Fundamentals Final Exam

Hepatitis B transmission

blood and body fluids Healthcare workers at risk

Which medication will the physician most likely prescribe to increase urine output for patient with CHF? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

2) Furosemide

Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally.

Justice

You are administering flu shots to college students, faculty and staff.

primary health protection.

After suffering a heart attack, a patient needs cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of Needs, cardiac rehab addresses what need? 1) Safety and Security 2) Physiological 3) Self-actualization 4) Self-esteem

2) Physiological Cardiac rehabilitation most directly addresses the patient's physiological need for physical activity as well as health and healing.

A nurse is caring for an 80 year old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Doing whatever it takes for the patient, no matter the cost 4) Involving the patient and family in formulating outcomes

1) Developing culturally appropriate outcomes 4) Involving the patient and family in formulating outcomes

A patient takes anticoagulants. Which is the most important for the nurse to include on the patient's care plan? Teach the patient to: 1) Use an electric razor for shaving 2) Apply skin moisture 3) Use less soap 4) Floss teeth daily

1) Use an electric razor for shaving

Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Wearing a gown 4) Wearing a face mask

1) Washing hands

Before administering medication, the nurse must verify the rights of medication administration which include: 1) right patient, right room, right drug, right route, right time 2) right drug, right dose, right route, right physician, right time 3) right patient, right drug, right route, right equipment, right time 4) right patient, right drug, right dose, right route, right time, right documentation

4) right patient, right drug, right dose, right route, right time, right documentation

The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking. 2) Availability of community resources. 3) Adherence to a low-fat diet 4) Importance of physical exercise.

2) Availability of community resources.

Which of the following is an example of an illness prevention activity? 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering the immunization for HPV 4) Teaching a diabetic client about his diet

3) Administering the immunization for HPV

Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care

3) Consulting

Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Patient 4) Nurse

3) Patient

According to Maslow's hierarchy of needs, which patient need should the nurse address first? 1) Protecting against falls. 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change

3) Promoting rest in the critically ill patient

Which of the following behaviors indicates the highest potential for spreading infectious among patients. The nurse ___________________ 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds 3) washes hands only after leaving patients room 4) uses cold water for medical asepsis.

3) washes hands only after leaving patients room

A patient tells the nurse, "I can't see well enough to read anymore. I have new glasses but it is still hard." What should the nurse advise the patient to do first? 1) Go back to the eye doctor and have the glasses checked. 2) Buy some audio books and listen to those. 3) Adapt to reading less. 4) Install a bright, but glare-free light near where you read.

4) Install a bright, but glare-free light near where you read.

A patient with end-stage cancer is prescribed morphine to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative

4) Palliative

A patient is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow, which level is the patient struggling with? 1) Physiological 2) Safety & Security 3) Love & Belonging 4) Self-esteem

4) Self-esteem

Which of the following is an example of data that should be validated? 1) The patient's weight is 185 lbs at the clinic 2) The patient's liver function test is elevated 3) The patients blood pressure if 160/90: he says that is normal for him 4) The patient says she eats a low sodium diet: later describes eating fast foods

4) The patient says she eats a low sodium diet: later describes eating fast foods

The nurse is talking to a class of children ages 9-12. For this group, it would be most important for the nurse to discuss______. 1) Safe sex practices 2) Healthy food choices 3) Importance of getting enough sleep 4) Use of seat belts and safety equipment

4) Use of seat belts and safety equipment

Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) apply to every patient on a particular unit 2) included medical and nursing diagnoses 3) specify each patient outcomes for each day 4) help to ensure that important interventions are not overlooked.

4) help to ensure that important interventions are not overlooked.

A client with terminal cancer states she is not afraid of death, but is afraid of the process of dying. Which of the following is the best response? A. "What aspects of the dying process are you most concerned about?" B. "Those are normal feelings." C. "What can I do to help?" D. "I'm so sorry."

A. "What aspects of the dying process are you most concerned about?"

The nurse is providing an educational session to new employees, and the topic is abuse to the older client. The nurse tells the employees that which client is most characteristic of a victim of abuse A. A 90-year-old woman with advanced Parkinson's disease B. A 68-year-old man with newly diagnosed cataracts C. A 70-year-old woman with early diagnosed Lyme's disease D. A 74-year-old man with moderate hypertension

A. A 90-year-old woman with advanced Parkinson's disease

Which age group would have the most tendency towards eating disorders? A. Adolescence B. Toddlerhood C. Preschool D. Infancy

A. Adolescence

Which stage of development is most unstable and challenging regarding the development of personal identity? A. Adolescence B. Toddlerhood C. Middle Childhood D. Young adulthood

A. Adolescence

A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to A. Allow the newborn infant to signal a need B. Anticipate all of the needs of the newborn infant C. Avoid the newborn infant during the first 10 minutes of crying D. Allow the infant to cry, once lessen, then attend to the infant

A. Allow the newborn infant to signal a need

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment

What is true about the use of silence in therapeutic communication? select all that apply: A. Maintaining silence is an effective communication technique. B. Maintaining silence is generally overused and doesn't work. C. The receiver will become uncomfortable with silence. D. The ability to use silence effectively requires skill and timing. E. Purposeful use of silence often conveys respect.

