3303 Fundamental Lecture Mastery Level Question Chapters 19, 24

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply. a. Basophils b. T-Lymphocytes c. Neutrophils d. Monocytes e. Eosinophils

a. Basophils c. Neutrophils e. Eosinophils

Which organization audits charts regularly? a. The Joint Commission b. Sigma Theta Tau International c. National League for Nursing d. American Nurses Association

a. The Joint Commission

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? a. When hands are visibly soiled b. Before direct contact with clients c. After completing a wound dressing d. After direct contact with clients

a. When hands are visibly soiled

Surgical asepsis is defined as: a. absence of all microorganisms. b. absence of all virulent microorganisms. c. use of hand washing, gowning, and gloving. d. slowed growth of microorganisms.

a. absence of all microorganisms.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? a. The plan includes interventions, evaluation, and response. b. Subjective data should be included when documenting. c. Objective data are what the client states about the problem. d. Abnormal laboratory values are common items that are documented.

b. Subjective data should be included when documenting.

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of: a. Aerobic activity b. Survival adaptation c. Means of transmission d. Spore production

b. Survival adaptation

Which of the following are considered the building blocks of the immune system? a. Macrocytes b. T lymphocytes c. Macrophages d. Red blood cells

b. T lymphocytes

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? a. Lung sounds b. The lower extremities c. Heart rate and rhythm d. The abdominal area

b. The lower extremities

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a. Use a critical pathway to document the physical assessment. b. Write a narrative note in the designated nursing section. c. Place the narrative note chronologically after the respiratory therapist's note. d. Review the laboratory results under the health care provider section.

b. Write a narrative note in the designated nursing section.

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? a. continue with droplet precautions b. change to airborne precautions c. change to contact precautions d. change to standard precautions

b. change to airborne precautions

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? a. "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue." b. "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." c. "I will obtain a mask from the staff and wash my hands before touching my family member." d. "I will not visit my family member in the first 3 days of my cold."

c. "I will obtain a mask from the staff and wash my hands before touching my family member."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? a. "The provider will need to give permission for you to review." b. "I am sorry I can't access that information." c. "Only authorized persons are allowed to access client records." d. "Let me get that for you."

c. "Only authorized persons are allowed to access client records."

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? a. Don't follow through with the order, and delete it from the record b. Ask the secretary to call the provider back and take the order c. Inform the provider, to ensure safety for the client, it must be read back d. Proceed with the order since the nurse heard it the first time

c. Inform the provider, to ensure safety for the client, it must be read back

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? a. FOCUS data, action, and response note b. problem, intervention, and evaluation note c. charting by exception d. narrative notes

c. charting by exception

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? a. Place the client in a private room that has monitored negative air pressure. b. Use respiratory protection when entering the room. c. Keep visitors 3 feet (1 m) from the client. d. Wear gloves whenever entering the client's room.

d. Wear gloves whenever entering the client's room.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as: a. bacteria. b. fungus. c. virus. d. parasite.

d. parasite.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 3Fever, possible urinary tract infection 1Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 2"I don't feel well. I've been urinating often, and it burns when I urinate." 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

2"I don't feel well. I've been urinating often, and it burns when I urinate." 1Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3Fever, possible urinary tract infection 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? a. "All visitors who enter the room must wear N95/surgical masks." b. "Under no circumstances should you touch the client." c. "Everyone who enters the room must wear a gown and gloves." d. "No visitors are allowed in the room to decrease the spread of disease."

a. "All visitors who enter the room must wear N95/surgical masks."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? a. "Legal policy requires nursing practice to be permanently integrated into the client record." b. "The facility requires us to document client care this way because of the computer application used." c. "It would be easier to do it that way. You could develop a tool to use." d. "The electronic health record we use does not allow us to use different formats."

a. "Legal policy requires nursing practice to be permanently integrated into the client record."

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? a. Fungi b. Helminths c. Rickettsiae d. Protozoans

a. Fungi

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? a. indwelling catheter b. specimen containers c. bath blanket d. face shields

a. indwelling catheter

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: a. interpretation of data. b. relevant data. c. factual statement. d. important information.

a. interpretation of data.

The most common infection in children is: a. neurologic. b. respiratory. c. urinary. d. gastrointestinal.

b. respiratory.

