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Mary Ann Hogan RN, MSN, Mary Jean Ricci, Carl Ross
1. The nurse has explained a therapeutic diet to a client. To ensure that learning
has occurred, the nurse should do which of the following?
Rationale: It is important for the nurse to listen to the feedback given by the client
to ensure the message sent was the message received. Repetition is important in
the teaching process but does not evaluate clients' understanding (option 1).
Options 3 and 4 are unnecessary as part of evaluation.
Strategy: The critical phrase is to ensure learning has occurred. In cognitive learning
the nurse should listen to the client's verbalization of information to evaluate
learning.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 465.
2. A nurse is trying to establish whether an unconscious client can
communicate. Which of the following would be the best approach for the nurse to
use?
The correct answer was: Ask questions that elicit a single act or response
Strategy: The critical words are best approach. Remember that even if a client is
unconscious, hearing may be present. Keep statements simple. Questioning should
be yes/no.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 438.
3. A client who is blind has been admitted to the cardiac unit. Which of the
following actions by the nurse would be best to promote adjustment to the
environment?
Rationale: A client who is blind does not have the benefit of nonverbal cues to
facilitate communication. It is important for the nurse to respond vocally to the
client's needs. Options 1 and 4 are approaches that a nurse should use with a client
who is hearing impaired. Placing a sign on the client's door encroaches on
confidentiality.
Client Need: Safe, Effective Care Environment: Safety and Infection Control
Strategy: The critical words are blind and promote adjustment. Remember to
always announce your presence to visually impaired client, familiarize the client
with environment, and keep the environment consistent.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 948-949.
You answered incorrectly: Each time the nurse provides care; Whenever the client's
condition changes; After returning to the unit following an endoscopic procedure
The correct answers were: Whenever the client's condition changes; After returning
to the unit following an endoscopic procedure
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 337-338.
The correct answer was: Ensure safety and continuity of care for client
Strategy: The critical words are client information shared and consulting nutritionist.
Recall that nurses collaborate to share information to implement plan of care,
ensure client safety and provide continuity of care.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 340.
Strategy: Note that the critical words are record review. Recall that maintaining a
client's confidentiality is a key nursing responsibility to aid in making the correct
selection.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 28-29.
You answered correctly: Organize the record according to client's specific needs or
problems.
Strategy: The critical words are problem oriented format. Recall that in problem
oriented charting, the medical record has a problem list in the front of the chart to
guide care and documentation.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 330-331.
8. Which of the following would be the best method for the nurse to use in
describing a client's emotional state when charting?
Strategy: The critical words are best method and emotional state. Recall that to
document any client problem, it is important to include both subjective and
objective data.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 341.
9. The home care nurse has asked the client to demonstrate self-injection
technique. In doing so, the nurse is primarily attempting to determine which of the
following?
You answered correctly: Client's ability to perform the skill
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 465.
10. The nurse determines that which of the following would be the most
appropriate time to use confrontation as a therapeutic technique in communication?
You answered correctly: When a good relationship exists and client's anxiety level is
low
Strategy: The critical words are most appropriate time and confrontation.
Remember that in order for any communication to be most effective, there should
be a working therapeutic relationship. Reason that since confrontation could
produce anxiety in the client, it is better to do so when the client's baseline anxiety
level is low.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 432.
11. The nurse is working with a student nurse in a psychiatric rotation who will be
interviewing a client. The nurse encourages the student to use which of the
following as the best method to document the interaction?
Rationale: Process recordings are educational tools used to assist student learners
to examine objectively their communication styles and effects on the client.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 440.
12. Which of the following teaching strategies is most likely to be effective for a
nurse to use when providing health instruction to an adolescent client?
You answered correctly: Client contracting
Strategy: The critical words are teaching strategies and adolescent. Recall that
client teaching must be adapted to the client's developmental level to be most
effective. Recall also that a learning contract permits freedom to accomplish goals
and fosters respect which teens may find appealing.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 462.
13. The nurse working in an agency that uses the focus method for charting
would enter which of the following items in the data section of the focus note?
Rationale: The statement "Lungs clear to auscultation" would go under the Data
section using the focus charting method. The Action section records the nursing
intervention used to address a client need. The Response section records the
client's reaction or response to care delivered. Client outcome statements are not a
category used in focus charting.
