Fundamental Assignment for 200 questions ATI
A charge nurse is providing teaching to a nursing team member about the competencies required for interprofessional collaboration. Which of the following statements by the nursing team member indicates an understanding?
"Communication with other team members is a competency that promotes openness in client care."
A nurse is reviewing ethical principles with a nursing colleague. Which of the following statements by the nursing colleague indicates an understanding of ethical principles?
"Nonmaleficence is our nursing obligation to do no harm to our clients."
A nurse is providing instructions to a client about the Press Ganey survey. Which of the following statements by the client indicates an understanding?
"This survey will ask me about my satisfaction of services provided."
A nurse is teaching about professional values with a newly licensed nurse. The newly licensed nurse requests that the nurse provide more information about social justice. Which of the following statements should the nurse make?
"You must treat all clients fair regardless of any personal bias."
A charge nurse is reviewing morning laboratory reports for clients on the unit. The charge nurse should recognize that which of the following laboratory findings is the priority to report to the provider?
A client who has an INR of 5.2.
A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take?
Face the client while talking.
A nurse does not take a client's apical heart rate, but documents that it was taken in the client's electronic health record (EHR). Which of the following terms describes the nurse's actions?
Falsification
A nurse is instructing a client who has heart disease about ways to improve their health such as eating a heart healthy diet. Which of the following concepts is the nurse demonstrating to the client?
Health promotion
A nurse is planning discharge for a client who has a sacral pressure injury and has a prescription for daily dressing changes. Which of the following resource referrals should the nurse anticipate from the provider for this client?
Home care
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. Hyperlipidemia Diabetes mellitus Medication history Cholesterol level Prealbumin level
Hyperlipidemia is incorrect. Hyperlipidemia increases the client's risk for heart disease. Diabetes mellitus is correct. Diabetes mellitus causes a decrease in tissue perfusion and impaired sensation, which increases the risk for delayed wound healing. Medication history is correct. Corticosteroids decrease the formation of collagen and fibroblasts which are needed for wound healing. Cholesterol level is incorrect. The client's cholesterol level is greater than the expected reference range placing the client at risk for heart disease. Prealbumin level is correct.
A community health nurse is discussing with a newly licensed nurse social determinants of health (SDOH). Which of the following should the newly licensed nurse identify as an example of the social and community context determinant of health?
Lack of access to transportation
A nurse is reinforcing teaching with a newly licensed nurse about barriers with interprofessional collaboration among members of the health care team. Which of the following information should the nurse include?
Lack of communication among team members
A nurse is instructing a newly licensed nurse about the scope and standard of nursing practice. Which of the following describes standards of practice?
Lists a set of skills that all nurses should be competent performing. Outlines responsibilities that every nurse is expected to provide regardless of their role.
A charge nurse is determining client acuity levels. The nurse should consider the time spent completing which of the following tasks when determining acuity?
Medication administration
A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?
Planning
The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication? Select all that apply. Smoking history Prednisone Metformin WBC count Glucose level Type 2 diabetes mellitus
When analyzing cues, the nurse should identify that type 2 diabetes mellitus, smoking history, and prednisone use place the client at risk for surgical complications, such as for delayed wound healing and infection. Smoking cigarettes also increase the client's risk for atelectasis and pneumonia.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Mucous membranes pink, skin warm and dry. Coughing and clearing throat when eating. Voice hoarse after swallowing. Temperature 38 °C (100.4 °F) Bilateral breath sounds with wheezing heard in upper lobes. Oxygen saturation 88% on room air.
When analyzing cues, the nurse should recognize that coughing and clearing throat when eating, voice hoarse after swallowing, bilateral breath sounds with wheezing heard in upper lobes, and oxygen saturation 88% on room air are manifestations of dysphagia and possible aspiration and require immediate follow-up. The nurse should obtain a prescription for supplemental oxygen and place the client on aspiration precautions.
Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again. Temperature 37.5° C (99.5° F) Client is difficult to arouse. Respirations 10/min Pulse oximetry 89% on room air Pupils are 3 mm, equal and reactive to light
When evaluating outcomes, the nurse should identify that the client is difficult to arouse, a respiratory rate of 10/min, and a pulse oximetry of 89% on room air indicates worsening of the client's condition and requires immediate follow-up. The nurse should stimulate the client to take deep breaths, apply supplemental oxygen, and obtain a prescription for naloxone to reverse the effects of the morphine.
Which of the following factors could present a barrier to the nurse effectively communicating with the client? Select all that apply. Client's hearing deficit Volume of the client's television Numerous visitors in the client's room Increase in pain after ambulation Adverse effects of opioid analgesic Using earphones while listening to music
When recognizing cues, the nurse should identify that a hearing deficit, environmental factors, pain or distress, and adverse effects of opioid analgesia all hinder effective communication. The nurse should stand in front of the client in sufficient lighting when speaking. The TV volume should be down or off, and the nurse should speak slowly and clearly. The nurse can also politely ask visitors to remain quiet while the nurse speaks to the client, or request that they temporarily leave the room if necessary.
A nurse is providing teaching with a nursing colleague about sentinel events. Which of the following statements by the nursing colleague indicates an understanding?
"An example of a sentinel event is administering incompatible blood products to a client."
A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first?
A client who has pneumonia and has developed wheezing.
A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first?
A client who reports they have fallen while ambulating.
A nurse is teaching a class about professionalism. The nurse should include that leaving a computer terminal unattended after logging on is an example of which of the following?
Unprofessionalism
A nurse is preparing an in-service about motivational interviewing for a group of staff nurses. Which of the following statements should the nurse make when discussing the OARS mnemonic?
A = Providing affirmations to encourage the client
A nurse is obtaining informed consent from a client who is scheduled for a procedure. Which of the following roles is the nurse demonstrating?
advocate
A nurse is caring for a client who is chemically impaired. Which of the following is a key topic in the cascade of care framework for opioid use disorder (OUD)?
Recovery
A client asks a nurse about copayments for health insurance. Which of the following statements should the nurse make?
"Your copayment is a fixed fee you must pay at the time service is rendered."
A nurse is preparing a presentation about hospice care services. Which of the following statements should the nurse plan to make during the presentation?
"Hospice care services keep the family updated on the client's condition."
A nurse in a clinic is providing education with an older adult client about Medicare. Which of the following statements by the client indicates an understanding?
"My prescriptions are covered under Part D."
A nurse is discussing Peplau's theory of the four phases of interpersonal relationships. Which of the following statements should the nurse make?
"Orientation is the first phase and occurs when a client reaches out for help."
A nurse is preparing an in-service to review the Code of Ethics (COE) with a group of nursing colleagues. Which of the following statements should the nurse make during the in-service about the COE?
"Professional expectations are included in the COE."
A nurse is caring for a client who is pregnant. The client states that they are not sure that their health plan will cover the pregnancy. Which of the following statements should the nurse make?
"The Affordable Care Act includes maternity and newborn care. Therefore, your pregnancy is covered under your health insurance plan."
A nurse is updating the Minimum Data Set (MDS) forms for the residents of a long-term care facility. A nursing colleague asks about the significance of MDS documentation. Which of the following statements should the nurse make?
"The MDS forms provide documentation of each resident's assessment, including their cognitive and physical status."
A nurse is teaching a client newly diagnosed with type I diabetes mellitus. A referral for a dietician has been initiated. Which of the following statements by the client indicates the purpose for the referral?
"The dietician will help me with my diet due to diabetes."
A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make?
"The living will states the client's wishes regarding lifesaving measures."
A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching?
"This service assists with making me comfortable during my illness."
A nurse is planning care for a client who has a tracheostomy. Which of the following interprofessional team members should the nurse anticipate a provider's prescription for a referral to manage the client's tracheostomy?
Respiratory therapist
A nurse checks a client to evaluate the effectiveness of a pain medication. Which of the following components of professionalism is the nurse demonstrating?
Responsibility
A charge nurse is teaching a newly licensed nurse about accessing a client's medical records. Which of the following should the nurse include?
A nurse can only access the records of clients they are actively caring for.
A nurse is teaching a class about the steps of critical thinking. The nurse should include that interpreting data is included in which of the following steps?
