NCLEX Exam: Nursing Process (24

Items)

1. Once a nurse assesses a clients condition and identifies appropriate nursing
diagnoses, a:
1. Plan is developed for nursing care.
2. Physical assessment begins
3. List of priorities is determined.
4. Review of the assessment is conducted with other team members.
2. Planning is a category of nursing behaviors in which:
1. The nurse determines the health care needed for the client.
2. The Physician determines the plan of care for the client.
3. Client-centered goals and expected outcomes are established.
4. The client determines the care needed.
3. Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the clients:
1. Physician
2. Non Emergent, non-life threatening needs
3. Future well-being.
4. Urgency of problems
4. A client centered goal is a specific and measurable behavior or response
that reflects a clients:
1. Desire for specific health care interventions
2. Highest possible level of wellness and independence in function.
3. Physicians goal for the specific client.
4. Response when compared to another client with a like problem.
5. For clients to participate in goal setting, they should be:
1. Alert and have some degree of independence.
2. Ambulatory and mobile.
3. Able to speak and write.
4. Able to read and write.
6. The nurse writes an expected outcome statement in measurable terms. An
example is:
1. Client will have less pain.
2. Client will be pain free.
3. Client will report pain acuity less than 4 on a scale of 0-10.
4. Client will take pain medication every 4 hours around the clock.
7. As goals, outcomes, and interventions are developed, the nurse must:
1. Be in charge of all care and planning for the client.
2. Be aware of and committed to accepted standards of practice from nursing and
other disciples.
3. Not change the plan of care for the client.
4. Be in control of all interventions for the client.
8. When establishing realistic goals, the nurse:
1. Bases the goals on the nurses personal knowledge.
2. Knows the resources of the health care facility, family, and the client.
3. Must have a client who is physically and emotionally stable.
4. Must have the clients cooperation.
9. To initiate an intervention the nurse must be competent in three areas,
which include:
1. Knowledge, function, and specific skills
2. Experience, advanced education, and skills.
3. Skills, finances, and leadership.
4. Leadership, autonomy, and skills.
10. Collaborative interventions are therapies that require:
1. Physician and nurse interventions.
2. Nurse and client interventions.
3. Client and Physician intervention.
4. Multiple health care professionals.
11. Well formulated, client-centered goals should:
1. Meet immediate client needs.
2. Include preventative health care.
3. Include rehabilitation needs.
4. All of the above.
12. The following statement appears on the nursing care plan for an
immunosuppressed client: The client will remain free from infection
throughout hospitalization. This statement is an example of a (an):
1. Nursing diagnosis
2. Short-term goal
3. Long-term goal
4. Expected outcome
13. The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged
erythema at incision site; and client remains afebrile. These statements are
examples of:
1. Nursing interventions
2. Short-term goals
3. Long-term goals
4. Expected outcomes.
14. The planning step of the nursing process includes which of the following
activities?
1. Assessing and diagnosing
2. Evaluating goal achievement.
3. Performing nursing actions and documenting them.
4. Setting goals and selecting interventions.
15. The nursing care plan is:
1. A written guideline for implementation and evaluation.
2. A documentation of client care.
3. A projection of potential alterations in client behaviors
4. A tool to set goals and project outcomes.
16. After determining a nursing diagnosis of acute pain, the nurse develops
the following appropriate client-centered goal:
1. Encourage client to implement guided imagery when pain begins.
2. Determine effect of pain intensity on client function.
3. Administer analgesic 30 minutes before physical therapy treatment.
4. Pain intensity reported as a 3 or less during hospital stay.
17. When developing a nursing care plan for a client with a fractured right
tibia, the nurse includes in the plan of care independent nursing interventions,
including:
1. Apply a cold pack to the tibia.
2. Elevate the leg 5 inches above the heart.
3. Perform range of motion to right leg every 4 hours.
4. Administer aspirin 325 mg every 4 hours as needed.
18. Which of the following nursing interventions are written correctly? (Select
all that apply.)
1. Apply continuous passive motion machine during day.
2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift.
19. A clients wound is not healing and appears to be worsening with the
current treatment. The nurse first considers:
1. Notifying the physician.
2. Calling the wound care nurse
3. Changing the wound care treatment.
4. Consulting with another nurse.
20. When calling the nurse consultant about a difficult client-centered
problem, the primary nurse is sure to report the following:
1. Length of time the current treatment has been in place.
2. The spouses reaction to the clients dressing change.
3. Clients concern about the current treatment.
4. Physicians reluctance to change the current treatment plan.
21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a
difficult nursing problem. The primary nurse is obligated to:
1. Implement the specialists recommendations.
2. Report the recommendations to the primary physician.
3. Clarify the suggestions with the client and family members.
4. Discuss and review advised strategies with CNS.
22. After assessing the client, the nurse formulates the following diagnoses.
Place them in order of priority, with the most important (classified as high)
listed first.
1. Constipation
2. Anticipated grieving
3. Ineffective airway clearance
4. Ineffective tissue perfusion.
23. The nurse is reviewing the critical paths of the clients on the nursing unit.
In performing a variance analysis, which of the following would indicate the
need for further action and analysis?
1. A clients family attending a diabetic teaching session.
2. Canceling physical therapy sessions on the weekend.
3. Normal VS and absence of wound infection in a post-op client.
4. A client demonstrating accurate medication administration following teaching.
24. The RN has received her client assignment for the day-shift. After making
the initial rounds and assessing the clients, which client would the RN need to
develop a care plan first?
1. A client who is ambulatory.
2. A client, who has a fever, is diaphoretic and restless.
3. A client scheduled for OT at 1300.
4. A client who just had an appendectomy and has just received pain medication.
Answers and Rationale
1. A
2. B
3. D
4. B
5. A
6. C
7. B
8. B
9. A
10. D
11. D
12. B
13. D
14. D
15. A
16. D. This is measurable and objective.
17. B. This does not require a physicians order. (A & D require an order; C is not
appropriate for a fractured tibia)
18. C. It is specific in what to do and when.
19. B. Calling in the wound care nurse as a consultant is appropriate because he or
she is a specialist in the area of wound management. Professional and competent
nurses recognize limitations and seek appropriate consultation. (a. This might be
appropriate after deciding on a plan of action with the wound care nurse specialist.
The nurse may need to obtain orders for special wound care products.
c. Unless the nurse is knowledgeable in wound management, this could delay
wound healing. Also, the current wound management plan could have been
ordered by the physician. d. Another nurse most likely will not be knowledgeable
about wounds, and the primary nurse would know the history of the wound
management plan.)
20. A. This gives the consulting nurse facts that will influence a new plan.
(b, c, and d. These are all subjective and emotional issues/conclusions about the
current treatment plan and may cause a bias in the decision of a new treatment plan
by the nurse consultant.)
21. D. Because the primary nurse requested the consultation, it is important that
they communicate and discuss recommendations. The primary nurse can then
accept or reject the CNS recommendations. (a. Some of the recommendations may
not be appropriate for this client. The primary nurse would know this information.
A consultation requires review of the recommendations, but not immediate
implementation. b. This would be appropriate after first talking with the CNS
about recommended changes in the plan of care and the rationale. Then the
primary nurse should call the physician. c. The client and family do not have the
knowledge to determine whether new strategies are appropriate or not. Better to
wait until the new plan of care is agreed upon by the primary nurse and physician
before talking with the client and/or family.)
22. C, D, A, B.
23. B.
24. B. This clients needs are a priority.


NCLEX Exam: Legal and Ethical
Considerations (65 Items)
1. The best explanation of what Title VI of the Civil Rights Act mandates is
the freedom to:
1. Pick any physician and insurance company despite ones income
2. Receive free medical benefits as needed within the county of residence
3. Have equal access to all health care regardless of race and religion
4. Have basic care with a sliding scale payment plan from all health care facilities
2. Which statement would best explain the role of the nurse when planning
care for a culturally diverse population? The nurse will plan care to:
1. Include care that is culturally congruent with the staff from predetermined
criteria
2. Focus only on the needs of the client, ignoring the nurses beliefs and practices
3. Blend the values of the nurse that are for the good of the client and minimize the
clients individual values and beliefs during care
4. Provide care while aware of ones own bias, focusing on the clients individual
needs rather than the staffs practices
3. Which factor is least significant during assessment when gathering
information about cultural practices?
