Nursing Care and Responsibilities

Total points19/114

The nursing process involves the following:

0/1
Assessment, diagnosis, planning, intervention and evaluation
Assessment, differentiation, planning, intervention, evaluation
Assessment, planning, intervention, evaluation
Assessment, planning, referring, evaluation

Correct answer
Assessment, diagnosis, planning, intervention and evaluation

What are the steps of the nursing process?

0/1
Assessing, diagnosing, planning, implementing, and evaluating
Assessing, planning, implementing, evaluating, documenting
Assessing, observing, diagnosing, planning, evaluating
Assessing, reacting, implementing, planning, evaluating

Correct answer
Assessing, diagnosing, planning, implementing, and evaluating

When do you see problems or potential problems?

0/1
Assessment
Planning

Implementation
Evaluation
Correct answer
Assessment

A walk-in client enters into the clinic with a chief complaint of abdominal
pain and diarrhea. The nurse takes the client's vital sign thereafter. What
phrase of nursing process is being implemented here by the nurse?
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Assessment
Diagnosis
Planning
Implementation

Correct answer
Assessment

Constipation needs to be sort out during:

0/1
Planning
Assessment
Implementation
Evaluation

Correct answer
Assessment

At what stage of the nursing process does the revision of the care plan occur?
0/1
Assessment

Planning
Implementation
Evaluation
Correct answer
Evaluation

When do you plan a discharge?

0/1
24 hours within admission
72 hours within admission
48 hours within admission
12 hours within admission

Correct answer
24 hours within admission

Hospital discharge planning for a patient should start:

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When the patient is medically fit

On the admission assessment

When transport is available

Correct answer
On the admission assessment

Which statement is not correct about the nursing process?

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An organised, systematic and deliberate approach to nursing with the aim of
improving standards in nursing care

It uses a systematic, holistic, problem solving approach in partnership with the patient
and their family

It is a form of documentation

It requires collection of objective data

Correct answer
It requires collection of objective data

What is comprehensive nursing assessment?

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It provides the foundation for care that enables individuals to gain greater control over
their lives and enhance their health status

An in-depth assessment of the patient’s health status, physical examination, risk

factors, psychological and social aspects of the patient’s health that usually takes
place on admission or transfer to a hospital or healthcare agency

An assessment of a specific condition, problem, identified risks or assessment of care;

for example, continence assessment, nutritional assessment, neurological assessment
following a head injury, assessment for day care, outpatient consultation for a specific
condition

It is a continuous assessment of the patient’s health status accompanied by monitoring

and observation of specific problems identified

Correct answer
An in-depth assessment of the patient’s health status, physical examination, risk
factors, psychological and social aspects of the patient’s health that usually takes
place on admission or transfer to a hospital or healthcare agency

Nursing process is best illustrated as:

1/1
Patient with medical diagnosis
Task oriented care
Individualised approach to care

All of the above

Which of the following descriptors is most appropriate to use when stating

the "problem" part of a nursing diagnosis?
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Grimacing
Anxiety
Oxygenation saturation 93%

Output 500 mL in 8 hours

Correct answer
Anxiety

To prepare a client for discharge home from an acute care facility, a nurse
knows that the planning process must begin at what point?
0/1
The night before discharge

Upon admission to the hospital

Prior to discharge
When the client indicates the readiness for discharge planning and teaching

Correct answer
Upon admission to the hospital

Making sure that people are involved in and central to their care is now
recognised as a key component of developing high quality health care. This is
because it is hoped that putting people at the centre of their care will:
0/1

● Help people get the care they wanted when they are enrolled in the NHS

● Help improve the quality of the services available

● Help people be more active in looking for health care providers themselves

● Help reduce some of the pressures on providing social services

Correct answer
Help improve the quality of the services available

As a nurse, you make sure that the patient and public safety is protected.
Thus, you work within the limits of your competence, exercising your
professional 'duty of candour' and raising concerns immediately whenever
you come across situations that put patients or public safety at risk. Which is
the least effective way to protect a patient's safety?
0/1

● Support the exchange of information at all levels without fear and against
authority gradients - is known to be associated with constant awareness to the
possibility of hazard or harm

● Support for continual learning, growth and adaptation even under stress by
valuing relevant knowledge, skills and observations even at the lowest levels of
hierarchy

● Support the willingness and capacity to look beyond first impressions, labels
and old beliefs - organisations must remain closely in touch with activities and
facts on the ground in the daily operations

● Support the openness culture that encourages clear lines to report concerns and
reinforces the attitudes that prevent safeguarding concerns from scrutiny where
staff at all levels feel confident that they can voice their concerns without fear
of victimization

Correct answer
Support the openness culture that encourages clear lines to report concerns and
reinforces the attitudes that prevent safeguarding concerns from scrutiny where staff
at all levels feel confident that they can voice their concerns without fear of
victimisation

The nurse wants to involve a patient in a programme of care geared towards

the patient to quit smoking. The nurse should make use of which of the
following in communicating to or involving patient in the plan of care:
0/1
National nursing database
Ehealth services
Nicotine replacement therapy
Core care plans

Correct answer
Core care plans

One of the principal responsibilities of a nurse is to educate patients,

however, time and work-related constraints can interfere with the provision
of patient education. Which of the following is most crucial and can influence
the patient's ability to retain pre-operative information?
0/1
Timing of the education
Educational level of the patient and family
The information is appropriate for the patient's understanding
All of the options above

Correct answer
Timing of the education

Who should be responsible in proper disposal of sharps

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Healthcare assistant
Doctor
Registered Nurse
The professional who used the sharp

Correct answer
The professional who used the sharp

Who is responsible in disposing sharps?

