the potential of a minimum of 14 hours on thetopic, the goal has a high possibility to be attained. Two hours (120 minutes) is notsufficient time to answer and correct and review rationales of 85 questions withany degree of thoroughness or effectiveness. Two hours is a reasonable time toanswer the questions themselves, with no additional action. Planning to spend 8hours a day focusing on NCLEX-PN® review is a goal that is difficult for manypeople to attain. Retaining information over this length of time is often decreased.Starting at the beginning of the review book and working through the entire bookcan potentially be an effective plan, once timeframes are attached to the activities.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis5)Several nursing students are discussing what they have heard about the NCLEX-PN® examinationfrom graduates of their nursing program and nurses who work in the facilities where they havebeen doing clinical practice. They are concerned because they have heard that the licensingexamination does not test what really happens in hospitals and what nurses really do. They havealso heard that the questions on the test are nothing like the ones in review books. Whatinformation will be of most value for the student nurses in preparing for the licensing examination?(Select all that apply.)5)A)"A lot of the questions are about setting priorities. And you can't just use the ABCDs."B)"The questions are about what LPN/LVNs do in the first 3 years they work after graduatingfrom a nursing school."C)"Some people had ten drug questions and some didn't have any."D)"Two people said their whole exam was about maternity and they didn't have any med-surgat all."E)"Twenty-five of the questions don't count, so you will really only answer 60 questions."F)"They have other kinds of questions on the exam besides multiple choice. For some of themyou have to fill in things like IV drip rates."Answer:A, C, FExplanation:A)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in theirquestions; the questions, regardless of area of practice, are all examples of one areaof client need and one step in the nursing process. The test containsalternate-format questions, including more than one correct response(multiple-multiple response), fill-in-the-blank, identifying an area on a picture orgraph, and sequence ordering of actions.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis6
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B)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in theirquestions; the questions, regardless of area of practice, are all examples of one areaof client need and one step in the nursing process. The test containsalternate-format questions, including more than one correct response(multiple-multiple response), fill-in-the-blank, identifying an area on a picture orgraph, and sequence ordering of actions.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisC)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in theirquestions; the questions, regardless of area of practice, are all examples of one areaof client need and one step in the nursing process. The test containsalternate-format questions, including more than one correct response(multiple-multiple response), fill-in-the-blank, identifying an area on a picture orgraph, and sequence ordering of actions.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisD)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in their
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E)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in theirquestions; the questions, regardless of area of practice, are all examples of one areaof client need and one step in the nursing process. The test containsalternate-format questions, including more than one correct response(multiple-multiple response), fill-in-the-blank, identifying an area on a picture orgraph, and sequence ordering of actions.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisF)The NCLEX-PN® was developed and is updated every 3 years by the NationalCouncil of State Boards of Nursing (NCSBN), when a vocational nursing jobanalysis study is done. The exam tests the skills and knowledge required forentry-level practice in practical/vocational nursing. The NCLEX-PN® testsknowledge of client needs and the use of the nursing process in all areas in whichthe LPN/LVN is employed. To be successful on the examination, the test-takermust be able to think critically, set priorities, determine initial actions, and identifyappropriate and inappropriate responses to a question. Some test-takers mayhave what appears to be more or less focus on one area of practice in theirquestions; the questions, regardless of area of practice, are all examples of one areaof client need and one step in the nursing process. The test containsalternate-format questions, including more than one correct response(multiple-multiple response), fill-in-the-blank, identifying an area on a picture orgraph, and sequence ordering of actions.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis8
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6)An assigned client of a nurse experiences a cardiopulmonary arrest, is resuscitated, and transferredto the intensive care unit. The client's room needs to be cleared of the equipment that was usedduring the code blue, and the client's belongings need to be gathered and sent to the intensive careunit. It is essential that this nurse first:6)A)Dispose of all used syringes, needles, and medication vials used during the code blue in asharps container.B)Call for a new emergency cart to be delivered to the unit.C)Itemize, document, and transfer the client's belongings.D)Wash his or her hands.Answer:BExplanation:A)Before doing anything with the room or the client's belongings, it is essential thatthe nurse arrange for a replacement of the emergency cart. A nursing unit shouldnever be without a fully stocked cart. All of the other choices will be done atvarious times during the process. They should not be the nurse's initial action.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisB)Before doing anything with the room or the client's belongings, it is essential thatthe nurse arrange for a replacement of the emergency cart. A nursing unit shouldnever be without a fully stocked cart. All of the other choices will be done atvarious times during the process. They should not be the nurse's initial action.