Strategy: The critical terms are data section and focus charting. Awareness of the
components of common methods of recording will assist the nurse in accurate
documentation. Recall that focused charting utilizes the format of data, action and
response. Since lungs sounds provide information about client status, they are data
and would be charted as such.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 334.
14. The physician is giving the nurse a telephone order for a client. The most
appropriate action by the nurse would be to do which of the following?
You answered correctly: Read back the order to the physician, copy it onto the
physician order sheet, and document it as a telephone order.
Rationale: Repeating the order back to the physician verifies that the nurse has
heard the order correctly. The other options do not represent acceptable nursing
practice. Having another nurse hear the order involves a third person in the
communication process and may not validate the information.
Strategy: The core issue of the question is the safe and appropriate way to
document a telephone order. Remember client safety is the most important aspect
of taking orders over phone and reading back the order ensures that the order that
was recorded was the order given.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 346.
15. A quality improvement nurse has been assigned to complete a record review
of a unit's nursing documentation. The primary goal of the nurse is to do which of
the following?
You answered correctly: Determine that the nursing care received by clients meets
established standards.
Strategy: The critical terms are quality improvement and primary goal. Recall that
quality activities are the way to improve systems and care to help you in making a
selection.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 322-323.
16. A nurse is evaluating a client's ability to change the surgical dressing before
discharge. During the demonstration, the nurse notices the client has not performed
the procedure correctly. What would be the most appropriate action by the nurse?
You answered correctly: Praise client for aspects of procedure done accurately and
correct client's mistakes
Rationale: Praising the client for steps performed correctly provides positive
reinforcement. In addition, explaining the client's mistakes reinforces the correct
way to perform the procedure. For the nurse to re-do the dressing decreases the
client's confidence. Praising the client without correcting the mistakes gives
feedback that the procedure was done correctly. Having the client repeat the
procedure and stating it was done correctly without further guidance does not
reinforce or assist learning.
Strategy: The critical phrase is client has not performed the procedure correctly.
Recall that positive reinforcement fosters learning and that incorrect performance
needs to be corrected in order for the proper learning to occur. Select the option
that provides for both of these.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 465.
17. A facility has recently implemented a critical pathway for clients undergoing
hip replacement surgery. Using the critical pathway, when would the nurse write a
progress note?
The correct answer was: When client does not meet goals as expected
Rationale: Progress notes generally are written when the client does not respond as
expected and does not meet the client care goals. Most critical pathways use
charting by exception when client goals are not met, and these instances are
referred to as variances.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 336.
18. Which of the following would the nurse select as an appropriate nursing
diagnosis for clients attending a community health educational program on accident
prevention for the school-aged child?
Strategy: The core issue of the question is the ability to select an appropriate
nursing diagnosis. Because the ability to use NANDA nursing diagnoses is an
essential nursing skill, review this information now if this question was difficult.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 288.
19. The nurse should write which of the following learning objectives when
developing a teaching plan for an assigned client?
You answered correctly: Prior to discharge the client will identify 4 signs of infection
Strategy: The critical phrase is learning objective. Recall the criteria for learning
objectives and use the process of elimination to make a selection.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, p. 458.
20. A client with diabetes mellitus is not following the recommended diet and is
inconsistent about taking oral antidiabetic medication. When beginning to discuss
this situation with the client, which of the following is most important for the nurse
to do first?
You answered correctly: Find out what the client knows about diabetes mellitus.
Rationale: When presenting information to a client it is important that the nurse find
out what the client already knows and build on the client's existing knowledge. It is
not necessary to consult with a physician or to have family members present. It is
important when teaching to begin with basic concepts and progress to complex.
However, clients may be already aware of the basic concepts. Nurses should always
find out what the client knows first.
Strategy: The critical words are most important and first. This tells you that more
than one option may be correct but that one of them has priority in terms of
sequence. Recall basic education principles to aid in making the correct selection.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall, pp. 452-453.
21. The nurse would ask a client to perform the self injection technique following
the nurse's demonstration during what phase of the nursing process?
Rationale: When teaching a skill to a client the means of evaluation is observing the
client perform the skill to determine if the teaching/learning goal has been reached.
This action represents the evaluation phase of the nursing process.
Strategy: The critical phrases are ask a client to perform and following nurse's
demonstration. Recall that return demonstration is the method used to evaluate a
psychomotor skill.