0/1
Registered nurse

Nurse assistant
Whoever used the sharps
Whoever collects the garbage

Correct answer
Whoever used the sharps

How can risks be reduced in the healthcare setting?

1/1
 ● By adopting a culture of openness and transparency and exploring the root
causes of patient safety incidents

● Healthcare will always involve risks so incidents will always occur; we need to
accept this

● Healthcare professionals should be encouraged to fill in incident forms; this

will create a culture of ‘no blame’

● By setting targets which measure quality

All but one describes holistic care:

1/1

❖ A system of comprehensive or total patient care that considers the physical,

emotional, social, economic, and spiritual needs of the person; his or her
response to illness; and the effect of the illness on the ability to meet self-care
needs

❖ It embraces all nursing practice that has enhancement of healing the whole
person from birth to death as it’s goals

❖ An all nursing practice that has healing the person as its goal

❖ It involves understanding the individual as a unitary whole in mutual process

with the environment

Adam, 46 years old is of Jewish descent. As his nurse, how will you plan his
dietary needs?
0/1
Assume he strictly needs Jewish food

Ask relatives to bring food from kosher market

Ask a rabbi to help you plan
Ask the patient about his diet preferences
Correct answer
Ask the patient about his diet preferences

Patient-centred care is best defined as:

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Care is focused on the doctor

Care is focused on the health team

Care is focused on the patient
Care is focused on the environment

Correct answer
Care is focused on the patient

Which of the following is not a component of end of life care?

0/1
Resuscitation and defibrillation
Reduce pain
Maintain dignity

Provide family support

Correct answer
Resuscitation and defibrillation

Mr. James, 72 years old, is a registered blind admitted on your ward due to
dehydration. He is encouraged to drink and eat to recover. How will you best
manage this plan of care?
1/1

● Ask the patient the assistance he needs

● Delegate someone to feed him

● Ask the relatives to assist in feeding him

● Look for volunteer to assist with his needs

The rehabilitation nurse wishes to make the following entry into a client's
plan of care: "Client will reestablish a pattern of daily bowel movements
without straining within two months." The nurse would write this statement
under which section of the plan of care?
0/1

● Long-term goals

● Short-term goals

● Nursing orders

● Nursing diagnosis/problem list

Correct answer
Long-term goals

After instructing the client on crutch walking technique, the nurse should
evaluate the client's understanding by using which of the following methods?
0/1
Have client explain produce to the family
Achievement of 90 on written test
Explanation
Return demonstration

Correct answer
Return demonstration

A nurse should be able to show awareness of his/her role in health promotion

and supporting a healthy lifestyle. Whilst providing health education to a
group of patients with cancer about management of their non-healing
wounds, it is important for one to:
0/1
Consider individual wound management priorities
Review the patient’s treatment plan
Determine the locations of the wounds
Verify the types of cancer

Correct answer
Consider individual wound management priorities

It is important to read the label on every IV bag because:

0/1
Different IV solutions are packaged similarly
The label contains the expiration date of the IV fluid
A and B
A only

Correct answer
A and B

Julie, 50 years old, was admitted to the hospital with gastrointestinal bleed
presumed to be oesophageal varices. It has been recommended that she needs
to be transfused with blood; however, due to her religious and personal
beliefs, she needed volume expanding agents. Unfortunately, she died a few
hours after admission. Before dying, she said that it was God’s will, which
she believed was right. Which of the following statements is false?
0/1

● Health professionals should be aware of imposing one’s world view upon

others and strive to be more receptive and sensitive to the needs of others

● Individual choice, consent and the right to refuse treatment is important

● It is important for all health professionals to do any means to keep a patient

alive regardless of traditions and beliefs

● None of the Above

Correct answer
It is important for all health professionals to do any means to keep a patient alive
regardless of traditions and beliefs

Pauleena, 57 years old, suffered from a very dense left sided Cerebrovascular
Accident / Stroke. She was unconscious and unresponsive for several days
with IV fluids for hydration. Since her recovery from stroke, she has been
prescribed to commence enteral feeding through a fine bore nasogastric tube,
in which she signed her consent in front of her who have always been
supportive of her decisions. However, she tends to pull out her NGT when
she is by herself in her room. She died of malnutrition after a few days.
Which of the following statements is true?
0/1
 ● Nurses should have the empathy to listen to more than just the spoken word

● Nurses should practice in accordance to Pauleena’s best interest while

providing support to the family and listening to their concerns and wishes

● Pauleena needs to be supported with questions related to mortality and meaning

of life Therapautic communication is also essential

● All of the above

Correct answer
All of the above

Which of the following sets of needs should be included in your service

user’s person centred care plan?
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● Social, spiritual and academic needs

● Medical, psychological and financial needs

● Physical, medical, social, psychological and spiritual needs

● A and B only

● All of the above

Correct answer
Physical, medical, social, psychological and spiritual needs

What is likely to be true of a nurse's duties when she acts as a case manager
providing community-based nursing services to a specific group of
individuals?
0/1
 ● The nurse will care for clients at the center, in their homes, and in the hospital