For which client would the use of standard precautions alone be appropriate? a. a client with TB who needs medications administered b. a client with diphtheria who needs p.m. care c. an incontinent client in a nursing home who has diarrhea d. a child with chickenpox who is treated in the emergency room

c. an incontinent client in a nursing home who has diarrhea

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? a. "It will let me see everything that has been done and things that need to be done." b. "It will give me a better sense of what my workload will be today." c. "It makes our client feel like we care, especially if we start the day off with a clean room." d. "It will allow for us to see the client and possibly increase client participation in care."

d. "It will allow for us to see the client and possibly increase client participation in care."

Which term describes foreign particles that enter a host and stimulate the body's immune response? a. Phagocyte b. Macrophage c. Antibody d. Antigen

d. Antigen

Which nursing action is a component of medical asepsis? a. insertion of an intravenous catheter b. drawing blood from a central line c. insertion of an indwelling urinary catheter d. handwashing after removing gloves

d. handwashing after removing gloves

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? a. stationary b. resolution c. invasion d. prodromal

d. prodromal

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? a. "Any information that can identify a person is considered a breach of client privacy." b. "You may continue to post about a client, as long as you do not use the client's name." c. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." d. "All aspects of clinical practice are confidential and should not be discussed."

a. "Any information that can identify a person is considered a breach of client privacy."

The nurse is getting ready to change the client's saturated, infected leg dressing. The client requests that the nurse delay it until the night shift. Which response does the nurse provide this client? a. "Saturated dressings increase the risk of the spread of infection." b. "We can change it later; I will reinforce your dressing for now." c. "I will inform the incoming nurse of your request." d. "You do not need to worry; I can change your dressing quickly."

a. "Saturated dressings increase the risk of the spread of infection."

What is the second line of defense in microbial invasion? a. Inflammation b. Disease c. Infection d. Disability

a. Inflammation

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? a. Omitting clients' responses to nursing interventions b. Identifying nursing diagnoses or clients' needs c. Documenting clients' health histories and discharge planning d. Recording nursing interventions

a. Omitting clients' responses to nursing interventions

Which are appropriate actions for protecting clients' identities? Select all that apply. a. Place light boxes for examining X-rays with the client's name in private areas. b. Document all personnel who have accessed a client's record. c. Ensure that clients' names on charts are visible to the public. d. Orient computer screens toward the public view. e. Have conversations about clients in private places where they cannot be overheard.

a. Place light boxes for examining X-rays with the client's name in private areas. b. Document all personnel who have accessed a client's record. e. Have conversations about clients in private places where they cannot be overheard.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? a. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. b. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. c. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. d. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.

a. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply. a. The nurse is going from one room to another to introduce themself at the start of the shift. b. The nurse is exiting a room after completed indwelling urinary catheter care. c. The nurse has just completed documentation and is entering another client's room. d. The nurse has entered the client's room to adjust settings on the intravenous pump. e. The nurse has assisted a client with changing and caring for a new colostomy.

a. The nurse is going from one room to another to introduce themself at the start of the shift. c. The nurse has just completed documentation and is entering another client's room. d. The nurse has entered the client's room to adjust settings on the intravenous pump.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? a. Translators may need additional explanations of medical terms. b. Talking directly to the translator facilitates the transfer of information. c. Talking loudly helps the translator and the client understand the information better. d. It is always okay to not use a translator if a family member can do it.

a. Translators may need additional explanations of medical terms.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. a. current orders b. what the client watched on television during the shift c. any abnormal occurrences with the client during the shift d. identifying demographics, including diagnosis e. what time the nurse will return for the next shift

a. current orders c. any abnormal occurrences with the client during the shift d. identifying demographics, including diagnosis

A nurse is documenting a client's care in the electronic health record. This is the third entry being made by the nurse for the day. The nurse would sign the entry using which signature? a. Jane Smith, RN b. J. Smith, RN c. JS d. Jane Smith

b. J. Smith, RN

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a. conferring. b. a referral. c. reporting. d. a consultation.

b. a referral.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: a. Rationales are only important while the nurse is in training. b. Some facilities do not require them on their plans of care. c. Although not written, the nurse must know or question the rationale before performing an action. d. The use of rationales is not commonly practiced in the clinical setting. e. The rationale is deleted to provide additional charting space in the computer system.

c. Although not written, the nurse must know or question the rationale before performing an action.

