Exam #3 Prep U

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate?

"12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids"

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

An adult with diabetes receives 20 units of insulin each morning and evening. How will the nurse teach the client to administer the insulin?

"Use an insulin syringe and give 20 units."

A nurse manager attempts to achieve performance improvement in the emergency department of a busy inner-city hospital. Which nursing actions follow Haase and Miller's recommended steps in performance improvement? Select all that apply.

-The nurse discovers that there is a problem with the triage system that is in place in the emergency department. -The nurse calls a meeting of the emergency department interdisciplinary team to effect change in the triage process. -The nurse organizes a task force to implement change in the triage process of a busy emergency department. -The nurse meets with the emergency department staff to assess changes made to the triage process.

A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include? Select all that apply.

-Unexpected event -Cause of the event -Actions taken in response to the event

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

The nurse is reassessing a client with leukemia who has received several packed red blood cell transfusions over the past week. Which question should the nurse ask the client to evaluate the treatment?

Have you had any fevers?

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

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 referral

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

Which action describes buccal medication administration?

placing a medication underneath the upper lip or in the side of the mouth

A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?

surgical incision

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

therapeutic range

A nurse needs to administer a subcutaneous heparin injection to a client. Which injection site is most suitable for heparin?

abdomen

A nurse is performing a sensitivity test on a client. What would be the best type of injection to use for this procedure?

intradermal

The nurse is teaching a client with diabetes about insulin dosing. Which teaching will the nurse include? Select all that apply.

-"Insulin needles are very short in length." -"Insulin injections are usually less painful than other injections."

Which are examples of breaches of client confidentiality? Select all that apply.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

Which are uses of documentation in client records? Select all that apply.

-Quality improvement -Research -Decision analysis -Financial reimbursement

A nurse is preparing to administer a subcutaneous injection of heparin. Which size needle would be most appropriate to use?

28-gauge

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

-Auscultate for bowel sounds. -Begin feedings with clear broth. -Consult with a dietitian regarding appropriate foods.

Which are appropriate actions for protecting clients' identities? Select all that apply.

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

Which are high-risk errors in documentation? Select all that apply.

-Inadequate admission assessment -Failure to document completely -Charting in advance -Falsifying client records

A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling narcotic medications? Select all that apply.

-Maintain an accurate account of the use of the medication. -Record each medication used from the stock supply. -Count each narcotic medication at the change of each shift.

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

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

The nurse is teaching a client with diabetes how to withdraw insulin from a vial. In which order should the nurse explain the steps to the client?

-Select appropriate syringe and needle. -Remove the metal cover from the rubber stopper. -Fill the syringe with a volume of air equal to the volume that will be withdrawn from the vial. -Pierce the rubber stopper with the needle and instill the air. -Invert the vial, hold, and brace it while pulling on the plunger. -Date and initial the vial for future use.

Which information about the client would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.

-Sex/gender -Admission date -Insurance

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

-The client is blind. -The client denies the need for education.

What would be considered a "right" of drug administration? Select all that apply.

-right drug -right documentation -right dose -right client

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle?

Do not recap the needle; place it in a puncture-resistant container.

A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration?

Facilitate communication between the different professionals and attempt to coordinate care.

Which situation accurately describes a recommended guideline when administering oral medications to clients?

If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

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?

It provides quick access to abnormal findings.

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client?

Medication that is not administered should be documented along with the reason.

A nurse is providing care for a client who is intubated and receiving nasogastric tube feedings. The nurse assesses the client before and after each feeding and performs necessary interventions to maintain the patency of the nasogastric tube. The nurse is engaged in which type of intervention when maintaining the tube patency?

Psychomotor

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.

A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which action should the nurse perform to ensure that all the medication is equally distributed when withdrawing?

Tap the top of the ampule before withdrawing the medicine.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

charting by exception (CBE)

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which action should the nurse perform to prevent gastric reflux?

help client into fowlers position

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing?

intradermal

A nurse is using an 18-gauge needle to administer medication to a client. The nurse knows that, when compared with a 27-gauge needle, an 18-gauge needle has which feature?

larger diameter

A nurse is caring for a client with a puncture wound in the proliferation phase of the wound repair process. Which description reflects this phase of the wound repair process?

period during which new cells fill and seal a wound

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care