Final Exam (All past exam questions)

Order of Nursing Process

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? A) "I know this is hard for you. Is there any way I can help?" B) "Sitting in the dark is not going to cure your cancer. Let's open the curtains." C) "I am so sorry you are going through this." D) "Can you please tell me why you are crying?"

A) "I know this is hard for you. Is there any way I can help?"

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) "Will you prescribe a complete blood count to check the white blood cell count and a culture?" B) "The client's temperature has been 102°F (38.9°C) for the last 6 hours." C) "The client was admitted today with a urinary tract infection." D) "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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

You have four clients with discharge orders. Which client below would you want to suggest homecare for? A) A 40 year old diabetic who needs assistance getting to the restroom. B) A 59 year old client who is a left lower leg amputee who had an appendectomy and has been ambulating okay. C) A 46 year old who uses illegal drugs. D) An 80 year old who has used a walker for years.

A) A 40 year old diabetic who needs assistance getting to the restroom.

An autocratic nurse is The Boss. A nurse who leads using this management style makes all decisions and gives specific orders and directions to all nurses and staff members. There's also a low tolerance for mistakes and the people who make them. When would this type of leadership be best? A) An emergency situation B) Team building exercise C) Gaining trust among nursing and staff D) Day to day operations on the unit

A) An emergency situation

The laissez-faire nurse is the opposite of the autocratic nurse. In this style, the nurse provides no specific direction for team members, and adopts more of a hands-off approach to managing. When might this type of leadership be utilized? A) An experienced team of nurses on a telemetry unit B) A team with mostly new nurses who are highly motivated C) A team of nurses in the operating room D) A mixture of new and experienced nurses on a medical/surgical unit.

A) An experienced team of nurses on a telemetry unit

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome? A) Ask the client to demonstrate self-injection of insulin B) Ask family members how much trouble the client is having with injections. C) Ask the client to verbally repeat the steps of the injection. D) Ask the client how comfortable the client is with injections.

A) Ask the client to demonstrate self-injection of insulin

A nurse suspects that the client with Diabetes does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? A) Ask the clienn to verbalize the medication regimen and diet modifications required. B) Ask the nutritionist to give the client strict meal plans to follow. C) Refer the client to available community resources and support groups. D) Ask the endocrinologist to explain the treatment plan to the client and family again.

A) Ask the clientn to verbalize the medication regimen and diet modifications required.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? A) Assess the client to determine the cause of the pain. B) Consult with the physician for additional pain medication. C) Discuss the frequency of pain medication administration with the client. D) Assist the client to reposition and splint the incision.

A) Assess the client to determine the cause of the pain.

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice? A) Code of Ethics for Nursing B) Standards of care C) Definition of nursing D) Values clarification

A) Code of Ethics for Nursing

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? A) Consult with a more experienced nurse. B) Contact the client's health care provider. C) Continue to collect assessment data. D) Document the data for future reference.

A) Consult with a more experienced nurse.

What is appropriate discharge planning for a patient with newly diagnosed diabetes? A) Educating patient about prescribed medications and how to monitor glucose B) creating a plan of care for the patient that address's current problems C) preparing the patient for multiple stays in the hospital D) Explaining that the patients normal life activities will be altered forever

A) Educating patient about prescribed medications and how to monitor glucose

Which quality is essential to be a student nurse leader, a registered nurse leader, and a nurse administrator leader? A) Flexibility B) Physical stamina C) Independence D) Vulnerability

A) Flexibility

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply. A) Identify the day and time for each entry B) Document in chronological order C) Leave blanks in the charting D) Acknowledge the client's response to the medication E) Sign every entry

A) Identify the day and time for each entry B) Document in chronological order D) Acknowledge the client's response to the medication E) sign every entry

A client has been admitted to your unit with shortness of breath. The 02 saturation is 90% on 2L via nasal cannula. What would be the most priority nursing diagnosis for the nurse to use to address this client's problem? A) Ineffective Breathing Pattern related to inadequate ventilation B) Self-Care Deficit related to shortness of breath C)Risk for falls related to inadequate ventilation D) Impaired Verbal Communication related to shortness of breath

A) Ineffective Breathing Pattern related to inadequate ventilation

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Make recommendations for revising the plan of care B) Continue to follow the written plan of care C) Ask another health care professional to design a plan of care D) State "goal will be met at a later date.

A) Make recommendations for revising the plan of care

Most litigation in the hospital comes from the: A) Nurse following an order that is incomplete or incorrect B) Supervisor watching a new employee check his or her skills level C) Nurse documenting blame on the physician when a mistake is made D) Nurse abandoning the clients when going to lunch

A) Nurse following an order that is incomplete or incorrect

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply. A) Pain level is currently a 2 following administration of intravenous morphine. B) The client has a clean and dry abdominal dressing. C) No new labs have been ordered after surgery. D) The client's hobby is modeling, which we had a conversation about. E) Ms. J-Lo is in Room 7, admitted postoperatively for an open appendectomy.