Analysis
A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following examples?
A nurse informs their sibling who works on another unit that the nurse's client has HIV.
A charge nurse is providing an in-service to a group of staff members on incivility. Which of the following situations should the nurse include as an example of lateral violence?
A nurse rolls their eyes at another nurse after providing report.
A nurse teaches about breaches in nursing practice with a newly licensed nurse. Which of the following examples should the nurse include?
A nurse smells alcohol on a colleague's breath who is on duty and keeps quiet about it.
A nurse who has a valid license in one a state is planning to move to another state. Which of the following actions should the nurse take to obtain reciprocity?
Apply for a new license in the new state
A nurse administers the wrong medication to a client. After assessing the client, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?
Accountability
A nurse is teaching a class about the novice-to-expert model for nursing competence to a group of nurses. A nurse who has some experience but still requires clinical support is in which of the following stages of competence?
Advanced beginner
A nurse is teaching a class about the transition from novice to expert nurse. The nurse should include that a nurse who requires support from a mentor is at which of the following stages?
Advanced beginner
A nurse is teaching a client about the benefits of an electronic health record. Which of the following information should the nurse include in the teaching?
Allows client access to their medical record electronically at any time
A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record. Which of the following information should the nurse include?
Allows health care team members to document client care
A nurse at an outpatient clinic is preparing a class for new parents to promote exclusive breastfeeding for all infants during their first year of life. Which of the following professional values is the nurse demonstrating?
Altruism
A nurse wants to become more involved in nursing on a national level. Which of the following organizations should the nurse join?
American Nurses Association
History of hypertension is correct. Hypertension is associated with arterial wall thickening and increased peripheral resistance which can lead to heart disease. History of smoking is correct. Nicotine causes vasoconstriction, which can increase blood pressure and heart rate, and lead to heart disease. Daily exercise is incorrect. Daily exercise can increase peripheral circulation, reduce stress, and strengthen cardiac muscle, which can reduce the risk of heart disease. History of rheumatoid arthritis is incorrect. A history of rheumatoid arthritis places the client at risk for a fall, but it is not a risk factor for heart disease. Cholesterol level is correct. The client's cholesterol level is greater than the expected reference range which places the client at risk for heart disease. Hyperlipemia can result in restrictive blood flow to cardiac arteries. Fasting glucose level is incorrect.
Arrange for the client to receive home health care services
A nurse is preparing a presentation on heart health at a community center for a group of clients. Which of the following actions should the nurse take to facilitate learning?
Articulate wording at a slow pace.
A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include?
Asking open-ended questions
A nurse is discussing types of communication styles with a group of staff nurses. Which of the following information should the nurse include?
Assertive communicators are confident in their communications.
A nurse is preparing a poster presentation for a group of staff nurses about factors influencing communication. Which of the following factors should the nurse include when discussing cognitive factors?
Autism spectrum disorder
A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client?
Autonomy
A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take?
Review the facility's policies and procedures manual about removing IV catheters.
Which of the following findings require follow-up by the nurse? Select all that apply. Blood pressure Anxiety Oxygen saturation Breath sounds Breath sounds Irregular heart rate Chest tightness
Blood pressure is correct. Anxiety is correct. Irregular heart rate is correct. Chest tightness is correct.
A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance?
Bureaucratic leader
A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?
Client reports chest pain after mowing lawn this morning
A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?
Client's bedside
A nurse is discussing FACT charting with a newly licensed nurse. Which of the following is an example of factual charting?
Client's heart sounds are regular with S1 and S2 sounds. No murmurs auscultated.
The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply. Use clean technique when changing the catheter dressing. Change the catheter dressing every 2 days. Clean the access port on the CVAD line with povidone-iodine prior to use. Perform hand hygiene for 10 sec prior to changing the catheter dressing. Use friction when cleaning the access port.
Change the catheter dressing every 2 days is correct. Clean the access port on the CVAD line with povidone-iodine prior to use is correct. Use friction when cleaning the access port is correct.
A nurse is working on a unit and suspects a coworker is chemically impaired. Which of the following members of the chain of command should the nurse notify first?