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? a. Call for help and ask for new supplies. b. Proceed with the procedure since it was only touched by the client. c. Discard the sterile field and the supplies and start over. d. Change the sterile field, but reuse the sterile equipment.

c. Discard the sterile field and the supplies and start over.

Which mask should the nurse don when caring for a client with tuberculosis? a. Low-efficiency particulate air (LEPA) b. Surgical mask c. Filtered respirator d. No mask is needed

c. Filtered respirator

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take? a. Ask the child to stay at least 2 feet (0.6 meters) away from all other clients. b. Ask the parent to take the child home. c. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes. d. Have all clients in the waiting room don face masks.

c. Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The health care provider, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? a. FOCUS charting b. narrative charting c. SOAP charting d. PIE charting

c. SOAP charting

Which action should the nurse perform first after an exposure to a client's body fluids? a. Change the clothing that was exposed. b. Get tested for both HIV and hepatitis. c. Wash the exposed area with soap and water. d. Take the postexposure prophylaxis.

c. Wash the exposed area with soap and water.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a. a client whose rehabilitation potential is not good b. a client whose status is stabilized c. a client who is homebound and needs skilled nursing care d. a client who is not making progress in expected outcomes of care

c. a client who is homebound and needs skilled nursing care

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a. reimbursement b. organization c. subjectivity d. objectivity

c. subjectivity

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? a. "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety." b. "No medical issues overnight that require immediate attention." c. "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." d. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

d. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

A nurse is preparing to obtain a specimen for an anaerobic wound culture. The nurse would obtain the specimen from which area? a. Edge of the wound b. Deep into the cavity c. Drainage on the dressing d. Area of active drainage

d. Area of active drainage

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform? a. Open sterile packages so that the first edge of the wrapper is directed toward you. b. Consider the outer 3-in edge of a sterile field to be contaminated. c. Consider the outside of the sterile package to be partially sterile. d. Hold sterile objects above waist level to prevent accidental contamination.

d. Hold sterile objects above waist level to prevent accidental contamination.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? a. Documentation b. Dialogue c. Verification d. Reporting

d. Reporting

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? a. SOAP b. MAR c. PIE d. SBAR

d. SBAR

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. a. A discussion of the meal plan for a client with diabetes b. A review of a client's current progress in the plan of care c. A recommendation for pain management by the emergency department health care provider who admitted the client a week ago d. A conversation addressing the need for durable medical equipment when the client goes home e. A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made

a. A discussion of the meal plan for a client with diabetes b. A review of a client's current progress in the plan of care d. A conversation addressing the need for durable medical equipment when the client goes home e. A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? a. Client's record and occurrence report b. Care plan and client's record c. Occurrence report and critical pathway d. Critical pathway and care plan

a. Client's record and occurrence report

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? a. Disinfect it with alcohol swabs. b. Sterilize it by placing it in the autoclave. c. Discard it in the waste can. d. Do nothing; it can be used again immediately.

a. Disinfect it with alcohol swabs.

Which actions should the nurse take before making an entry in a client's record? Select all that apply. a. Identifying the form appropriate to be used for documenting b. Reviewing the agency's list of approved abbreviations c. Locating clients' files within an electronic health record system d. Checking that clients' names are not identified within the chart forms e. Choosing the charting format that the nurse prefers

a. Identifying the form appropriate to be used for documenting b. Reviewing the agency's list of approved abbreviations c. Locating clients' files within an electronic health record system

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? a. The nurse removes her gown and then removes her gloves. b. The nurse applies nonmedicated hand cream after performing hand hygiene. c. The nurse performs hand hygiene before putting on gloves. d. The nurse performs hand hygiene after touching the client's surroundings.

a. The nurse removes her gown and then removes her gloves.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? a. perform hand hygiene before and after entering the client's room b. wear gloves when touching the client c. avoid direct contact with the client d. wear a mask and gown in the client's room

a. perform hand hygiene before and after entering the client's room

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? a. "There are a lot of infectious processes around and there is nothing that can be done." b. "As we age, our immune system does not function as well." c. "You will have to limit who comes to visit since they may be exposing you." d. "It is possible that you are not washing your hands well enough."

b. "As we age, our immune system does not function as well."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? a. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." b. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." c. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." d. "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin."

b. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? a. "It is alright if you want to look at the supplies. Just be careful not to touch them." b. "I have set up this sterile field for your procedure, so please do not touch anything around the tray." c. "Do not touch this, or I will have to start over." d. "Everything is ready, I will leave the tray here for the provider."

b. "I have set up this sterile field for your procedure, so please do not touch anything around the tray."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? a. "Are you questioning the care of your child?" b. "I will arrange access for you to review the record after you put your request in writing." c. "Only the client has the right to review the health care records." d. "No, the health care provider will not give you access to review the records."

b. "I will arrange access for you to review the record after you put your request in writing."