A. Maintaining silence is an effective communication technique. D. The ability to use silence effectively requires skill and timing. E. Purposeful use of silence often conveys respect.

Without authorization, a nurse administers an extra dose of a narcotic tranquilizer to an agitated client. The nurse's coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker's lack of involvement? A. Taking no action is still considered an unethical action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable because the coworker is only a bystander.

A. Taking no action is still considered an unethical action by the coworker.

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects an appropriate legal and ethical obligation? A. The nurse refused to give any information to the caller, citing rules of confidentiality B. The nurse hangs up on the caller C. The nurse confirms that the person has been at the facility, but adds no additional information D. The nurse suggest that the caller speak to the client's therapist

A. The nurse refused to give any information to the caller, citing rules of confidentiality

A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the nurse use to encourage the patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition

A. Using open-ended questions and silence

What types of food are gluten free?

Rice Corn vegetables nuts and seeds legumes fruits buckwheat Quinoa olives avocados

An individual's right of self-determination and freedom of decision making.

Autonomy

A client who has denied drug allergies has a telephone order for IM penicillin. Before the nurse administers the medication, the client states, he thinks he may have developed a rash after "some drug." Which is the correct action? A. Administer the drug and document a possible previous drug reaction. B. Hold the drug and contact the prescribing physician. C. Contact the pharmacist for guidance. D Contact the supervisor for guidance.

B. Hold the drug and contact the prescribing physician.

The nurse provides medication instructions to a client about digoxin. Which statement by the client indicates an understanding of its adverse effects? A. "Blurred vision is expected." B. "If my pulse rate drops below 60 beats per minute, I should let my cardiologist know." C. "This medication may cause headache and weakness but that its nothing to worry about." D. "If I am nauseated or vomiting. I should stay on liquids and take some liquid antacids."

B. "If my pulse rate drops below 60 beats per minute, I should let my cardiologist know."

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

B. Autonomy

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B. Call the prescriber to discuss the order and the nurse's concern

How may a nurse charting for a pediatric patient best be perceived as non-threatening? A. Tightly crossing his/her arms B. Maintaining an open posture C. Maintaining a tense, upright posture D. standing at the bedside

B. Maintaining an open posture

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B. Suggesting the medication can be diluted in a beverage

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B. The client's urine output was 450 mL

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to "tie-down" the client and then does so against the client's wishes. C. The nurse hides the client's clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to the family.

B. The nurse threatens to "tie down" the client and then does so against the client's wishes.

which of the following is an example of an intentional tort? A. a nurse failed to assess a client's obvious symptoms of neuroleptic malignant syndrome. B. a nurse physically places an irritating client in 4-point restraints C. a nurse makes a medication error and reports the incident D. a nurse gives a patient information to an unauthorized person

B. a nurse physically places an irritating client in 4-point restraints

Doing good for clients and providing benefit balanced against risk.

Beneficence

When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You're having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too."

C. "You're having difficulty sleeping?"

Which of the following choices is a core nursing value that involves promoting good, preventing harm, and removing the patient from harm? A. Malfeasance B. Autonomy C. Beneficence D Veracity

C. Beneficence

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C. Include the client and family when setting goals and formulating the plan of care

The nurse caring for a client experiencing dystocia during labor determines that the priority is which action? A. Position changes and providing comfort measures B. explanations about what is happening to the client C. Monitoring for changes in the condition of the mother and the fetus D. Reinforcement of breathing techniques learned in child-birth preparatory classes

C. Monitoring for changes in the condition of the mother and the fetus (use Maslow's Hierarchy of Needs) The correct option is the only one that mentions both the mother and the baby

A nurse frequently looks at her watch while giving a patient a bed bath. What message is being conveyed to the patient from the nurse? A. She desires to spend more time with the patient B. She is anxious to listen to the patient's concerns C. She is feeling hurried D. She likes her watch

C. She is feeling hurried

The nurse does an admission interview with a Native American client. The client does not make eye contact and remains silent for extended periods of time and withdraws when the nurse reaches out to touch the client's hand when reassuring her about her treatment. Which of the following is the most likely reason for the client's behavior? A. The client is frightened. B. The client is dishonest. C. The client is exhibiting cultural traits. D. The client speaks little English.