A) Pain level is currently a 2 following administration of intravenous morphine. B) The client has a clean and dry abdominal dressing. C) No new labs have been ordered after surgery. E) Ms. J-Lo is in Room 7, admitted postoperatively for an open appendectomy.

You are a nurse on a telemetry unit providing care to several patients. Which patient may need home health care? A) Patient who is safely walking with a walker following an abdominal surgery B) patient who had hip replacement surgery C) A patient who had an appendectomy D) A patient who is recovering from the flu

A) Patient who is safely walking with a walker following an abdominal surgery

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

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

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important? A) Speak directly to the client. B) Ensure that family members are present. C) Have the interpreter write out all of the information listed in the unit brochure. D) Give all of the discharge instructions at once.

A) Speak directly to the client

The nurse is developing goals for a client who has been admitted for newly diagnosed diabetes. What goal written by the nurse requires revision? A) The client will understand how to use the glucometer machine. B) By 10/23, the client will state when to notify the health care provider after discharge. C) By 10/23, the client will state three ways to identify low blood sugar. D) By 10/23, the client will demonstrate correct use of the glucometer machine.

A) The client will understand how to use the glucometer machine.

You visit your patient's home for her home health visit. During the visit, your patient's spouse has a question about his personal medications that he is on. What should the nurse do? A) The husband's medication question is not for you to answer, as he is not under your nursing care. Refer him to his physician or pharmacist B) Realize that he is now your patient also. C) Give the patient a vague answer so that you don't upset him. D) Since you are caring for his wife, it's appropriate for you to answer his medication questions

A) The husband's medication question is not for you to answer, as he is not under your nursing care. Refer him to his physician or pharmacist

Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply A) The nurse documents the client's response to suctioning. B) The nurse performs tracheostomy care using sterile technique. C) The nurse sets an anxiety level of 3 or less with the client. D) The nurse determines the client did not lose the expected 2 pounds (0.90kg). E) The nurse identifies that a client's pain is snot being adequately treated.

A) The nurse documents the client's response to suctioning. D) The nurse determines the client did not lose the expected 2 pounds (0.90kg). E) The nurse identifies that a client's pain is snot being adequately treated.

Which nursing action reflects evaluation? A) The nurse measures urine output following administration of diuretic. B) The nurse auscultates the client's lungs and abdomen. C) The nurse identifies that the client does not tolerate activity. D) The nurse sets a tolerable pain rating with the client.

A) The nurse measures urine output following administration of diuretic.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others? A) Therapeutic communication B) Purposive communication C) Metacommunication D) Intrapersonal communication

A) Therapeutic communication

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply. A) Verify the number in the fax machine as correct prior to transmission. B) Print client information to a printer shared with another unit. C) Access client information on the portable computer in the hallway where visitors are present. D) Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. E) Exit the client's room when called on the hospital-issued cell phone about another client on the team.

A) Verify the number in the fax machine as correct prior to transmission. D) Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. E) Exit the client's room when called on the hospital-issued cell phone about another client on the team.

The democratic nurse manager takes input from subordinates, and encourages open communication. The decision making ultimately is with the manager, but stakeholders and team members are asked for honest feedback, and given feedback in return. When would this be best utilized? A) When the manager wants to build relationships with the staff B) During an emergency situation C) When a concrete decision needs to be made quickly D) When big decisions need to be made on the unit.

A) When the manager wants to build relationships with the staff

What are the major areas of health care today? A) access to health care B) quality C) safety D) affordability E) timeliness

A) access to health care B) quality C) safety D) affordability

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an over-distended bladder. the client expresses being nervous and informs the nurse that this is the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis related to this client's concerns? A) Anxiety B) physical immobility C) Compromised D) overdistention

A) anxiety

Which one of the following is the nurse's best legal safeguard? A) competent, safe practice B) union contract C) malpractice insurance D) patient education

A) competent, safe practice

The goals of the healthcare reform include which of the following? Select all that apply A) cost containment B) improved access and quality of services C) limiting services D) decrease care for all E) limiting access for those who are uninsured

A) cost containment B) improved access and quality of services

How might one define leadership? Select all that apply A) guiding B) educating C) motivating D) directing others E) controlling

A) guiding B) educating C) motivating D) directing others

The ICU nurses are overwhelmed with patients today and now have an unlicensed assistive personnel (UAP) in the unit to assist with tasks. Which task can the registered nurse delegate to the UAP? A) helping with ROM exercises B) preparing a sterile field for a patient that will have a central line inserted C) assessing vitals of all patients D) gathering information about a patient's medical history

A) helping with ROM exercises

Your patient is supposed to be discharged home later today. You notice that the patient is having severe issues with ambulation. You also notice that the spouse is struggling to help. What should you do next? A) notify the social worker B) notify the physical therapist C) notify the occupational therapist D) notify another family member that can help assist with care

