ADRN 110

A client treated for depression is ready for discharge from the hospital and tells the nurse, "It would be great if we could meet for coffee should I start feeling low again." Which statement indicates that the nurse understands the boundaries of the therapeutic relationship?

"Before you leave the hospital, I will make sure you have information about the crisis center."

A nurse is caring for a client following a tonsillectomy and fails to routinely assess the back of the client's throat for signs of bleeding. The nurse manager reviews the client's chart and notices the omission of the assessments. Which is the best response to the nurse regarding the missing assessments?

"Failure to complete these assessments constitutes negligent behavior

A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use?

"Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

A nurse who usually works on the surgical unit is asked to float to the oncology unit because of staffing needs. Which statement by the nurse indicates the possibility of the nurse experiencing culture shock?

"I am very stressed now because I do not understand how things work on this unit."

Which statement made by the nurse managing the care of an anorexic teenager demonstrates an understanding of the client's typical, initial reaction to the nurse?

"I realize this must be very difficult for you but try to remember I'm not your enemy."

Which statement(s) by the nurse could be a barrier to a nurse-client relationship? Select all that apply

"I slept poorly last night because of the storm too." "Your previous nurse should have applied the ointment to your wound when the dressing was changed." "I am sorry for the delay. The client in the next room had a seizure." "I will assist you to the bathroom after I complete vital signs on the rest of the clients." "Can you tell me that story when I am not so busy?"

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?

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

A nurse performs a spiritual and religious assessment for a client. The client identifies as an atheist. Which statement made by the nurse ensures therapeutic communication?

"Is there anything you would like me to include in the spirituality part of your assessment?"

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?

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

A nurse and client are working together to help the client make lifestyle changes to promote improved health. The nurse is having the client sign a contractual agreement for the work they will do together. Which statements by the nurse reflect the proper purposes of such agreements? Select all that apply.

"Our goals are defined, as are ways to meet them." "With this contract, we show that we are both dedicated to improving your health."

The mother of a 6-month-old child reports she has been hearing so much about autism spectrum disorder. She questions if this is something that can be tested for. What response by the nurse is appropriate?

"Screening is recommended between 18 and 24 months or when concerns are identified."

The nurse is caring for a child. The nurse is trying to ensure that the family's cultural practices are supported. Which statement by the nurse indicates a lack of understanding regarding cultural competence?

"Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of.

The nurse is admitting a client to the hospital. The nurse gives the client information about client rights while in the hospital. Which statement by the client indicates that more teaching is needed?

"The doctor can copy my information and send it to my son."

Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

"The system should be safe, effective, efficient, patient centered, timely, and equitable."

A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply.

"What good am I?" "I'm such a horrible person." "Who would want to marry me now the way I look?" "I feel like I'm so ugly."

A client from a minority culture has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate?

"What type of food do you eat at home?"

The healthcare provider orders a new medication for a 5-year-old client. The nurse educator asks the student, "What is a medication dose affected by?" What is the best response by the student? Select all that apply.

"disease state,"weight"

A nurse is conducting a teaching session with a group of adolescent females at a local women's health clinic. When describing appropriate screening guidelines for cervical cancer, at which age would the nurse would instruct the group to have their first Papanicolaou test?

21

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?

A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment

Which of the following best reflects the rationale for evidence-based practice?

A means to ensure quality care

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

A prospective payment plan based on a predetermined fixed cost

A nurse has developed a plan of care for a patient with a nursing diagnosis of "risk for spiritual distress." Which interventions would the plan most likely include? Select all that apply

Actively listen to the patient. Demonstrate acceptance of the patient Encourage the patient to talk about his or her faith.

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge?

Affordable Care Act

A woman is in the second stage of labor, 8-cm dilated and 90% effaced. She keeps very quiet without expressing any outward signs of pain. Which intervention by the nurse would be most appropriate in this situation?

Allow the woman to labor according to her cultural beliefs.

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate?

Ask the client's consent before sharing any information with the niece.

A nurse is assigned to work with a client who has a disability. The nurse believes that all people with disabilities have a poor quality of life and are dependent and nonproductive. What type of barrier will this client experience?

Attitudinal barrier

Which action should a nurse perform to avoid disrupting family routine when visiting to provide home care

Avoid coming during mealtimes.

The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take?

Call a break in the meeting and talk to the nurse in a private place.

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin?

Chlamydia trachomatis

Why are health promotion and illness prevention a key responsibility of nurses

Chronic illnesses are the leading health problem in the world.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Class I (Mild)

A nurse practitioner is working in a crowded neighborhood where the population is primarily immigrants from China. The nurse has designed a research study to follow children from kindergarten to the age of 25. She is going to be looking at their diet, successful progression in school, health practices, and development of disease, to name a few items. This type of research is known as:

Cohort study

A client who has multiple sclerosis (MS) has been diagnosed with ineffective coping related to a diagnosis of chronic health alteration. What outcome is least appropriate to include in a plan of care?

