Nursing 2200 Art of Professional Nursing Q & A w/ Rationales, Exams of Nursing

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NURSING 2 200

Art of Professional

Nursing

Q & A w/ Rationales

1. A nurse is caring for a patient who has been diagnosed with terminal cancer. The patient expresses anger, sadness, and fear about his condition and asks the nurse why this is happening to him. The nurse should: a) Explain the stages of grief and tell the patient that his feelings are normal. b) Avoid discussing the patient's emotions and focus on his physical needs. c) Encourage the patient to talk to a spiritual leader or counselor. d) Validate the patient's feelings and provide empathic listening.* Rationale: The correct answer is d. The nurse should validate the patient's feelings and provide empathic listening, which are essential skills for therapeutic communication and relationship building. The nurse should not explain the stages of grief, as this may sound dismissive or patronizing. The nurse should not avoid discussing the patient's emotions, as this may make the patient feel isolated or ignored. The nurse should not encourage the patient to talk to a spiritual leader or counselor, unless the patient expresses a desire to do so, as this may impose the nurse's values or beliefs on the patient.
2. A nurse is conducting a health assessment of a new client at a community health center. The client is a 35-year- old woman who immigrated from India two years ago. The nurse should: a) Use an interpreter if the client has limited English

integrating the best available research evidence with clinical expertise and patient values, which helps improve the quality and outcomes of care. EBP is not a method of applying standardized guidelines and protocols, although these may be derived from EBP. EBP is not a strategy of using trial and error, as this may be inefficient or risky. EBP is not a technique of basing clinical decisions on intuition and experience, although these may be considered along with research evidence.

4. A nurse is working in a palliative care unit that provides end-of-life care for patients with terminal illnesses. The nurse recognizes that one of the main goals of palliative care is to: a) Cure the underlying disease or condition. b) Prolong life as much as possible. c) Relieve pain and suffering.* d) Hasten death. Rationale: The correct answer is c. Palliative care is a holistic approach that aims to relieve pain and suffering, as well as address the physical, emotional, social, and spiritual needs of patients and their families. Palliative care does not aim to cure the underlying disease or condition, although it may provide treatments that improve symptoms or quality of life. Palliative care does not aim to prolong life as much as possible, although it may do so indirectly by enhancing comfort and well-being. Palliative care does not aim to hasten death, although it may respect the patient's wishes for withholding or withdrawing life-sustaining treatments.

5. A nurse is leading a quality improvement project in her unit to reduce the incidence of pressure ulcers among hospitalized patients. The nurse uses the Plan-Do-Study- Act (PDSA) cycle as a framework for implementing change. The nurse should: a) Plan: Identify the problem, set goals, and develop an action plan.* b) Do: Test the action plan on a small scale and collect data. c) Study: Analyze the data and compare the results with the goals. d) Act: Implement the change on a larger scale or modify the plan based on the results. e) All of the above.* Rationale: The correct answer is e. The PDSA cycle is a systematic and iterative process for planning, testing, evaluating, and implementing change. The nurse should follow the steps of the PDSA cycle in order to achieve the desired improvement. The nurse should plan by identifying the problem, setting goals, and developing an action plan. The nurse should do by testing the action plan on a small scale and collecting data. The nurse should study by analyzing the data and comparing the results with the goals. The nurse should act by implementing the change on a larger scale or modifying the plan based on the results.
6. A nurse is caring for a patient who has a urinary catheter in place. The nurse observes that the urine drainage bag is empty and the tubing is kinked. The nurse should: a) Clamp the tubing and change the drainage bag.

dependent on the patient's weight and muscle mass, although these factors may affect the injection site and angle.

8. A nurse is educating a patient who has diabetes mellitus about self-care management. The nurse instructs the patient to check his blood glucose level regularly and to report any signs of hypoglycemia or hyperglycemia. The nurse should teach the patient that some of the common signs of hypoglycemia are: a) Headache, blurred vision, and dry mouth. b) Nausea, vomiting, and abdominal pain. c) Shaking, sweating, and hunger.* d) Thirst, frequent urination, and fruity breath. Rationale: The correct answer is c. Hypoglycemia is a condition in which the blood glucose level is too low, usually below 70 mg/dL. Some of the common signs of hypoglycemia are shaking, sweating, hunger, dizziness, confusion, irritability, and weakness. These signs are caused by the activation of the sympathetic nervous system and the release of adrenaline in response to low blood glucose. Headache, blurred vision, and dry mouth are more likely to be signs of hyperglycemia or dehydration. Nausea, vomiting, and abdominal pain are more likely to be signs of diabetic ketoacidosis or gastroenteritis. Thirst, frequent urination, and fruity breath are more likely to be signs of hyperglycemia or diabetic ketoacidosis.
9. A nurse is performing hand hygiene before entering a patient's room. The nurse should:

a) Wash hands with soap and water for at least 15 seconds.* b) Use an alcohol-based hand rub for at least 20 seconds. c) Dry hands with a paper towel and turn off the faucet with the same towel.* d) Apply moisturizer to prevent skin dryness and cracking. e) All of the above except b.* Rationale: The correct answer is e. The nurse should wash hands with soap and water for at least 15 seconds, as this will remove dirt, organic matter, and most transient microorganisms from the hands. The nurse should use an alcohol-based hand rub for at least 20 seconds only if soap and water are not available or if hands are not visibly soiled, as this will kill most microorganisms but not remove them from the hands. The nurse should dry hands with a paper towel and turn off the faucet with the same towel, as this will prevent recontamination of the hands from the faucet or the environment. The nurse should apply moisturizer to prevent skin dryness and cracking, As

protocols without considering patient preferences. Answer: c) EBP incorporates the best available research evidence with clinical expertise and patient values. Rationale: EBP involves using the best available research evidence, the nurse's clinical expertise, and considering patient preferences and values to make informed clinical decisions. Options a, b, and d do not accurately represent EBP.

3. During a shift handover, a nurse mentions that a patient's pain is being adequately managed using patient-controlled analgesia (PCA). Which of the following statements accurately describes PCA? a) PCA ensures the complete elimination of pain. b) PCA allows the patient to self-administer IV medications at a fixed rate. c) PCA requires continuous monitoring by nursing staff. d) PCA is contraindicated in patients with impaired cognitive function. Answer: c) PCA requires continuous monitoring by nursing staff. Rationale: PCA involves the patient self-controlling the administration of pain medication within safe parameters. It requires continuous monitoring by nursing staff to assess the patient's pain level, potential side effects, and response to the medication. Options a, b, and d do not accurately

describe PCA.

4. A nurse is caring for a patient who needs enteral tube feeding. Which of the following nursing interventions is essential during enteral tube feeding administration? a) Elevating the head of the bed to at least 30 degrees. b) Administering the feeding at room temperature. c) Providing intermittent bolus feedings to enhance digestion. d) Refraining from flushing the feeding tube with water. Answer: a) Elevating the head of the bed to at least 30 degrees. Rationale: Elevating the head of the bed to at least 30 degrees helps prevent aspiration during enteral tube feeding. Option b is incorrect because enteral tube feeding should be administered at body temperature to prevent gastrointestinal discomfort. Options c and d do not accurately reflect best practices in enteral tube feeding.
5. A nurse is documenting a patient's medical record using the SOAP format. Which of the following components belongs to the "S" (Subjective) section of the SOAP format? a) Vital signs. b) Objective assessment findings. c) Patient's chief complaint. d) Nursing diagnosis.

objective data? a) The patient complains of severe abdominal pain. b) The patient's blood pressure is 130/80 mmHg. c) The patient is fearful and anxious. d) The patient reports feeling cold. Answer: b) The patient's blood pressure is 130/80 mmHg. Rationale: Objective data are measurable and observable, such as vital signs, laboratory values, and physical examination findings. In this case, the patient's blood pressure is measurable and objective. Options a, c, and d are examples of subjective data, as they reflect the patient's feelings and perceptions.

8. A nurse is assisting a patient with terminal cancer in creating an advance healthcare directive. Which of the following statements accurately describes an advance healthcare directive? a) It can only be created by the healthcare provider. b) It becomes active immediately after its creation. c) It guides decisions about medical treatment in case the patient becomes unable to communicate. d) It requires the patient's signature only, without the need for witnesses. Answer: c) It guides decisions about medical treatment in case the patient becomes unable to communicate. Rationale: An advance healthcare directive is a legal

document that provides instructions regarding the patient's healthcare decisions if they become unable to communicate their wishes. Options a, b, and d do not accurately describe an advance healthcare directive.

