th Buttaro: Primary Care, A Collaborative Practice, 6 Ed. Chapter 1: The Evolving Landscape of Collaborative Practice Test Bank Multiple Choice 1. Which assessments of care providers are per... formed as part of the Value Based Purchasing initiative? Select all that apply. a. Appraising costs per case of care for Medicare patients b. Assessing patients’ satisfaction with hospital care c. Evaluating available evidence to guide clinical care guidelines d. Monitoring mortality rates of all patients with pneumonia e. Requiring advanced IT standards and minimum cash reserves ANS: A, B, D Value Based Purchasing looks at five domain areas of processes of care, including efficiency of care (cost per case), experience of care (patient satisfaction measures), and outcomes of care (mortality rates for certain conditions. Evaluation of evidence to guide clinical care is part of evidence-based practice. The requirements for IT standards and financial status are part of Accountable Care Organization standards. REF: Value Based Purchasing 2. What was an important finding of the Advisory Board survey of 2014 about primary care preferences of patients? a. Associations with area hospitals b. Costs of ambulatory care c. Ease of access to care d. The ratio of providers to patients ANS: C As part of the 2014 survey, the Advisory Board learned that patients desired 24/7 access to care, walk-in settings and the ability to be seen within 30 minutes, and care that is close to home. Associations with hospitals, costs of care, and the ratio of providers to patients were not part of these results. REF: The New Look of Primary Care 3. A small, rural hospital is part of an Accountable Care Organization (ACO) and is designated as a Level 1 ACO. What is part of this designation? a. Bonuses based on achievement of benchmarks b. Care coordination for chronic diseases c. Standards for minimum cash reserves d. Strict requirements for financial reporting ANS: A A Level 1 ACO has the least amount of financial risk and requirements, but receives shared savings bonuses based on achievement of benchmarks for quality measures and expenditures. Care coordination and minimum cash reserves standards are part of Level 2 ACO requirements. Level 3 ACOs have strict requirements for financial reporting. REF: Accountable Care Organizations th Buttaro: Primary Care, A Collaborative Practice, 6 Chapter 2: Translating Research Into Clinical Practice Test Bank Multiple Choice Ed. 1. Which is the most appropriate research design for a Level III research study? a. Epidemiological studies b. Experimental design c. Qualitative studies d. Randomized clinical trials ANS: B The experimental design is the most appropriate design for a Level III study. Epidemiological studies are appropriate for Level II studies. Qualitative designs are useful for Level I studies. Randomized clinical trials are used for Level IV studies. REF: Level III Research/Experimental Design 2. What is the purpose of clinical research trials in the spectrum of translational research? a. Adoption of interventions and clinical practices into routine clinical care b. Determination of the basis of disease and various treatment options c. Examination of safety and effectiveness of various interventions d. Exploration of fundamental mechanisms of biology, disease, or behavior ANS: C Clinical research trials are concerned with determining the safety and effectiveness of interventions. Adoption of interventions and practices is part of clinical implementation. Determination of the basis of disease and treatment options is part of the pre-clinical research phase. Exploration of the fundamental mechanisms of biology, disease, or behavior is part of the basic research stage. REF: Translational Science Spectrum 3. What is the purpose of Level II research? a. To define characteristics of interest of groups of patients b. To demonstrate the effectiveness of an intervention or treatment c. To describe relationships among characteristics or variables d. To evaluate the nature of relationships between two variables ANS: C Level II research is concerned with describing the relationships among characteristics or variables. Level I research is conducted to define the characteristics of groups of patients. Level II research evaluates the nature of the relationships between variables. Level IV research is conducted to demonstrate the effectiveness of interventions or treatments. REF: Level II Research th Buttaro: Primary Care, A Collaborative Practice, 6 Ed. Chapter 3: The Patient, the Provider, and Primary Care: An Integrated Perspective Test Bank Multiple Choice 1. A patient takes glucosamine chondroitin to help control osteoarthritis pain. Which medications, taken in conjunction with this medication, are of concern? a. Anticholinergic drugs b. Beta blocker medications c. Blood-thinning agents d. Narcotic analgesics ANS: C Glucosamine chondroitin can prolong bleeding if taken with other blood-thinning agents. It does not have anticholinergic effects, cardiac effects or analgesic effects. REF: Alternative Therapies for Common Chronic Conditions/Joint Pain 2. The provider learns that a patient is taking herbal supplements for a variety of reasons. What is an important point to discuss with this patient about taking such supplements? a. Because they are not FDA approved, they are not safe b. Dietary supplements are safer than most prescription medications c. Many supplements lack clear clinical evidence of efficacy d. Supplements should not be taken with prescription medications ANS: C Many dietary supplements lack clinical evidence to support their use. Even though they are not FDA approved, federal law mandates that the products are safe and cannot make misleading claims about use. Supplements are not necessarily safer than prescription drugs. Supplements may be taken with prescription medications as long as the effects, side effects, and drug interactions are known. REF: Alternative Therapies for Common Chronic Conditions 3. Which dietary supplements have shown some effectiveness in reducing blood pressure in patients with hypertension? Select all that apply. a. Chromium picolinate b. Cinnamon c. CoQ10 d. Garlic extract e. L-arginine ANS: C, D, E CoQ10, garlic extract, and L-arginine have demonstrated effectiveness in reducing blood pressure in some studies. Chromium picolinate and cinnamon have been studied for effects on glucose tolerance and fasting glucose. REF: Alternative Therapies for Common Chronic Conditions/Prehypertension and Hypertension th Buttaro: Primary Care, A Collaborative Practice, 6 Chapter 16: Lifestyle Management Test Bank Multiple Choice Ed. 1. A 60-year-old patient who leads a sedentary lifestyle has expressed an interest in beginning an aerobic exercise program. What will the provider include when counseling this patient about this program? a. Begin with a 45 to 60 minute workout b. Include a 1 to 2 minute warm up before exercise c. Maintain a heart rate between 80 and 128 beats per minute d. Stretching should be performed prior to activity ANS: D The heart rate should be kept between 50% and 80% of the maximum heart rate (220 minus the patient’s age = 160), which is 80 to 128 beats per minute. Patients who are not conditioned should begin with a 20 minute