C. The client is exhibiting cultural traits.

Which nurse is demonstrating the assessment phase of the nursing process? A. The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate

When assessing an older adult., the nurse may expect an increase in: A. Nail growth B. Skin turgor C. Urine residual D. Nerve conduction velocity

C. Urine residual

if a person with celiac disease went out to eat what foods would be the best choice? A. garden salad with croutons B. crispy chicken nuggets and rice C. quinoa with banana slices D. cupcake with ice cream

C. quinoa with banana slices

A client tells the nurse that she has always hated her mother, who left the client behind with her abusive father when the parents divorced. The mother has been trying to reestablish a relationship with the client, who is now 23 years old, but the client remains uncertain and angry. Which spiritual need is the client grappling with? A. Love B. Faith C. Hope D. Forgiveness

Forgiveness

A client scheduled for surgery states to the nurse, "I'm not sure if I should have this surgery." Which response by the nurse is appropriate? A. "Its your decision." B. "Don't worry. Everything will be fine." C. "Why don't you want to have this surgery?" D. "Tell me what concerns you have about the surgery."

D. "Tell me what concerns you have about the surgery." (don't use techniques that ask "Why")

The husband of a client who has an esophageal tube tells the nurse, "I thought having this tube down her throat the first time would convince my wife to quit drinking." The nurse should make which response to the client's husband? A. "I think you are a good person to stay with your wife." B. "alcoholism is a disease that affects the whole family." C. "Have you discussed this subject at the All-Anon meetings?" D. "You sound frustrated with dealing with your wife's drinking."

D. "You sound frustrated with dealing with your wife's drinking."

A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"

D. "You've been feeling like a failure for a while?"

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D. Evaluation

While observing the team leader irrigating a PICC line, a new nurse notes that the team leader has broken aseptic technique and contaminated the irrigating syringe. Which of the following actions is most appropriate? A. Report the team leader to a supervisor B. Ask the team leader after the irrigation if a sterile technique was required. C. Say nothing because the new nurse is inexperienced D. Tell the team leader immediately that the irrigating syringe was contaminated

D. Tell the team leader immediately that the irrigating syringe was contaminated

A client with a diagnosis of cancer is receiving morphine sulfate for pain. The nurse should employ which priority action in the care of the client? A. monitor stools B. monitor urine output C. encourage fluid intake D. encourage the client to cough and deep breathe

D. encourage the client to cough and deep breathe (Think ABCs for the answer)

Values, moral frameworks, and codes of ethics influence the professional nurse's moral decisions in which of the following ways? A: The nurse will provide direct client care that is consistent with the nurse's personal values B: The nurse will seek to ensure that the client's values and the nurses are the same C: The choice of moral framework determines what the client outcome will be D: The nurse is bound to act according to the nurses' code of ethics even if the nurse's values are different

D: The nurse is bound to act according to the nurses' code of ethics even if the nurse's values are different

The nurse must administer eye drops to a 6-month-old infant, but the child clinches the eyes tightly to avoid the drops. Which of the following actions is the most appropriate? A. Attempt to instill the drops at a later time. B. Force the infant's eyes open using the thumb and index finger. C. Gently restrain the head and apply the drops at the inner canthus. D. Pull down the lower lid with the thumb and instill the drops into the conjunctival sac.

Gently restrain the head and apply the drops at the inner canthus.

You are teaching stress management techniques to middle school students at Martin Luther King Jr. Leadership Academy.

Health promotion

You are teaching fourth graders at Buchanan Elementary School about self-esteem.

Health promotion.

Which is a major concern when providing drug therapy for older adults? A. Older adults may chew on tablets instead of swallowing them B. Older adults have difficulty in swallowing large tablets C. Alcohol is used by older adults to cope with the multiple problems of aging D. Hepatic clearance is reduced in older adults

Hepatic clearance is reduced in older adults

Doing no harm to clients.

Nonmaleficence

You are teaching young children what to do if another attempts to inappropriately touch their bodies.

Primary Health protection

You are at Hope Behavioral Health Services in a residential setting for persons with persistent mental illnesses. You are doing a group teaching project on hand washing, proper disposal of used Kleenex, and sneezing into your elbow rather than your hand.