1. Language, timing
2. Touch, eye contact
3. Biocultural needs
4. Pain perception, management expectations
4. Transcultural nursing implies:
1. Using a comparative study of cultures to understand similarities and differences
across human groups to provide specific individualized care that is culturally
appropriate
2. Working in another culture to practice nursing within their limitations
3. Combining all cultural beliefs into a practice that is a nonthreatening approach
to minimize cultural barriers for all clients equality of care
4. Ignoring all cultural differences to provide the best generalized care to all
clients.
5. What should the nurse do when planning nursing care for a client with a
different cultural background? The nurse should:
1. Allow the family to provide care during the hospital stay so no rituals or
customs are broken
2. Identify how these cultural variables affect the health problem
3. Speak slowly and show pictures to make sure the client always understands
4. Explain how the client must adapt to hospital routines to be effectively cared for
while in the hospital
6. Which activity would not be expected by the nurse to meet the cultural
needs of the client?
1. Promote and support attitudes, behaviors, knowledge, and skills to respectfully
meet clients cultural needs despite the nurses own beliefs and practices
2. Ensure that the interpreter understands not only the language of the client but
feelings and attitudes behind cultural practices to make sure an ethical balance can
be achieved
3. Develop structure and process for meeting cultural needs on a regular basis and
means to avoid overlooking these needs with clients
4. Expect the family to keep an interpreter present at all times to assist in meeting
the communication needs all day and night while hospitalized
7. Ethical principles for professional nursing practice in a clinical setting are
guided by the principles of conduct that are written as the:
1. American Nurses Associations (ANAs) Code of Ethics
2. Nurse Practice Act (NPA) written by state legislation
3. Standards of care from experts in the practice field
4. Good Samaritan laws for civil guidelines
8. A bioethical issue should be described as:
1. The physicians making all decisions of client management without getting input
from the client
2. A research project that included treating all the white men and not treating all
the black men to compare the outcomes of a specific drug therapy.
3. The withholding of food and treatment at the request of the client in a written
advance directive given before a client acquired permanent brain damage from an
accident.
4. After the client gives permission, the physicians disclosing all information to
the family for their support in the management of the client.
9. When the nurse described the client as that nasty old man in 354, the
nurse is exhibiting which ethical dilemma?
1. Gender bias and ageism
2. HIPPA violation
3. Beneficence
4. Code of ethics violation
10. The distribution of nurses to areas of most need in the time of a nursing
shortage is an example of:
1. Utilitarianism theory
2. Deontological theory
3. Justice
4. Beneficence
11. Nurses are bound by a variety of laws. Which description of a type of law
is correct?
1. Statutory law is created by elected legislature, such as the state legislature that
defines the Nurse Practice Act (NPA).
2. Regulatory law includes prevention of harm for the public and punishment for
those laws that are broken.
3. Common law protects the rights of the individual within society for fair and
equal treatment.
4. Criminal law creates boards that pass rules and regulations to control society.
12. Besides the Joint Commission on Accreditation of Healthcare
Organizations (JACHO), which governing agency regulates hospitals to allow
continued safe services to be provided, funding to be received from the
government and penalties if guidelines are not followed?
1. Board of Nursing Examiners (BNE)
2. Nurse Practice Act (NPA)
3. American Nurses Association (ANA)
4. Americans With Disabilities Act (ADA)
13. When a client is confused, left alone with the side rails down, and the bed
in a high position, the client falls and breaks a hip. What law has been
broken?
1. Assault
2. Battery
3. Negligence
4. Civil tort
14. When signing a form as a witness, your signature shows that the client:
1. Is fully informed and is aware of all consequences.
2. Was awake and fully alert and not medicated with narcotics.
3. Was free to sign without pressure
4. Has signed that form and the witness saw it being done
15. Which criterion is needed for someone to give consent to a procedure?
1. An appointed guardianship
2. Unemancipated minor
3. Minimum of 21 years or older
4. An advocate for a child
16. Which statement is correct?
1. Consent for medical treatment can be given by a minor with a sexually
transmitted disease (STD).
2. A second trimester abortion can be given without state involvement.
3. Student nurses cannot be sued for malpractice while in a nursing clinical class.
4. Nurses who get sick and leave during a shift are not abandoning clients if they
call their supervisor and leave a message about their emergency illness.