A) notify social worker

You have orders to discharge your patient to a long-term care facility. The patient cannot safely go by their private vehicle so an ambulance is coming to transfer the patient to the long-term care facility. Who does the nurse need to give report to? A) paramedic and nurse at long-term care facility B) nurse at long-term care facility C) paramedic D) physician at long-term care facility

A) paramedic and nurse at long-term care facility

Your patient is going to a long-term care facility. Where does the medical chart go? A) stays at the hospital B) goes with the patient C) is shredded D)is sent out to be audited

A) stays at the hospital

During admission of your patient with hyperglycemia, you are developing the plan of care. The nurse recognizes that the goals established for this patient are more likely to be accomplished when: A) the patient assists in the development of goals B) when the patient is told what goals will be established C) when the nurse develops all goals D) the patient assists in the development of the outcomes

A) the patient assists in the development of goals

The nurse suspects that another staff member may have a substance use disorder. What changes would the nurse observe that would indicate possible substance use? Select all that apply. A) Adherence to completing work assignment B) A decrease in personal hygiene and appearance C) Clients frequently reporting ineffective pain relief following administration of opioids D) Arriving on time to work consistently E) Confusion about clients' plans of care

B A decrease in personal hygiene and appearance C) Clients frequently reporting ineffective pain relief following administration of opioids E) Confusion about clients' plans of care

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 (shortness of breath). The nurse telephones the health care provider and provides an SBAR report. Which statement represents the second step in this type of communication? A) "I am calling because the client receiving blood has developed dyspnea and had crackles." B) "This client has a medical history of heart failure." C) "I think the client would benefit from intravenous furosemide." D) "It seems like this client has fluid volume overload."

B) "This client has a medical history of heart failure."

Which are examples of objective data? Select all that apply. A) A client's report of being unable to breathe B) A client's temperature C)Breath sounds on auscultation D)Laboratory test results E)A client's report of pain

B) A client's temperature C) Breath sounds on auscultation D) Laboratory test results

Which patient is the most appropriate for receiving outpatient care? A) A patient who is complaining of chest pain B) A patient complaining of arm pain after playing baseball. C) A patient who is complaining of shortness of breath D) A patient who is complaining of a headache

B) A patient complaining of arm pain after playing baseball.

Which patient needs to evaluated for long-term care? A) A patient that is on 4L per nasal cannula B) A patient who had a stroke and cannot get around on their own C) A patient who is going to need physical therapy after being in a car accident and injuring their back. D) A patient diagnosed with pneumonia and is recovering

B) A patient who had a stroke and cannot get around on their own

An illegal immigrant with no health insurance sustained life-threatening injuries in an automobile accident. Which action in this case demonstrates the ethical principle of justice? A) Avoiding treating the client so as to not do any additional harm B) Airlifting the client to a local trauma center for emergency surgery C) Filing the paperwork for the client to receive retroactive health insurance D) Telling the client honest information about the client's medical condition and prognosis

B) Airlifting the client to a local trauma center for emergency surgery

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? A) Impaired Parenting B) Altered Gas Exchange C) Interrupted Breastfeeding D) Ineffective Thermoregulation

B) Altered Gas Exchange

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee? A) Decide the care for a client who is unable to voice an opinion. B) Assist in decision making based on the client's best interests. C) Present options about the type of care. D) Convince the family to choose a specific course of action.

B) Assist in decision making based on the client's best interests.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? A) Client will list positive coping strategies and use them. B) Client will identify one coping strategy to try by end of week. C) Client tries using relaxation as a means to cope. D) Client will learn to cope more effectively.

B) Client will identify one coping strategy to try by end of week.

Which example of client care is not the responsibility of the nurse? A) Tailoring treatment and medication regimens for each individual B) Answer Confirming a medical diagnosis C) Promoting safety and preventing harm; detecting and controlling risks D) Monitoring for changes in health status

B) Confirming a medical diagnosis

The nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? A) Call the family. B) Consult with another nurse. C) Wait and see whether the pain subsides. D) Chart the information.

B) Consult with another nurse.

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured below, what is the highest prioritized nursing diagnosis? A) Deficient Knowledge B) Decreased Cardiac Output C)Risk for Bleeding D) Anxiety

B) Decreased Cardiac Output

The nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? A) Administer an additional liter of intravenous fluids. B) Determine whether the prescribed treatment was effective. C) Check the client's skin turgor. D) Formulate a plan of care based on risk for dehydration.

B) Determine whether the prescribed treatment was effective.

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request? A) Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. B) Identify and recommend some credible websites appropriate to the spouse's learning needs. C) Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. D) This is unfortunately not something we currently do for clients in the hospital.

B) Identify and recommend some credible websites appropriate to the spouse's learning needs

What is the primary ethical dilemma posed when using restraints on an older adult client in a long-term care setting who is confused? A) It limits personal safety. B) It threatens autonomy. C) It increases confusion. D) It prevents self-directed care.

B) It threatens autonomy.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? A) Emphasize to the client the importance of following the treatment plan. B) Medicate the client and wait 30 minutes to ambulate C) Explain to the client the benefits of ambulation. D) Ambulate the client and medicate after ambulation.