● The nurse sees only clients who come to the office

● The nurse works independently of other health care professionals

● The nurse will not continue client care if it involves long-term needs

Correct answer
The nurse will care for clients at the center, in their homes, and in the hospital

A client is to be discharged home from a hospital using crutches or a

wheelchair. The client lives alone with three cats. Which assessment
parameter is most important on the initial home visit?
0/1

● Whether the client will be able to keep medical appointments

● Whether the client desires spiritual counseling

● Whether the home has stairs and/or throw rugs

● Whether the client has financial resources for payment

Correct answer
Whether the home has stairs and/or throw rugs

To provide effective feedback to a client, the nurse will focus on:

0/1

● The present and not the past

● Making inferences of the behaviors observed

● Providing solutions to the client

● The client
Correct answer
The present and not the past

Which of the following actions jeopardise the professional boundaries

between patient and nurse
0/1

● Focusing on social relationship outside working environment

● Focusing on needs of patient related to illness

● Focusing on withholding value opinions related to the decisions

Correct answer
Focusing on social relationship outside working environment

In using social media like Facebook, these are the best way to adhere to your
Code of Conduct as a nurse, except?
1/1

● Never have relationship with previous patient

● Never post pictures concerning your practice

● Never tell you are a nurse

● Always rely solely in your FBs privacy setting

The worst advice you can give a student nurse with regards to the use of
social networking sites like Facebook?
1/1

● Do not identify yourself as a nurse

● Do not engage in a personal discussion or relationship with a patient or former

patient
● Do not post a picture of a patient's child even if they allow you to
 ● You can rely on the sites privacy settings

As an RN in charge you are worried about a nurse's act of being very active
on social media site, that it affect the professionalism. Which one of these is
the worst advice you can give her?
1/1

● Do not reveal your profession of being a Nurse on social site

● Do not post any pictures of client's even if they have given you permission

● Do not involve in any conversions with client's or their relatives through a

social site
● Keep your profile private

Nurses assume responsibility on patient with cane. Which of the following is

the nurse’s topmost priority in caring for a patient with cane?
0/1

● Mobility

● Safety

● Nutrition

● Rest periods

Correct answer
Safety

In the context of assessing risks prior to moving and handling, what does T-I-
L-E stand for?
0/1

● Task – individual – lift – environment

● Task – intervene – load – environment

● Task – intervene – load – equipment

 ● Task – individual – load – environment

Correct answer
Task – individual – load – environment

Barbara, a 75-year old patient from a nursing home was admitted on your
ward because of fractured neck of femur after a trip. She will require an
open-reduction and internal fixation (ORIF) procedure to correct the injury.
Which of the following statements will help her understand the procedure?
0/1

● You are going to have an ORIF done to correct your fracture

● Some metal screws and pins will be attached to your hip to help with the
healing of your broken bone

● The operation will require a metal fixator implanted to your femur and adjacent
bones to keep it secured

● The ORIF procedure will be done under general anaesthesia by an orthopaedic

surgeon

Correct answer
Some metal screws and pins will be attached to your hip to help with the healing of
your broken bone

Lisa, a working mother of 3, has approached you during a recent attendance

of her daughter in Accident and Emergency because of an acute asthma
attack about smoking cessation. What is your most appropriate response to
her?
1/1

● Smoking cessation will help prevent further asthma attack

● Referral can be made to the local NHS Stop Smoking Service

● Discuss with her the NICE recommendations on smoking cessation

 ● It is not common for people like her to stop smoking

A nurse finds it very difficult to understand the needs of a child with learning
disability. She goes to other nurses and professionals to seek help. How you
interpret this action
0/1

● The nurse is short of self confidence

● A nurse, who is well aware of her limitations sought help from others She
worked within her competency

● She doesn’t have the kind of courage a nurse should have

Correct answer
A nurse, who is well aware of her limitations sought help from others She worked
within her competency

Monica is going to receive blood transfusion. How frequently should we do

her observation?
0/1
Temperature and pulse before the blood transfusion begins, then every hour, and at
the end of bag/unit

Temperature, pulse, blood pressure and respiration before the blood transfusion
begins, then after 15 min, then as indicated in local guidelines, and finally at the end
of bag/unit

Temperature, pulse, blood pressure and respiration and urinalysis before the blood
transfusion, then at end of bag

Pulse, blood pressure and respiration every hour, and at the end of the bag
Correct answer
Temperature, pulse, blood pressure and respiration before the blood transfusion
begins, then after 15 min, then as indicated in local guidelines, and finally at the end
of bag/unit
During blood transfusion, a patient develops pyrexia, and loin pain. Nurse
interprets the situation as
0/1

● Common reaction to transfusion

● Adverse reaction to blood transfusion

● Patient has septicaemia

Correct answer
Adverse reaction to blood transfusion

A nurse explains to a student that the nursing process is a dynamic process.

Which of the following actions by the nurse best demonstrates this concept
during the work shift?
1/1

● Nurse and client agree upon health care goals for the client

● Nurse reviews the client's history on the medical record

● Nurse explains to the client the purpose of each administered medication

● Nurse rapidly reset priorities for client care based on a change in the client's
condition

Nursing care should be:

0/1

● Task oriented

● Caring medical and surgical patient

● Patient oriented, individualistic care

● All

Correct answer
Patient oriented, individualistic care

How the nurse assesses the quality of care given?