17. Most litigation in the hospital comes from the:
1. Nurse abandoning the clients when going to lunch
2. Nurse following an order that is incomplete or incorrect
3. Nurse documenting blame on the physician when a mistake is made
4. Supervisor watching a new employee check his or her skills level
18. The nurse places an aquathermia pad on a client with a muscle sprain.
The nurse informs the client the pad should be removed in 30 minutes. Why
will the nurse return in 30 minutes to remove the pad?
1. Reflex vasoconstriction occurs.
2. Reflex vasodilation occurs.
3. Systemic response occurs.
4. Local response occurs.
19. A client has recently been told he has terminal cancer. As the nurse enters
the room, he yells, My eggs are cold, and Im tired of having my sleep
interrupted by noisy nurses! The nurse may interpret the clients behavior
as:
1. An expression of the anger stage of dying
2. An expression of disenfranchised grief
3. The result of maturational loss
4. The result of previous losses
20. When helping a person through grief work, the nurse knows:
1. Coping mechanisms that were effective in the past are often disregarded in
response to the pain of a loss
2. A persons perception of a loss has little to do with the grieving process.
3. The sequencing of stages of grief may occur in order, they may be skipped, or
they may recur.
4. Most clients want to be left alone.
21. A client is hospitalized in the end stage of terminal cancer. His family
members are sitting at his bedside. What can the nurse do to best aid the
family at this time?
1. Limit the time visitors may stay so they do not become overwhelmed by the
situation.
2. Avoid telling family members about the clients actual condition so they will not
lose hope.
3. Discourage spiritual practices because this will have little connection to the
client at this time.
4. Find simple and appropriate care activities for the family to perform.
22. When caring for a terminally ill client, it is important for the nurse
maintain the clients dignity. This can be facilitated by:
1. Spending time to let clients share their life experiences
2. Decreasing emphasis on attending to the clients appearance because it only
increases their fatigue
3. Making decisions for clients so they do not have to make them
4. Placing the client in a private room to provide privacy at all times
23. What are the stages of dying according to Elizabeth Kubler-Ross?
1. Numbing; yearning and searching; disorganization and despair; and
reorganization.
2. Accepting the reality of loss, working through the pain of grief, adjusting to the
environment without the deceased, and emotionally relocating the deceased and
moving on with life.
3. Anticipatory grief, perceived loss, actual loss, and renewal.
4. Denial, anger, bargaining, depression, and acceptance.
24. Bereavement may be defined as:
1. The emotional response to loss.
2. The outward, social expression of loss.
3. Postponing the awareness of the reality of the loss.
4. The inner feeling and outward reactions of the survivor.
25. A client who had a Do Not Resuscitate order passed away. After
verifying there is no pulse or respirations, the nurse should next:
1. Have family members say goodbye to the deceased.
2. Call the transplant team to retrieve vital organs.
3. Remove all tubes and equipment (unless organ donation is to take place), clean
the body, and position appropriately.
4. Call the funeral director to come and get the body.
26. A clients family member says to the nurse, The doctor said he will
provide palliative care. What does that mean? The nurses best response is:
1. Palliative care is given to those who have less than 6 months to live.
2. Palliative care aims to relieve or reduce the symptoms of a disease.
3. The goal of palliative care is to affect a cure of a serious illness or disease.
4. Palliative care means the client and family take a more passive role and the
doctor focuses on the physiological needs of the client. The location of death will
most likely occur in the hospital setting.
27. Which of the following is not included in evaluating the degree of heritage
consistency in a client?
1. Gender
2. Culture
3. Ethnicity
4. Religion
28. When providing care to clients with varied cultural backgrounds, it is
imperative for the nurse to recognize that:
1. Cultural considerations must be put aside if basic needs are in jeopardy.
2. Generalizations about the behavior of a particular group may be inaccurate.
3. Current health standards should determine the acceptability of cultural practices.
4. Similar reactions to stress will occur when individuals have the same cultural
background.
29. To respect a clients personal space and territoriality, the nurse:
1. Avoids the use of touch
2. Explains nursing care and procedures
3. Keeps the curtains pulled around the clients bed
4. Stands 8 feet away from the bed, if possible.
30. To be effective in meeting various ethnic needs, the nurse should:
1. Treat all clients alike.
2. Be aware of clients cultural differences.
3. Act as if he or she is comfortable with the clients behavior.
4. Avoid asking questions about the clients cultural background.
31. The most important factor in providing nursing care to clients in a specific
ethnic group is:
1. Communication
2. Time orientation
3. Biological variation
4. Environmental control
32. A health care issue often becomes an ethical dilemma because:
1. A clients legal rights coexist with a health professionals obligation.
2. Decisions must be made quickly, often under stressful conditions.
3. Decisions must be made based on value systems.
4. The choices involved do not appear to be clearly right or wrong.
33. A document that lists the medical treatment a person chooses to refuse if
unable to make decisions is the:
1. Durable power of attorney
2. Informed consent
3. Living will
4. Advance directives
34. Which statement about an institutional ethics committee is correct?
1. The ethics committee is an additional resource for clients and health care
professionals.
