Foundations of Nursing Exam 1 ATI

A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle?

10° angle

A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience?

Competent

A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include?

Encourage the client to ask questions

Which of the following is your highest priority action for ensuring overall safety during medication administration?

Identify the patient by two acceptable methods

A nurse is explaining National Patient Safety Goals (NPSGs) to a newly licensed nurse. The nurse should include that which of the following is a goal addressed in the NPSGs?

Improving staff communication

A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take?

Lower the volume of the television

A nurse is assisting with teaching a class about quality core measures. Which of the following information should the nurse include?

Quality core measures are a standard of care for treatment.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Record the time and length of the seizure

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use?

Schedule a face-to-face unit staff meeting.

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?

"Effective hand washing can decrease hospital infection rates."

A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make?

"Finish the entire course of the prescription"

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"Give the client choices regarding their bathing preferences to encourage them to bathe."

A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make?

"I am unable to send your discharge instructions via email due to the HIPAA Privacy Act."

A nurse is discussing culturally competent care with another nurse. Which of the following statements should the nurse include?

"Use a medical interpreter for a client who does not speak the same language."

A patient drinks 8 oz of water. Which of the following is a correct conversion of the patient's intake?

240 mL

A nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field?

A cotton ball dampened with sterile normal saline is placed on the field. The nurse turns to address the client's question concerning the procedure. The procedure is postponed for 30 min to accommodate the client. A liquid is poured into a sterile container from a distance of 25 cm (10 inch)

A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

Can you tell me what month it is?

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection?

Cleaning the least soiled areas prior to cleaning the most soiled areas.

A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take?

Come back in a few minutes to administer the medication.

A nurse is assisting on a quality improvement committee to decrease the number of client falls occurring at night. After identifying the problem, which of the following is the next step the nurse should take?

Complete a literature review.

A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role?

Coordinating and overseeing the care the client is receiving

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request?

Cultural factor

A nurse is inspecting the anterior chest of a client. Which of the findings should the nurse report to the provider?

Distended veins in one breast

A nurse educator is planning a presentation for nurses about the opioid epidemic. Which of the following is a strategy promoted by the U.S. Department of Health and Human Services to address this epidemic?

Educate nurses and other health care personnel about naloxone.

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

Enamel protects the teeth from pathogens.

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client?

Fall history, medical diagnosis, use of assistive devices, mental status

A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take.

Gather all necessary supplies. Place rubber mat. Assist patient into bathroom. Instruct patient on using safety bars when getting in and out of the tub. Instruct the patient to remain in the tub for no longer than 20 mins.

A nurse is providing teaching to an assistive personnel about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give?

Grasp only the inside of the glove with your ungloved hand

A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first?

Have a second nurse confirm the insulin dose.

A nurse is teaching a newly licensed nurse about providing oral care for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I'll swab the client's mouth with chlorhexidine

A nurse is using evidence-based practice (EBP) to address the incidence of catheter-associated infections on a surgical unit. According to EBP, which of the following actions should the nurse take first?

Identify a clinical problem.

A nurse is assisting a quality improvement team that is using the Plan-Do-Study-Act (PDSA) model to address an increase in pressure injuries on a medical unit. Which of the following actions should the nurse identify as an example of the "Do" step of the PDSA model?

Implementing a new evidence-based practice protocol

A nurse is a member of a committee that is using evidence-based practice (EBP) to decrease the incidence of central line infections. The nurse should identify that which of the following interventions is part of the implementation step of EBP?

Incorporating the new practice into client care

A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication?

Nonverbal

A nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?

Nutritional status, hygiene, posture

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?

Oral

A nurse is documenting vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on O2 2L/min via nasal cannula

A nurse is preparing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the mastoid area for pain

A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating?

Passive- aggressive

A nurse is reviewing the contributions made by various nursing organizations that have impacted the nursing profession. The nurse should identify that which of the following are contributions made by The American Nurses Association (ANA)? (Select all that apply.)

Providing a definition of nursing is correct, lobbying for whistleblower protection is correct, providing all registered nurses with competency expectations is correct.

A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply.)

Psychosocial factors, situational factors

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take?

Raise the room temperature.