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisC)Before doing anything with the room or the client's belongings, it is essential thatthe nurse arrange for a replacement of the emergency cart. A nursing unit shouldnever be without a fully stocked cart. All of the other choices will be done atvarious times during the process. They should not be the nurse's initial action.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisD)Before doing anything with the room or the client's belongings, it is essential thatthe nurse arrange for a replacement of the emergency cart. A nursing unit shouldnever be without a fully stocked cart. All of the other choices will be done atvarious times during the process. They should not be the nurse's initial action.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysis7)A candidate for licensure in practical/vocational nursing will take the NCLEX-PN® tomorrow. Inthe 24 hours before arriving at the testing site, it is essential that the test-taker:7)A)Have a bottle of water and a nutritious snack to take along to the test.B)Select one review book to take along for last-minute checking should something come tomind.C)On the day of the test, plan time to have a leisurely breakfast or lunch, depending upon thescheduled testing time.D)Make sure that the name and address on the test-taker's identification matches theinformation provided to the board and testing site.Answer:D9
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Explanation:A)If there is a discrepancy in the name, address, or any other form of identification(photo, fingerprints), the candidate will not be allowed to sit for the examination,regardless of having a scheduled appointment. Taking a bottle of water and anutritious snack is a good idea, but it is not essential to taking the test. Having aleisurely breakfast or lunch may be a good idea, but it is not essential. Eatingmoderately, limiting sugar, increasing protein food sources, and relaxing during ameal at least 1 to 2 hours before the test will help to stabilize the blood sugar andprovide energy for thinking and doing. Plan to leave all review books at home.Attempting to "look up" everything one might think of during this time will likelyincrease anxiety.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationB)If there is a discrepancy in the name, address, or any other form of identification(photo, fingerprints), the candidate will not be allowed to sit for the examination,regardless of having a scheduled appointment. Taking a bottle of water and anutritious snack is a good idea, but it is not essential to taking the test. Having aleisurely breakfast or lunch may be a good idea, but it is not essential. Eatingmoderately, limiting sugar, increasing protein food sources, and relaxing during ameal at least 1 to 2 hours before the test will help to stabilize the blood sugar andprovide energy for thinking and doing. Plan to leave all review books at home.Attempting to "look up" everything one might think of during this time will likelyincrease anxiety.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationC)If there is a discrepancy in the name, address, or any other form of identification(photo, fingerprints), the candidate will not be allowed to sit for the examination,regardless of having a scheduled appointment. Taking a bottle of water and anutritious snack is a good idea, but it is not essential to taking the test. Having aleisurely breakfast or lunch may be a good idea, but it is not essential. Eatingmoderately, limiting sugar, increasing protein food sources, and relaxing during ameal at least 1 to 2 hours before the test will help to stabilize the blood sugar andprovide energy for thinking and doing. Plan to leave all review books at home.Attempting to "look up" everything one might think of during this time will likelyincrease anxiety.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationD)If there is a discrepancy in the name, address, or any other form of identification(photo, fingerprints), the candidate will not be allowed to sit for the examination,regardless of having a scheduled appointment. Taking a bottle of water and anutritious snack is a good idea, but it is not essential to taking the test. Having aleisurely breakfast or lunch may be a good idea, but it is not essential. Eatingmoderately, limiting sugar, increasing protein food sources, and relaxing during ameal at least 1 to 2 hours before the test will help to stabilize the blood sugar andprovide energy for thinking and doing. Plan to leave all review books at home.Attempting to "look up" everything one might think of during this time will likelyincrease anxiety.AssessmentSafe, Effective Care Environment-Coordinated CareApplication10
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8)A client's religious preference on the admission form is indicated as Orthodox Jewish. The nurse isdelivering a full liquid meal tray to this client. The client is receiving chemotherapy for cancer andis being encouraged to have a high caloric intake. Before giving the meal tray to the client, the nurseshould recognize that which of the items may need to be removed from the tray?(Select all that apply.)8)A)Tea and sugarB)EnsureC)Cream of chicken soupD)Fruit smoothieE)Plain vanilla custard puddingF)2 percent milkAnswer:C, E, FExplanation:A)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysisB)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysisC)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysisD)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysis11
