Fundamentals Prep U CH. 13, 14, 15,16,17,24,35,7
The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? a) "If the client's blood pressure falls outside normal limits, come get me." b) "Notify me right away if the client's systolic blood pressure is 170 or greater." c) "Let me know if the client's blood pressure becomes elevated." d) "I need to know if the client's blood pressure changes from his normal baseline."
"Notify me right away if the client's systolic blood pressure is 170 or greater." Explanation: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted for and what action to take. The other three options are vague and do not provide adequate direction for the UAP. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 15: Implementing, p. 300.
A 67-year-old man's right lower quadrant pain has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis and treatment? a) "Patient is at risk of impaired lung function due to anesthesia." b) "Potentially complicated respiration as a result of surgery" c) "PC: Atelectasis related to surgery" d) "Risk for respiratory complications due to anesthesia"
"PC: Atelectasis related to surgery" Explanation: To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 247.
A nursing student asks the clinical instructor to explain the difference between quality improvement and quality assurance. Which response by the clinical instructor is appropriate? a) "Quality improvement focuses on processes, data, and statistical thinking." b) "Quality assurance is concerned with patient satisfaction." c) "Quality improvement focuses on organization structure and individuals." d) "Quality assurance promotes empowerment and collaboration."
"Quality improvement focuses on processes, data, and statistical thinking." Explanation: Quality improvement focuses on processes, data, statistical thinking, and patient satisfaction and promotes empowerment and collaboration. Quality assurance focuses on organization structure and individuals and is externally driven. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 16: Evaluating, p. 319.
A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has a) Inaccurate evaluation b) Impaired cluster interpretation c) Ineffective database d) A lack of cues or premature closure
A lack of cues or premature closure Explanation: The lack of adequate cues is called premature closure. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 258.
Which of the following nursing students would most likely be held liable for negligence? a) A nursing student who performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound. b) A nursing student administers medication to a resident, while working as a nursing assistant at a local nursing home. c) The nursing student who reports that insulin was not administered to the client by the nurse on the previous shift. d) A nursing student who completes an incident report after administering a medication to a client who experiences an adverse reaction to the medication.
A nursing student administers medication to a resident, while working as a nursing assistant at a local nursing home. Explanation: The nursing student who administers medication to a resident, while working as a nursing assistant at a local nursing home is performing a task outside the scope of the job responsibilities of a nursing assistant. The other options demonstrate legally defensible actions by the nursing student. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 129.
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a) A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. b) A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. c) A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. d) A patient who resides in Indiana has required hospitalization during a vacation in Hawaii.
A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. Explanation: Among the provisions of HIPAA are patients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 328.
Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: You are preparing to apply a transcutaneous electrical nerve stimulation (TENS) unit. Arrange the following steps in the correct order. 1 Apply electrodes to the prescribed location. 2 Turn on the TENS unit. 3 Plug electrodes into the TENS unit. 4 Secure unit to the patient. 5 Assure that patient can feel the tingling sensation. 6 Adjust intensity to prescribed setting.
Apply electrodes to the prescribed location. Plug electrodes into the TENS unit. Turn on the TENS unit. Assure that patient can feel the tingling sensation. Adjust intensity to prescribed setting. Secure unit to the patient. Explanation: These are the steps involved in preparing to apply a TENS unit. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 35: Comfort, p. 1131.
A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient? a) Monitor arterial blood gas results for 1 minute. b) Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. c) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. d) Use a pulse oximeter to count the respirations for 1 minute.
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. Explanation: Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 550.
An ultrasonic Doppler is used for a) Aiding palpation of pulse and rhythm b) Auscultating diastolic blood pressure c) Auscultating a pulse that is difficult to palpate d) Aiding palpation of diastolic blood pressure
Auscultating a pulse that is difficult to palpate Explanation: A Doppler device can be used to detect a pulse that is not easily palpable. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 526.
When the nurse inserts an ordered urinary catheter into the patient's urethra after the patient has refused the procedure and the patient suffers an injury, the patient may sue the nurse for which type of tort? a) Dereliction of duty b) Invasion of privacy c) Battery d) Assault
Battery Explanation: Battery is the actual carrying out of such threat (unlawful touching of a person's body). A nurse may be sued for battery if he or she fails to obtain consent for a procedure. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 117.
What ensures continuity of care? a) Critical thinking b) Communication c) Reassessment d) Integration
Communication Explanation: Communication ensures continuity of care and provides essential data for revision or continuation of care.... (more) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 348.
Which of the following is an example of a nursing diagnosis? a) Hypoglycemia b) Dehydration c) Constipation d) Depression
Constipation Explanation: Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 252.