A nurse is having difficulty obtaining a pulse ox reading from a client. The nurse should identify which of the following factors can interfere with obtaining a pulse ox reading?

Recent scan with contrast dye

A nurse is assisting with developing a quality improvement (QI) plan to reduce the incidence of medication errors in an acute care unit. The nurse should recognize that which of the following actions is included in the identifying step of the QI process?

Recognizing a need for a change

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temp of the client?

Rectal

A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media?

Reviewing the use of a fitness application with a client

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin, Which of the following actions should the nurse take?

Rinse the client's skin with water

A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating?

Sender

A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client?

Speak to the client clearly and at a slow pace

A nurse observes an assistive personnel make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task?

The AP reuses the client's blanket and spread.

A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include?

The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficult decisions.

A nurse is reviewing the health history of a client during a routine office visit. Which of the following observations by the nurse is an example of the client demonstrating health literacy?

The client states they understand their health care information and treatments

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?

The epidermis consists of squamous epithelial cells.

Which of the following is the most appropriate documentation of a patient's response to a pain medication?

The patient reports pain decreased to 3/10, 30 min after medication administration

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

Urinary incontinence can cause a yeast infection.

A nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan?

Use a standardized communication tool

A nurse is performing foot care for a client. Which of the following actions should the nurse take?

Use a towel to completely dry between the toes.

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?

Use an alternative method for determining the client's pain level.

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply)

Use of assistive devices, height and weight, behavior and mood

A nurse is planning to complete a physical assessment on a client. Which of the following actions should the nurse plan to include?

Use quotation marks when documenting client statements

A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?

Wear clean gloves to apply the transdermal medication

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

"The skin contains Langerhans cells that kill pathogens."

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?

A client who has impaired kidney function

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? Select all that apply

A client's visitor falls in the hallway, a client develops an unexpected reaction to a medication, a client's dentures are lost

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include?

A fluoride mouthwash should be used to promote oral health.The teeth should be brushed twice daily for 2 min.Poor oral hygiene can lead to gingivitis.Use a soft-bristled toothbrush for brushing the teeth.

A nurse is assisting with teaching a class about incident reports. The nurse should include that which of the following situations requires an incident report?

A nurse administers the wrong medication to a client.

A nurse is assisting with teaching a class about sentinel events. The nurse should include that which of the following situations is a sentinel event?

A nurse infused an incompatible blood product to a client.

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next?

Activate the fire alarm

A nurse is talking with a client who arrived at the clinic over an hour ago and states, "Doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the client and notifies the provider, relaying the needs of the client. In which of the following roles is the nurse performing?

Advocate

A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.)

Age of the client, lipid solubility of a medication, route of administration

An uncommon, unexpected, or individual drug response though to result from genetic predisposition is called

An idiosyncratic effect

A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?

Ask the client to explain the information using their own words.

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

Auscultate bowel sounds prior to palpating

You have a handwritten medication order that is difficult to read. Which of the following is the most appropriate action to take to avoid an error in medication administration?

Call the medical producer for clarification of the order

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? Select all that apply

Catheter-associated urinary tract infection, central line-associated bloodstream infection, surgical site infection

A nurse is assessing a client's vital signs. while counting the number of respirations. Which of the following information should the nurse collect?

Characteristics of the respirations

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply)

Dirty clothing, unexplained physical injuries, malnourished appearance

A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take?

Ensure the client is wearing their glasses during teaching.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning?

Ensure the room is well lit

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe the involuntary movement?

Fasciculation

A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of following components of the model?

Feedback

A nurse is reviewing historical nursing data and how it has impacted nursing care. The nurse should identify that which of the following nursing pioneers is credited with first using evidence-based practice in caring for clients?

Florence Nightingale

A nurse is assisting with teaching about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include?

Frequent reports of not being treated fairly

With which route of drug administration are there no barriers to absorption?

Intravenous

A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address the client's questions. Which of the following describes the Healthy People initiative?

It is a set of objectives for improving the health of Americans.

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? Select all that apply

Locks the brakes on the client's bed, checks the max weight on the lift before using it, performs a safety check before lifting the client

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events?