2. The ethics committee relieves health care professionals from dealing with
ethical issues.
3. The ethics committee would be the first option in addressing an ethical dilemma.
4. The ethics committee replaces decision making by the client and health care
providers.
35. The nurse is working with parents of a seriously ill newborn. Surgery has
been proposed for the infant, but the chances of success are unclear. In
helping the parents resolve this ethical conflict, the nurse knows that the first
step is:
1. Exploring reasonable courses of action
2. Collecting all available information about the situation
3. Clarifying values related to the cause of the dilemma.
4. Identifying people who can solve the difficulty.
36. Miss Mary, an 88-year old woman, believes that life should not be
prolonged when hope is gone. She has decided that she does not want
extraordinary measures taken when her life is at its end. Because she feels this
way, she has talked with her daughter about her desires, completing a living
will and left directions with her physician. This is an example of:
1. Affirming a value
2. Choosing a value
3. Prizing a value
4. Reflecting a value
37. The scope of Nursing practice is legally defined by:
1. State nurses practice acts
2. Professional nursing organizations
3. Hospital policy and procedure manuals
4. Physicians in the employing institutions
38. A student nurse who is employed as a nursing assistant may perform any
functions that:
1. Have been learned about in school
2. Are expected of a nurse at that level
3. Are identified in the positions job description
4. Require technical rather than professional skill.
39. A confused client who fell out of bed because side rails were not used is an
example of which type of liability?
1. Felony
2. Assault
3. Battery
4. Negligence
40. The nurse puts a restraint jacket on a client without the clients
permission and without the physicians order. The nurse may be guilty of:
1. Assault
2. Battery
3. Invasion of privacy
4. Neglect
41. In a situation in which there is insufficient staff to implement competent
care, a nurse should:
1. Organize a strike
2. Inform the clients of the situation
3. Refuse the assignment
4. Accept the assignment but make a protest in writing to the administration.
42. Which statement about loss is accurate?
1. Loss is only experienced when there is an actual absence of something valued.
2. The more the individual has invested in what is lost, the less the feeling of loss.
3. Loss may be maturational, situational, or both.
4. The degree of stress experienced is unrelated to the type of loss.
43. Trying questionable and experimental forms of therapy is a behavior that
is characterized of which stage of dying?
1. Anger
2. Depression
3. Bargaining
4. Acceptance
44. All of the following are crucial needs of the dying client except:
1. Control of pain
2. Preservation of dignity and self-worth
3. Love and belonging
4. Freedom from decision making
45. Cultural awareness is an in-depth self-examination of ones:
1. Background, recognizing biases and prejudices.
2. Social, cultural, and biophysical factors
3. Engagement in cross-cultural interactions
4. Motivation and commitment to caring.
46. Cultural competence is the process of:
1. Learning about vast cultures
2. Acquiring specific knowledge, skills, and attitudes
3. Influencing treatment and care of clients
4. Motivation and commitment to caring.
47. Ethnocentrism is the root of:
1. Biases and prejudices
2. Meanings by which people make sense of their experiences.
3. Cultural beliefs
4. Individualism and self-reliance in achieving and maintaining health.
48. When action is taken on ones prejudices:
1. Discrimination occurs
2. Sufficient comparative knowledge of diverse groups is obtained.
3. Delivery of culturally congruent care is ensured.
4. People think/know you are a dumbass for being prejudiced.
49. The dominant value orientation in North American society is:
1. Use of rituals symbolizing the supernatural.
2. Group reliance and interdependence
3. Healing emphasizing naturalistic modalities
4. Individualism and self-reliance in achieving and maintaining health.
50. Disparities in health outcomes between the rich and the poor illustrates: a
(an)
1. Illness attributed to natural, impersonal, and biological forces.
2. Creation of own interpretation and descriptions of biological and psychological
malfunctions.