Reference Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 320.
22. A nurse planning learning activities for a client who needs to learn to self-
inject insulin would choose what activity to involve the client and validate the
client's ability to perform a skill?
Rationale: Return demonstrating is an activity that actively involves the client and
increases learner retention. The other options involve visual (options 1 and 2) and
auditory (option 3) learning, but do not engage the client as fully as when the client
participates actively.
Strategy: Critical words are learning activities and actively involve the client. Recall
that psychomotor skills such as insulin self-injection are demonstrated by the nurse
and followed by client return demonstration.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 449.
23. A nurse who is preparing a teaching plan for a diabetic client assesses the
client's health beliefs, cultural values, and motivation for which specific purpose?
You answered correctly: Increase the likelihood of the client successfully mastering
the material and learning skills.
Rationale: The client is more likely to accept a plan consistent with the client's value
system. If not, the plan may be more difficult for a client to accept, and the nurse
may need to modify it later based on the assessment data. Although the nurse
wants to demonstrate caring (option 1), the assessment is not done at this time to
evaluate learning. Clients are complex and learning about their culture, values and
motivation does not guarantee that the nurse will understand how the client might
respond to the plan of care (option 2). The assessment is broader than just
determining which behaviors by the client need to change to increase the state of
health.
Strategy: Note that the question addresses the broad range of client beliefs, cultural
values, and motivation. Reason that the correct option must also represent a broad
answer.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 453.
24. The nurse concludes that a client who verbalizes an understanding of the
anger she felt after being diagnosed with cancer demonstrates which of the
following?
Strategy: The critical phrase is an understanding of the anger. Consider that anger
is an emotional response to associate it with the affective domain.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 448.
The correct answers were: Explain the purpose of the assessment and what is
involved; Maintain a distance of 3 feet when not actually performing an assessment
technique
Rationale: The client will be less anxious about intimate space being invaded if the
client knows the reason why and how it relates to health care. Ignoring the client's
discomfort sends the message that the client's feelings are not important.
Acknowledging the client's discomfort may be beneficial but is not the best option.
Most clients prefer 3 feet intimate space. Deferring the assessment is not
appropriate nursing practice.
Strategy: The critical term is best approach. To answer the question correctly, recall
that people are generally uncomfortable when healthcare providers are in close
proximity and that explanations tend to ease anxiety regarding unfamiliar
situations.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing; concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, pp. 266-267.
26. A nurse providing teaching on weight reduction compliments the client on
exercising daily. This action will promote the teaching plan by providing the client
with which of the following?
Strategy: The critical phrase is promote the teaching plan. Recall that use of various
techniques for reinforcing positive behavior changes will increase the likelihood
those changes will be maintained and that providing feedback helps one to learn.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 450.
27. When interpreting a client's message it is important for the nurse to assess
which of the following?
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 214.
28. The nurse has been called to "float" to another department to take the place
of a nurse who is going home. Prior to floating, the nurse's first priority should be to:
Strategy: The core issue of the question is the nursing action that takes highest
priority. Keep in mind that clear communication, which includes documentation, is
key to providing safe client care. Eliminate option 1 because the individual client
plans of care may detail the interventions needed by the clients. Putting up all side
rails could be a means of restraint (option 3). Documentation (option 2) takes
priority over telling the client one is floating (option 4).
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, pp. 344-345.
29. After charting in a client's record, the nurse has discovered the charting was
done in the wrong client's chart. How should the nurse correct this problem?
You answered correctly: Draw a line through the information and write "error" and
initial it.
Rationale: The proper way to correct an error is to draw a line through the
information and write the word "error" and initial the above it. All other ways listed
are incorrect because they violate guidelines for legally defensible charting.
Client Need: Safe, Effective Care Environment: Safety and Infection Control
Strategy: The critical phrases are wrong client's chart and correct this error. Recall
that after making an error in the client record, do not erase, blot out, or use
correction fluid.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, p. 342.
You answered correctly: Abbreviations are consistent with the facility's policies
Client Need: Safe, Effective Care Environment: Safety and Infection Control
Strategy: The critical words are acceptable and abbreviations. Apply guidelines for
legal documentation and institutional policies and use the process of elimination to
make a selection.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of
nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson
Education, pp. 342-343.