Charge nurse
A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods is the nurse utilizing?
Charting by exception (CBE)
A nurse is preparing a presentation on the history of nursing. The nurse should include in the presentation that which of the following contributors founded the American Red Cross?
Clara Barton
A nurse provides a handoff report using the introduction, situation, background, assessment, recommendation, and readback (I-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component?
Client broke hip 24 hr ago due to fall
A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?
Right communication
A nurse in the emergency department (ED) is preparing to teach a newly licensed nurse about the Emergency Medical Treatment and Labor Act (EMTALA). Which of the following information should the nurse include?
Clients must receive a medical screening evaluation (MSE).
A nurse in the emergency department (ED)[MH1] [TB2] is preparing to teach a newly licensed nurse about the Emergency Medical Treatment and Labor Act (EMTALA). Which of the following information should the nurse include?
Clients must receive a medical screening evaluation (MSE).
A nurse looks up information in a client's medical record but is not involved in the care of the client. The nurse is violating which of the following standards of professional performance?
Code of ethics
A director of nursing is reviewing a new nursing program curriculum. Which of the following governing bodies should the nurse identify as providing program accreditation?
Commission on Collegiate Nursing Education (CCNE)
A nurse overhears two assistive personnel (APs) disagreeing about client care assignments. Which of the following actions by the nurse demonstrates conflict resolution?
Confront the APs to discuss their argument.
A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?
Demographic data
A nurse is reviewing the background of electronic health records (EHR). Which of the following institutions was the first to introduce EHRs?
Department of Veteran Affairs
A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?
Disease prevention
A nurse is answering questions at a school meeting about government entities that regulate health care. The nurse should include that which of the following organizations advocates for the delivery of culturally competent health care?
Indian Health Service (IHS)
A nurse is admitting a client who reports they are currently unemployed. Which of the following factors of the social determinants of health (SDOH) is challenging for the client?
Economic stability
A charge nurse is providing an in-service to a group of nurses about benefits of an interprofessional team. Which of the following information should the nurse include?
Efficiency in client-care services
A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following information should the nurse include when discussing the electronic mode of communication?
Electronic communication includes video conference calls with clients.
A nurse is providing an in-service on the Healthy People 2030 framework. Which of the following information should the nurse include?
Establishes health objectives for Americans
A nurse is collecting research to revise the protocol for specimen collection on their unit. From which of the following sources should the nurse retrieve the information?
Evidence-based practice
A nurse is teaching a class about the transition from novice to expert nurse. The nurse should include that a nurse who is a preceptor to new staff members is at which of the following stages?
Expert
A nurse is teaching a newly licensed nurse about professionalism. The nurse should include that which of the following demonstrates unprofessional behavior by a nurse?
Explaining the steps of a surgical procedure to a client.
A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?
Focus charting
A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of accountability?
Following the rights of medication administration to administer a medication to a client.
A nurse is teaching a class on health care regulation to a group of newly hired nurses. The nurse should include that which of the following agencies enforces laws to ensure medications go through strict testing before being sold to the public?
Food and Drug Administration (FDA)
A nurse manager is reviewing the Healthy Nurse, Healthy Nation program developed by the American Nurses Association (ANA) for a presentation for a group of staff nurses. Which of the following is one of the five initiatives of this program?
Get adequate sleep.
A traveling nurse is taking a temporary assignment out of state. Which of the following information should the nurse identify is the purpose of the Nursing Licensure Compact (NLC)?
Grants the nurse permission to practice in more than one state
A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?
Guide the client away from background noise.
A nurse is administering a continuous IV solution via a computerized infusion pump to a client who is dehydrated. Which of the QSEN competencies is the nurse demonstrating?
Informatics
A nurse is preparing a poster presentation for staff nurses about communication. Which of the following information should the nurse include about Berlo's model of communication?
It is often referred to as the S-M-C-R model of communication.
Click to highlight the information in the client's medical record that requires intervention by the nurse. To deselect a finding, click on the finding again. Client is repositioned every 2 hr. Passive range of motion exercises to affected extremities performed once each day. Feet warm, pedal pulses 2 + bilaterally. Joint contracture noted to right wrist. Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness, skin intact.