workout; conditioned individuals may increase up to 60 minutes. The warm up should be 3 to 6 minutes and longer if it is cold. Stretching is performed after the activity when the muscles are warm. REF: Exercise 2. Routine screening blood tests at an annual physical exam reveal a fasting glucose level of 125 mg/dL and a hemoglobin A1C of 6.2%. What will the provider do, based on these results? a. Evaluate the patient for impaired glucose tolerance b. Reassure the patient that these are normal values c. Suggest that the patient begin an exercise program d. Tell the patient that these results indicate diabetes ANS: A The fasting blood glucose level is normal, but the HgA1C indicates impaired glucose tolerance. If the HgA1C were greater than 6.4%, the patient would be diagnosed with diabetes. Until the results are evaluated, suggestions for treatment are not indicated. REF: Diabetes 3. The primary care provider is screening a patient using the CAGE criteria. What will the provider include in this assessment? Select all that apply. a. Number of times per week eaten in restaurants b. Sodium and sugar intake c. Sources of daily dairy intake d. Total number of servings of fruits and vegetables e. Types of meats and proteins ANS: A, C, E The CAGE questionnaire is designed to evaluate the intake of saturated fat and cholesterol, so the provider will ask about sources of dairy, the number of times eating foods not made at home, and the types of meats and proteins eaten. The questionnaire does not evaluate for sodium, sugar, fruits, or vegetables. REF: Box 16-1: Dietary CAGE Questions for Assessment of Intake of Saturated Fat and Cholesterol Advanced Practice Nursing : Essentials for Role Development 4th Edition Joel Test Bank Chapter 1 . Advanced Practice Nursing: Doing What Has to Be Done-Radicals, Renegades, and Rebels MULTIPLE CHOICE 1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development. ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is assessed with anthropometric data. Sexual development is assessed using physical examination. REF: 6 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor. ANS: C The expected stage of development for a preschooler (3 to 4 years old) is preoperational. Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old. REF: 5 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 3. The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight. ANS: D Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to asdifferentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation. REF: 2 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching. ANS: C The Denver II is the most commonly used measure of developmental status used by health care professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool. REF: 4 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. failure to thrive. c. fetal alcohol syndrome. d. hydrocephaly. ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay. REF: 9 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition. ANS: C Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes), hence determination of development and would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development. REF: 1 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurses best initial response is to a. refer the child to a psychologist. b. explain that playing make believe with dolls and people is normal at this age. c. complete a developmental screening. d. separate the child from the mother to get more information. ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time. REF: 5 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything. ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to know everything with their logical thinking and deductive reasoning, but that would not explain why they would act like a child. Chapter 2. Emerging Roles of the Advanced Practice Nurse Test Bank Multiple Choice 1. An APRN is about to examine a patient in the emergency department. A colleague states to the APRN “This patient is probably just seeking pain medication.” Regardless of his or her colleague’s comment he or she enter the examination room and treat the patient as if he or she is trustworthy and has good motives. Which of the ten essential elements of dignity is the APRN utilizing? a. Inclusion b. Benefit of the doubt c. Acceptance of identity d. Recognition ANS: B Treating others as if they are trustworthy, starting with the premise that they have good motives and are acting with integrity are all key points of benefit of the doubt. Benefit of the doubt is one of the ten essential elements of dignity. 2. An APRN approaches his or her patients as neither inferior nor superior and gives others the freedom to express their authentic selves without being judged. Which of the ten essential elements of dignity is the APRN utilizing? a. Safety b. Accountability c. Acceptance of identity d. Benefit of doubt ANS: C The acceptance of identity is one of the ten essential elements of dignity. Approaching people as neither inferior nor superior to you, giving others the freedom to express their authentic selves without fear of being negatively judged, interacting without prejudice or bias, accepting how race, religion, gender, class, sexual orientation, age, disability, and so on are at the core of someone’s identities, and assuming they have integrity are all included in the essential elements of acceptance of identity. 3. Communication problems often plague ethical dilemmas, which of the following is often at the forefront of communication problems regarding clinicians? a. Poor knowledge of the situation b. Language barriers c. Poor independence d. Failure to speak up ANS: D All of the answers may contribute to ethical dilemmas but failure of a clinician to speak up about a real or potential ethical problem is commonly identified. Erosion of open and honest communication is typically the first theme encountered in many ethical dilemmas. 4. A 76-year-old patient is admitted to the hospital after suffering a spinal compression fracture. The patient is unable to ambulate adequately on his or her own and requires assistance for basic needs. Your assessment is that the patient will recover their strength within 2 weeks. The billing department at the facility notifies you that the patient may not stay in the hospital for more than 2 days. The patient does not wish to be transferred to a nursing facility and wishes to remain in the hospital for the remaining 12 days to gain strength. Which of the following best defines this scenario? a. Interprofessional conflict b. Communication problems c. Legal issues d. Multiple commitments ANS: A This ethical scenario plays out routinely in medical care as an element of interprofessional conflict. The clinician wishes to respect patient autonomy but must understand and express the best interests of the patient to a multidisciplinary team. 5. An APRN is scheduled to complete his or her shift at 7 p.m. on a particular day. A new patient arrives 5 minutes prior to the time the APRN is expected to leave. He or she is asked by a supervisor to stay beyond their scheduled time to assess the patient and provide care. Which of the following best defines this scenario? a. Interprofessional conflict b. Multiple commitments c. Communication problems d. Legal issues ANS: B APRNs often fail to practice self-care and it is a significant threat to ethical practice. Multiple commitments including obligations to multiple parties involving the patient, employer, and legal system may create a scenario for ethical issues in nursing practice. Societal issues including cost containment pressures in health systems are likely partially responsible for development of this scenario. 