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their patients? a) "Assess your patient after receiving nursing report and again before giving a report to the next shift of nurses." b) "Assessment data about the patient should be collected continuously." c) "Assessment data should be collected prior to the physician rounding on the unit." d) "Assess your patient at least hourly if the patient's vital signs are unstable and every 2 hours if the vital signs are stable."
Correct response: "Assessment data about the patient should be collected continuously." Explanation: Data about the patient are collected continuously because the patient's health status can change quickly. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 12: Assessing, p. 223.
Why is coding important when writing a nursing diagnosis? a) Allows for direct reimbursement for nurses b) Enhances the professionalism of the nursing process c) Provides legal characteristics for licensure d) Evaluates the diagnostic statement for accuracy
Correct response: Allows for direct reimbursement for nurses Explanation: Coding of nursing diagnoses in computerized systems allows direct reimbursement of nurses. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 259.
A client is brought to the Emergency Room in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis in the client? a) Impaired spontaneous ventilation b) Ineffective breathing pattern c) Impaired gas exchange d) Ineffective airway clearance
Correct response: Impaired spontaneous ventilation Explanation: Ineffective spontaneous ventilation is the most appropriate nursing diagnosis for the client because he is unable to breathe as the result of respiratory failure. Ineffective breathing pattern is appropriate when the client has difficulty breathing due to a high respiratory rate. Ineffective airway clearance is an inaccurate diagnosis here because the airways are clear and not blocked by secretions. Additionally, the diagnosis of impaired gas exchange is inappropriate because there is no known lung pathology or anemia. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 253.
The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? a) Licensed practical nurse b) Registered nurse c) A senior nursing student present for clinical d) Nursing assistant
Correct response: Nursing assistant Explanation: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 15: Implementing, p. 299-300.
A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial to him. Which of the following nursing diagnoses relates to this client's condition? a) Ineffective coping related to anxiety and fear of surgery b) Anxiety related to fear of death during surgery c) Knowledge deficit: treatment regimen related to surgical outcomes d) Risk related to unknown outcome of surgery
Correct response: Risk related to unknown outcome of surgery Explanation: The client expresses fear of the risks related to unknown outcome of surgery. The appropriate nursing diagnosis is fear related to potential risk and surgical outcomes. Fear is always related to a known source; in this case it is the surgery. Anxiety is always related to unknown sources and is not applicable in this case. Coping and knowledge deficit are not related to fear of surgery. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 253.
What does the nursing diagnosis represent? a) Maladaptation b) Cues c) Symptoms d) Signs
Cues Explanation: Each nursing diagnosis represents a pattern of related client cues. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 245.
A nursing instructor is describing the components of an actual nursing diagnosis. Which of the following would the instructor include as a characteristic feature of diagnostic labels? a) Describes conditions, circumstances, or etiologies that contribute to the problem b) Describes some qualification of the specific nursing diagnosis c) Describes the characteristics of the human response under consideration d) Describes the essence of the problem using as few words as possible
Describes the essence of the problem using as few words as possible Explanation: Diagnostic labels describe the essence of the problem using as few words as possible. The descriptors describe changes in condition, state of the client, or some qualification of the specific nursing diagnosis. The definition describes the characteristics of the human response under consideration. The related factors describe conditions, circumstances, or etiologies that contribute to the problem. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 259.
What gives additional meaning to a nursing diagnosis? a) Composition b) Dysfunction c) Qualifications d) Descriptors
Descriptors Explanation: Descriptors are words used to give additional meaning to a nursing diagnosis. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 255.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a) Initial planning b) Discharge planning c) Comprehensive planning d) Ongoing planning
Discharge planning Explanation: Discharge planning begins at the time of admission with the nurse teaching the client and family specific knowledge and skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 268.
A patient states that his recent fall was caused by the fact that his scheduled antihypertensives were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the patient. Which of the following measures should the nurses prioritize when anticipating that legal action may follow? a) Liaise with the hospital's legal department as soon as possible. b) Consult with practice advisors from the state board of nursing. c) Enlist support from nursing and nonnursing colleagues from the unit. d) Document the patient's claims and the events surrounding the alleged incident.
Document the patient's claims and the events surrounding the alleged incident. Explanation: It is imperative for nurses to carefully and accurately document assessment findings and the nursing care that they provide, a fact that is especially salient when legal action is anticipated. This thorough and accurate assessment should precede consultation with the legal department, the state board of nursing, and colleagues. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 119.
The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent? a) Meaningful recognition b) True collaboration c) Effective decision making d) Appropriate staffing
Effective decision making Explanation: Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations. Appropriate staffing ensures that client needs are effectively matched with nurse competencies. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses and between nurses and other health team member for client care. Meaningful recognition highlights the value each nurse brings to the work for the organization, such as certification. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 16: Evaluating, p. 317.