3. Influence of socioeconomic factors in morbidity and mortality.
4. Combination of naturalistic, religious, ad supernatural modalities.
51. Culture strongly influences pain expression and need for pain medication.
However, cultural pain:
1. May be suffered by a client whose valued way of life is disregarded by
practitioners.
2. Is more intense, thus necessitating more medication.
3. Is not expressed verbally or physically
4. Is expressed only to others of like culture.
52. The dominant values in American society on individual autonomy and
self-determination:
1. Rarely have an effect on other cultures
2. Do have an effect on health care
3. May hinder ability to get into a hospice program
4. May be in direct conflict with diverse groups.
53. In the United States, access to health care usually depends on a clients
ability to pay for health care, either through insurance or by paying cash. The
client the nurse is caring for needs a liver transplant to survive. This client has
been out of work for several months and does not have insurance or enough
cash. A discussion about the ethics of this situation would involve
predominantly the principle of:
1. Accountability, because you as the nurse are accountable for the well being of
this client.
2. Respect of autonomy, because this clients autonomy will be violated if he does
not receive the liver transplant.
3. Ethics of care, because the caring thing that a nurse could provide this patient is
resources for a liver transplant.
4. Justice, because the first and greatest question in this situation is how to
determine the just distribution of resources.
54. The code of ethics for nurses is composed and published by:
1. The national league for Nursing
2. The American Nurses Association
3. The Medical American Association
4. The National Institutes of Health, Nursing division.
55. Nurses agree to be advocates for their patients. Practice of advocacy calls
for the nurse to:
1. Seek out the nursing supervisor in conflicting situations
2. Work to understand the law as it applies to the clients clinical condition.
3. Assess the clients point of view and prepare to articulate this point of view.
4. Document all clinical changes in the medical record in a timely manner.
56. Successful ethical discussion depends on people who have a clear sense of
personal values. When many people share the same values it may be possible
to identify a philosophy of utilitarianism, with proposes that:
1. The value of people is determined solely by leaders in the Unitarian church.
2. The decision to perform a lover transplant depends on a measure of the moral
life that the client has led so far.
3. The best way to determine the solution to an ethical dilemma is to refer the case
to the attending physician.
4. The value of something is determined by its usefulness to society.
57. The philosophy sometimes called the code of ethics of care suggests that
ethical dilemmas can best be solved by attention to:
1. Relationships
2. Ethical principles
3. Clients
4. Code of ethics for nurses.
58. In most ethical dilemmas, the solution to the dilemma requires negotiation
among members of the health care team. The nurses point of view is valuable
because:
1. Nurses have a legal license that encourages their presence during ethical
discussions.
2. The principle of autonomy guides all participants to respect their own self-
worth.
3. Nurses develop a relationship to the client that is unique among all professional
health care providers.
4. The nurses code of ethics recommends that a nurse be present at any ethical
discussion about client care.
59. Ethical dilemmas often arise over a conflict of opinion. Once the nurse has
determined that the dilemma is ethical, a critical first step in negotiating the
difference of opinion would be to:
1. Consult a professional ethicist to ensure that the steps of the process occur in
full.
2. Gather all relevant information regarding the clinical, social, and spiritual
aspects of the dilemma.
3. List the ethical principles that inform the dilemma so that negotiations agree on
the language of the discussion.
4. Ensure that the attending physician has written an order for an ethics
consultation to support the ethics process.
60. The nurse practice acts are an example of:
1. Statutory law
2. Common law
3. Civil law
4. Criminal law
61. The scope of Nursing Practice, the established educational requirements
for nurses, and the distinction between nursing and medical practice is
defined by:
1. Statutory law
2. Common law
3. Civil law
4. Nurse practice acts
62. The clients right to refuse treatment is an example of:
1. Statutory law
2. Common law
3. Civil laws
4. Nurse practice acts
63. Even though the nurse may obtain the clients signature on a form,
obtaining informed consent is the responsibility of the:
1. Client
2. Physician
3. Student nurse
4. Supervising nurse.
64. The nurse is obligated to follow a physicians order unless:
1. The order is a verbal order
2. The physicians order is illegible
3. The order has not been transcribed
4. The order is an error, violates hospital policy, or would be detrimental to the
client.