6. An APRN works in a primary care clinic. The APRN wishes to treat a patient’s disease with a specific medication that is far superior to other treatments. The APRN has never encountered issues prescribing this therapy as first-line treatment in the past. The APRN is informed by this particular patient’s insurance that they require proof that the APRN has tried a far less effective therapy for 1 month prior to paying for the medication. Which of the following best describes the forces at work in this scenario? a. Communication problems b. Legal issues c. Interprofessional conflict d. Societal issues ANS: D Societal issues including cost containment pressures in health systems are likely responsible for development of this scenario. Interprofessional conflicts would best be involved in this scenario if this is applied in a multidisciplinary team scenario. 7. Which of the following are defined as the four elements of core competency development in ethical decision making for APRNs? a. Knowledge development, knowledge application, creating an ethical environment, promoting social justice b. Knowledge development, educating others, creating an ethical environment, promoting social justice c. Knowledge development, knowledge application, effective communication, promoting social justice d. Knowledge development, knowledge application, creating an ethical environment, understanding legal barriers ANS: A The core competency of ethical decision making for APRNs is best organized into four key elements: knowledge development, knowledge application, creating an ethical environment, and promoting social justice. 8. Which of the following examples best describes the knowledge development element of core competency development for ethical decision making? a. Analyzing the policymaking process b. Using self-reflection during patient case reviews c. Applying ethical decision-making model to a clinical problem d. Mentoring others to develop ethical practice ANS: B The use of knowledge development is a key element of core competency development for ethical decision making. It involves gaining knowledge of ethical theories and developing the abilit y to distinguish a true ethical dilemma from a situation of moral distress or other clinically problematic situation. Becoming sensitive to ethical dimensions of clinical practice and fidelity conflicts, developing values clarification (self-reflection), and interpreting reactions and emotions of others are all elements of knowledge development and moral sensitivity. 9. An APRN joins a group promoting awareness about abuse in long-term nursing care facilities. He or she advocates for policies that protect the health care rights of individuals who are not able to care for themselves independently. The APRN most likely employed which of the following elements of core competency development for ethical decision making? a. Promoting social justice b. Knowledge development c. Creating an ethical environment d. Knowledge application ANS: A Skills or behaviors for promoting social justice within a health care system include the ability to analyze the policy process and advocacy, communication, and leadership skills that promote involvement in health policy initiatives supporting social justice. 10. An APRN interacts with a patient and another colleague to achieve the best outcome ofan ethical dilemma. The APRN most likely used which of the following elements of core competency development for ethical decision making? a. Knowledge application b. Creating an ethical environment c. Promoting social justice d. Knowledge development ANS: A Applying ethical decision-making models to clinical problems, using skilled communication regarding ethical issues, and facilitating decision making by using select strategies are involved in the use of knowledge application. 11. An APRN works at a hospital system that provides care to a large proportion of Asian- American citizens. The APRN develops a presentation for newly hired employees about the cultural belief systems held by many in this population group. This describes the use of which of the following elements of core competency development for ethical decision making? a. Creating an ethical environment b. Promoting social justice c. Knowledge application d. Knowledge development ANS: A Creating an ethical environment may include the use of preventative ethics and awareness of environmental barriers to ethical practice. 12. Application of existing rules and doctrine as a guide for ethical decision making is best described as which ethical approach? a. Narrative ethics b. Care-based ethics c. Casuistry d. Principle-based ethics e. Virtue-based ethics ANS: D In principle-based ethical decision making, the principles or rules in contention are balanced and interpreted with the contextual elements of the situation. However, the final decision and moral justification for actions are based on principles. 13. Which ethical approach uses comparisons of precedent-setting cases and current scenarios? a. Principle-based ethics b. Casuistry c. Care-based ethics d. Narrative ethics e. Virtue-based ethics ANS: B Casuistry is an ethical approach which uses comparisons of precedent-setting cases and current scenarios. 14. Which approach emphasizes the particulars of a case or story as a vehicle for discerning the meaning and values embedded in the ethical decision making? a. Principle-based ethics b. Casuistry c. Virtue-based ethics d. Care-based ethics e. Narrative ethics ANS: E Narrative ethics emphasizes the particulars of a case or story as a vehicle for discerning the meaning and values embedded in the ethical decision making. 15. Which ethical approach sees individuals as interdependent rather than independent and focuses on parties in a relationship? a. Principle-based ethics b. Care-based ethics c. Narrative ethics d. Casuistry e. Virtue-based ethics ANS: B Care-based ethics emphasizes creating and sustaining responsive connections with others, importance of contact and subjectivity in discerning ethical action, and sees individuals as interdependent rather than independent and focuses on parties in a relationship. Multiple Choice 16. As defined by Kilpatrick et al. (2016), which of the following is a hallmark of the role of the CNS? a. Adapting to changing needs of patients, nurses, and health care systems b. Advanced knowledge and skills c. Lack of educational requirements d. Ability to independently practice ANS: A A hallmark of the role is the ability of the CNS to adapt to changing needs of patients, nurses, and health care systems (Kilpatrick, Tchouaket, Carter, Bryant-Lukosius, & DiCenso, 2016). This versatility allows for a CNS to transition between positions as a primary caregiver or educator depending on the environment. 