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E)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysisF)The dietary laws and practices for the Orthodox Jewish person include theseparation of milk and meat at a meal. If this cannot be avoided, the milk productsare consumed before the meat products. Cream of chicken soup, 2 percent milk,and vanilla custard pudding are all milk-based products. In addition, cream ofchicken soup contains a meat base or flavoring. All of the food items are allowedon a full liquid diet.AssessmentPsychosocial IntegrityAnalysis9)A 17-year-old client has returned to the hospital for reparative intestinal and orthopedic surgeryfor multiple gunshot wounds that were received 1 month previously. The client has an ileostomythat he has been caring for. The client also has a methicillin-resistant staphylococcus aureusinfection in a nonhealed incision where hip surgery was done. All of the following medicationorders have been written for the client. Which of the following orders will the nurse not need tocommunicate with the physician about?9)A)Bisacodyl (Dulcolax) suppository 10 mg PR prn. Hold for loose stools.B)Loperamide (Imodium) 5 ml PO after each loose stool. Do not exceed three doses in 24 hours.C)Simethicone (Mylanta) 40 mg Chewable tablet after meals prn for excess flatusD)Ducosate sodium (Colace) 100 mg PO every day prn. Hold for loose stools.Answer:CExplanation:A)The client has an ileostomy and will always have loose stools, which makesducosate sodium, bisacodyl suppository, and loperamide inappropriate for thisclient. Simethicone (Mylanta) is used as an antiflatulent to relieve gasaccumulation in the gastrointestinal system. Clients with ileostomies often haveincreased flatulence, which can be controlled by antiflatulent medications andavoiding gas-forming foods.AssessmentPhysiological Integrity-Pharmacological TherapiesAnalysisB)The client has an ileostomy and will always have loose stools, which makesducosate sodium, bisacodyl suppository, and loperamide inappropriate for thisclient. Simethicone (Mylanta) is used as an antiflatulent to relieve gasaccumulation in the gastrointestinal system. Clients with ileostomies often haveincreased flatulence, which can be controlled by antiflatulent medications andavoiding gas-forming foods.AssessmentPhysiological Integrity-Pharmacological TherapiesAnalysis12
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C)The client has an ileostomy and will always have loose stools, which makesducosate sodium, bisacodyl suppository, and loperamide inappropriate for thisclient. Simethicone (Mylanta) is used as an antiflatulent to relieve gasaccumulation in the gastrointestinal system. Clients with ileostomies often haveincreased flatulence, which can be controlled by antiflatulent medications andavoiding gas-forming foods.AssessmentPhysiological Integrity-Pharmacological TherapiesAnalysisD)The client has an ileostomy and will always have loose stools, which makesducosate sodium, bisacodyl suppository, and loperamide inappropriate for thisclient. Simethicone (Mylanta) is used as an antiflatulent to relieve gasaccumulation in the gastrointestinal system. Clients with ileostomies often haveincreased flatulence, which can be controlled by antiflatulent medications andavoiding gas-forming foods.AssessmentPhysiological Integrity-Pharmacological TherapiesAnalysis10)A graduate practical/vocational nurse is preparing to take the licensing examination and decides towrite to the National Council of State Boards of Nursing to obtain information about theNCLEX-PN® test plan. The graduate nurse will most correctly expect that this information willinclude:10)A)Suggestions for review books that have been helpful for test preparation.B)The percentage of accuracy required to pass the examination.C)The distribution of content in the four categories of client needs.D)Who to contact to schedule a time and place to take the licensing examination.Answer:CExplanation:A)The National Council of State Boards of Nursing provides information about theNCLEX-PN® exam that includes the percentages given to content in each of thefour categories of client needs. Individual state boards of practical/vocationalnursing will notify the testing service of the candidate's eligibility to test. Thetesting service will then provide testing site information as well as an authorizationto test (ATT). The NCSBN does not publish a passing score or percentage. Anabbreviated version of the test plan, along with practice questions, can be found inthe preface or first chapter of many NCLEX-PN® review books and is beneficial toread. The information from the NCSBN does not provide suggestions for reviewbooks.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis13
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B)The National Council of State Boards of Nursing provides information about theNCLEX-PN® exam that includes the percentages given to content in each of thefour categories of client needs. Individual state boards of practical/vocationalnursing will notify the testing service of the candidate's eligibility to test. Thetesting service will then provide testing site information as well as an authorizationto test (ATT). The NCSBN does not publish a passing score or percentage. Anabbreviated version of the test plan, along with practice questions, can be found inthe preface or first chapter of many NCLEX-PN® review books and is beneficial toread. The information from the NCSBN does not provide suggestions for reviewbooks.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisC)The National Council of State Boards of Nursing provides information about theNCLEX-PN® exam that includes the percentages given to content in each of thefour categories of client needs. Individual state boards of practical/vocationalnursing will notify the testing service of the candidate's eligibility to test. Thetesting service will then provide testing site information as well as an authorizationto test (ATT). The NCSBN does not publish a passing score or percentage. Anabbreviated version of the test plan, along with practice questions, can be found inthe preface or first chapter of many NCLEX-PN® review books and is beneficial toread. The information from the NCSBN does not provide suggestions for reviewbooks.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisD)The National Council of State Boards of Nursing provides information about theNCLEX-PN® exam that includes the percentages given to content in each of thefour categories of client needs. Individual state boards of practical/vocationalnursing will notify the testing service of the candidate's eligibility to test. Thetesting service will then provide testing site information as well as an authorizationto test (ATT). The NCSBN does not publish a passing score or percentage. Anabbreviated version of the test plan, along with practice questions, can be found inthe preface or first chapter of many NCLEX-PN® review books and is beneficial toread. The information from the NCSBN does not provide suggestions for reviewbooks.