0/1

● Reflective process

● Clinical bench marking

● Peer and patient response

● All the above

Correct answer
All the above

A patient doesn't take a tablet which is prescribed by the doctor. Which

action by the nurse would be most appropriate?
0/1

● Report the incident to senior nurse or ward in charge

● Inform the pharmacist

● Do nothing and respect the patients choice

● Routinely document this in the medicine chart and also record it in the nurses
notes

Correct answer
Routinely document this in the medicine chart and also record it in the nurses notes

After the death of a 46-year-old male client, the nurse approaches the family
to discuss organ donation options. The family consents to organ donation and
the nurse begins to process. Which of the following would be most helpful to
the grieving family during this difficult time?
1/1
Calling the client, a donor
Provide care to the deceased client in a careful and loving way

Encourage the family to make a quick decision

Tell them that there is no time to all other family members for advice
While providing care to a terminally ill client, the nurse has asked questions
about death. Which of the following would be beneficial to support the
client’s spiritual needs?
0/1

● Nothing

● Ask if they want to die

● Ask if they want anything special before they die

● Provide support, compassion, and love

Correct answer
Provide support, compassion, and love

Under the Yellow Card Scheme you must report the following except:
0/1

● Faulty brakes on a wheelchair

● Suspected side effects to blood factor, except immunoglobulin products

● Counterfeit or fake medicines or medical devices

Correct answer
Suspected side effects to blood factor, except immunoglobulin products

Mrs X informs the nurse that she has lost her job due to excessive absences
related to her wound. The nurse should:
1/1

● Encourage the patient to express her feelings about the job loss

● Contact social services to assist the patient with accessing available resources

● Evaluate Mrs X’s understanding of her wound management

● Explain to Mrs X that she can no longer be seen at the clinic without a job
Margaret has been diagnosed with Hepatic Adenoma. Her results are as
follows – benign tumor as shown on triphasic CT Scan and alpha feto
proteins within normal range. She is asymptomatic and does not appear
jaundice, but she appears to be very anxious. As a nurse, what will you
initially do?
0/1

● Sit down with Margaret and discuss about her fears; use therapeutic
communication to alleviate anxiety

● Refer her to a psychiatrist for treatment

● Discuss invasive procedure with patient, and show her videos of the operation

● Take her to the surgeon’s clinic and discuss about consent for invasive
procedure

Correct answer
Sit down with Margaret and discuss about her fears; use therapeutic communication to
alleviate anxiety

One of your residents has been transferred from the hospital to your nursing
home after having been admitted for a week due to a chest infection. On
transfer, you have noted that he had several dressings on his thighs, which he
has not had before. What should you do?
0/1

● If the dressings are intact, document it on the nursing notes and indicate that the
dressings need to be changed after 48 hours

● Change the dressings if they look soiled and document this on the wound
assessment form

● Remove the dressings whether they are intact or not, assess the wounds,
document this on the wound assessment form and redress the wounds

● All of the above

Correct answer
Remove the dressings whether they are intact or not, assess the wounds, document
this on the wound assessment form and redress the wounds

During your medical rounds, you have noted that Mrs X was upset. She has
verbalised that she misses her family very much, and that no one has been to
visit lately. What would likely be your initial intervention?
1/1

● Contact Mrs X’s family and encourage them to visit her during the weekend

● Sit next to Mrs X and listen attentively Allow her to talk about things that cause
her anxiety

● Collaborate with the GP for a care plan review and request for antidepressants
to be prescribed

● All of the above

● None of the above

On admission of a service user, you have done an informal risk assessment

for pressure sores, and you have noted that the patient is currently not at risk.
What will be your next step?
0/1

● Include the Repositioning Chart on your patient’s daily notes, and instruct your
carers/HCA’s to turn your patient every two hours

● Alert the General Practitioner about your patient’s condition

● Reassess your patient on a regular basis and document your observations

● Modify your patient’s diet to maintain intact skin integrity

Correct answer
Reassess your patient on a regular basis and document your observations

You were on your rounds with one of the carers. You were turning a patient
from his left to his right side. What would you do?
0/1

● Both of you can stay on one side of the bed as you turn your patient

● You go on the opposite side of the bed and use the bed sheet to turn your
patient

● You keep the bed as low as possible because the patient might fall

● You go on the opposite side and grab the slide sheet to use

Correct answer
You go on the opposite side and grab the slide sheet to use

The nurse is preparing to move an adult who has right sided paralysis from
the bed into a wheel chair. Which statement describes the best action for the
nurse to take?
0/1

● Position the wheel chair on the left side of the bed

● Keep the head of the bed elevated 10 degree

● Protect the client’s left arm with a sling during the transfer

● Bend at the waist while helping the client into a standing position

Correct answer
Position the wheel chair on the left side of the bed

A client with a right arm cast for fractured humerus states, “I haven’t been
able to straighten the fingers on the right hand since this morning.” What
action should the nurse take?
0/1

● Assess neurovascular status to the hand

 ● Ask the client to massage the fingers

● Encourage the client to take the prescribed analgesic

● Elevate the arm on a pillow to reduce oedema

Correct answer
Assess neurovascular status to the hand

As a nurse you are responsible for looking after patient’s nutritional needs
and to maintain good weight during hospitalization. How would you achieve
this?
1/1

● Providing all clients with liquid nutritional supplements

● Assessing all patients using MUST screening tool and by taking patients
preferences into consideration
● Checking daily weigh and documenting