B) Medicate the client and wait 30 minutes to ambulate

What is an example of the doctrine of double effect? A) Physician orders the less expensive of two tests. B) Nurse gives ordered high dose of morphine to dying patient. C) Health care provider advises patient of two different treatments. D) A medical error doubles the cost of the patient's hospital stay.

B) Nurse gives ordered high dose of morphine to dying patient.

Which situation is an example of battery that the nurse may witness while performing duties at the health care facility? A) Verbal violence towards another nurse. B) Performing a surgical procedure without getting consent C) Telling the client that the client may not leave the hospital D) Taking the client's photograph without consent

B) Performing a surgical procedure without getting consent

A client with hypertension being seen for follow-up care has a blood pressure of 170/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the past 2 weeks. What is the nurse's most appropriate action? A) Interview the family to determine if the client is giving accurate information. B) Report the findings to the physician for further plans. C) Reinforce the instructions for the treatment regimen to the client. D) Inform the client that the blood pressure medication will have to be changed.

B) Report the findings to the physician for further plans.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? A) Continue assisting the client to the bathroom to ensure the client's safety. B) Revise the care plan to allow the client to ambulate to the bathroom independently. C) Instruct the client's family to assist the client to ambulate to the bathroom. D) Consult with the physical therapist to determine the client's ability.

B) Revise the care plan to allow the client to ambulate to the bathroom independently.

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? A) Potential for Pneumonia related to bed rest. B) Risk for Impaired Skin Integrity related to bed rest. C) Immobility related to confinement of bed D) Ineffective Airway Clearance related to bed rest.

B) Risk for Impaired Skin Integrity related to bed rest.

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? A) Diabetes B) Risk for unstable blood glucose C) hypertension D) appendicitis

B) Risk for unstable blood glucose

The scope of Nursing practice is legally defined by: A) Professional nursing organizations B) State nurses practice acts C) Hospital policy and procedure manuals D) Physicians in the employing institutions

B) State nurses practice acts

As a student nurse you are learning about health-care reform. How can you help? A) Do well in your nursing courses B) Support legislation to improve care C) Students should not participate in shaping health care reform. D) Volunteer

B) Support legislation to improve care

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. A) The client asks the nurse to repeat the instructions. B) The client discusses the specifics of what was taught during the session C)The client verbalizes understanding of the instructions. D) The client is able to answer the nurse's questions. E) The client tells the nurse that the client's spouse will handle the care.

B) The client discusses the specifics of what was taught during the session C) The client verbalizes understanding of the instructions. D) The client is able to answer the nurse's questions.

A nursing diagnosis is written as Disturbed Body Image related to scar on the left side of the face. What does the phrase "Disturbed Body Image" identify? A) The expected outcome of the plan of care B) The health state or problem of the client C) A cue to determining a health problem D) The major defining characteristic of a health problem

B) The health state or problem of the client

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? A) Posting the sign "NPO after midnight" over the bed B) Updating the diet orders in the client's plan of care C) Obtaining written consent for the diagnostic procedure D) Adding the diagnosis "Altered Nutrition, Less Than Required"

B) Updating the diet orders in the client's plan of care

You notice another nurse on the floor not wearing gloves when helping a client use the restroom. How do you react? A) She is your best friend on the floor so you don't say anything right now. B) You should let the nurse know they must use gloves and wash their hands before and after patient care. C) Immediately tell the nursing supervisor. D) This is acceptable behavior if you can guarantee you won't get any bodily fluids on you.

B) You should let the nurse know they must use gloves and wash their hands before and after patient care.

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document? A) Proof of health care power of attorney B) A living will C) An order for Do Not Resuscitate (DNR)

B) a living will

A patient at home gets a laceration on their hand while cutting a piece of fruit. The patient will need stitches. Which facility is most appropriate for this patient? A) emergency department B) ambulatory care center (aka. outpatient or urgent care center) C) call 911 so they can make the most appropriate decision D) primary health care provider's office

B) ambulatory care center (aka. outpatient or urgent care center)

Which ethical principle is related to the idea of nursing students controlling their life and outcome of nursing school? A) beneficence B) autonomy C) confidentiality D) nonmaleficence

B) autonomy

The nursing instructor notices that there are major conflicts between the students within one cohort. The instructor suggests that each person put aside their differences for a time and determine a common major goal. Which conflict resolution style does the instructor display? A) competing B) collaborating C) avoiding D) smoothing

B) collaborating

A client is brought to the emergency department by an adult child, who states, "I am unable to care for my parent anymore. Although I would like to, financially and physically I can't do it anymore." What ethical problem is the adult child experiencing? A) Uncertainty B) distress C) dilemma D) dissatisfaction

B) distress

A client states that the client's recent fall was caused by his scheduled anti-hypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? A) Enlist support from nursing and non-nursing colleagues from the unit. B) Document the client's claims and the events surrounding the alleged incident. C) Consult with the hospital's legal department as soon as possible. D) Consult with practice advisors from the state board of nursing.