Near-miss event

A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Observe for the use of accessory muscles during inspiration

A nurse is explaining to a newly licensed nurse that caring for clients involves lifelong learning by the nurse. The nurse should include which of the following as examples of learning opportunities for nurses? (Select all that apply)

Online continuing education journals, nursing skill refresher, continuing education presentation, participating in healthcare research

A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps?

Position the tray so that the top flap is farthest away from their body. Open the flap furthest from their body. Open side flaps. Open the flap closest to their body.

A nurse is discussing quality measurement with a newly licensed nurse. The nurse should include that medication reconciliation is an aspect of which of the following parts of quality measurement?

Process

Prior to entering the surgical-scrub area, which of the following PPE items should a nurse don?

Protective eyewear, hair cover, mask, shoe covers

A nurse is reviewing a health care facility's policy that states to use a gauze dressing over IV insertion sites. After completing a literature review, the nurse discovers that evidence-based practice (EBP) indicates to use a transparent dressing over IV sites. Which of the following actions should the nurse take next?

Recommend changing the procedure to the policy and procedure committee.

A drug's generic name is the

Same as the nonproprietary name

A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first?

Stop the infusion of the vancomycin.

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110 bpm. The nurse should identify this as which of the following unexpected findings?

Tachycardia

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings?

Tachypnea

A nurse is reviewing the contributions of various nursing organizations that provide support in caring for clients. The nurse should identify that which of the following agencies provides The Nursing Scope and Standards of Practice?

The American Nurses Association (ANA)

A nurse is assisting with teaching a newly licensed nurse about the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include?

The HCAHPS tool is issued to measure client satisfaction about health care service.

A nurse is reviewing the Institute of Medicine (IOM) Future of Nursing report to better understand proposed educational requirements of nurses. Which of the following organizations is responsible for publishing this report?

The National Academy of Medicine

A nursing student expresses a desire to become more involved with the nursing profession on a national level. Which of the following organizations should the student join?

The National Student Nurses' Association

A nurse has accepted a position at a hospital in the state where they live. The nurse should identify that which of the following regulates the nurse's actions when they begin working?

The State Nurse Practice Act

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding?

The client reports they feel sad and lonely most of the time

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? Select all that apply

The date the med was mixed, the dose of the mixed medication, the time the medication was mixed

A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client?

The deltoid muscle can be used to administer intramuscular injections.

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety?

The edges of stairs are marked with brightly colored tape

When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?

The inner edge of the cuff will lie against the skin and thus will not be sterile.

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicated an understanding of the teaching?

The nurse holds onto the plug to unplug a client's electronic bp machine

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect bp? (Select all that apply)

Time of day, obesity, diuretic medication, smoking

A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis?

To control the introduction of micro-organisms at the catheter site

A nurse should identify that which of the following is the goal of surgical asepsis?

To create and maintain a micro-organism-free environment

A nurse in a long-term care facility took a picture of a client and posted it on the internet. This action by the nurse is an example of which of the following?

Violating the code of ethics for nurses.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Washing the client in bed is less effective than taking a shower.

While waiting for a sterile procedure to begin, how should the nurse position their hands and arms?

With hands clasped together in front of the body above waist level

A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing?

"You said that you're sad. What is making you feel sad?"

A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take?

Administer the medication to the client in a liquid form.

A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take?

Administer the medication within 30 min of the health care provider prescribing the medication.

Which of the following demonstrates the correct use of one of the six rights of medication administration?

Administering a patient's medication by the route the provider has prescribed

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include which of the following? Select all that apply

Blood transfusion incompatibility, wrong-site surgery, ineffective insulin usage

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

Health promotion programs emphasize behavior changes in relation to prevention of illness.

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Inspect the pattern of hair distribution

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during the assessment?

Instruct the client to swallow, apply downward pressure and ask the client to shrug their shoulders, request the client to move their head forward and backward and then side to side

A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.)

Move the client to a quiet area or private room, speak at a slower pace, avoid using medical terminology

A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory range?

The client takes a narcotic pain medication for chronic pain

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

The cuticle of the nail forms a barrier to prevent infections.

A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.)

Verbal, written, nonverbal

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations?

