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1. Two days post-op, Nurse Rhea observes that the
abdominal incision of patient Robert is red, hot
and swollen. She remarks to Nurse Rhonda that
the patient is having an infection. This is an
example of a/an:
A. Fact

B. Judgment

C. Inference

D. Opinion
ï. A Nurse is practicing critical
thinking with intellectual humility
when he/ she is:
A. Willing to seek new information which admittedly is
unknown to him/ her.
B. Thinking independently with consideration to wide range
of ideas.

C. Assessing all viewpoints with same standards and not


basing judgements on personal biases.
D. Perseveres in finding effective solutions
¢. A 60 year old male client suffers from expressive
aphasia after a cardiovascular attack. When the
nurse asks the client how he is feeling, his wife
answers for him. The nurse should:
A. Return later to speak to the client after the wife has gone
home.

B. Tell the wife to allow the client to speak for himself.

C. Ask the wife how she knows how the client is feeling.

D. Acknowledge the wife but look at the client for response.


Ä. Which of the following is a correctly stated
nursing diagnosis?
A. Pain related to severe headache

B. Fluid Replacement related to fever

C. Impaired skin integrity related to improper positioning

D. Altered thought process possibly related to unfamiliar


surroundings
K. Which is a correct goal/ desirable outcome?

A. Client drinks ïK00 ml of fluid.

B. Client recalls K symptoms of diabetes before discharge.

C. Client ͚s ankle measures less than 10 inches in circumference.

D. Client walks the length of the hall in a cane.


6. The client requests that his family members be
allowed to stay overnight with him in his room. To
determine whether this request can be honoured,
the nurse needs to consult the:
A. Hospital policies

B. Orthopedic Protocols

C. Standardized careplan

D. Organizational Chart
V. Which step of the implementing phase of the
nursing process is done first?

A. Carrying out nursing orders

B. Reassessing the client

C. Determining the need for assistance

D. Documenting interventions
. Which charting entry would be the most
defensible in court?
A. Client fell out of bed.

B. Client drunk on admission.

C. Large bruise on left thigh.

D. Notified Dr. Jones of BP of 90/Ä0.


9. The case management model using critical
pathways would be appropriate for client with
which diagnosis?
A. Myocardial Infarction

B. Diabetes Mellitus, Hypertension

C. Myocardial Infarction, Diabetes Mellitus, Hypertension

D. Diabetes Mellitus, Hypertension, infected foot ulcer,


senile dementia
10. Telephone Orders are often relayed in
Princeton Plainsborough Hospital. Which of the
following correctly follows the guidelines?
A. Nurse Jem writes down Dr. Cameron͛s order, repeats it back to her as ï0 u of insulin
every 6 hours, trascribes it onto the physician͛s order sheet with remarks of VO

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11. The new nurse supervisor conducts an evaluation of
the level of care provided to clients. Which question
allows her to assess the demonstrable changes in the
client͛s health status as a result of nursing care?
A. How many clients who have colostomy experience an infection that
delays discharge?

B. 
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C. Are equipments in the nurses station functional?

D. Do nurses perform and record chest assessment including


auscultation once/ shift?
1ï. An elderly client refuses to have her blood pressure
taken during rounds. What should the nurse do?

A. Leave the patient and come back at a later time

B. Stay with the patient and explore her reasons for refusal

C. Sit with the client and allow her time to gather her thoughts

D. Ask her assigned nurse yesterday to take over.


1¢. The client has a high priority nursing diagnosis of Risk for
Impaired Skin Integrity related to the need for several weeks of
imposed bed rest. When evaluating the care plan after one week,
the nurse finds the client has not developed impaired skin integrity.
The most appropriate action with regards to the care plan would be
to:
A. Delete the diagnosis since the problem has not occurred.

B. Keep the diagnosis since the risk factors are still


present.
C. Modify the nursing diagnosis to impaired mobility

D. Denote the nursing diagnosis to a lower priority.


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