17. Which of the following has complicated clarifying the work and core competency of all CNSs? a. Varying educational, competency, and practice standards b. Bureau of Labor Statistics’ failure to capture data c. Lack of interest d. Advancement of the nurse practitioner role ANS: A Varying educational, competency, and practice standards have complicated clarifying the work and core competencies of all CNSs, regardless of specialty. The failure of the Bureau of Labor Statistics to track CNS providers only creates barriers when it comes to counting the number of CNSs in the United States. 18. Which of the following is a central competency for CNSs according to the Hamric model? a. Indirect care of patients and families b. Ethical decision making c. Direct care of patients and families d. Systems leadership e. Conduct of research ANS: C Direct care of patients or clients is the central core competency of the Hamric model and links each of the other competencies. 19. According to the NACNS model, emphasis on which of the following competencies is largest? a. Indirect care of patients and families b. Ethical decision making c. Conduct of research d. Direct care of patients and families e. Systems leadership ANS: D Direct care of patients or clients is the largest competency of the three spheres according to the NACNS model and encompasses the other two. 20. A CNS relocates to another state and begins a new job. Which of the following would guide his or her ability to practice certain procedures or skills? a. State scope of practice and facility policy b. American Medical Association policy c. State scope of practice d. Facility policy ANS: A The scope of practice is those activities a health care individual is allowed to perform within his or her profession. It is the responsibility of the CNS to adhere to each state’s rules in which they practice. Additionally, facilities may impose additional restrictions or limitations for a CNS to perform procedures or skills. 21. The National Association of Clinical Nurse Specialists has seven core competencies published for the CNS role. Which of the following is not included at the highest level? a. Coaching competency b. Professionalism competency c. Direct care competency d. Systems leadership competency ANS: B The National Association of Clinical Nurse Specialists’ Core Competencies include at the highest level seven competencies: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision making, moral agency, and advocacy. 22. Each of the following is specifically described in the NACNS’s three spheres of influence for the CNS role except: a. Nurses/nursing practice b. Organization/system c. Leadership d. Patient ANS: C The NACNS has defined the CNS role as operating between the three spheres of influence: the patient, the organization/system, and the nurse/nursing practice. The CNS should employ Hamric’s seven competencies across the three spheres of influence. 23. According to a 2016 ruling, how has the Department of Veterans Affairs alleviated state- based practice regulations at VA facilities? a. Allows CNS to work at full practice authority b. Allows CNS to practice according to their home state’s regulation c. Provides immediate licensures d. Provides malpractice insurance free of charge ANS: A In 2016, the Department of Veterans Affairs alleviated state-based practice regulations by allowing CNS to work at full practice authority inside VA facilities and not within a state’s scope of practice. 24. Which of the following is major regulatory barrier for many CNS specialties in relation to the Consensus Model? a. Poor reimbursement for services b. Lack of specialty certification examinations c. Lack of education d. Poor CNS involvement in advocacy ANS: B A lack of specialty certification examinations in some areas is a major regulatory barrier for many CNS specialties in relation to the Consensus Model. 25. With regard to prescriptive authority, how did Oregon manage CNSs whose original education curriculum did not include prescription of pharmacologic agents? a. Take a specialized state-specific examination regarding prescriptive authority b. Permanent exclusion from prescriptive authority c. An advanced pharmacology course and complete 150 supervised hours d. 2080 hours involved in a collaborative agreement ANS: C Oregon’s regulation for inclusions of CNSs whose original education curriculum did not include prescription of pharmacologic agents includes the completion of an advanced pharmacology course and a minimum of 150 hours of supervised pharmacologic management. Minnesota requires 2080 hours of practice within a collaborative agreement with a licensed CNP, CNS, or physician experienced with similar patients. Wisconsin requires advanced practice nurse prescribers to pass an examination on Wisconsin’s statutes and rules of practice. 26. States have each independently created regulation regarding advanced practice. With regard to prescriptive authority, what requirement has Wisconsin implemented regarding authorization of CNSs as advanced practice nurse prescribers? a. 2080 hours involved in a collaborative agreement b. An advanced pharmacology course and complete 150 supervised hours c. Permanent exclusion from prescriptive authority d. Take a specialized state-specific examination regarding prescriptive authority ANS: D Wisconsin requires advanced practice nurse prescribers to pass an examination on Wisconsin’s statutes and rules of practice. Oregon’s regulation for inclusions of CNSs whose original education curriculum did not include prescription of pharmacologic agents includes the completion of an advanced pharmacology course and a minimum of 150 hours of supervised pharmacologic management. Minnesota requires 2080 hours of practice within a collaborative agreement with a licensed CNP, CNS, or physician experienced with similar patients. 27. Which factor led to a decrease of CNSs entering CNS programs in 1990s? a. Repurposing CNSs into quality managers and educator roles b. Increased job positions c. Increase in facility funding for NP programs d. Lack of emphasis on primary care ANS: A Several forces led to the initial decline in the number of students entering CNS programs. Fiscal restraints of health care facilities, repurposing CNSs into other roles, increased emphasis in primary care, and rapid growth of NP programs have previously and continue to contribute to decreased numbers of students entering CNS programs. 28. Which of the following is an important defining characteristic of the difference of the CNS role from an NP? a. Time spent among three spheres of influence b. Primarily involved in direct care c. Does not provide consultations d. Time spent primarily as patient advocate ANS: A One key defining difference of the CNS role is that the time spent performing competencies is across three spheres of influence. In the NP role, most time is spent in direct care management of patients. Both may provide consultations and all clinicians should act as a patient advocate. 