A nurse is caring for a young patient on a ventilator with no brain activity.

The physician discusses options with the family, one of which is removing life support and allowing the patient to die.

The nurse recognizes a decisional conflict related to religious beliefs and treatment options.

The nurse utilizes the HOPE Tool for spiritual assessment.

Which question is NOT part of the HOPE Tool?

Do you have spiritual practices that are helpful to you?

What makes you feel that your belief is correct?

Are you part of a religious or spiritual community?

What sustains you and keeps you going?.

Answer and Explanation

The Correct Answer is B

The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.

Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.

Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.

Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.

Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

A. Soaking extremities in hot water. B. Administering warmed intravenous fluids. C. Administering hot whirlpool therapy. D. Replacing wet clothing with dry clothing.

Correct Answer is D

Explanation

Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Correct Answer is C

Explanation

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

Correct Answer is D

Explanation

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?