● Assessing nutritional status, client preferences and needs, making individual

food choices available, checking daily weight and documentation

One of your young patient displayed an overt sexual behaviour directly to

you. How will you best respond to this?
0/1

● Talk to the patient about the situation, to re- establish and maintain professional
boundaries and relationship

● Ignore the behaviour as this is part of the development process

● Report the patient to their relatives

● Inform line manager of the incident

Correct answer
Talk to the patient about the situation, to re- establish and maintain professional
boundaries and relationship

The patient under a nurse's care is showing sexual behaviours toward

him/her, what should the nurse do?
0/1

● File an incident report, do not care for the patient anymore

● Write the patient's behaviour on the patient's chart

● This is normal as the patient is sick, later as the medication kicks off it will
soon be over
● Talk to the patient about the behaviour, attempt to re-establish professional
relationship, talk to the line manager

Correct answer
Talk to the patient about the behaviour, attempt to re-establish professional
relationship, talk to the line manager

Post surgery, the doctor tells the patient that treatment is not working. The
doctor instructed the nurse to stay with the patient until the nurse specialist
arrive. What should the nurse do?
1/1

● Document outcomes in the patient's chart

● Sit silently with patient until nurse specialist arrives

● Ask the patient if he wants to discuss what the doctor said

● Do not leave the patient unattended and try to answer his questions

A registered nurse is new to the diagnosis of her patient. What is the best
response of the nurse?
0/1

● The nurse should come early for her shift and spend more time to care for the
patient
 ● The nurse should spend an hour in library, learn about the new diagnosis and
then take care of the patient

● The nurse should clarify her doubts with her senior on duty and with the
doctors about the diagnosis and plan nursing care accordingly

● The nurse should request the other staff to continue with the shift as she lacks
knowledge about the diagnosis

Correct answer
The nurse should clarify her doubts with her senior on duty and with the doctors about
the diagnosis and plan nursing care accordingly

A client diagnosed of cancer visits the OPD and after consulting the doctor
breaks down in the corridor and begins to cry. What would the nurses best
action?
0/1

● Ignore the client and let her cry in the hallway

● Inform the client about the preparing to come forth next appointment for further
discussion on the treatment planned

● Take her to a room and try to understand her worries and do the needful and
assist her with further information if required

● Explain her about the list of cancer treatments to survive

Correct answer
Take her to a room and try to understand her worries and do the needful and assist her
with further information if required

A patient has sexual interest in you. What would you do?

0/1
 ● Just avoid it, because the problem can be the manifestation of the underlying
disorder, and it will be resolved by its own as he recovers

● Never attend that patient

● Try to re-establish the therapeutic communication and relationship with patient

and inform the manager for support

● Inform police

Correct answer
Try to re-establish the therapeutic communication and relationship with patient and
inform the manager for support

A client is diagnosed with cancer and is told by surgery followed by

chemotherapy will be necessary, the client states to the nurse, "I have read a
lot about complementary therapies. Do you think I should try it?". The nurse
responds by making which most appropriate statement?
0/1

● It is a tendency to view one's own ways as best

● You need to ask your physician about it

● I would try anything that I could if I had cancer

● There are many different forms of complementary therapies, let's talk about
these therapies

Correct answer
There are many different forms of complementary therapies, let's talk about these
therapies

An antihypertensive medication has been prescribed for a client with

hypertension. The client tells the clinic nurse that they would like to take an
herbal substance to help lower their blood pressure. The nurse should take
which action?
0/1

● Tell the client that herbal substances are not safe and should never be used

● Teach the client how to take their BP so that it can be monitored closely

● Encourage the client to discuss the use of an herbal substance with the health
care provider

● Tell the client that if they take the herbal substance they will need to have their
BP checked frequently

Correct answer
Encourage the client to discuss the use of an herbal substance with the health care
provider

Mrs. A is posted for CT scan. Patient is afraid cancer will reveal during her
scan. She asks "why is this test". What will be your response as a nurse?
0/1

● Tell her that you will arrange a meeting with a doctor after the procedure

● Give a health education on cancer prevention

● Ignore her question and take her for the procedure

● Understand her feelings and tell the patient that it is normal procedure

Correct answer
Understand her feelings and tell the patient that it is normal procedure

A patient with a Bipolar Disorder makes a sexually inappropriate comment to

the nurse. One should take which of the following actions?
0/1
 ● Ignore the comment because the client has a mental health disorder and cannot
help it

● Report the comment to the nurse manager

● Ignore the comment, but tell the incoming nurse to be aware of the client’s
propensity to make inappropriate comments

● Tell the client that is it inappropriate for clients to speak to any nurse that way

Correct answer
Tell the client that is it inappropriate for clients to speak to any nurse that way

Betty has been assessed to be very confused and with impaired mobility. She
wants to go to the dining room for her meal, but she wants a cardigan before
doing so. What will you do?
0/1

● Give her wet wipes for her hands before dinner

● Disregard the cardigan and take her to the dining room

● Ask her what she means by a cardigan

● Make her comfortable in a wheelchair, and cover her legs with a blanket

Correct answer
Ask her what she means by a cardigan

You were assisting Mrs X with personal care and hygiene. She has been
assessed to have mental capacity. In her wardrobe, you have seen a dress that
is quite difficult to wear and a pair of trousers, which is quite easy to put on.
You are trying to make a decision which one to put on her. Which of the
following is a person centred intervention?
0/1