A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate? a. "There is bleeding into the interstitial space in the area." b. "It is the result of blood accumulating in the dilated vessels." c. "There is pressure on, and injury to, the local nerves." d. "It's due to the fluid accumulating in the area."

b. "It is the result of blood accumulating in the dilated vessels."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? a. "The care plan is the only way for nurses to document what they do." b. "The care plan is required for every client by The Joint Commission." c. "The care plan shows the medical diagnosis for the client." d. "The care plan provides additional documentation about the work of the nurse."

b. "The care plan is required for every client by The Joint Commission."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? a. "I am concerned that the client might be exhibiting sepsis." b. "Will you prescribe a complete blood count to check the white blood cell count and a culture?" c. "The client was admitted today with a urinary tract infection." d. "The client's temperature has been 102°F (38.9°C) for the last 6 hours."

b. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

An older adult client is admitted into the hospital due to tuberculosis. In addition to standard precautions, which transmission-based precautions should the nurse initiate? a. Droplet b. Airborne c. Contact d. Fomite

b. Airborne

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection? a. Protozoa b. Healthcare-associated infection (HAI) c. Helminth d. Virus

b. Healthcare-associated infection (HAI)

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform? a. Consider the outside of the sterile package to be partially sterile. b. Hold sterile objects above waist level to prevent accidental contamination. c. Consider the outer 3-in edge of a sterile field to be contaminated. d. Open sterile packages so that the first edge of the wrapper is directed toward you.

b. Hold sterile objects above waist level to prevent accidental contamination.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? a. Transfer report b. Incident report c. Nurse's shift report d. Telemedicine report

b. Incident report

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? a. Write the order in the client's record. b. Inform the health care provider that a written order is needed. c. Add the new order to the medication administration record. d. Call the pharmacy to have the order entered in the electronic record.

b. Inform the health care provider that a written order is needed.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? a. It documents assessments on separate forms. b. It provides quick access to abnormal findings. c. It records progress under problems, intervention, and evaluation. d. It provides and refers to a client's problem by a number.

b. It provides quick access to abnormal findings.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. a. Making the names of clients on charts visible to the public b. Keeping record of people who have access to clients' records c. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards d. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public e. Obscuring identifiable names of clients and private information about clients on clipboards

b. Keeping record of people who have access to clients' records d. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public e. Obscuring identifiable names of clients and private information about clients on clipboards

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a. Notify the client relations department about the breach of privacy. b. Remind the UAP about the client's right to privacy. c. Document the UAP's conversation. d. Report the UAP to the nurse manager.

b. Remind the UAP about the client's right to privacy.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? a. Access the health care record at the bedside and show the client how to navigate the electronic health record. b. Review the hospital's process for allowing clients to view their health care records. c. Explain that only a paper copy of the health care record can be viewed by the client. d. Discuss how the hospital can be fined for allowing clients to view their health care records.

b. Review the hospital's process for allowing clients to view their health care records.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? a. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. b. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. c. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. d. The nurse sends or directs someone to take action in a specific nursing care problem.

b. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that: a. the client's symptoms are typical of an older adult client. b. an older adult can have an infection without a fever. c. without an elevated temperature, infection is not present. d. an infection was present and has dissipated.

b. an older adult can have an infection without a fever.

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? a. clean environment b. handwashing c. sterile gauze d. sterile gloves

b. handwashing

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: a. need to obtain legal representation to update their health records. b. have the right to copy their health records. c. can be punished for violating guidelines. d. are required to obtain health record information through their insurance company.

b. have the right to copy their health records.