9. A nurse is educating a group of nursing students about cultural competence in nursing practice. Which of the following statements best represents cultural competence? a) Cultural competence refers to providing care according to the nurse's cultural beliefs and practices. b) Cultural competence involves ignoring cultural differences to promote uniform care delivery. c) Cultural competence requires understanding and respecting individual and cultural differences in healthcare. d) Cultural competence focuses on maintaining a homogenous healthcare environment. Answer: c) Cultural competence requires understanding and respecting individual and cultural differences in healthcare. Rationale: Cultural competence involves understanding and respecting individual and cultural differences in healthcare, providing care that aligns with the patient's cultural beliefs and practices. It promotes culturally sensitive and tailored care. Options a, b, and d do not accurately represent cultural competence.
10. A nurse is caring for a patient with impaired physical mobility. Which of the following actions best promotes

their pain on a scale of 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The FLACC scale is commonly used for pain assessment in non-verbal or preverbal patients. The Wong-Baker FACES scale is commonly used to assess pain in pediatric patients. The McGill Pain Questionnaire is a more comprehensive pain assessment tool.

12. A nurse is providing care to a patient who requires wound dressing changes. Which of the following statements best describes the rationale behind sterile technique during wound care? a) Sterile technique prevents bacteria from entering the wound. b) Sterile technique speeds up the healing process. c) Sterile technique does not require hand hygiene. d) Sterile technique eliminates the need for wearing gloves. Answer: a) Sterile technique prevents bacteria from entering the wound. Rationale: Sterile technique is used during wound care to prevent bacteria from entering the wound, minimizing the risk of infection. Options b, c, and d do not accurately describe the rationale for sterile technique.
13. A nurse is caring for a patient with a nursing diagnosis of impaired gas exchange related to decreased lung function. Which of the following interventions should the nurse prioritize?

a) Assisting the patient with deep breathing and coughing exercises. b) Encouraging the patient to ambulate regularly. c) Administering oxygen therapy as prescribed. d) Providing emotional support and reassurance. Answer: c) Administering oxygen therapy as prescribed. Rationale: Administering oxygen therapy as prescribed is the priority intervention for a patient with impaired gas exchange. Options a, b, and d are important interventions but are secondary to ensuring adequate oxygenation.

14. A nurse is developing a plan of care for a patient with impaired urinary elimination. Which of the following interventions should the nurse include? a) Limiting fluid intake to reduce the frequency of urination. b) Encouraging the patient to drink sufficient fluids to maintain hydration. c) Instructing the patient to void every 6 hours, even if there is no urge. d) Administering antidiuretic medication to reduce urine production. Answer: b) Encouraging the patient to drink sufficient fluids to maintain hydration. Rationale: Encouraging the patient to drink sufficient fluids is important to maintain hydration and promote optimal

C:

Question: Which of the following best describes the primary responsibility of a professional nurse? A: Providing emotional support to patients B: Administering medications accurately C: Ensuring the cleanliness of the hospital ward D: Assisting physicians in surgical procedures Answer: B Rationale: The primary responsibility of a professional nurse is to administer medications accurately, ensuring patient safety and well-being. Question: What is the purpose of the nursing process? A: To prioritize patient needs B: To assess the physician's diagnosis C: To provide a framework for patient care D: To manage hospital resources efficiently Answer: C Rationale: The nursing process provides a systematic framework for the delivery of patient-centered care, encompassing assessment, diagnosis, planning, implementation, and evaluation. Question: Which ethical principle emphasizes the importance of doing no harm to the patient? A: Autonomy B: Beneficence C: Non-maleficence

D: Justice Answer: C Rationale: The ethical principle of non-maleficence underscores the nurse's duty to avoid causing harm to the patient. Question: When caring for a patient with a communicable disease, which type of isolation precautions should be implemented? A: Contact precautions B: Droplet precautions C: Airborne precautions D: Standard precautions Answer: Varies based on the specific disease Rationale: The type of isolation precautions to be implemented depends on the mode of transmission of the specific communicable disease, hence the correct answer varies based on the disease. Question: What is the purpose of the Braden Scale in nursing practice? A: Assessing pain levels in patients B: Evaluating risk for pressure ulcers C: Measuring blood pressure variations D: Monitoring oxygen saturation levels Answer: B Rationale: The Braden Scale is used to assess a patient's risk for developing pressure ulcers, considering factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear.