Fundamentals Exam 1
Examples of evidence-based practice (EBP) include which of the following? (Select all that apply)
- Catheter associated urinary tract infectious practice alert -prevention of pressure ulcers -pain assessment - fifth vital sign
The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for the all-staff education is most likely to benefit the greatest number of residents?
- Education nurses on how to prevent falls
When assessing a client's blood pressure manually, the nurse can use which arteries? (Select all that apply).
-Brachial -Radial -Popliteal
Advantages of open-ended questions include what? (Select all that apply):
-they let the client do the talking -they can provide information the interviewer did not ask for -the interview is able to listen and observe
The physician's admitting orders indicate that the client is to be placed in a high-Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed?
45-60
An adolescent has recently had a ring inserted into her navel. What is the greatest risk facing the adolescent as a result of this activity?
A local and or systemic infection
The World Health Organization (WHO) defines health as which of the following?
A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity
A registered nurse, by the name of Alicia Jones, is documenting assessments at the beginning of the shift. How should the nurse sign the entry?
A. Jones, RN
When evaluating a resident for transition from a long-term care facility to a home environment, what may the nurse ask the resident to perform?
ADLs
Nurses are responsible for making sure their educational background and clinical experience are adequate to fulfill the nursing responsibilities delineated by the job description. What is one way to violate this responsibility?
Accepting assignments that the nurse feels are unsafe
An elderly client has impaired sensation in her lower extremities. What educational statement would be necessary to reduce her risk of injury?
Always test the temperature of the bath before stepping in
All individuals, according to Maslow's Hierarchy of Needs, have which of the following?
Basic Human Needs
A grade school nurse is addressing parents at a Parent Teacher Association (PTA) meeting regarding car safety. What is a recommended safety guideline for grade school children?
Booster seats should be used for children until they are 4 feet 9 inches tall and between 80-100 pounds
A child is admitted to the emergency department with a fractured arm. During the admission interview, the nurse should implement what communication technique to elicit the most information from the parents?
Clarifying questions
What nursing statement may be seen as the first line in a SOAP note?
Client complaining of abdominal pain rated 8/10
The student nurse knows lack of mobility contributes to negative outcomes throughout the body. What is a negative effect of immobility on the musculoskeletal system?
Contracture
A nurse is documenting care given to a client with a new right leg amputation. The nurse accidently documents a dressing change was performed on the left leg. What would be the best action to correct this error?
Draw a single line through the entry, write mistaken entry, and initial it
Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review?
EBP
When caring for a client who is visually impaired, the nurse will do which of the following?
Explain the reason for touching the client before doing so
The documentations states, "patient is highly satisfied with her spiritual wellness." What supporting documentation supports the highest spiritual wellness?
Having peace and harmony with your values and actions
A staff development nurse is teaching proper body mechanics to newly hired nursing assistants at a long term care facility. What technique can be used to help prevent a back injury?
Holding the object that you are lifting close to your body
A nurse is planning care for a 17 year old following a motor vehicle accident. Which of Erickson's developmental stages should the nurse keep in mind in the planning?
Identity vs. Role Confusion
A nursing student is conducting a literature review to find evidence-based practice (EBP) standards for the nursing care of clients diagnosed with diabetes. The student nurse knows that the first step in this process is to locate reputable sources of information. Which sources below would not be appropriate for the nursing student to use for the literature review?
Medline: an online database of health care related journals Diabetes Care: a peer reviewed journal published by the American Diabetes Association Cumulative Index to Nursing and Allied Health Literature
The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. What cultural group would require an alternative meal choice?
Muslim
What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered?
Nursing care now uses EBP as a means of ensuring quality care
A nurse is collecting data from a client who has required strict bedrest for 1 week. What should the nurse identify as an indication that the client is ready to ambulate?
Performs active ROM exercises of all extremities
There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing?
Person/Patient
A nurse is administering influenza immunizations at a local clinic. What level of disease prevention is the nurse demonstrating?
Primary
What is the primary purpose of an incident report?
Quality improvement
After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation?
Scientific Knowledge
What charting entry would be the most defensible in court?
The client has 3 + edema to left lower medial ankle
Identify the statement that is not therapeutic communication?
The nurse educates the client by stating "what you did was wrong. You shouldn't do that"
A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client?
They tend to prefer some distance between themselves and others
The student nurse knows lack of mobility contributes to negative outcomes throughout the body. What is a negative effect of immobility on the cardiovascular system?
Thrombus formation
What drawbacks does charting by exception (CBE) have?
Vulnerability to legal liability since the nurse's safe, routine care is not recorded
Barriers to evidence-based practice (EBP) include which of the following?
an organizational culture that does not support change
A charge nurse is implementing the ISBARR communication tool for nurses and physicians. How can the nurse help to reduce resistance to this change?
explain the change by listing advantages to nurses, physicians and patients
Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls?
lock wheels on beds and wheelchairs
A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." What action should the nurse take?
notify the surgeon that the client wishes to withdraw informed consent from procedure
A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit?
orient the client to the room and environment thoroughly upon admission
A group of nurses are planning to investigate the effectiveness of turning immobilized stroke clients' more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which of the following will the "O" in the team's PICO question refer to?
preventing skin breakdown
The student nurse knows mobility contributes to positive outcomes throughout the body. What is a positive effect of mobility on the respiratory system?
prevention of respiratory secretions from pooling
The student nurse knows mobility contributes to positive outcomes throughout the body. What is a positive effect of mobility on the urinary system?
prevents stasis of urine in the bladder
What is one of the most significant trends in health care today?
shift from hospitals to community based care
When a labor and delivery nurse tells a coworker that an Asian client probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing what?
sterotype
When providing nursing care to an African American individual, which of the following cultural factors should the nurse consider?
values and beliefs are often present oriented