Communicates a sense of helplessness to his spouse.

The nurse has a client who reminds the nurse of the nurse's sister, with whom the nurse has a close and positive relationship. This phenomenon is best characterized by which term

Countertransference

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

Countertransference

A family has recently immigrated. All members are quickly learning the language and the children are all in public school. Both parents are working and adapting to the new culture. What is this family demonstrating?

Cultural assimilation

A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation?

Discuss the matter with the other nurse, reminding the other nurse not to use the client's phone because it has a call display feature.

The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?

Document the client's request in the nursing care plan.

The client is newly diagnosed with type 2 diabetes. After teaching the client about diabetes and how to self-administer insulin, the nurse identifies which client response as a need for additional education?

During the return demonstration, the client draws up insulin, leaving tiny bubbles in the syringe

The nurse manager is concerned about the large number of adolescent mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?

Enlist volunteers to help develop a community outreach project that will educate adolescents on methods to prevent pregnancy.

Nurses are aware that variety and diversity occur both within and across groups. Which factor leads to cultural benefits as a result of diversity?

Equal opportunity exists for various cultural perspectives

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Hold the medication and report the information to the physician to ensure client safety.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

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?

Incident report

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

The nurse is assessing a family parented by a 60-year-old grandmother and three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns

The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take?

Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room.

The pediatric nurse is caring for a boy 5 years of age, who is being seen in the clinic today. He is very worried that the doctor may harm his body. His mother asks the nurse if this is normal for this age. The nurse shares with the mother that the very young child worries about which of the following related to his body?

Intactness and mutilation

Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?

Intellectual development

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls.

Which statement is correct regarding glargine insulin?

It cannot be mixed with any other type of insulin

Which individual provided community-based care and founded public health nursing?

Lillian Wald

The camp nurse is participating in a craft activity (cutting paper with blunt tip safety scissors) with a group of children. One of the children stands next to the nurse and begins to talk excitedly about the day at the camp. What action(s) will the nurse take to demonstrate active listening? Select all that apply.

Look at the child. Place the scissors on the table. Be patient while the child talks.

The nurse is preparing to administer the second dose of ordered antibiotics to a client and notes that the first dose of medication is still in the automated medication-dispensing system. The medication administration record (MAR) does not show that the initial dose was given. What is the appropriate nursing action?

Notify the health care provider

A nurse is conducting a staff development program on the Healthy People 2030 determinants of health. The nurse notes that the participants need additional education based on which statement?

Nursing practice should focus solely on the management of chronic disease.

A nurse is reading a journal article about how health care delivery in the United States compares with that in other nations in the world. The article goes on to describe areas for which the United States ranks near the bottom in comparison with other nations. The nurse demonstrates understanding of this article by identifying which area as being deficient in the United States when compared with other nations? Select all that apply.

Obesity Infant mortality Drug-related deaths Heart disease

Which nursing action helps to maintain a sense of self for clients?

Offering a simple explanation before initiating any procedure

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using?

Palliative care

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?

Planning

Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch?

Postherpetic neuralgia

A nurse who is not familiar with using automated intravenous (IV) pumps is moving to a unit that uses them frequently. The nurse is anxious about using the device. What is the most appropriate way for the nurse to lessen this anxiety?

Practice using the device under the supervision of a more experienced nurse before using it with a client

The nurse is providing education regarding 2030 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy?

Provide education to sexually active females about proper condom usage

Which are major premises of a quality-improvement (QI) program? Select all that apply.

QI determines whether nursing standards are being upheld. QI programs may be mandated by some governmental agencies. QI focuses on processes rather than individuals QI's focus is on ensuring excellence in care.

Which statement best conveys the relationship between race and ethnicity?

Race denotes physical characteristics, while ethnicity is rooted in a common heritage

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?

Record "T.O." at the end of the order.

While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements

Religion is a collection of spiritual beliefs and practices.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager.

Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply.

Requesting native cuisine Listening to folk music and dance Asking to wear unique clothing

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?

Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?

Rinse their eyes with water, report the incident, and go to Employee Health.

A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition?

Role strain

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

Role-playing

The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion?

Roman Catholic

A nurse encourages a young female whose leg was amputated to continue to pursue her dream to become a dancer. How does the nurse identify this need to reach one's potential through full development of one's unique capability?

Self-actualization

A nurse is assessing a client's self-perception. Which dimension is reflected by the client's statement, "I want to use my skills to become the best artist I can be"?

Self-expectation

A nurse overhears another nurse make a statement that indicates racism. The nurse makes this determination based on which characteristic indicative of social value?

Skin color

The nurse is caring for a client whose language skills are very limited in the dominant language, and an interpreter has been obtained. The interpreter appears to be telling the client more than the nurse is saying and possibly providing an opinion or medical advice. Which action is appropriate for the nurse to take?