● Ask her what she prefers; show her the clothes and let her choose
 ● Let Mrs X wear her trousers

● Explain to her that the dress is so difficult to put on

● Tell her that the trousers will make her more comfortable if she chooses it

Correct answer
Ask her what she prefers; show her the clothes and let her choose

One of your residents in the nursing home has requested for a glass of
whiskey before she goes to bed. What would you do?
0/1

● Refuse to give it / ignore the request

● Explain that the whiskey will cause her harm

● Give her a shot of whiskey, as requested

● Give her a glass of apple juice and tell her it is whiskey

Correct answer
Give her a shot of whiskey, as requested

A client, who has had visitors the last two evenings during the unit's regular
evening visitors hours, 6:00 p.m. to 8:00 p.m., asks, "What time can I have
visitors this evening?" Which of the following would be the best response to
this question?
0/1

● "Don't you remember what time you visitor have been coming?"

● You are worried about visiting hours

 ● You want to know when you can have visitors?

● Visiting hours are from 6:00 pm to 8:00 pm

Correct answer
Visiting hours are from 6:00 pm to 8:00 pm

A critically ill client asks the nurse to help him die. Which of the following
would be an appropriate response for the nurse to give this client?
0/1

● "Tell me why you feel death is your only option"

● "How would you like to do this?"

● "Everyone dies sooner or later"

● "Assisted suicide is illegal in this country"

Correct answer
"Tell me why you feel death is your only option"

The 4-year-old son of a deceased male is asking questions about his father.
Which of the following activities would be beneficial for this young child to
participate in?
0/1

● Nothing because he is too young to understand death

● Tell him his father has gone away, never to return

● Tell him his father is sleeping

● Explain that his father has died and give him the option of attending the funeral

Correct answer
Explain that his father has died and give him the option of attending the funeral
A young woman has suffered fractured pelvis in an accident, she has been
hospitalized for 3 days, when she tells her primary nurse that she has
something to tell her but she doesnot want the nurse to tell anyone. She says
that she had tried to donate blood and tested positive for HIV. What is best
action of the nurse to take?
0/1

● Document this information on the patient’s chart

● Tell the patient’s physician

● Inform the healthcare team who will come in contact with the patient

● Encourage the patient to disclose this information to her physician

Correct answer
Encourage the patient to disclose this information to her physician

The nurse is admitting a client, on initial assessment the nurse tries to inquire
the patient if he has been taking alternative therapies and OTC drugs but the
client becomes angry and refuses to answer saying the nurse is doing so
because he belongs to an ethnic minority group, what is the nurse’s best
response?
0/1

● The nurse will stop asking questions as it is upsetting to the patient

● Wait and give some time for the client to get adjusted to modern ways of
hospitalization

● The nurse will politely explain to the patient about alternative therapies such as
St Johns Wort which interact with drugs

● The nurse will assign another nurse to ask questions

Correct answer
The nurse will politely explain to the patient about alternative therapies such as St
Johns Wort which interact with drugs
Which is the most appropriate phrase to communicate?
0/1

● "I'm sorry, your mother died"

● "I'm sorry, your mother gone to heaven"

● "I'm sorry, your mother is no longer with us"

● "I'm sorry, your mother passed away"

Correct answer
"I'm sorry, your mother died"

One of your patient has challenged your recent practice of administering a

subcutaneous low-molecular weight heparin (LMWH) without disinfecting
the injection site. The guidelines for nursing procedures do not recommend
this method. Which of the following response will support your action?
1/1

● "We were taught during our training not to do so as it is not based on evidence"

● "Our guidelines, which are based on current evidence, recommends a non-

disinfection method of subcutaneous injection"

● "I am glad you called my attention I will disinfect your injection site next time
to ensure your safety and peace of mind"

● "Disinfecting the site for subcutaneous injection is a thing of the past We are in
an evidence-based practice now"

A nurse is caring for clients in the mental health clinic. A women comes to
the clinic complaining of insomnia and anorexia. The patient tearfully tells
the nurse that she was laid off from a job that she had held for 15 years.
Which of the following responses, if made by the nurse, is most appropriate?
0/1

● "Did your company give you a severance package?"

 ● "Focus on the fact that you have a healthy, happy family"

● "Losing a job is common nowadays"

● "Tell me what happened"

Correct answer
"Tell me what happened"

When do we need to document?

0/1

● As soon as possible after an event has happened to provide current up to date

information about the care and condition of the patient or client

● Every hour

● When there are significant changes to the patient’s condition

● At the end of the shift

Correct answer
As soon as possible after an event has happened to provide current up to date
information about the care and condition of the patient or client

In a patient with hourly monitoring, when does a nurse formally document

the monitoring?
0/1

● Every hour

● When there are significant changes to the patient’s condition

● At the end of the shift

 ● Mid of shift

Correct answer
Every hour

NMC defines record keeping as all of the following except:

0/1

● Helping to improve advocacy

● Showing how decisions related to patient care were made

● Supporting effective clinical judgements and decisions

● Helping in identifying risks, and enabling early detection of complication

Correct answer
Helping to improve advocacy

You are transcribing the patient's medications to the discharge letter. What
should you ensure before the letter is sent?
1/1