29. Which of the following is most important to stabilize the future of the CNS role? a. Decreased educational requirements b. CNS conducted independent research c. Unity around NCSBN affirmation of CNSs being APRNs d. NP restrictions of roles ANS: C There are several important factors that influence the stability of the CNS role in the future. These include unity around NCSBN affirmations of CNSs as APRNs, articulating contributions to patients, families, and health care systems, ensuring educational curricula are upheld and helpful, partnering with others in practice and research, and seeking national recognition for the role. 30. Which of the following is provided as part of the Consensus Model? a. Decrease educational requirements b. Collaboration among physicians c. Reimbursement for services d. Title protection ANS: D The Consensus Model provides title protection for CNSs and provides for a grandfather clause to include APRNs who graduated from accredited programs and began practicing prior to the implementation of the Consensus Model. Chapter 3. Role Development: A Theoretical Perspective Test Bank Multiple Choice 31. The federal government’s criterion to establish health professional shortage areas (HPSAs) is based on which of the following statistics? a. Average family income less than two-thirds of national poverty level b. An area in which there are less than 500 individuals for every primary care physician (PCMD) c. Average family income less than half of national poverty level d. An area in which there are more than 4500 individuals for every primary care physician (PCMD) e. An area in which there are more than 3500 individuals for every primary care physician (PCMD) ANS: E The federal government establishes health professional shortage areas (HPSAs) that are primarily based on the criterion that an area has more than 3500 individuals for every primary care physician (PCMD). 32. What is a downfall of the HPSA’s calculation? a. Is only recalculated every 10 years b. Does not include other PCP designations (PAs, NPs) c. Does not adjust for inflation d. Has a lower weighted average for NP versus MD providers ANS: B The health professional shortage areas (HPSAs) are currently only calculated based on primary care physicians (PCMDs) and do not take into account other primary care providers such as PAs and NPs. 33. Some community health centers can apply for a special designation if they are an entity that serves a population that is medically underserved or a specially medically underserved population comprised of migratory and seasonal agricultural workers, the homeless, and residents of public housing. What is this designation? a. Federally qualified health center (FQHC) b. Patient-centered medical home (PCMH) c. School-based health center (SBHC) d. Nurse-led health center (NLHC) ANS: A The HRSA Bureau of Primary Care enables these safety net organizations to receive a variety of enhanced federal support by applying for designation as a federally qualified health center (FQHC). 34. Which of the following is not a common characteristic of a school-based health center (SBHC)? a. No parental requirement for consent for treatment b. Close integration with the school c. Comprised of a multidisciplinary team d. Located in schools or on school grounds ANS: A Nearly all SBHCs require parental consent for full treatment of adolescents, except in states where such adolescents can consent for certain treatments like contraception, pregnancy, drug abuse, and/or sexually transmitted infections. 35. A nurse practitioner provides care at a veteran’s clinic managed by the Department of Veterans Affairs. The state in which he or she practices prohibits many procedures. Which of the following is most accurate regarding the care the NP provides? a. Additional licensure is required to practice in VA systems by the state b. NP must be supervised for all skills c. State practice regulations override VA regulations d. Full practice authority is allowed inside the VA system ANS: D In 2016, The Department of Veterans Affairs granted full practice authority to NPs, CNSs, and CNMs. This allows these providers to work at full practice authority inside VA facilities and not confined within a state’s scope of practice. 36. Medical care provided by primary care providers (PCMD, PCNP) as part of the patient- centered medical home (PCMH) model encompasses the full spectrum of primary care including standards of accessibility, continuity, comprehensiveness, integrated care, and interprofessional care. This model was first defined for what population group? a. Geriatrics b. Gynecology c. Pediatrics d. Mental health ANS: C The patient-centered medical home (PCMH) model was first developed for the pediatric medical community for development of children with complex medical conditions. 37. Which of the following is reducing the restrictions of access to consultations for patients with complex or high-risk conditions, effectively reducing the burden of primary care practices? a. PCMH Model b. CONNECT Project c. Project ECHO d. PCT-LEAP Project ANS: C Technical innovations such as Project ECHO and eConsults are increasing access and advancing care by easing the burden of connecting primary care practices and patients with consultants through the use of technology. This allows for faster access to consultants for patients with complex or high-risk medical conditions. 38. A medical visit that comprises several patients in a group with similar conditions where patients discuss their health status, therapeutic regimes, behavioral modifications, and how to handle them is called: a. Project ECHO b. Convenient care clinics c. Shared medical appointments d. Group therapy ANS: C Shared medical appointments are a reimbursable type of visit that may include a multidisciplinary team where patients with similar conditions discuss their health status, therapeutic regimes, behavioral modifications, and how to handle them in a group setting. 39. According to the American Association of Nurse Practitioners: 2017 NP Fact Sheet, NPs have been in practice an average of how many years? a. 9 years b. 14 years c. 7 years d. 11 years ANS: D In 2017, the average NP has been in practice for 11 years. 40. According to the American Association of Nurse Practitioners: 2017 NP Fact Sheet, which of the following is the largest area of certification? a. Pediatrics b. Acute care c. Psychiatric/mental health d. Primary care e. Tertiary Care ANS: D About 89.2% of NPs are certified in an area of primary care as of 2017 including Adult, Adult- Gerontology, Family, Gerontology, Pediatric-Primary Care, and Women’s Health. 41. According to the American Association of Nurse Practitioners: 2017 NP Fact Sheet and the AANP National Nurse Practitioners Database, approximately how many NPs are licensed in the United States? a. 1,26,000 b. 2,34,000 c. 3,18,000 d. 3,81,000 e. 4,08,000 ANS: B As of 2017, there are more than 2,34,000 NPs licensed to practice in the United States. 42. Which of the following has shown promising outcomes for NPs in achievement of competence, confidence, and mastery as well as increased levels of NP satisfaction? a. NP Postgraduate Residency Programs b. Work in Underserved population areas c. Increased NP Pay d. Decreased malpractice claims e. Advancement of NP care practices ANS: A NP Postgraduate Residency Programs still need additional research on outcomes, policy considerations, and academic arrangements. Early studies have suggested that NPs who complete a residency program acquire higher achievement of competence, confidence, and mastery as well as increased levels of NP satisfaction. 