B) document the client's claims and the events surrounding the alleged incident

A nurse forgot to document that a client drank 120ml of water at 0830. It is now 1030. What action should the nurse take? A) Document the water for the 1030 time. B) Document the water for the 0830 time C) Do not document this water since too much time has lapsed. D) Fill out an incident report.

B) document the water for the 0830 time

The registered nurse in a busy emergency department is delegating tasks to an unlicensed assistive personnel (UAP)? Which task is appropriate for the UAP to complete? A) irrigating a wound B) getting a urine specimen C) taking an order over the telephone from doctor D) inserting a catheter

B) getting a urine specimen

You are the registered nurse on a medical/surgical floor. There is a Licensed Practical Nurse (LPN) that has a team of patients. Which nursing tasks would she have you (as the RN) complete? A) inserting a Foley catheter B) giving morphine sulfate 4mg IVP C) assisting her patients D) completing a dressing change

B) giving morphine sulfate 4 mg IVP

You are the registered nurse caring for several pediatric patients. Which task would be best for the RN to delegate to an unlicensed assistive personnel (UAP)? A) silencing an alarm on IV pump B) helping secure a 2 yr old who needs an IV C) educating a teen about proper hygiene D) giving a patient's vitamin to her

B) helping secure a 2 yr old who needs an IV

A patient diagnosed with lung cancer has been given less than 4 months to live. The nurse discusses hospice care. Which aspect of the patient's health status indicates that hospice care is appropriate? A) the patient wishes to treat the disease with alternative medicine B) life expectancy is less than 6 months C) the patient does not have family D) the patient is diagnosed with metastatic cancer

B) life expectancy is less than 6 months

A nurse is providing patient care in a hospital setting. Who has responsibility and accountability for the nurse's actions? A) physician B) nurse C) hospital D) head nurse (or charge nurse)

B) nurse

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? A) diagnosis B) planning C) evaluation D) implementation

B) planning

You are a nurse on a medical/surgical unit. Your patient has possibly had a stroke this morning. You have several things that must be done. Which therapist would help with a swallow test to ensure they do not have difficulty swallowing fluids and food? A) respiratory therapist B) speech therapist C) occupational therapist D) physical therapist

B) speech therapist

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? A) The nurse informs the family about advance directives. B) The nurse ensures that the client's family signs the consent form. C) The nurse ensures that the client signs the consent form. D)The nurse informs the family about the living will.

B) the nurse ensures that the client's family signs the consent form

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply. A) Do nothing as long as Client B has no reaction. B) Contact the provider to report the error. C) Complete an incident report. D) Tell Client A that the wrong drugs were given to Client B. E) Assess Client B thoroughly.

B)Contact the provider to report the error. C) Complete an incident report. E) Assess Client B thoroughly.

Which is the primary reason for a nurse collecting data continuously on a client? A) Most facilities require it for reimbursement. B) The client's health status can change quickly C) It gives the nurse more information to document on the client. D) It makes the client feel as if the nurse is spending more time with the client.

B)The client's health status can change quickly

A nurse posts the following to their social media account; "Today was a bad day at work; my patients were tough to work with, especially one in particular". What response by the nurse manager is most appropriate? A) "It's okay to discuss these things with your best friend, but not on social media." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with family." C) "Any information that can identify a person is considered a breach of client privacy." D) "You may continue to post about a client, as long as you do not use the client's name."

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

The health care provider is yelling at the nurse in the patient's room because the patient has not received an intravenous antibiotic. Which statement by the nurse demonstrates appropriate assertiveness? A) "You should have written your order more clearly than you did." B) "It's the fault of the previous nurse, who left it for me to do." C) "Let's go to the nurses' station, and I will explain." D) "I have other patients and have been very busy today."

C) "Let's go to the nurses' station, and I will explain."

A client is questioning the need for surgery. The client asks the nurse, "What should I do?" Which answer by the nurse is based on advocacy? A) "If I were you, I would not have this surgical procedure." B) "You should ask some of the more experienced nurses this question." C) "Tell me why you do not want the surgery." D) "Let me talk to your doctor, and I will let you know what I find out."

C) "Tell me why you do not want the surgery."

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A) A 68-year old with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning. B) A 4-year old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly. C) A 45-year old with burns to the upper arms and chest and soot on the face who is restless and anxious D) An 18-year old sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who talking on a cell phone.

C) A 45-year old with burns to the upper arms and chest and soot on the face who is restless and anxious

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview? A) Document that the client refused the interview. B) Use the information that is on the electronic health record and eliminate the need for the interview. C)Administer prescribed pain medication prior to conducting the interview. D) Inform the client that the interview must proceed before getting anything that will alter perception

C) Administer prescribed pain medication prior to conducting the interview.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? A) Delegate the health education to a colleague B) Boost the morale of the client. C) Assess for cultural differences. D) Replace one-on-one teaching with written materials.

