A tympanic temperature reading is generally considered more accurate than a rectal temperature because it measures core body temperature directly from the eardrum.
Correct Answer
False
Rectal temperature is generally considered the most accurate non-invasive measure of core body temperature, whereas tympanic can be affected by probe placement and cerumen.
Question 2
When assessing a client's respiration rate, the nurse should observe the client's chest rise and fall without informing them, to prevent conscious alteration of breathing patterns.
Correct Answer
True
Patients can consciously alter their breathing patterns if aware they are being observed, leading to an inaccurate respiratory rate measurement.
Question 3
Alcohol-based hand rubs are effective for hand hygiene in all clinical situations, including when hands are visibly soiled or after caring for a patient with Clostridioides difficile.
Correct Answer
False
Alcohol-based hand rubs are not effective against Clostridioides difficile spores or when hands are visibly soiled; soap and water must be used in these situations.
Question 4
Standard precautions are applied to the care of all patients in healthcare settings, regardless of their diagnosis or presumed infection status.
Correct Answer
True
Standard precautions are the minimum infection prevention practices that apply to all patient care, based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.
Question 5
Applying a physical restraint to a confused patient is appropriate primarily to prevent them from interfering with necessary medical treatments, such as pulling out an IV line.
Correct Answer
False
Physical restraints should only be used as a last resort, after all less restrictive alternatives have failed, and primarily to ensure the physical safety of the patient or others, not merely for convenience or to prevent interference with treatment.
Question 6
Incident reports, also known as variance or occurrence reports, are confidential documents used for quality improvement and risk management, and should not be placed in the client's permanent medical record.
Correct Answer
True
Incident reports are internal documents for quality improvement and identifying system issues, not part of the patient's legal medical record.
Question 7
During the assessment phase of the nursing process, the nurse's primary goal is to interpret all collected data and formulate definitive nursing diagnoses.
Correct Answer
False
The primary goal of the assessment phase is to collect comprehensive data about the patient's health status; interpretation and formulation of diagnoses occur in the diagnosis phase.
Question 8
A well-written patient-centered goal in the planning phase of the nursing process should be Specific, Measurable, Achievable, Realistic, and Time-bound (SMART).
Correct Answer
True
SMART goals provide clear targets for patient care and facilitate objective evaluation of outcomes.
Question 9
Charting by exception is a documentation method that involves writing comprehensive narrative notes for all patient care activities, including routine observations.
Correct Answer
False
Charting by exception involves documenting only significant findings or deviations from the norm, assuming all other standards of care are met, to reduce documentation time.
Question 10
The nurse is legally and ethically obligated to maintain the confidentiality of all patient information, as protected by regulations like the Health Insurance Portability and Accountability Act (HIPAA).
Correct Answer
True
Patient confidentiality is a fundamental principle of nursing practice and a legal requirement under regulations such as HIPAA.
Question 11
When performing an abdominal assessment, the correct order of techniques is palpation, auscultation, percussion, and then inspection.
Correct Answer
False
For abdominal assessment, the correct order is inspection, auscultation, percussion, and then palpation, to avoid altering bowel sounds through palpation or percussion.
Question 12
Subjective data in a patient assessment includes information that the patient states or perceives, such as "I feel nauseous" or "My pain is an 8 out of 10."
Correct Answer
True
Subjective data comes directly from the patient's perspective and cannot be directly measured or observed by the nurse.
Question 13
Orthostatic hypotension is indicated by a drop in systolic blood pressure of at least 20 mmHg or in diastolic blood pressure of at least 10 mmHg when changing from a lying to a standing position.
Correct Answer
True
These specific parameters define orthostatic hypotension, which is a significant risk factor for falls and dizziness.
Question 14
Droplet precautions require the use of an N95 respirator mask because the infectious droplets can remain suspended in the air for extended periods.
Correct Answer
False
Droplet precautions require a surgical mask, not an N95 respirator, because droplets are large and travel short distances (typically 3-6 feet) before falling, unlike airborne particles which remain suspended.
Question 15
The use of a gait belt is an appropriate safety measure to assist a patient with ambulation, providing a secure grasp for the nurse to support the patient if they lose balance.
Correct Answer
True
Gait belts enhance patient safety during transfers and ambulation by providing a stable point of contact for the caregiver to maintain control and prevent falls.
Question 16
Nursing interventions are solely dependent actions, meaning they always require a physician's order before the nurse can implement them.
Correct Answer
False
Nursing interventions include independent actions (initiated by the nurse based on their knowledge), dependent actions (requiring a physician's order), and collaborative actions (requiring multiple healthcare disciplines).
Question 17
Accurate and timely documentation serves as a legal record of nursing care provided and can be used in court to demonstrate adherence to professional standards.
Correct Answer
True
Documentation is a crucial legal document that reflects the care provided, the patient's response, and the nurse's actions, and can be used as evidence in legal proceedings.
Question 18
When assessing a patient's peripheral pulses, the nurse should palpate both carotid arteries simultaneously to compare their strength and equality.
Correct Answer
False
Palpating both carotid arteries simultaneously can compromise cerebral blood flow and is unsafe; carotid arteries should be palpated one at a time.
Question 19
A pulse deficit, which is the difference between the apical pulse and the radial pulse, may indicate a cardiac dysrhythmia such as atrial fibrillation.
Correct Answer
True
A pulse deficit occurs when not all apical heartbeats are strong enough to produce a palpable peripheral pulse, often seen in conditions like atrial fibrillation.
Question 20
Donning sterile gloves is the first step a nurse should take when preparing for a sterile procedure, immediately after entering the patient's room.
Correct Answer
False
The first step in preparing for a sterile procedure, after performing hand hygiene, is typically to open the sterile field and don other necessary PPE *before* donning sterile gloves, as gloves are the last item to be applied to maintain sterility.
Question 21
The "Rights of Medication Administration" include the right patient, right drug, right dose, right route, right time, right documentation, right reason, right assessment, right response, and right to refuse.
Correct Answer
True
These 'Rights' are a comprehensive framework for safe medication administration, ensuring patient safety and preventing errors by guiding the nurse through critical checks.
Question 22
The evaluation phase of the nursing process is primarily focused on determining if all planned nursing interventions were carried out correctly, regardless of patient outcomes.
Correct Answer
False
The evaluation phase focuses on determining whether patient goals and outcomes were achieved and if the plan of care needs revision, not solely on whether interventions were correctly performed.