65. The nursing theorist who developed transcultural nursing theory is
1. Dorothea Orem
2. Madeleine Leininger
3. Betty Newman
4. Sr. Callista Roy
Answers and Rationale
1. C.
2. D. Without understanding ones own beliefs and values, a bias or preconceived
belief by the nurse could create an unexpected conflict or an area of neglect in the
plan of care for a client (who might be expecting something totally different from
the care). During assessment values, beliefs, practices should be identified by the
nurse and used as a guide to identify the choices by the nurse to meet specific
needs/outcomes of that client. Therefore identification of values, beliefs, and
practices allows for planning meaningful and beneficial care specific for this client.
3. C. Cultural practices do not influence biocultural needs because they are inborn
risks that are related to a biological need and not a learned cultural belief or
practice.
4. A. Transcultural care means that by understanding and learning about specific
cultural practices the nurse can integrate these practices into the plan of care for a
specific individual client who has the same beliefs or practices to meet the clients
needs in a holistic manner of care.
5. B. Without assessment and identification of the cultural needs, the nurse cannot
begin to understand how these might influence the health problem or health care
management.
6. D. It is not the familys responsibility to assist in the communication process.
Many families will leave someone to help at times, but it is the hospitals legal
obligation to find an interpreter for continued understanding by the client to make
sure the client is fully informed and comprehends in his or her primary language.
7. A. This set of ethical principles provides the professional guidelines established
by the ANA to maintain the highest standards for ideal conduct in practice. As a
profession, the ANA wanted to establish rules and then incorporate guidelines for
accountability and responsibility of each nurse within the practice setting.
8. B. The ethical issue was the inequality of treatment based strictly upon racial
differences. Secondly, the drug was deliberately withheld even after results showed
that the drug was working to cure the disease process in the white men for many
years. So after many years, the black men were still not treated despite the outcome
of the research process that showed the drug to be effective in controlling the
disease early in the beginning of the research project. Therefore harm was done.
Nonmaleficence, veracity, and justice were not followed.
9. A. Stereotyping an old man as nastyis a gender bias and an ageism issue.
The nurse is verbalizing a negative descriptor about the client.
10. C. Justice is defined as the fairness of distribution of resources. However,
guidelines for a hierarchy of needs have been established, such as with organ
transplantation. Nurses are moved to areas of greatest need when shortages occur
on the floors. No floor is left without staff, and another floor that had five staff will
give up two to go help the floor that had no staff.
11. A. Statutory law is created by legislature. It creates statues such as the NPA,
which defines the role of the nurse and expectations of the performance of ones
duties and explains what is contraindicated as guidelines for breech of those
regulations.
12. D. If the hospital fails to follow ADA guidelines for meeting special needs, the
facility loses funding and status for receiving low-income loans or reimbursement
of expenses. ADA protects the civil rights of disabled people. It applies to both the
hospital clients and hospital staff. Privacy issues for persons who are positive for
human immunodeficiency virus (HIV) have been one issue in relationship to
getting information when hospital staff have been exposed to unclean sticks. The
ADA allows the infected client the right to choose whether or not to disclose that
information.
13. C. Knowing what to do to prevent injury is a part of the standards of care for
nurses to follow. Safety guidelines dictate raising the side rails, staying with the
client, lowering the bed, and observing the client until the environment is safe. As
a nurse, these activities are known as basic safety measures that prevent injuries,
and to not perform them is not acting in a safe manner. Negligence is conduct that
falls below the standard of care that protects others against unreasonable risk of
harm.
14. D. Your signature as a witness only states that the person signing the form was
the person who was listed in the procedure.
15. A. A guardian has been appointed by a court and has full legal rights to choose
management of care.
16. A. Anyone, at any age, can be treated without parental permission for an STD
infection. The client is advised to contact sexual partners but is not required to
give names. Permission from parents is not needed, based upon current privacy
laws.
17. B. The nurse is responsible for clarifying all orders that are illegible,
unreasonable, unsafe, or incorrect. The failure of the nurse to question the
physician about an order creates an area of liability on the nurses part because this
is perceived as a medical action and not the role of the nurse to write orders. Some
RNs do have prescriptive privileges based upon advanced degrees and
certification. Therefore the nurse who cannot correct the order must document that
the physician was called and clarification or a new order was given to correct the
unclear or illegible one that was currently on the chart. Phone calls, follow-up, and
lack of follow-up by the physician should also be documented if there is a problem
with getting the information in a timely manner. The nurse must show the
sequence of events of a situation in a clear manner if there is any conflict or
question about any orders or procedures that were not appropriate. Assessments
and documentation of the clients status should also be included if there is a
potential risk for harm present. Contact of the staffs chain of command should
also be specifically stated for the proof of the responsibilities being followed
according to hospital policy.