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis11)A licensed practical/vocational nurse is deciding whether to apply for a nursing position in a statethat adjoins the one in which she is licensed. The job advertisement indicates that the state has anurse licensure compact with the state in which the LPN/LVN is licensed. Should the nurse beemployed in the second state, her primary legal responsibility is to:11)A)Be certified for basic life support as a healthcare provider CPR (cardiopulmonaryresuscitation) with AED (automatic external defibrillator) for infants, children, and adults, inthe state of employment.B)Notify the board of nursing in the compact state of her intent to practice there.C)Understand the meaning of nurse licensure compact.D)Read the nurse practice act of the compact state.Answer:B14
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Explanation:A)The nurse licensure compact (a multistate compact) is an agreement between andamong states that licensed nurses may practice in those states without having alicense in that state. The agreement (or compact) is based on similarities in thenurse practice act of the collaborating states. Legally, the nurse must notify theboard of nursing of that state, be free of any disciplinary action against him or her,and will be subject to the laws of the employing state. Reading the relevant nursepractice act and understanding the meaning are not legal requirements, they areboth actions the professional nurse will use to increase knowledge. Basic lifesupport certification does not limit practice to one state or area.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationB)The nurse licensure compact (a multistate compact) is an agreement between andamong states that licensed nurses may practice in those states without having alicense in that state. The agreement (or compact) is based on similarities in thenurse practice act of the collaborating states. Legally, the nurse must notify theboard of nursing of that state, be free of any disciplinary action against him or her,and will be subject to the laws of the employing state. Reading the relevant nursepractice act and understanding the meaning are not legal requirements, they areboth actions the professional nurse will use to increase knowledge. Basic lifesupport certification does not limit practice to one state or area.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationC)The nurse licensure compact (a multistate compact) is an agreement between andamong states that licensed nurses may practice in those states without having alicense in that state. The agreement (or compact) is based on similarities in thenurse practice act of the collaborating states. Legally, the nurse must notify theboard of nursing of that state, be free of any disciplinary action against him or her,and will be subject to the laws of the employing state. Reading the relevant nursepractice act and understanding the meaning are not legal requirements, they areboth actions the professional nurse will use to increase knowledge. Basic lifesupport certification does not limit practice to one state or area.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationD)The nurse licensure compact (a multistate compact) is an agreement between andamong states that licensed nurses may practice in those states without having alicense in that state. The agreement (or compact) is based on similarities in thenurse practice act of the collaborating states. Legally, the nurse must notify theboard of nursing of that state, be free of any disciplinary action against him or her,and will be subject to the laws of the employing state. Reading the relevant nursepractice act and understanding the meaning are not legal requirements, they areboth actions the professional nurse will use to increase knowledge. Basic lifesupport certification does not limit practice to one state or area.EvaluationSafe, Effective Care Environment-Coordinated CareApplication15
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13)A graduate nurse has gathered various suggestions for decreasing test-taking anxiety as part ofhis/her preparation for the practical/vocational nurse licensing examination. In the time prior toactually taking the examination, it will be most beneficial for the candidate to: (Select all thatapply.)13)A)Travel to the testing site prior to the scheduled testing appointment, and duplicate as muchas possible the circumstances of the actual testing day.B)Consciously change thoughts of failure to thoughts of success.C)Stop all intake of coffee, tea, and alcohol.D)Attend a 2-day professional review course the week before taking the examination.E)Create and use daily a visualization of taking the test, feeling comfortable and in control, andanswering questions accurately.F)Practice deep relaxation exercises before and while answering review questions.Answer:A, B, EExplanation:A)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysis17
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B)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysisC)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysis18
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D)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysisE)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysis19