Joint contractures noted to right wrist requires intervention by the nurse. The nurse should apply a splint to the client's affected joint to reduce the contracture. Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness requires intervention by the nurse. The client has a stage 1 pressure injury on the heal. The nurse should use pillows and cushions to protect and promote blood flow to bony prominences. Passive range of motion exercises to affected extremities performed once each day requires intervention by the nurse. The nurse should perform passive range of motion to the client's affected extremities at least every 8 hr to reduce the risk for contractures. (Potter 843) Client is repositioned every 2 hrs does not require intervention by the nurse. The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. (Berman 1107) Feet warm, pedal pulses 2 + bilaterally does not require intervention by the nurse. The nurse should identify the client has adequate circulation to the feet
A nurse is due to renew their nursing license. Which of the following information should the nurse identify is the purpose of renewal?
Maintains the nurse's the right to practice nursing.
A nurse is performing a medication reconciliation while admitting an older adult client transferred from a long-term care facility. Which of the following should the nurse identify as part of the medication reconciliation process?
Medications from another facility
A nurse is discussing advancing interprofessional communication on the unit. Which of the following should the nurse identify as a barrier to this advancement?
Misunderstanding of roles
A nurse is teaching a class on ethical principles. The nurse should include that protecting a client's safety by not causing harm refers to which of the following ethical principles?
Nonmaleficence
A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?
Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care.
A nursing instructor is discussing the regulation of nursing programs to a group of nursing students. Which of the following information should the nursing instructor include?
Nursing programs are governed by the state's board of nursing.
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Obtain a daily weight on a client who has heart failure.
A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?
Obtaining a blood pressure for a client who is to be discharged later in the day.
A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?
Ondansetron 4 mg IV bolus for nausea and vomiting
A nurse is discussing clients' protected health information (PHI) with a newly hired nurse. Which of the following information should the nurse include in the discussion?
PHI includes a client's payment information.
A nurse is providing an in-service to a group of newly licensed nurses on the Nurse Practice Act (NPA). Which of the following is the first step in defining the scope of nursing in the NPA practice?
Pass a law to regulate nursing practice of a law within a state
A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?
Physical therapist
A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation?
Physiological
A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?
Plan time for disruptions.
A charge nurse is providing teaching to a newly licensed nurse on the advantages of electronic documentation. Which of the following information should the nurse include in the teaching?
Portal that allows clients to interact with providers
A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?
Potassium level 3 mEq/L
A newly licensed nurse is applying for their first job and wants guidance on pay. Which of the following professional standards should the nurse review?
Principles of Nursing Practice
A nurse is teaching a class about professionalism. The nurse should include that joining a professional organization is an example of which of the following?
Professional commitment
A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (I-SBSR-R) on a client. Which of the following information should be included in the situation component?
Provider notified of client's back pain
A charge nurse is teaching a newly licensed nurse about the purpose of the National Academy of Medicine. Which of the following information should the charge nurse include in the teaching?
Provides information as well as solutions on national health issues
A nurse is attending training on de-escalation techniques. Which of the following is a benefit of de-escalation techniques?
Reduces restraint use
A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include?
Regulates and monitors laws set by the Nurse Practice Act.
A nurse is collecting data to determine the best practice for reducing pressure injuries in clients. Which of the following roles is the nurse taking?
Researcher
A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?
Researcher
A public health nurse is preparing an educational session at a community health center about the social determinants of health (SDOH). Which of the following information should the nurse include?
SDOH are conditions in an individual's environment that affect their well-being.
A nurse is preparing a client for a colonoscopy. The client has a family history of colon cancer. Which of the following types of prevention is the nurse demonstrating?
Secondary
A nurse is performing discharge teaching with a client who has a wound that requires home health care. Which of the following team members should the nurse contact for consultation?
Social worker
A nurse is providing discharge instructions to a client who lives in subsidized housing and is concerned about being able to afford their medications. Which of the following factors should the nurse identify is affecting the client's health?
Socioeconomic
A nurse is preparing a discharge plan for a client using the IDEAL toolkit. Which of the following does the toolkit identify as one of the five key areas that the nurse should discuss with the client?