18. A. If heat is applied for 1 hour or more, blood flow is reduced by reflex
vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat
application
19. a. In the anger stage of Kubler-Rosss stages of dying, the individual resists the
loss and may strike out at everyone and everything, in this case, the nurse.
20. C. Grief is manifested in a variety of ways that are unique to an individual and
based on personal experiences, cultural expectations, and spiritual beliefs. The
sequencing of stages or behaviors of grief may occur in order, they may be
skipped, or they may reoccur. The amount of time to resolve grief also varies
among individuals.
21. D. It is helpful for the nurse to find simple care activities for the family to
perform, such as feeding the client, washing the clients face, combing hair, and
filling out the clients menu. This helps the family demonstrate their caring for the
client and enables the client to feel their closeness and concern. a. Older adults
often become particularly lonely at night and may feel more secure if a family
member stays at the bedside during the night. The nurse should allow visitors to
remain with dying clients at any time if the client wants them. It is up to the family
to determine if they are feeling overwhelmed, not the nurse.
22. A. Spending time to let clients share their life experiences enables the nurse to
know clients better. Knowing clients then facilitates choice of therapies that
promote client decision making and autonomy, thus promoting a clients self-
esteem and dignity.
23. D.
24. D.
25. C. The body of the deceased should be prepared before the family comes in to
view and say their goodbyes. This includes removing all equipment, tubes,
supplies, and dirty linens according to protocol, bathing the client, applying clean
sheets, and removing trash from the room.
26. B. The goal of palliative care is the prevention, relief, reduction, or soothing of
symptoms of disease or disorders without effecting a cure.
27. A.
28. B.
29. B.
30. B.
31. A.
32. D.
33. D.
34. A.
35. B.
36. C.
37. A.
38. C.
39. D.
40. B.
41. D.
42. C.
43. C.
44. D.
45. A. Cultural awareness is an in-depth examination of ones own background,
recognizing biases and prejudices and assumptions about other people.
46. B. Cultural competence is the process of acquiring specific knowledge, skills,
and attitudes that ensure delivery of culturally congruent care.
47. A.
48. A.
49. D.
50. C. Disparities in health outcomes between the rich and the poor illustrate the
influence of socioeconomic factors in morbidity and mortality. Social factors such
as poverty and lack of universal medical insurance compromise the health status of
the poor and unemployed.
51. A. Nurses need not assume that pain relief is equally valued across groups.
Cultural pain may be suffered by a client whose valued way of life is disregarded
by practitioners.
52. D. The dominant value in American society of individual autonomy and self-
determination may be in direct conflict with diverse groups. Advance directives,
informed consent, and consent for hospice are examples of mandates that my
violate clients values.
53. D. Justice refers to fairness. Health care providers agree to strive for justice in
health care. The term often is used during discussions about resources. Decisions
about who should receive available organs are always difficult.
54. B. the ANA has established widely accepted codes that professional nurses
attempt to follow.
55. C. Nurses strengthen their ability to advocate for a client when nurses are able
to identify personal values and then accurately identify the values of the client and
articulate the clients point of view.
56. D. A utilitarian system of ethics proposes that the value of something is
determined by its usefulness.
57. A. The ethic of care explores the notion of care as a central activity of human
behavior. Those who write about the ethics of care advocate a more female biased
theory that is based on understanding relationships, especially personal narratives.
58. C. When ethical dilemmas arise, the nurses point of view unique and critical.
The nurse usually interacts with clients over longer time intervals than do other
disciples.
59. B. Each step in the processing of an ethical dilemma resembles steps in critical
thinking. The nurse begins by gathering information and moves through
assessment, identification of the problem, planning, implementation, and
evaluation.
60. A.
61. D.
62. B.
63. B.
64. D.
65. (B) Madeleine Leininger. Madeleine Leininger developed the theory on
transcultural theory based on her observations on the behavior of selected people
within a culture.