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F)Incorporating anxiety-reducing strategies into the overall plan of review for theNCLEX-PN® gives the test-taker the opportunity to determine which ones arehelpful and less helpful. It also reinforces the strategy, which strengthens it as apositive habit. Focus on success rather than failure. Take control of as much of theprocess as possible, reduce the unknown, and have a realistic travel plan. Inaddition to Plan A, have at least one optional plan (for potential changes in childcare arrangements, transportation, weather, etc.). Visualizing the actual testingexperience provides information for the candidate that can be incorporated intopositive habit changes, as well as increasing overall comfort, self-confidence, andsuccess. Completely ceasing the intake of these beverages is not necessary, andmay cause increased anxiety. Intake should be limited, especially the day beforeand the day of the test. The use of deep relaxation exercises before and whileanswering questions is not appropriate or helpful. A mild level of anxiety in thetest-taker is physiologically and psychologically helpful. Short, focused relaxationstrategies are more helpful during the test time, such as counting from 10 to 1,moving the body and/or the chair back from the computer screen to remind thetest-taker to be objective and to provide a little space, or taking several deep, slowbreaths. Many candidates for the licensing examination benefit from taking aprofessional review course. Two-day courses are generally quite intense andwould be better taken earlier than 1 week before the exam is scheduled.ImplementationPsychosocial IntegrityAnalysis14)A student nurse who is within 2 weeks of graduating from nursing school is caring for a client whois a retired nurse who graduated from an LPN/LVN program in 1963. As part of the conversationduring morning care, the retired nurse and the student talk about how nursing has stayed the sameand how it has changed over 40 years. Which comment by the retired nurse will be of most valuefor the student in preparing for the licensing examination?14)A)"I've heard that the exam is now given on a computer. I suppose it's faster that way."B)"Having a license means that the public is protected from having unqualified people practiceas nurses."C)"The examination was given several times during the year and sometimes there were over1,000 people taking the exam at the same time."D)"I always renewed my license when it was due, whether I was working or not. In fact, it's stillcurrent. I like going to various workshops to hear what is new in nursing and healthcare andgetting my continuing education units."Answer:BExplanation:A)The purpose of licensing examinations in nursing (both for the LPN/LVN and theRN) has been, since Mississippi first passed laws for this in 1914, to protect thepublic by setting minimum qualifying safety and effectiveness standards fornursing performance. Knowing how the examination was given in the past isinteresting, but not of much value for preparing for the current examination. Astudent who is almost ready to graduate should, by now, have the information thatthe licensing examination is computerized. The statement about renewing thelicense is good information for the student to remind him or her not to let a licenselapse and that continuing education units will be required. It has no direct valuefor the student nurse who is preparing for the licensing examination.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis20
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B)The purpose of licensing examinations in nursing (both for the LPN/LVN and theRN) has been, since Mississippi first passed laws for this in 1914, to protect thepublic by setting minimum qualifying safety and effectiveness standards fornursing performance. Knowing how the examination was given in the past isinteresting, but not of much value for preparing for the current examination. Astudent who is almost ready to graduate should, by now, have the information thatthe licensing examination is computerized. The statement about renewing thelicense is good information for the student to remind him or her not to let a licenselapse and that continuing education units will be required. It has no direct valuefor the student nurse who is preparing for the licensing examination.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisC)The purpose of licensing examinations in nursing (both for the LPN/LVN and theRN) has been, since Mississippi first passed laws for this in 1914, to protect thepublic by setting minimum qualifying safety and effectiveness standards fornursing performance. Knowing how the examination was given in the past isinteresting, but not of much value for preparing for the current examination. Astudent who is almost ready to graduate should, by now, have the information thatthe licensing examination is computerized. The statement about renewing thelicense is good information for the student to remind him or her not to let a licenselapse and that continuing education units will be required. It has no direct valuefor the student nurse who is preparing for the licensing examination.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysisD)The purpose of licensing examinations in nursing (both for the LPN/LVN and theRN) has been, since Mississippi first passed laws for this in 1914, to protect thepublic by setting minimum qualifying safety and effectiveness standards fornursing performance. Knowing how the examination was given in the past isinteresting, but not of much value for preparing for the current examination. Astudent who is almost ready to graduate should, by now, have the information thatthe licensing examination is computerized. The statement about renewing thelicense is good information for the student to remind him or her not to let a licenselapse and that continuing education units will be required. It has no direct valuefor the student nurse who is preparing for the licensing examination.EvaluationSafe, Effective Care Environment-Coordinated CareAnalysis15)It is the first day of class for beginning vocational nursing students. There are 50 students in theclass. During the general discussion of the course, the instructor mentions that to become a licensedvocational nurse, the graduate must take a national examination called the NCLEX-PN®. Theinstructor then asks the class when they think it would be appropriate to begin studying for theexamination. Which of the following is the most appropriate suggestion by a student?15)A)"When we start practicing what we are learning in the classroom and lab in the clinicalsetting."B)"Within 2 weeks after we finish the course because the sooner we take the exam, the better wewill remember the information."C)"About halfway through the program when we have had some theory and practice."D)"Today, as we begin our classes."Answer:C21
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Explanation:A)In order to study for the licensing examination, the student must have begun toestablish a knowledge base of nursing theory and practice. The student can beginto prepare for the licensing examination by listening carefully, taking notes, andclarifying information as needed. The student should apply the study andtest-taking habits from the course to the licensing examination. The questionrequires critical thinking, application of prior learned information, and recognizingthat the student has a personal responsibility for his or her learning beginning thefirst day of the course. Halfway through a nursing program, the student canreinforce previous learning and assist with learning new information by practicingNCLEX-PN® questions.AssessmentSafe, Effective Care Environment-Coordinated CareAnalysisB)In order to study for the licensing examination, the student must have begun toestablish a knowledge base of nursing theory and practice. The student can beginto prepare for the licensing examination by listening carefully, taking notes, andclarifying information as needed. The student should apply the study andtest-taking habits from the course to the licensing examination. The questionrequires critical thinking, application of prior learned information, and recognizingthat the student has a personal responsibility for his or her learning beginning thefirst day of the course. Halfway through a nursing program, the student canreinforce previous learning and assist with learning new information by practicingNCLEX-PN® questions.AssessmentSafe, Effective Care Environment-Coordinated CareAnalysisC)In order to study for the licensing examination, the student must have begun toestablish a knowledge base of nursing theory and practice. The student can beginto prepare for the licensing examination by listening carefully, taking notes, andclarifying information as needed. The student should apply the study andtest-taking habits from the course to the licensing examination. The questionrequires critical thinking, application of prior learned information, and recognizingthat the student has a personal responsibility for his or her learning beginning thefirst day of the course. Halfway through a nursing program, the student canreinforce previous learning and assist with learning new information by practicingNCLEX-PN® questions.AssessmentSafe, Effective Care Environment-Coordinated CareAnalysisD)In order to study for the licensing examination, the student must have begun toestablish a knowledge base of nursing theory and practice. The student can beginto prepare for the licensing examination by listening carefully, taking notes, andclarifying information as needed. The student should apply the study andtest-taking habits from the course to the licensing examination. The questionrequires critical thinking, application of prior learned information, and recognizingthat the student has a personal responsibility for his or her learning beginning thefirst day of the course. Halfway through a nursing program, the student canreinforce previous learning and assist with learning new information by practicingNCLEX-PN® questions.AssessmentSafe, Effective Care Environment-Coordinated CareAnalysis22
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Answer KeyTestname: C371)A2)D3)A4)C5)A, C, F6)B7)D8)C, E, F9)C10)C11)B12)A13)A, B, E14)B15)C23
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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)Many hospitals are no longer allowing the use of the letter "Q" as an abbreviation either alone or incombination (such as QID, QW, or QS). What is the primary reason for this action?1)A)It is more accurate to write "every" instead of "Q".B)Errors are reduced when fewer abbreviations are used in orders and in communicatinginformation.C)Not all nurses know that "Q" means "quaque" in Latin.D)A hospital may not have computerized ordering and physicians' handwriting is often hard toread.Answer:BExplanation:A)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client's record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysisB)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client's record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysisC)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client's record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysis1
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D)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client's record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysis2)A student nurse is documenting client care in a client's medical record. The client's wife, who is aphysician on the hospital staff, asks the student for the client's chart. The most appropriate actionby the student nurse at this time is to:2)A)Refer the physician to the charge nurse.B)Give the chart to the physician and complete the nursing documentation when the chart isavailable.C)Tell the physician that she is not allowed to read the chart unless she is involved in herhusband's care.D)Ask the client's wife if her husband has given his permission for the chart to be read.Answer:AExplanation:A)A client's medical record is confidential information and is to be read only by thosedirectly involved in the client's care. Regardless of the relationship of the physicianto the client and the physician's status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client's wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysisB)A client's medical record is confidential information and is to be read only by thosedirectly involved in the client's care. Regardless of the relationship of the physicianto the client and the physician's status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client's wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysis2
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C)A client's medical record is confidential information and is to be read only by thosedirectly involved in the client's care. Regardless of the relationship of the physicianto the client and the physician's status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client's wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysisD)A client's medical record is confidential information and is to be read only by thosedirectly involved in the client's care. Regardless of the relationship of the physicianto the client and the physician's status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client's wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysis3)A newly licensed nurse has accepted a position with a nursing registry. The nurse will be going toseveral different hospitals and will be required to document according to each particular facility'spolicy. Regardless of the documentation method or system, the nurse knows that the primary focusof client documentation is:3)A)To communicate client status and responses using the nursing process.B)To record nursing actions performed in accordance with medical and nursing diagnoses.C)To prevent legal action should an error be made during a client's hospital stay.D)To coordinate all members of the healthcare team.Answer:AExplanation:A)A client's medical record documents the client's ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client's care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationB)A client's medical record documents the client's ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client's care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplication3
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C)A client's medical record documents the client's ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client's care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationD)A client's medical record documents the client's ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client's care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplication4)A home health nurse is making an initial visit to a homebound client. Based on the assessment data,the nurse recognizes that all of the following activities need to be done. Which activity should thenurse plan to do first?4)A)Contact the client's pastor to convey the client's request for a visit.B)Confer with the client's weekly housekeeper about the client's safety needs.C)Contact the physician to suggest that the client be prescribed a daily laxative.D)Arrange for the client to receive daily meals from Meals on Wheels.Answer:BExplanation:A)In this question, safety takes priority in determining how to plan the nursing tasks.Two choices indicate physiological level needs (nutrition, elimination) that need tobe addressed. The scenario does not indicate that either need is of an urgent oremergency nature. Spiritual/psychosocial needs will not take priority over safetyor physiological needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisB)In this question, safety takes priority in determining how to plan the nursing tasks.Two choices indicate physiological level needs (nutrition, elimination) that need tobe addressed. The scenario does not indicate that either need is of an urgent oremergency nature. Spiritual/psychosocial needs will not take priority over safetyor physiological needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysisC)In this question, safety takes priority in determining how to plan the nursing tasks.Two choices indicate physiological level needs (nutrition, elimination) that need tobe addressed. The scenario does not indicate that either need is of an urgent oremergency nature. Spiritual/psychosocial needs will not take priority over safetyor physiological needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis4
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D)In this question, safety takes priority in determining how to plan the nursing tasks.Two choices indicate physiological level needs (nutrition, elimination) that need tobe addressed. The scenario does not indicate that either need is of an urgent oremergency nature. Spiritual/psychosocial needs will not take priority over safetyor physiological needs.PlanningSafe, Effective Care Environment-Coordinated CareAnalysis5)A client is being assisted to ambulate for the first time after abdominal surgery. Which of thefollowing observations by the nurse during the ambulation is most important to include in thenarrative charting?5)A)Fatigue after ambulatingB)Mild nausea when first getting upC)Moderate pain during ambulationD)Syncope during ambulationAnswer:DExplanation:A)Lightheadedness and dizziness during ambulation are safety concerns. It isessential that this information be communicated verbally and in written form.Fatigue, mild nausea, and pain are expected when a client is ambulating for thefirst time after surgery, and with abdominal surgery. It is appropriate to commenton all of the observations, but it is most important to comment on a major variance.AssessmentPhysiological Integrity-Reduction of Risk PotentialAnalysisB)Lightheadedness and dizziness during ambulation are safety concerns. It isessential that this information be communicated verbally and in written form.Fatigue, mild nausea, and pain are expected when a client is ambulating for thefirst time after surgery, and with abdominal surgery. It is appropriate to commenton all of the observations, but it is most important to comment on a major variance.AssessmentPhysiological Integrity-Reduction of Risk PotentialAnalysisC)Lightheadedness and dizziness during ambulation are safety concerns. It isessential that this information be communicated verbally and in written form.Fatigue, mild nausea, and pain are expected when a client is ambulating for thefirst time after surgery, and with abdominal surgery. It is appropriate to commenton all of the observations, but it is most important to comment on a major variance.AssessmentPhysiological Integrity-Reduction of Risk PotentialAnalysisD)Lightheadedness and dizziness during ambulation are safety concerns. It isessential that this information be communicated verbally and in written form.Fatigue, mild nausea, and pain are expected when a client is ambulating for thefirst time after surgery, and with abdominal surgery. It is appropriate to commenton all of the observations, but it is most important to comment on a major variance.AssessmentPhysiological Integrity-Reduction of Risk PotentialAnalysis5