43. The Triple Aim Initiative was launched in 2007 by the Institute for Healthcare Improvement (HIT) which focused on three dimensions of health care: experience of care, per capita cost, and population health. Which fourth aim was proposed in 2014 by Bodenheimer and Sinsky in a call to redesign the initiative? a. Improved clinician experience b. Prevention c. Increased reimbursements d. Decreased adverse events ANS: A Bodenheimer and Sinsky proposed a fourth aim “improved clinician experience” which brings to light the facts that the “joy” has gone out of practicing medicine. Other studies have shown that patient outcomes suffer if providers feel overwhelmed, overworked, or powerless. 44. The American Academy of Pediatrics questioned which of the following negative outcomes of Community Care Clinics (CCCs)? (Select all that apply.) a. Uneven EHR interoperability with community primary care providers b. Lack of longitudinal relationships with providers c. Incentives to overprescribe d. Increased patient satisfaction e. Decreased wait times ANS: A, B, C In 2014, the American Academy of Pediatrics had questions regarding CCCs and their possible incentives to overprescribe, lack of longitudinal relationships with providers, and uneven EHR interoperability with community primary care providers that may negatively impact the health care system. Chapter 4. Educational Preparation of Advanced Practice Nurses: Looking to the Future 45. Which of the following is the most essential component to lead clinical staff and programs effectively as an advanced practice registered nurse? a. Clinical credibility b. Appropriate education c. Years of experience d. Age ANS: A All of the options may attribute to effectively leading clinical staff and programs as an APRN. Direct care is the central competency of advanced practice nursing and excellence in direct care requires clinical credibility to lead other clinical staff. Years of experience or age may or may not be related to direct care. Appropriate education is important for clinical leadership, but clinical credibility requires experience combined with direct care. 46. An advanced practice registered nurse in an outpatient clinic has a phone conference with a cardiologist regarding a patient’s condition. This is an example of: a. Social services b. Point-of-care encounter c. Indirect care d. Direct care ANS: C This is an example of indirect care of clinical practice. Direct care or direct clinical practice refers to those activities and functions that the APRN performs within the patient-nurse interface. 47. Which of the following is considered indirect care? a. Forming a therapeutic relationship during patient examination b. Discharge planning c. Consideration of which medication to prescribe a patient d. Patient education regarding medication side effects ANS: B Indirect care or indirect clinical practice refers to those activities and responsibilities that occur outside of the patient-nurse interface. They may include consultation with other health care providers, discharge planning, care coordination, communication with insurance companies, education or supervision of other medical staff, or billing and coding for services rendered. The other options are examples of direct care. 48. Which of the following is considered direct care? a. Forming a therapeutic relationship during patient examination b. Increasing knowledge of a disease process to better care for a complex patient c. Prior authorization of prescriptions d. Consultant phone call about patient condition ANS: A Direct care or direct clinical practice refers to those activities and functions that the APRN performs within the patient-nurse interface. Examples of direct care include physical acts of diagnosis, monitoring, treatment, or direct patient education that occur in the patient-nurse interface. It can be with the patient or family members. The other options are examples of indirect care. 49. An APRN is preparing a patient to be discharged from an emergency department. Which of the following activities is considered direct care? a. Speaking with the patient’s primary care provider b. Electronically transmitting prescriptions to pharmacy c. Discharge planning documentation d. Discharge patient education ANS: D The decision to discharge a stable patient requires that the APRN evaluated the patient and his or her clinical condition and determined it to be stable; this most likely required direct clinical care including a physical examination and medical decision making and discharge-related patient education. 50. An APRN evaluates and modifies his or her clinical practice routines by reading and following updates and recommendations from various journals and organizations such as the United States Preventative Task Force (USPSTF). Which characteristic of advanced direct care practice is the APRN utilizing? a. Use of reflective practice b. Use of a holistic perspective c. Expert clinical performance d. Use of evidence as a guide for practice ANS: D Using evidence as a guide for practice is one of six characteristics for advanced direct care practice. Reading research reports, searching health care databases, acquiring skills to analyze evidence, and working with colleagues regarding evidence-based improvements in care are all examples of using evidence as a guide for practice. 51. During a patient encounter the APRN remembers the patient mentioned during a previous visit that the patient’s child was applying to colleges. The APRN asks which college the patient’s child chose to attend. Discussing this at the beginning of the patient encounter utilizes what characteristic of advanced direct care practice? a. Formation of therapeutic partnerships with patients b. Expert clinical performance c. Use of a holistic perspective d. Use of reflective practice ANS: A The formation of therapeutic partnerships with patients is one of six characteristics for advanced direct care practice. The APRN is effectively using good conversational style to create a strong therapeutic relationship with the patient. Use of a holistic perspective would only be correct if this conversation was used in relation to the patient’s care. 52. An APRN starts a patient on a specific medication chosen over a compatible medication due to a decreased risk of sedation. The medication was chosen because the patient has an occupation driving a truck. Which characteristic of advanced direct care practice is the APRN utilizing? a. Formation of therapeutic partnerships with patients b. Use of a holistic perspective c. Expert clinical performance d. Use of reflective practice ANS: B Using a holistic perspective includes identifying patterns of symptoms combined with the effect of the individual patient. This may include the patient’s view of his or her own health or the impact that his or her disease or treatments may affect his or her overall quality of life. Expert clinical performance is incorrect because the medication was chosen solely based on the effect of medication side effects on the patient’s social life. 53. An APRN encounters an angry and combative patient during his or her shift. The next day he or she meets and speaks with a colleague involved with the patient to discuss how the department handled the incident as well as his or her personal beliefs regarding the care of combative patients. Which characteristic of advanced direct care practice is the APRN utilizing? a. Use of evidence as a guide for practice b. Expert clinical performance c. Diverse approaches to and interventions for Health and Illness Management d. Use of reflective practice ANS: D The use of reflective practice is an important characteristic of advanced direct practice care. Meeting with colleagues and teachers regarding clinical scenarios are important aspects of reflective practice as you explore personal values, social beliefs, and behaviors. Since the meeting was not regarding evidence-based improvements of care or strategies to improve the outcome of similar patients the other options are incorrect. 54. An APRN works in a critical care environment. He or she identifies a patient he or she believes to be at risk for decompensation and intervenes quickly. Which characteristic of advanced direct care practice is the APRN utilizing? a. Use of evidence as a guide for practice b. Expert clinical performance c. Use of reflective practice d. Diverse approaches to and interventions for Health and Illness Management ANS: B Expert clinical performance is the development of specialized knowledge, experience, and complex situations the APRN will encounter during patient care. Deeply understanding clinical knowledge and interpretation of data are aspects of expert clinical performance. 55. An APRN encounters an angry and combative patient during his or her shift. The next day he or she begins analyzing patient outcomes as they correlate with different treatment modalities. Which characteristic of advanced direct care practice is the APRN utilizing? a. Expert clinical performance b. Use of evidence as a guide for practice c. Use of reflective practice d. Diverse approaches to and interventions for Health and Illness Management ANS: B Systematic reviews of existing journals, health care statistics, and working with colleagues in an attempt to improve outcomes and understand clinical scenarios are examples of excellent use of evidence as a guide for practice. In this scenario the other options are incorrect; the APRN had not just discussed his or her personal beliefs, nor was specifically reviewing patient data for his or her personal knowledge development. 56. An APRN is working in a rural community health center providing community health services to poverty-stricken families He or she works at government agencies and regional medical centers to coordinate care for patients who cannot afford it. At these facilities the APRN gains experience using lower cost strategies to provide effective care. Which characteristic of advanced direct care practice is the APRN utilizing? a. Expert clinical performance b. Use of reflective practice c. Diverse approaches to and interventions for Health and Illness Management d. Use of evidence as a guide for practice ANS: C Diverse approaches to and interventions for health and illness management include the interpersonal interventions to guide or coach patients, acquiring new ways to treat patients, providing preventative services, coordinating services among care sites and multiple providers, and acquiring knowledge about complementary therapies. 57. An APRN in an emergency department is utilizing a new type of IV catheter for the first time. He or she seeks out a colleague more familiar with the device for supervision. Which characteristic of advanced direct care practice is the APRN utilizing? a. Expert clinical performance b. Use of reflective practice c. Formation of therapeutic partnerships with patients d. Use of a holistic perspective ANS: A Expert clinical practice includes more than just providing excellent care at your current level. It also includes having an understanding of scenarios, situations, and procedures where you may be overwhelmed or less confident and then seeking out expert assistance or guidance. This provides the best outcomes for the patient and furthers the clinical understanding. 58. A female patient is undergoing an elective surgery that has a risk of blood loss. She is a Jehovah’s Witness and due to her religious beliefs does not want blood transfusions to be administered. The APRN delays the patient’s surgery and recommends she donate her own blood to be administered during the surgery if needed. Which characteristic of advanced direct care practice is the APRN utilizing? a. Use of evidence as a guide for practice b. Expert clinical performance c. Use of a holistic perspective d. Formation of therapeutic partnerships with patients ANS: C Understanding the patient’s spiritual and life values, additional context of the patient’s life, possible life changes, and the effects of their disease or treatments are all factors that must be considered when using a holistic perspective. 59. Which of the following will most likely enhance the patient-APRN relationship and increase communication? a. Longer appointment duration b. Printed education guides c. Having a caregiver present at the time of examination d. Active listening ANS: D A foundation of excellent communication begins with listening to the patient. Each of the other options may improve the outcome of the patient but establishing effective therapeutic relationships with patients involves listening to their concerns to establish trust, increase patient satisfaction, increase adherence to treatment plans, and improve patient outcomes. 60. With which of the following types of patients would it be most difficult to establish a therapeutic partnership? a. Mentally disabled patient b. Toddler c. Elderly patient d. A patient with tonal hearing loss ANS: A While all of the patients in this question may be more challenging, only the mentally disabled patient has expressed limitations in communication. A mentally disabled patient may not be able to comprehend instructions, and the level of understanding may not be able to be fully expressed. An elderly patient, a patient with hearing loss, and a toddler are still able to effectively communicate their level of understanding. Modifications in communication strategies may be required in all of the patients. 61. Which of the following techniques should be utilized when communicating with all elderly patients who have hearing loss? a. Administer testing for understanding b. Face the patient c. Use verbal aids d. Write down instructions ANS: B During the initial encounter with a patient with a communication barrier, the level of the barrier should first be assessed. Additional therapies may not be needed if simply sitting directly facing the patient can achieve effective communication. The same methods for ensuring understanding should be used in patients with hearing loss, such as having them repeat instructions or voice their level of understanding. 62. An elderly male patient is being seen by the APRN. Which of the following techniques for effective communication should be initially avoided? a. Speaking in a louder voice b. Appropriate touch c. Maintain eye contact d. Face the patient ANS: A Remember that assumptions should never be initially made about any patient and always speaking in a louder voice may be considered offensive. An elderly patient does not always have hearing loss or dementia, and strategies to assess the level of understanding should be used if suspicions exist. 63. An APRN is working in an outpatient care clinic for diabetics. He or she is responsible for starting newly diagnosed diabetic patients on long-acting basal insulin to control their fasting morning blood glucose levels. The APRN starts a 55-year-old obese patient 35 units of long- acting insulin nightly. The APRN chooses this dose solely based on the weight of the patient and does not review the patient’s current medication list. The APRN has previously used this method successfully in many patients who were admitted to the hospital. Three days later the patient is found unconscious at home by family members, transported to the emergency department, and expires. After an investigation the patient had administered only the prescribed amount of insulin as directed by the APRN. Which of the following factors most likely attributed to the patient’s poor outcome? a. Patient education b. Lack of knowledge c. Thinking error d. Lack of evidence-based practice ANS: C The APRN in this clinical scenario made a thinking error. While it is possible that other factors could have influenced the poor outcome, the dose of the insulin was unlikely individualized to this patient. Tunnel vision and treating each patient the same are examples of thinking errors. Failing to review the patient’s medication list for short-duration medications like steroids and antibiotics, as well as other comorbidities, increases risks for medication side effects. Although the APRN had administered similar doses to other patients previously, those patients were inside medical facilities with close observation to avoid adverse events. 64. An APRN is treating a 44-year-old female patient with 10/10 chest pain in an emergency department. This patient has a history of severe anxiety and has run out of her anxiety medication. She has been seen three times in the previous month for the same pain. The APRN discharges the patient home with a refill of her anxiety mediations but without a full cardiac workup. The patient dies at home and an autopsy reveals a myocardial infarction as the cause of death. Which of the following would have most likely prevented the poor outcome of the patient? a. Proper documentation b. Therapeutic communication c. Avoiding premature closure d. Patient education ANS: C Avoidance of thinking errors of medical providers is imperative to excellent patient care. While therapeutic communication may have elicited additional information about this patient the APRN should remain constantly open to re-evaluation of patients, be aware of personal biases and assumptions, and ensure critical data are obtained on each patient. The use of a diagnosed “time- out” procedure sometimes is important to review a situation with fresh eyes and to prevent assumptive diagnosis and premature closure. 65. Use of which of the following strategies by an APRN would best prevent ethical conflicts during end-of-life care? a. Discussion with healthy patient during outpatient clinic b. Use of an ethics committee c. Discussion when life-threatening disease/accident occurs d. Discussion upon admission of a patient to a hospital ANS: A Avoiding ethical conflicts with patients, families, and their surrogates can best be avoided by having ethical discussions as early as possible. While all scenarios will avoid ethical conflicts, discussion and documentation with a healthy patient allows for prevention of ethical conflicts in end-of-life care. Remember that prevention is always the best treatment. 66. Which of the following scenarios is the best example of the concept of moral distress? a. 75-Year-old nursing colleague fired for being too old b. 45-Year-old female diagnosed with lung cancer who refuses appropriate treatment c. 4-Year-old child who died after receiving an incorrect medication d. Amputation of the incorrect limb during a surgical procedure ANS: B The most common cause of moral distress identified in a 2004 study is patient refusal of appropriate life-saving treatment. By definition, moral distress is when a provider knows an ethically appropriate action should be taken but barriers are encountered that discourage the action from being taken. Wrong site surgeries and medication errors are negligence. The firing of a person based on age is considered discrimination. 67. Which of the following strategies has been recommended when communicating about adverse events? a. Avoid apologizing or acknowledging the error occurred b. Notify the patient immediately that an adverse event has occurred c. Complete all documentation thoroughly prior to reporting the event to anyone d. Explain all known details to the patient immediately ANS: B Four steps recommended by a consensus group of Harvard hospitals in 2006 include the following: (1) tell the patient what happened immediately, but leave details of how and why for later when a thorough review has occurred; (2) take responsibility for the incident; (3) apologize and communicate remorse; (4) inform the patient and family what will be done to prevent similar events. 68. Which of the following are characteristics of direct clinical care provided by APRNs? (Select all that apply.) a. Use of reflective practice b. Use of evidence as a guide for practice c. Formation of therapeutic partnerships with patients d. Adequate supervision of others e. Use of a holistic perspective ANS: A, B, C, E The six characteristics of direct clinical care are use of a holistic perspective, formation of therapeutic partnerships with patients, expert clinical performance, use of reflective practice, use of evidence as a guide to practice, and use of diverse approaches to health and illness management. Adequate supervision of others is an example of indirect care. 69. A newly licensed APRN is working in a busy outpatient clinic. He or she continually runs late and cannot adequately gather all of the pertinent patient information during each patient encounter. This has caused the APRN to misdiagnose multiple patients. Which of the following may best alleviate the time pressures experienced by the APRN? (Select all that apply.) a. Avoid interruptions b. Increase visit length time c. Limit patient complaints allowed for each visit d. Use a systematic approach e. Set a timer to end each patient encounter ANS: A, B, D Time pressures are experienced at an even higher frequency in novice APRNs. Avoiding interruptions and increasing visit length time are the best options to alleviate time pressures. Setting a timer to end each patient encounter or limiting patient complaints would be inappropriate strategy for a novice APRN. Rushed or truncated encounters often lead to lack of therapeutic communication, incomplete physical examinations, and withholding of patient questions. Development of a systematic approach to each patient encounter is one of the best strategies to implement to increase APRN efficiency and is usually paramount as an APRN develops experience. Chapter 5. Global Perspectives on Advanced Nursing Practice 70. 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