Test results
A nurse is preparing to provide education to a client about the Affordable Care Act (ACA). Which of the following information should the nurse include?
The ACA reduces disparities in health care.
A nurse in a provider's office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following findings is the nurse's priority?
The client is experiencing shakiness.
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
The client seems to be more comfortable performing self-administration of insulin.
A nurse is teaching a client who has been newly diagnosed with diabetes mellitus. Which of the following information demonstrates health literacy by the client?
The client understands to take their blood glucose daily.
A nurse is caring for a client who is 3 hr postoperative following abdominal surgery. Which of the following assessment data should the nurse report to the provider?
The client urine output has been 50 mL since surgery.
Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again. T 38.6° C (101.5°F), oral. BP 112/54 mm Hg, supine Apical HR 108/min R 22/min Pulse oximetry 90% on 40% O2 via face mask Mucous membranes pink.
The client's temperature and heart rate has worsened and require follow-up by the nurse. The client's blood pressure is unchanged. The client's respiratory rate, pulse oximetry, and mucous membranes color have improved.
Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air
The client's temperature of 38° C (100.4°F) and heart rate 99/min have decreased, and the client's blood pressure of 106/60 mm Hg
A charge nurse is preparing an in-service about communication. Which of the following information should the nurse include when discussing Newcomb's ABX model of communication?
The model examines the role communication plays in society.
Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again. Temperature 37.5° C (99.5° F) Respirations 10/min Pulse oximetry 87% on room air Pupils are 3 mm, equal and reactive to light
The nurse should follow-up on the client's respiratory rate of 10/min and pulse oximetry of 87% on room air because the client is experiencing hypoxia due to the morphine. The nurse should report these findings to the charge nurse and provide the client with supplemental oxygen. The client might require naloxone to reverse the effects of the morphine. The client's temperature and pupils are within the expected reference range and do not require further action by the nurse.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Wound bed is red. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted Temp 38.9° C (102° F) Hct 37% (37% to 47%) WBC 13,500/mm3 (5000 to 10,000 mm3)
The nurse should identify that redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted, temp 38.9° C (102° F), and WBC 12,000/mm3 (5000 to 10,000 mm3) are associated with worsening of the client's condition and require follow-up.
A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders uses rewards to meet goals?
Transactional leader
A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders identifies common values to empower employees?
Transformational leader
Select the 3 findings that require immediate follow-up. Breath sounds at 1600 Temperature Urticaria Blood pressure at 1630 Report of dysphagia
Urticaria Blood pressure at 1630 Report of dysphagia
A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse plan to take?
Use a needle that retracts.
A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following techniques should the nurse include when discussing therapeutic communication?
Using silence
Select the 3 findings on day 3 that require immediate follow-up. PICC line insertion site Breath sounds Temperature Heart rate Oxygen saturation
When analyzing cues, the nurse should identify that redness and swelling at the PICC line insertion site, along with the client's elevated temperature and elevated heart rate, are manifestations of an infection and place the client at risk for sepsis. The nurse should report these findings immediately to the provider.
The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Day 1: Abdomen soft, nondistended. Ileostomy present. Stoma is red. Stoma draining brown liquid stool. Client will not look at stoma. Client states they are not interested in learning about stoma care. Day 2: Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas. Stoma with small amount of bleeding noted during cleaning.
When analyzing cues, the nurse should identify that the client not looking at the stoma and stating they are not interested in learning about stoma care, and the skin around the stoma is reddened and has small open areas, requires intervention. Not looking at the stoma and stating they are not interested in learning about stoma care is an indication that the client is experiencing disturbed body image. The nurse should encourage the client to express their feelings and obtain a referral for an ostomy nurse. The skin surrounding the stoma is reddened and has small open areas are indications of impaired skin integrity due to irritation. Skin irritation can occur due to leakage of stool or from improper removal of the stoma adhesive. The nurse should implement measures to decrease the client's skin irritation and reduce their risk for infection.