● The next of kin's details are included in the letter

● The letter is checked by a registered practitioner for accuracy

● It cannot be sent because transcription is not allowed in any circumstances

● The letter is signed off by the nurse-in-charge

A nurse documented on the wrong chart. What should the nurse do?
0/1

● Immediately inform the nurse in charge and tell her to cross it all off

● Throw away the page

 ● Write line above the writing; put your name, job title, date, and time

● Ignore the incident

Correct answer
Write line above the writing; put your name, job title, date, and time

When is the time to take the vital signs of the patients? Select which does not
apply:
0/1

● At least once every 12 hours, unless specified otherwise by senior staff

● When they are admitted or initially assessed

● On transfer to a ward setting from critical care or transfer from one ward to

● Every four hours

Correct answer
Every four hours

All should be seen in a good documentation except:

0/1

● Legible handwriting

● Name and signature, position, date and time

● Abbreviations, jargon, meaningless phrases, irrelevant speculation and

offensive subjective statements

● A correct, consistent, and factual data

Correct answer
Abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive
subjective statements

Taking a nursing history prior to the physical examination allows a nurse to

establish a rapport with the patient and family. Elements of the history
include all of the following except:
0/1

● The client’s health status

● The course of the present illness

● Social history

● Cultural beliefs and practices

Correct answer
The client’s health status

Adequate record keeping for a medical device should provide evidence of:
0/1

● A unique identifier for the device, where appropriate

● A full history, including date of purchase and where appropriate when it was
put into use, deployed or installed

● Any specific legal requirements and whether these have been met

● Proper installation and where it was deployed

● Schedule and details of maintenance and repairs

● The end-of-life date, if specified

● All of the above

Correct answer
All of the above

A registered nurse had a very busy day as her patient was sick, got intubated
and had other life saving procedures. She documented all the events and by
the end of the shift recognized that she had documented in other patient's
record. What is best response of the nurse?
0/1
She should continue documenting in the same file as the medical document cannot be
corrected
She should tear the page from the file and start documenting in the correct record

She should put a straight cut over her documentation and write as wrong, sign it with
her NMC code, date and time

She should write as wrong documentation in a bracket and continue

Correct answer
She should put a straight cut over her documentation and write as wrong, sign it with
her NMC code, date and time

A patient in one of your bays has called for staff. She needed assistance with
“spending a penny”. What will you do?
0/1

● Ask her if she wants a hot or cold drink, and give her one as requested

● Assist her to walk to the vending machine, and let her choose what she wants to
buy
● Assist her to walk to the toilet, and provide her with some privacy

● Help her find her purse, and ask her what time she will be ready to go out

Correct answer
Assist her to walk to the toilet, and provide her with some privacy

You are working in a nursing home (morning shift), and one of your residents
is still in the hospital. Nothing has been documented since admission. What
would you do?
0/1

● Ring the family and find out what happened to the resident
 ● Speak to your manager and tell her about it

● Ring the ward and request for an update from the nurse on duty

● Document that the resident is still in the hospital

Correct answer
Speak to your manager and tell her about it

After the handover, you noticed that the outgoing nurse documented an
intervention on a wrong patient chart. What should you do to correct it,
maintain safety and continuation of care?
0/1

● Discard the paper/ document

● Cross the wrong entry with a line, indicated it is an error, write the date, time,
name and signature, document the care correctly

● Leave it, never alter patient record

● Inform the nurse manager, let her draw a line on the entry and place her name
and signature

The nurse suspects that a client is withholding health-related information out

of fear of discovery and possible legal problems. The nurse formulates
nursing diagnoses for the client carefully, being concerned about a diagnostic
error resulting from which of the following?
0/1

● Incomplete data

● Generalise from experience

● Identifying with the client

● Lack of clinical experience

After finding the patient, which statement would be most appropriate for the
nurse to document on a datix/incident form?
0/1

● "The patient climbed over the side rails and fell out of bed"

● "The use of restraints would have prevented the fall"

● "Upon entering the room, the patient was found lying on the floor"

● "The use of a sedative would have helped keep the patient in bed"

Correct answer
"Upon entering the room, the patient was found lying on the floor"

A nurse documents vital signs without actually performing the task. Which
action should the charge nurse take after discussing the situation with the
nurse?
0/1

● Charge the nurse with malpractice

● Document the incident

● Notify the board of nursing

● Terminate employment

Correct answer
Document the incident

The nurse has made an error in documenting client care. Which appropriate
action should the nurse take?
0/1

● Draw a line through error, initial, date and document correct information

● Document a late addendum to the nursing note in the client’s chart

● Tear the documented note out of the chart

 ● Delete the error by using whiteout

Correct answer
Draw a line through error, initial, date and document correct information

Which of the following items of subjective client data would be documented

in the medical record by the nurse?
0/1

● Client's face is pale

● Cervical lymph nodes are palpable

● Nursing assistant reports client refused lunch

● Client feel nauseated

Correct answer
Client feel nauseated

Annie is on Cefalexin QID. You were working on a night shift and have
noticed that the previous nurse has not signed for the last two doses. What
should you do?
0/1
Document the incident and speak to your Manager

Check the rota, find out when he is back and leave a note on the MARS for him to
sign

Find out what the whistle blowing policy is about

Ask the qualified nurse to sign it on handover if it is definitely been administered

Correct answer
Document the incident and speak to your Manager

Providing patient centred nursing care is an expectation for all nurses. For a
patient with pyrexia, which of the following is the ritual nursing intervention?
0/1