Primary health protection

You are encouraging a client with a bipolar disorder to get a flu shot.

Primary health protection

You are in the Heartside Neighborhood and are leading a walking group for resident that will prepare them to walk the 5K at the River Bank Run

Primary health protection

You are teaching Creston High School students about the dangers of sexually transmitted diseases (STD's)

Primary health protection.

You are teaching adolescent girls with eating disorders about the importance of regular hand washing.

Primary health protection.

A right of limited physical or informational inaccessibility.

Privacy

One of the participants attending a parenting class asks the teacher "What is the leading cause of death during the first month of life? A. Bacterial sepsis B. Respiratory distress of newborn C. SIDS D. Neonatal hemorrhage

SIDS

You are screening elementary school children for head lice after an outbreak at the school.

Secondary health protection

You do a home visit in the Creston neighborhood and encounter an older adult who is obviously being neglected and abused. You make a call to adult protective services

Secondary health protection

You are conducting blood sugar screening at the South End Community Ministry (SECOM) during food pantry hours.

Secondary health protection.

You are leading a dance session for diabetic Latina women in Burton Heights to assist in integrating exercise into their regime for managing their blood sugar.

Tertiary health protection

You are working with school age kids who have asthma in a Living with Asthma program

Tertiary health protection

You are teaching neighborhood hypertension classes (i.e. diet, exercise, medication, stress) to clients identified by the Baxter Clinic.

Tertiary health protection.

Which age group has the greatest potential to demonstrate regression when they are sick? A. Infant B. Toddler C. Adolescent D. Young Adult

Toddler

Telling the truth and not intentionally deceiving or misleading clients.

Veracity

Hepatitis C transmission

blood IV drug users and reusing needles most at risk

a client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first? 1. elevate the arm 2. document the findings 3. medicate with an additional dose of an opioid 4. check for parasthesias and paralysis of the right arm

check for parasthesias and paralysis of the right arm

a client with a diagnosis of cancer is receiving morphine sulfate for pain. The nurse should employ which priority action in the care of the client? 1. monitor stools 2. monitor urine output 3. encourage fluid intake 4. encourage the client to cough and deep breathe.

encourage the client to cough and deep breathe

Hepatitis A transmission

fecal-oral route

Hepatitis signs and symptoms

flu-like symptoms N/V Gi upset Malaise

You are teaching elementary students at Henry Paidea Academy about nutrition.

health promotion.

Which of the following describes nursing diagnoses? A nursing diagnosis: 1. supports the nurse's diagnostic reading 2. supports the patient's medical diagnosis 3. identifies a patients response to a health issue 4. identifies a patients health problem

identifies a patients response to a health issue

Which of the following is an example of active listening behavior? 1. taking frequent notes 2. asking for more detail 3. leaning in, facing the patient 4. sitting with legs crossed

leaning in, facing the patient

The nurse caring for a client experiencing dystocia during labor determines that the priority is which action? 1. position changes and providing comfort measures 2. explanations about what is happening to the client 3. monitoring for changes in the condition of the mother and fetus 4. reinforcement of breathing techniques learned in child-birth preparatory classes

monitoring for changes in the condition of the mother and fetus

The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea during activity. After assisting the client to the bed and placing the client in high-fowler's position, the nurse should take which immediate action? 1. administer high-flow oxygen to the client 2. call the consulting cardiologist to report the findings 3. prepare to administer an additional dose of furosemide 4. obtain a set of vital signs and perform focused respiratory and cardiovascular assessments

obtain a set of vital signs and perform focused respiratory and cardiovascular assessments

Which of the following includes objective and subjective data? 1. patient's BP is 132/68 and HR is 88 2. patient's cholesterol is elevated, and stated that he likes fried food 3. patient states she is having trouble sleeping and drinks coffee at night 4. patient states he gets frequent headaches and takes aspirin for it

patient's cholesterol is elevated, and stated that he likes fried food

You are conducting door-to-door health teaching in the Baxter Neighborhood, in conjunction with lay community health workers, on factors that create risk for lead poisoning in children.

primary health protection.

Which of the following contributions of Florence Nightingale had an immediate impact on improving patient's health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) establishing nursing as a distinct profession

providing a clean environment

You are visiting a senior citizen at the Adams Park Apartments and conducting a health assessment.

secondary health protection.

You are working with the Nurse Practitioner at Health Intervention Services (HIS) as she sees a woman with frequent head aches and abdominal pain.

secondary health protection.

You are doing weekly home visits as a nurse case manager (i.e. nurse who coordinates all necessary care) for an older adult who has diabetes

tertiary health protection.