Speak privately with the interpreter and instruct them to only provide language interpretation.

Which are helpful tips for a nurse who has been active in health care policy and reform give to a nurse who is interested in becoming active in this area? Select all that apply.

Stay up to date regarding new pending legislature that will determine nursing practice. Join and participate in nursing associations. Advocate for the rights of all people in health care

A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?

Stereotyping

When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?

Talk with animation and vocal inflection to stimulate the client aurally.

Which organization audits charts regularly?

The Joint Commission

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with her in a one-bedroom apartment. Which of the following is a primary nursing concern?

The client does not have running water

The nurse is caring for several clients of different cultures. Which client situation would the nurse recognize as the client with highest risk of culture shock?

The client from Ethiopia states, "All these machines attached to me scare me and I need to get them off."

The nurse is conducting a physical examination of a child with a brachial plexus injury. Which finding would lead the nurse to be highly suspicious of Erb palsy?

The involved extremity is adducted, prone, and internally rotated.

While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind?

The nurse and client relationship is based on mutual sharing and negotiation.

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?

The nurse ensures a written consent is obtained prior to testing.

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution?

The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner?

Their readiness to learn is often related to a developmental task or social role.

A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?

They are responsible for the continued development and advancement of nursing.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

A client asks why three medications are prescribed to treat his tuberculosis. The nurse informs the client of which reasons?

To prevent resistance

The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care?

Tympanic rupture

A 10-month-old infant is admitted with a harsh, barking cough and respiratory stridor. What are the most appropriate precautions for the nurse to follow when caring for the child?

Use an isolation gown and gloves in the room.

A facility is planning to implement an update to the electronic health record. This update is designed to facilitate documentation of critical changes in clients' condition to save time that nurses spend when documenting these changes. An informatics nurse specialist asks a group of staff nurses to test this update to determine if it is working as it was designed. The nurses are involved in which type of testing?

User acceptance

The need for university-based nursing education programs was brought to light during which important historical time?

WORLD WAR 2

The nurse has drawn opioid pain medication into a syringe. When preparing to administer the medication, the client refuses, stating that pain is controlled currently at a level of 2 on a scale of 1 to 10. Which action should the nurse take to waste the medication?

Waste the medication with another nurse witness present.

The nurse is caring for a 2-year-old boy with a burn. What finding would warrant referral to a burn unit?

a chemical burn

Facility policies on wound dressing selection refer the nurse to a dressing algorithm. The nurse anticipates that the algorithm will include:

a step-by-step decision-making tree for dressing selection.

The nurse is caring for a 20-month-old girl with equivocal bacterial otitis media, a severe earache, and a temperature of 39°C (102.2°F). Which intervention would the nurse expect to implement?

administering antibiotics as soon as they're available

The client is brought to the hospital in a coma. The nurse understands that when a person is incapacitated, the document used to dictate the patient's written instructions for health care is called:

advance directive

A nurse is working at a facility that provides care to children with developmental disabilities. Which role would be the nurse's most important?

advocate

A client is admitted to the emergency room. The nurse completing the client's health history looks at the client and indicates that the client is "female" on the chart. What has the nurse failed to do in this situation?

assess the client's gender identity

A nurse and a nursing assistant are caring for a group of adolescents. Which task could the nurse safely delegate to the nursing assistant

assisting an adolescent diagnosed with paraplegia with a meal

A student is choosing an educational path and desires a nursing degree with a track for community nursing and leadership and that allows for classes in liberal arts. The student would best be suited in which type of program?

baccalaureate program

A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of:

cultural ritual.

The nurse observes that a coworker is unable to understand that an intelligent person would engage the services of a medicine man. The nurse's coworker has strong ethnocentric tendencies and an inability to recognize others' values, beliefs, and practices. The nurse understands that the coworker's behavior is an example of which attitude?

culture blindness

A nurse is attempting to provide education to a newly diagnosed diabetic. The client states, "It doesn't matter what I eat, my future health is up to God." The nurse understands that this client has:

external locus of control.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

Health education of a client by the nurse

is an independent function of nursing practice

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as

moxifloxacin 400 mg daily

A woman who just gave birth tells the obstetrical nurse that her mother has noticed that so much has changed in maternity care in recent years. One change she could likely be referring to is:

newborns stay at the mother's bedside as long the infant is well

Which guidelines define and regulate what the nurse may and may not do as a professional?

nurse practice act

A nurse manager reviews an employee's contribution to the nursing division annually. This process is:

performance appraisal.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should

stay with the client and encourage them to eat

Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy?

the cause of death can be discovered

Which of the following factors is most likely to present a challenge to the self-concept of a man 79 years of age?

the man's increasing level of dependence on his children

As part of a presentation on breast cancer being given to a local woman's group, the nurse describes the need for early detection through screening. Applying the guidelines from the American Cancer Society, the nurse would emphasize which recommendation?

yearly mammograms for women starting at age 40