● Administer antipyretics
 ● Remove heavy blankets

● Direct fan therapy

● Indirect fan therapy

Correct answer
Direct fan therapy

You are taking the rectal temperature of an elderly patient when it is

registered moderate hypothermia of 34 degrees Celcius. What should be the
most appropriate action by the nurse?
1/1

● Programme the reheating device to increase temperature as fast as possible

● Programme the reheating device to register the temperature to 36 degrees

● Programme the reheating device to increase temperature 2 degrees per hour

● Programme the reheating device to register the temperature to increase at 0.5 to

1 degree per hour

When do you consider using clean gloves acceptable as methods for

preventing infection?
0/1

● Dressing a necrotic wound

● Assessing IV insertion site

● Obtaining urine sample

● Accessing a central venous device

Correct answer
Accessing a central venous device

To address individual and family responses to health problems, theory-based

nursing practice is important for designing and implementing nursing
interventions. Dorothea Orem identified a theory of nursing practice. Which
of the following statements best exemplify Orem's theory?
0/1

● Promotes nursing care that increases a patient's self-care abilities

● Helps nurses provide culture-specific care that assists patients to achieve and
maintain health

● Assists nurses to identify behaviours associated with various stages of coping

with death and dying

● Facilities identification of a child's stage of development so that appropriate

nursing care is planned

Correct answer
Promotes nursing care that increases a patient's self-care abilities

Which nursing action is associated with Faye Glenn Abdellah's Patient-

Centred Approach to Nursing?
1/1

● The nurse identifies that although the patient has a serious chronic illness, the
patient states that he feels healthy because he can meet the responsibilities
required of him as a husband and a father

● The nurse collects data about a patient and organises it into overt and covert
problems as addressing the covert problems may solve the overt problems as
well

● The nurse plots a patient's health status in the quadrant of poor health with a
very unfavourable environment

● The nurse determines that the patient's need for oxygen is the priority with
reference to the 21 nursing problems
Which statement by a nurse meets Virginia Henderson's Principles and
Practice of Nursing?
0/1

● I see that you have applied makeup today for the first time since your surgery.

● I am your nurse for the next 12 hours. You can use your call bell to page me
when you need assistance.

● Your wife can visit everyday between 10 in the morning and 8 at night.

● A physical therapist will be in today to complete an evaluation so we can start

planning your care.

Correct answer
I am your nurse for the next 12 hours. You can use your call bell to page me when you
need assistance.

A nurse is caring for an older adult newly admitted to the hospital. The nurse
understands the importance of organising data and then prioritising needs
based on Roper-Logan-Tierney Model for Nursing. Based on the collected
data, which nursing action addresses the basic assumptions related to this
theory?
0/1

● Encourage the patient to increase oral fluid intake

● Seek an order for oxygen via nasal cannula

● Activate the bed alarm on the patient's bed

● Take vital signs every four hours

Correct answer
Seek an order for oxygen via nasal cannula

The nurse is conducting a patient-centred interview on a teenager who

conveys that she is not getting relief from shortness of breatheven if she uses
the prescribed inhaler. The nurse then decides to ask the patient to
demonstrate how she uses the inhaler and what she does when she gets no
relief. On the basis of Gordon's Functional Health Patterns, which pattern is
the nurse assessing?
0/1

● Health perception-health management pattern

● Value-belief pattern

● Cognitive-perceptual pattern

● Coping-stress tolerance pattern

Correct answer
Health perception-health management pattern

The nurse reviewed the patient's clinical record and assessed the patient.
Which statement by the patient indicates the conflict of ego integrity versus
despair according to Erik Erikson's Theory of Development?
1/1

● I really don't trust any of my doctors and their treatment plan.

● I don't care what the doctor says, I will do it my war or no way.

● I hope that in my next lifetime I get the chance to become a doctor.

● I feel that I will never get better because nothing ever goes well for me.

Which statement is accurate in relation to the concepts of health and wellness

indicated in the presented theoretical framework?
0/1

● Implies that people are unhealthy if they are unable to fulfill their roles in
society

● Promotes meeting basic-level needs first and then progressing to higher level
needs
 ● Supports teaching about how to alter internal and external factors to facilitate
adaptations

● Facilitates prediction of whether patients will likely improve in health or

experience a decline based on level of support

Correct answer
Facilitates prediction of whether patients will likely improve in health or experience a
decline based on level of support

A nurse is evaluating patient outcomes associated with learning about

hypertension and self-care. Which outcome indicates success in the
utilisation of the role-modeling theory?
0/1

● Patient explains how to interpret the serving size on a food label to calculate the
caloric value of the nutrient

● Patient is able to identify five foods high in salt that should be avoided when
receiving a low sodium diet

● Patient is able to assess that his blood pressure is within normal limits after
accurately obtaining a blood pressure reading using a sphygmomanometer

● Patient adheres to a weight-reduction diet, as evidenced by a weekly 2-lb

weight loss

Correct answer
Patient is able to assess that his blood pressure is within normal limits after accurately
obtaining a blood pressure reading using a sphygmomanometer

Which is an example of an independent nursing intervention?

0/1

● Administering enema
 ● Changing a soiled dressing

● Delegating the giving of bath to an unregistered practitioner

● Assisting a patient with a transfer from a bed to a chair

Correct answer
Assisting a patient with a transfer from a bed to a chair