Which of the following teaching methods is based on the cognitive domain of learning? Select all that apply. Give the client printed information describing diabetes mellitus. Engage in a question-and-answer session with the client. Ask the client how they feel about checking their blood glucose. Ask the client to demonstrate checking their blood glucose level. Give the client a fill-in-the blank quiz. Ask the client to describe the manifestations of hypoglycemia and hyperglycemia.
When taking actions, the nurse should identify that giving the client printed information describing diabetes mellitus, engaging in a question-and-answer session with the client, giving the client a fill-in-the blank quiz, and asking the client to describe the manifestations of hypoglycemia and hyperglycemia are teaching methods based on the cognitive domain of learning. A client who is thinking through, comprehending, and applying information is engaging in the cognitive domain of learning.
Click to highlight the timed components of the SMART outcome goals. To deselect a finding, click on the finding again. The client will teach back information about safe crutch walking on day 1. The client will demonstrate safe crutch walking. The client will not lean on the crutches to support their body weight. The client will ambulate 5 feet in one day. The client will walk 10 feet by day 2. The client will walk 20 feet by day 3. The client will explain 4 principles of crutch safety. The client will explain how to keep crutches in safe condition.
When taking actions, the nurse should identify that the timed component of SMART outcome goals are measurable outcomes based upon a specific time frame by which the client should accomplish the outcome. Day1, in one day, by day 2, and by day 3, are all measurable time frames to assist the nurse in evaluating whether outcome goals are achieved.
A nurse reports to their manager that the ostomy nurse is improperly managing the ostomies on the unit. The nurse informs their manager that they are afraid that the ostomy nurse is going to be mad at them now. Which of the following legal principles should the nurse manager plan to discuss with the nurse?
Whistleblowing
A nurse is caring for a client who is requesting not to be mechanically ventilated. The nurse notifies the client's provider about the client's concerns and respects the client's request. Which of the following professional values is the nurse utilizing?
autonomy
A nurse is organizing interprofessional team members to meet the needs of a client. Which of the following roles is the nurse taking?
care coordinator
A nurse in a provider's office is assigning acuity levels to four clients. To which of the following clients should the nurse assign an acuity level of 1?
exacerbation of asthma
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non-modifiable risk factor for disease?
genetics
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at greatest risk for developing Select... due to Select....
greatest risk to this client is a pressure injury from urinary incontinence and immobility.
A charge nurse is providing an in-service to a group of nurses about self-care. Which of the following information should the nurse include in the teaching?
healthy meals
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Conditions due to Findings. lead poisoning
pulmonary embolism due to possible deep vein thrombosis
A nurse is providing care to a client. Prior to exiting the client's room, the nurse ensures the client's bed is locked and their call light is within reach. Which of the following QSEN competencies is the nurse demonstrating?
safety
A nurse in a long-term care facility is caring for a client who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?
Take the client for a walk outdoors and ask them to talk about their family.
A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Telephone the interpreter that is designated for the facility to interpret the information.
A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
Planning
A nurse is teaching about delegation with a newly licensed nurse. Which of the following statements if made by the newly licensed nurse indicates understanding?
"I am responsible for ensuring that a delegated task is completed."
A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
A nurse is preparing to provide discharge teaching for an adolescent who has a cognitive disorder and their parents. Which of the following actions should the nurse take?
Use short directive statements.
A nurse is discussing interprofessional collaboration with a group of nurses. The nurse should include that which of the following is a core competency of the Interprofessional Education Collaborative (IPEC)?
Values and ethics
A community health nurse is caring for a client who has noticed that their drinking water isn't clear and reports they haven't been feeling well. The nurse should identify the client is at risk for which of the following conditions?
Waterborne disease
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Condition due to their Client Finding.
risk for constipation due to their oxycodone prescription
A nurse is reviewing the five levels of communication. Which of the following statements should the nurse identify as describing emotional communication?
speaker's state of emotions when sending a message
A nurse is applying knowledge to analyze a clinical situation. Which of the following roles is the nurse taking?
Critical thinker
A nurse is discussing a client's needs at an interdisciplinary team conference. The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care. Which of the nursing competencies is the nurse demonstrating?