C) Assess for cultural differences.

A nurse has just received report and is ready to begin the day. The priority client is still sleeping. What action should the nurse take next? A) Allow the client sleep until later in the morning B) See your other client's first and save this client's assessment for last C) Awake the client and explain that you need to do an assessment D) Revise the plan of care to add Ineffective Sleep Patterns

C) Awake the client and explain that you need to do an assessment

A client in the last stages of lung cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? A) Research other treatment options available for the client B) Ask if the client would like to speak with a spiritual adviser C) Collaborate with other disciplines to plan end-of-life care for the client D) Remind the client that positive thoughts are essential for recovery.

C) Collaborate with other disciplines to plan end-of-life care for the client

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes the goal of increasing oral intake. Why would the priority reason be for the nurse reviewing the plan of care for this client? A) To be sure the interventions are individualized B) To be sure the interventions are evidence-based C) To be sure the planned interventions are safe D) To be sure interventions follow hospital policy

C) To be sure the planned interventions are safe

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan? A) Lecture provided about infection, and client stated understanding what infection is. B) Spouse taught to flush feeding tube before and after medication. Denied further instruction needed. C) Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. D) Discussed wet-to-dry dressing changes, and client stated understanding.

C) Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique.

During the planning phase of the nursing process, a client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? A) Discuss the client's refusal with hospital risk managers. B) Discuss the client's options with other church members. C) Discuss possible alternatives to a blood transfusion with the physician. D)Discuss the risks and benefits of a blood transfusion with the client.

C) Discuss possible alternatives to a blood transfusion with the physician.

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? A) Institute a new policy on the prevention of client falls on the unit. B) Reprimand the nursing personnel responsible for the clients when the falls occurred. C) Investigate the circumstances that contributed to client fall.s D) Determine if client falls have increased on other units in the hospital.

C) Investigate the circumstances that contributed to client fall.s

A client has made no progress toward meeting any of the goals for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse best respond to this situation? A) Continue the current plan of care with the hope that the client will achieve the goals B) Replace the nursing plan of care with a plan written by the physical therapist C) Modify the plan of care to reflect the client's current functional ability D) Discontinue the plan of care and recommend the client be discharged

C) Modify the plan of care to reflect the client's current functional ability

You are a nurse in an ER. Your elderly client appears withdrawn around his daughter and has questionable bruises. What action should the nurse take? A) Ask for advice from another nurse on the floor B) Tell the client's daughter "how dare you abuse your father" C) Notify the nursing supervisor for further guidance. D) Ask the daughter to leave

C) Notify the nursing supervisor for further guidance.

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision (splint the incision mean placing a pillow over the abdomen to help support the area with the incision). What is the nurse's next step in implementing the plan of care? A) Instruct the client that pain medication is available at regular intervals. B) Notify the physician that the client has required pain medicaitions. C) Reassess the client to determine the effectiveness of the interventions D) Perform additional non-pharmacological pain interventions.

C) Reassess the client to determine the effectiveness of the interventions

A police officer has come into the ED and requested that you (the nurse) draw blood for a client. Your hospital policy states that before blood can be drawn the client needs to be a)under arrest or b)have a warrant out for their arrest. The police officer states that client is not under arrest and there is no warrant but that they absolutely must have the blood drawn. What is the nurse's action? A) Ask another nurse to draw the blood. B) Draw the blood immediately because the police officer out ranks the nurse. C)Remind the police officer that you cannot draw the client's blood unless the client is under arrest or if the police officer has a warrant. D) Ask your nursing supervisor to draw the blood since she will have the authority to do so.

C) Remind the police officer that you cannot draw the client's blood unless the client is under arrest or if the police officer has a warrant.

The patient is in severe pain and asks for pain medicine. The family refuses all pain medicine because they are afraid the medicine might end the patient's life. Where could the nurse obtain guidance in this situation? A) Discuss the situation with a colleague at another hospital. B) The nurse should not stand in the way of the family wishes. C) Review the literature about providing pain relief with the family. D) Refer the situation to the nursing supervisor

C) Review the literature about providing pain relief with the family.

After completing an assessment of a client, which data would the nurse determine is the priority for care? A) Lack of family and social support B) Type 1 Diabetes controlled by insulin C) Severe bleeding from a wound D) History of asthma and lung disease

C) Severe bleeding from a wound

A client has been admitted to the hospital for the treatment of pneumonia. Which statement constitutes a long-term outcome for this client? A) The client will demonstrate the correct use of the incentive spirometer B) The client will express an understanding of strategies for managing fatigue and shortness of breath C) The client will return home able to conduct activities of daily living (ADL's) without experiencing shortness of breath D) The client will ambulate 100 feet without supplementary oxygen or mobility aids.