"I'm glad you decided to continue your fitness routine."

A nurse is caring for a client who has suction equipment in their room. The client asks the nurse, "Why do you check my suction equipment every day even though I am not using it?" Which of the following statements should the nurse make?

"It is part of the quality assurance plan of the unit."

A nurse is assisting with teaching a class about types of research studies. The nurse should include that which of the following is an example of a randomized controlled trial (RCT)?

A study arbitrarily assigning people who smoke into either an experimental group or a control group to determine the effects of a new therapy to reduce smoking

A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply)

Ask the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level.

A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?

Assist the client as needed to ensure proper hygiene is performed.

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for a fire to occur? Select all that apply

Cooking oil, oxygen, heat

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance?

During an interview about the client's health history, when introducing themselves to the client, while collecting the client's vital signs

A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather?

Penlight, stethoscope, sphygmomanometer

You are giving a patient several PO medications to take. The patient tells you that she can only take one pill at a time. It is appropriate to

Remain at the bedside until you are sure the patient has taken all of the medications

A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements?

Report this omission to the charge nurse and the nurse on the next shift.

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.)

Respect the client during the conversation, allow time for reflection during the conversation with the client, show empathy during the conversation with the client.

A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using?

Restating

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

The nurse should have the client remove clothing from the unaffected side first.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)

The nurse's hands become visibly soiled.The nurse removes the meal tray of a client who has infectious diarrhea.The nurse empties the urinal of a client who has Clostridium difficile.

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? Select all that apply

The client's full name, the client's DOB, the client's telephone number

A nurse is caring for an adult who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse?

"Oral care is still important even though you are not eating."

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include?

Ask the patient in what order she typically performs her morning routine

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take?

Discuss with the client their individual perspective on health and illness.

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications?

Have the client confirm their name and date of birth.

A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?

Have the client perform a return demonstration of the procedure.

A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smoking cessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply.)

Health Promoter, nurse educator

When opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack?

Holding the sterile pack below waist or table level

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take?

Inspect the condition of each fingernail, compare the amplitude of the radial pulses bilaterally, palpate the shoulder, elbow, wrist, and finger joints

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client?

Lung sounds, bowel sounds, pedal pulses, mental status

A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.)

Mark the area around the automated medication dispensing system, provide the nurse administering medications with a vest, double check dosages of high-alert medications.

A nurse is caring for a patient who is on long-term bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes?

Moisture from excessive diaphoresis can cause skin breakdown

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply

Place the client on round-the-clock surveillance, remove the objects from the room that the client could use to arm themselves, search items brought into the client's room by visitors, screen the client for suicide ideation

A nurse is assisting with using the Plan-Do-Study-Act (PDSA) model to decrease client falls in a long-term care facility. The nurse should identify that developing guidelines to decrease falls is included in which of the following steps of the PDSA model?

Plan

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action?

Regularity of the pulse, strength of the pulse

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?

Remove the restraints with each vital sign check

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request assistance from the facility's interpreter.

A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows?

To encourage water and soap to flow away from the clean hands

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?

Trim the nails straight across.

A nurse is planning to use the identify, situation, background, assessment, recommendation, read-back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR?

The client's lab test results

A nurse is planning to take an orthostatic bp from a client who has a syncope. In what order should the nurse take the following steps?

Place the client in a supine position and allow them to rest, take the clients bp in the supine position, keep the cuff in place and assist the client to a seated position, take the client's blood pressure in a seated position, assist client to stand and obtain their bp

A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.)

Place the medication reconciliation form with the client's transfer documents, reinforce teaching about the medications to the client upon discharge, include over-the-counter medications in the medication reconciliation, compare the client's home medications with prescribed discharge medications.

A nurse is caring for a client who is reporting pain as a 4 on a scale 0-10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply)

The client reports that the pain has been present for 4 years, the client reports never feeling total relief from pain, the client reports that the pain is recurring and does not always originate in the same location

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection?

Perform hand hygiene

A nurse is caring for a client who reports experiencing chills and not feeling well. The nurse informs the client that they will need to have their temperature taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research?

Evidence-based practice

A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship?

Exploitation