Collaborator
Select the 3 findings that require immediate follow-up. WBC count Hgb Pulse oximetry Preoperative medication INR Blood pressure
When recognizing cues, the nurse should identify that the client's INR, combined with taking warfarin the morning of the procedure, places the client at risk for bleeding. The client's WBC count is greater than the expected reference range, which places the client at risk for an infection. Therefore, these findings should be reported to the provider.
A nurse at a clinic receives a provider's prescription to admit a child to an acute care facility for asthma management. The nurse provides teaching to the parents about acute care. Which of the following statements by the parent indicates an understanding of acute care?
"My child will receive medications to manage their condition."
Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision?
Clinical judgement
A charge nurse is teaching a newly licensed nurse the importance of client confidentiality. Which professional standards should the charge nurse refer to in the teaching?
Code of ethics for nurses
A nurse is scheduling a client for surgery. Which of the following actions should the nurse take to obtain precertification for the client to have surgery?
Contact the client's insurance carrier to obtain authorization
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. Which of the following types of prevention is the nurse demonstrating?
Tertiary
A nurse is teaching a class about the roles and responsibilities of a case manager. Which of the following responsibilities should the nurse include?
Organizes client services following discharge
A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of responsibility?
Performing hand hygiene before caring for a client.
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease?
Sunbathing
A nurse is preparing an educational session about The Joint Commission (TJC). Which of the following information should the nurse include?
TJC provides accreditation to facilities.
For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged. Temperature Pulse oximetry Respiratory rate Blood pressure Mucous membrane color
Temperature has worsened. Respiratory rate has improved. Pulse oximetry has improved. Blood pressure is unchanged. Mucous membrane color has improved.
Which of the following 3 actions should the nurse plan to take? Tell the client there is nobody else in the room. Administer an opioid narcotic to the client. Provide deep nasotracheal suctioning for the client. Place a fan to blow lightly toward the client. Turn the client on their side.
When taking action, the nurse should administer an opioid narcotic to the client, place a fan to blow lightly toward the client, and turn the client on their side to promote comfort and decrease respiratory distress.
A charge nurse is conducting an in-service for a group of nurses on the seven pillars of self-care created by the International Self-Care Foundation. Which of the following pieces of information should the nurse include?
wash foods prior to eating
A charge nurse in the emergency department is assigning acuity levels to four clients. To which of the following clients should the nurse assign an acuity level of 1?
A client who is having stroke-like symptoms that began 30 min ago.
A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?
A client who has a family history of breast cancer is scheduled for a mammogram.
A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the client. Which of the following ethical principles is the nurse demonstrating?
Fidelity
A nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? Select all that apply. History of hypertension History of smoking Daily exercise History of rheumatoid arthritis Cholesterol level Fasting glucose level
History of hypertension is correct. History of smoking is correct. Cholesterol level is correct.
Click to highlight the findings that increase the client's susceptibility to infection. To deselect a finding, click on the finding again. Client has a BMI of 16 History of type 2 diabetes mellitus Client is a nonsmoker Hct 47% (37% to 52%) Budesonide 6 mg PO qd
The client's BMI, history of type 2 diabetes mellitus, and corticosteroid prescription increase the client's susceptibility to infection.
A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply. Wear a protective gown while caring for the client. Place the client in a private room. Wear an N-95 respirator while caring for the client. Place the client in a negative pressure room. Place a mask on the client when they leave their room.
Wear a protective gown while caring for the client. Place the client in a private room.
For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply. Case manager Respiratory therapist Diabetes nurse educator Physical therapist Occupational therapist Enterostomal therapy nurse
When analyzing cues, the nurse should anticipate a provider's prescription for referrals to the case manager, respiratory therapist, physical therapist, and occupational therapist. A case manager is required to coordinate the health care team and identify any needs the client may have during admission and prior to discharge. A respiratory therapist is needed to assist with managing the client's asthma and oxygenation. A physical therapist is needed to manage the client's muscle weakness and mobility. An occupational therapist is needed to assist the client in maintaining the client's ADLs.
A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment. Osteoarthritis Occupation Furosemide Hyperlipidemia Naproxen Lovastatin
When analyzing cues, the nurse should identify that client's risk for developing hearing impairment includes their occupation and prescribed use of furosemide and naproxen.