C) The client will return home able to conduct activities of daily living (ADL's) without experiencing shortness of breath

Which outcome (goal) is correctly written? A) The abdominal incision will show no signs of infection B) The client will tolerate sitting up in the chair C) The client will verbalize five symptoms of infection within three days D) The nurse will change the abdominal dressing once daily

C) The client will verbalize five symptoms of infection within three days

All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all of the others? A) Providing hands-on client care B) Giving instructions to assistive personnel C) Thinking and reasoning about the client's care D) Carrying out physician orders

C) Thinking and reasoning about the client's care

A nurse is educating a newly diagnosed diabetic on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? A) Previous knowledge B) Preparation C) Anxiety d) Intelligence

C) anxiety

You just received report on a patient coming from the post-anesthesia care unit. Prior to surgery your patient was educated about the correct use of the incentive spirometer. When your patient comes to the floor she does not correctly demonstrate use of the IS. What should you do? A) Do not do anything. the patient is not wanting to learn B) call the pre-op area and ask to speak to the manager C) educate the patient on the correct use D) call the pre-op area and ask to speak to the nurse

C) educate the patient on the correct use

A nursing instructor is teaching students about the utilization of health care services and how the U.S. health care dollar is spent. Where is the highest percentage of health care money spent? A) long-term care B) physician office C) hospital D) home health

C) hospital

Your patient is being admitted to the hospital from the Emergency Department with a diagnosis of hyperglycemia. Which healthcare provider would the patient most likely be admitted under? A) hospitalist B) nurse C) primary care provider D) Emergency room physician

C) hospitalist

Why have health care costs for hospital admissions risen? A) number of surgeries has increased B) length of stay has increased C) length of stay has decreased D) number of surgeries has decreased

C) length of stays has decreased

You have a 72 year old patient with diabetes who is being admitted to the hospital. Which services would likely assist in payment? A) hospital B) Medicaid C) Medicare D) out-of-pocket pay

C) medicare

A confused client who fell out of bed because side rails were not used is an example of which type of liability? A) battery B) assault C) negligence D) felony

C) negligence

A nurse knows that the expression "Do not cause harm" refers to which ethical principle? A) fidelity B) justice C) nonmaleficence D) beneficence

C) nonmaleficence

What do we see trending in healthcare today that will greatly impact you as a nurse? A) uneducated consumers B) increase in nurses C) nursing shortage D) costs of healthcare is going down

C) nursing shortage

Your patient is struggling to put their socks on after hip replacement surgery. Which therapist would be best suited to help the patient learn this task? A) physical therapist B) speech therapist C) occupational therapist D) reflexologist

C) occupational therapist

An older adult has a disease process that causes her not to get around well anymore. She voices her concern about the stress her husband is under now that he cares for her full time. What might the nurse suggest? A) primary care B) bereavement care C) palliative care D) hospice care

C) palliative care

Even though the nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the: A) nurse B) client C) physician D) student nurse

C) physician

A home health nurse arrives at the home of a patient (an infant) who has just been discharged home, and finds that the infant is on a ventilator and is being cared for by the parents. What should the nurse do next? A) notify the parents that a mistake has been made and that the infant must return to the hospital B) inform the parents that only trained professionals should touch the ventilator C) provide teaching to the parents on how to operate the ventilator D) make a referral to an advanced practice nurse with training in ventilator care

C) provide teaching to the parents on how to operate the ventilator

QSEN is a project aimed at preparing future nurses to continually improve which aspects of the health care systems within which they work? A) Staffing and numbers of licensed personnel. B) Qualitative research and Quantitative research C) Quality and Safety D) Salary and benefits

C) quality and safety

A group of 5th grade students are learning about puberty. Which professional is most likely to lead the discussion? A) school counselor B) doctor C) School nurse D) teacher

C) school nurse

The nurse is educating a client regarding use of the incentive spirometer. When evaluating the client's knowledge about the incentive spirometer, which best represents that the client has learned correct use of this device? A) the client verbalizes items needed and how to perform the skill B) the client nods when asked about process and assists with cleanup C) the client organizes materials needed and gives return demonstration D) the client states understanding and passes a written test

C) the client organizes materials needed and gives return demonstration

You have four patients today and they each need you at the same time. Which nursing care task is acceptable for a registered nurse to delegate to an unlicensed assistive personnel (UAP)? A) discontinuing a patient's IV so that they can be discharged home B) assisting a patient to the restroom who has new onset chest pain C) transporting a patient to a procedure via wheelchair D) completing the admission of a new patient

C) transporting a patient to a procedure via wheelchair

Which example best describes continuity of care? A) trying to have a different nurse care for a patient each shift B) not going in a patient's room that you are not assigned to C) trying to have the same nurses care for the same patients whenever possible D) serving the needs of your patient

C) trying to have the same nurses care for the same patients whenever possible

In the hospital setting, when does discharge teaching begin? A) only when there is a procedure would we educate the patient B) upon discharge from the hospital C) upon admission to the hospital D) upon transferring within the hospital

C) upon admission to the hospital

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? A) Determine the necessity of the bag change. B) Ask the client how the bag is changed. C) Ask the family to assist with changing the bag. D) Ask a skilled nurse to assist with the procedure.