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6)A client has an order for morphine sulfate 10 mg sc every 3-4 hours prn. The nurse knows that eachtime the medication is given to the client, it is essential to perform narrative nursing documentationto communicate the:6)A)Subjective symptoms observed to determine level of pain.B)Medication was given subcutaneously as ordered.C)Client's blood pressure before the medication is given.D)Effect of the medication.Answer:DExplanation:A)Each time a "prn" medication is administered (or other nursing activity is done ona "prn" basis), additional narrative charting is required to communicate the effectof the action. It is more important to assess respirations prior to administeringmorphine sulfate. Route of administration is designated on the medicationadministration record and only one route has been ordered. The question asks forappropriate documentationafterthe medication is given, not before.EvaluationPhysiological Integrity-Pharmacologic and Parenteral TherapiesApplicationB)Each time a "prn" medication is administered (or other nursing activity is done ona "prn" basis), additional narrative charting is required to communicate the effectof the action. It is more important to assess respirations prior to administeringmorphine sulfate. Route of administration is designated on the medicationadministration record and only one route has been ordered. The question asks forappropriate documentationafterthe medication is given, not before.EvaluationPhysiological Integrity-Pharmacologic and Parenteral TherapiesApplicationC)Each time a "prn" medication is administered (or other nursing activity is done ona "prn" basis), additional narrative charting is required to communicate the effectof the action. It is more important to assess respirations prior to administeringmorphine sulfate. Route of administration is designated on the medicationadministration record and only one route has been ordered. The question asks forappropriate documentationafterthe medication is given, not before.EvaluationPhysiological Integrity-Pharmacologic and Parenteral TherapiesApplicationD)Each time a "prn" medication is administered (or other nursing activity is done ona "prn" basis), additional narrative charting is required to communicate the effectof the action. It is more important to assess respirations prior to administeringmorphine sulfate. Route of administration is designated on the medicationadministration record and only one route has been ordered. The question asks forappropriate documentationafterthe medication is given, not before.EvaluationPhysiological Integrity-Pharmacologic and Parenteral TherapiesApplication7)A nurse is to transport a client to dialysis. The client is not in her room and cannot be found on thenursing unit. Of the following possible actions, the nurse will most appropriately first contact the:7)A)Facility security to request their assistance.B)Client's physician to report that the client cannot be found.C)Client's family to see if the client is there.D)Hospital cafeteria because the client said she was hungry.Answer:A6
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Explanation:A)When a client cannot be located on a hospital unit, it is appropriate to request theassistance of hospital security before calling the family. Depending upon the typeof facility, the protocol may vary; i.e., a residential facility may not have on-sitesecurity or the client may have a history of leaving the facility and returning towhere he/she previously lived. Facility policies will vary and may call for initiallyusing the paging system to request that the client return to his or her room. Thephysician does not have to be notified as the first contact. Although the client maybe in the cafeteria, security can assist in obtaining this information.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisB)When a client cannot be located on a hospital unit, it is appropriate to request theassistance of hospital security before calling the family. Depending upon the typeof facility, the protocol may vary; i.e., a residential facility may not have on-sitesecurity or the client may have a history of leaving the facility and returning towhere he/she previously lived. Facility policies will vary and may call for initiallyusing the paging system to request that the client return to his or her room. Thephysician does not have to be notified as the first contact. Although the client maybe in the cafeteria, security can assist in obtaining this information.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisC)When a client cannot be located on a hospital unit, it is appropriate to request theassistance of hospital security before calling the family. Depending upon the typeof facility, the protocol may vary; i.e., a residential facility may not have on-sitesecurity or the client may have a history of leaving the facility and returning towhere he/she previously lived. Facility policies will vary and may call for initiallyusing the paging system to request that the client return to his or her room. Thephysician does not have to be notified as the first contact. Although the client maybe in the cafeteria, security can assist in obtaining this information.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisD)When a client cannot be located on a hospital unit, it is appropriate to request theassistance of hospital security before calling the family. Depending upon the typeof facility, the protocol may vary; i.e., a residential facility may not have on-sitesecurity or the client may have a history of leaving the facility and returning towhere he/she previously lived. Facility policies will vary and may call for initiallyusing the paging system to request that the client return to his or her room. Thephysician does not have to be notified as the first contact. Although the client maybe in the cafeteria, security can assist in obtaining this information.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysis8)A resident of a long-term care facility has been discharged after a five-day stay in an acute carefacility and is returning to the long-term care facility. The resident was hospitalized with bacterialpneumonia. It is most important that the charge nurse in the long-term care facility:8)A)Change the dates for the every 90-day required review of the client's comprehensiveassessment and care plan.B)Continue respiratory isolation measures for one more week.C)Facilitate the client's interaction with other residents after the five-day absence.D)Perform an admission assessment to determine current client needs.7
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