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? a. wearing protective eye wear for contact with this client b. wearing a particulate respirator for all care and interaction with this client c. placing the client in a regular, private room d. wearing a face mask when entering and staying at a distance from the client

b. wearing a particulate respirator for all care and interaction with this client

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? a. "This client has a medical history of heart failure." b. "It seems like this client has fluid volume overload." c. "I think the client would benefit from intravenous furosemide." d. "I am calling because the client receiving blood has developed dyspnea and had crackles."

c. "I think the client would benefit from intravenous furosemide."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism? a. "Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." b. "Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." c. "The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with." d. "If you do not wear gloves you will also get the infection."

c. "The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate? a. "If you notice that the newborn has a fever, then you need to have him seen by the doctor fairly quickly." b. "Infections in newborns are rare because they have little difficulty localizing infections" c. "Your infant's resistance comes from the antibodies you passed on to him before birth and now with breast feeding." d. "It usually takes about a month or two until the infant's immune system to become completely functional."

c. "Your infant's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."

A client is being screened for a parasitic infection and the health care provider orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: a. 5 days. b. 2 days. c. 3 days. d. 4 days.

c. 3 days.

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a. Notifying the nursing team of the client's condition b. Keeping an accurate medication record c. Accurately documenting client care on the client record d. Documenting client data on the flow sheet

c. Accurately documenting client care on the client record

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first? a. Inform the health care provider of the client's noncompliance b. Educate the client of the importance of infection prevention. c. Assess client's pain level and manage pain accordingly. d. Inform the client that these exercises must be done at regular intervals.

c. Assess client's pain level and manage pain accordingly.

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? a. Client in the ICU for one day b. Client with a history of eczema c. Client receiving chemotherapy d. Client on a short course of vancomycin

c. Client receiving chemotherapy

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? a. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. b. Client is requesting pain medications, is grimacing, and is diaphoretic. c. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." d. Client states expecting some pain, but it is more severe than anticipated.

c. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? a. ensuring that the surface where the sterile field will be set up is dry b. checking that the sterile dressing packages are intact before opening c. applying a new dressing with the gloves that were used to remove the old dressing d. describing each step verbally to the client before performing the dressing change

c. applying a new dressing with the gloves that were used to remove the old dressing

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? a. data base b. plan of care c. progress notes d. problem list

c. progress notes

Which statement is not true regarding a medication administration record (MAR)? a. After using an electronic MAR, the nurse should log off. b. The MAR identifies routine times for medication administration. c. The MAR distinguishes between routine and "as needed" medications. d. If the client declines the dose, the nurse does not have to document this on the MAR.

d. If the client declines the dose, the nurse does not have to document this on the MAR.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? a. Revising the facility's infection control protocols b. Encouraging visitors to adhere to isolation precautions c. Limiting visitors to family members over the age of 18 d. Incentivizing health care workers to utilize hand hygiene

d. Incentivizing health care workers to utilize hand hygiene

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? a. Tuberculosis and pneumonia b. Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus c. Clostridium difficile and diabetic ketoacidosis d. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

d. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information b. Releasing the client's entire health record when only portions of the information are needed c. Disclosing client health information for research purposes after obtaining permission from the client's health care provider d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

d. Submitting a written notice to all clients identifying the uses and disclosures of their health information

Which example may illustrate a breach of confidentiality and security of client information? a. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. b. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. c. The nurse provides information to a professional caregiver involved in the care of the client. d. The nurse provides information over the phone to the client's family member who lives in a neighboring state.

d. The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin? a. droplet b. airborne c. none d. contact

d. contact

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client? a. neutropenic precautions b. droplet precautions c. airborne precautions d. contact precautions

d. contact precautions

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? a. airborne b. contact c. none d. droplet

d. droplet

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a. gauging the nurse's professional performance over time b. following up the incident with other members of the care team c. protecting the nurse and the hospital from litigation d. identifying risks and ensuring future safety for clients

d. identifying risks and ensuring future safety for clients

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a. using only those abbreviations that are defined in full at another location in the client's chart. b. using only abbreviations whose meaning is self-evident to an educated health professional. c. ensuring that abbreviations are understandable to clients who may seek access to their health records. d. limiting abbreviations to those approved for use by the institution.

d. limiting abbreviations to those approved for use by the institution.

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? a. performs hand hygiene before donning gloves b. asks the client to state name and date of birth c. applies a mask with face shield d. removes gloves and walks out of the room

d. removes gloves and walks out of the room