D) Ask a skilled nurse to assist with the procedure.

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing? A) Negligence B) Battery C) Defamation D) Assault

D) Assault

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? A) Assess the client's activity level B) Assess the client's ability to care for self. C) Assess the client's medication regimen D) Assess the client's blood pressure

D) Assess the client's blood pressure

What is the new role nurses play in health care because of the Affordable Care Act (ACA)? A) Keeping the plan of care up to date B) Verifying that all documentation has been completed C) Identifying individuals at risk for developing obesity D) Collaborating with all agencies to provide for the patient's home health needs

D) Collaborating with all agencies to provide for the patient's home health needs

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing? A) Head to toe assessment B) General assessment C) Time-lapsed assessment D) Focused assessment

D) Focused Assessment

When signing a form as a witness, your signature shows that the client: A) Was free to sign without pressure B) Was awake and fully alert and not medicated with narcotics. C) Is fully informed and is aware of all consequences. D) Has signed that form and the witness saw it being done

D) Has signed that form and the witness saw it being done

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? A) High Risk for Injury related to impaired home management. B) High Risk for Injury related to abusive parents C) Child Abuse related to unsafe home environment. D)High Risk for Injury related to unsafe home environment.

D) High Risk for Injury related to unsafe home environment.

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? A) Document concerns about the order B) Refuse to administer the medication C) Administer the medication based on the order. D) Question the order for the medication.

D) Question the order for the medication.

Which outcomes should the nurse recognize as being the most appropriate for a client with a nursing diagnosis of Risk for Infection? A) The client takes the client's own temperature daily. B) The client takes the prescribed antibiotic. C) The client understands what symptoms to monitor for. D) The client has a normal temperature and no signs or symptoms of infection.

D) The client has a normal temperature and no signs or symptoms of infection.

A client nearing the end of life requests that the client be given no food or fluids. The physician orders the insertion of a feeding tube to feed the client. What is the primary concern of the nurse providing care? A) The nurse must follow the physician's orders. B) The physician's order creates a barrier to establishing an effective nurse-client relationship. C) The nurse is unable to provide care for the client. D) The nurse faces an ethical dilemma about inconsistent courses of action.

D) The nurse faces an ethical dilemma about inconsistent courses of action.

What best describes the hospital setting today? A) Chronic care needs B) Primary care centers C) Long-term care needs D) Acute care needs

D) acute care needs

Your patient needs to walk in the hall at least 3 times per day. Which safety intervention must the nurse perform first? A) ask the physician to change the order B) ask the UAP to help the patient with ambulation C) ask a family member to assist the patient with ambulation D) assess the need for assistance with ambulation.

D) assess the need for assistance with ambulation.

Which task would be best for the registered nurse to delegate to the unlicensed assistive personnel (UAP)? A) bathing a patient who has severe wounds B) transporting patient to procedure with chest pain C) ambulating a patient who is getting up for the first time after surgery D) bathing patient with severe C Diff

D) bathing patient with severe C Diff

The nurse is working at facility in St. Louis that is applying for Magnet recognition. The nurse understands that compared with other hospitals, Magnet hospitals have which direct effect on patient care? A) better nurse retention B) better job satisfaction scores C)longer patient stays D)better patient outcomes

D) better patient outcomes

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? A) reflection B) assessment C) caring D) clinical reasoning

D) clinical reasoning

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A) Nurse Practice Act (NPA) written by state legislation B) Standards of care from experts in the practice field C) Good Samaritan laws for civil guidelines D) code of ethics for nurses

D) code of ethics for nurses

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed? A) fraud B) slander C) assault D) invasion of privacy

D) invasion of privacy

A nurse documents the following in the client chart: client's lungs are clear to auscultation. This is an example of what aspect of client care? A) nursing diagnosis B) nursing eval C) nursing plan D) nursing assessment

D) nursing assessment

You are a nurse manager on a high acuity telemetry unit. Many changes will be made over the next several months and your staff is very resistant to the changes. What is a way the nurse can overcome the resistance? A) explain that they may want to consider finding a new place of employment B) explain the rationale of the change and that the change was mandated C) implement the change quickly and all at once D) provide opportunities for open communication and feedback

D) provide opportunities for open communication and feedback

To practice ethically, the nurse should avoid: A) Allowing an ethics committee to guide the nurse's practice B) Asking the client's family about their views on caring. C) Reviewing past cases before making decisions about practice. D) Allowing the nurse's own judgment to guide practice.

D)Allowing the nurse's own judgment to guide practice.

A diabetic client discovers that the client's name is published in a research report on diabetic care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? A) invasion of privacy B) negligence of duty C) defamation of character D) unintentional tort

invasion of privacy

The nursing 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) explain that only a paper copy of the health care record can be viewed by the client C) review the hospital's process for allowing clients to view their health care records D) discuss how the hospital can be fined for allowing clients to view their health care records

review the hospital's process for allowing clients to view their health care records