Choice Multiple question - Select all answer choices that apply. Which is an advantage of a standard classification of nursing interventions? Select all that apply. a) Promote the development of a reimbursement system for nursing services. b) Identify, label, validate, and classify nursing-sensitive client outcomes and indicators. c) Facilitate communication of nursing treatments to other nurses and other providers. d) Define and test measurement procedures for client outcomes and indicators. e) Enables researchers to examine the effectiveness and cost of nursing care.
Facilitate communication of nursing treatments to other nurses and other providers. • Promote the development of a reimbursement system for nursing services. • Enables researchers to examine the effectiveness and cost of nursing care. Explanation: Advantages of a standard classification of nursing interventions (NIC) include facilitating communication of nursing treatments to other nurses and other providers; promoting the development of a reimbursement system for nursing services; and enabling researchers to examine the effectiveness and cost of nursing care. The purposes of the Nursing Outcomes Classifications (NOC) are to (1) identify, label, validate, and classify nursing-sensitive client outcomes and indicators; (2) evaluate the validity and usefulness of the classification in clinical field-testing; and (3) define and test measurement procedures for client outcomes and indicators. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 15: Implementing, p. 288.
A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history? a) Old chart b) Family c) Physician d) Social worker
Family Explanation: Family members or significant others, if available, can provide information for a client who is confused or incapacitated. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 12: Assessing, p. 231.
During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies? a) State legislation b) Healthcare institution c) Federal legislation d) Board of nursing
Healthcare institution Explanation: The healthcare institution determines the unit and institutional policies. These policies may vary from institution to institution. Such policies may include clinical procedures, policies specific to the institution, and personnel and employment policies. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 112.
An example of a nursing diagnosis from the Perception/Cognition domain is: a) Health-Seeking Behaviors. b) Impaired Verbal Communication. c) Impaired Social Interaction. d) Readiness for Enhanced Sleep.
Impaired Verbal Communication. Explanation: Nursing diagnoses found in the Perception/Cognition domain are defined as those that involve the human information-processing system, including attention, orientation, sensation, perception, cognition, and communication. A nursing diagnosis included in the Perception/Cognition domain is Impaired Verbal Communication. Health-Seeking Behaviors is included in the Health Promotion domain. Readiness for Enhanced Sleep is included in the Activity/Rest domain. Impaired Social Interaction is included in the Role Relationships domain. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 252.
After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? a) Risk for infection b) Possible impaired adjustment c) Readiness for enhanced sleep d) Impaired urinary elimination
Impaired urinary elimination Explanation: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 243.
The temperature is 102° during a heat wave. The nurse can expect admissions to the emergency room to present with a) Decreased respirations b) Decreased heart rate c) Increased temperature d) Increased cardiac output
Increased temperature Explanation: Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 517.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a) Diagnosis b) Goal c) Intervention d) Evaluation
Intervention Explanation: A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 282.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a) Diagnosis b) Intervention c) Goal d) Evaluation
Intervention Explanation: A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 282.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a) Goal b) Evaluation c) Intervention d) Diagnosis
Intervention Explanation: A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 282.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? a) Made when not enough evidence supports the problem b) Is written as a two-part statement c) Describes potential for enhancement to a higher state d) Describes human response to a health problem
Is written as a two-part statement Explanation: The risk diagnoses are written as two-part statements because they do not include defining characteristics. An actual nursing diagnosis describes human response to a health problem. Wellness diagnoses describe potential for enhancement to a higher state. A possible nursing diagnosis is made when not enough evidence supports the problem. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 251.
What is meant by impaired state of equilibrium? a) It describes the client's condition b) It is common terminology c) It assists in planning care d) It is a nursing diagnosis
It describes the client's condition Explanation: Descriptors such as "impaired state of equilibrium" describe changes in condition, state of the client, or some qualification of the specific nursing diagnosis. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 255.
A concise document that provides most of the client's nursing and medical information is a(n) a) Past chart b) Office record c) Kardex d) Nursing care plan
Kardex Explanation: The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 342.
The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. What type of outcome is this an example of? a) Psychomotor outcome b) Cognitive outcome c) Physiologic outcome d) Affective outcome
Physiologic outcome Explanation: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive ou... (more) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 16: Evaluating, p. 308.
A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children? a) Radial b) Popiteal c) Temporal d) Brachial
Popiteal Explanation: In infants and small children, the lower extremities are commonly used for blood pressure monitoring. The more common sites are the popliteal, dorsalis pedis, and posterior tibial. Blood pressures obtained in the lower extremities are generally higher than if taken in the upper extremities. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 554.
Which of the following terms indicates a potentially serious patient condition? a) Afebrile b) Eupnea c) Pyrexia d) Pulse pressure
Pyrexia Explanation: Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 518.
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? a) Peer review b) Quality improvement c) Magnet status d) Quality assurance
Quality assurance Explanation: Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven continuous process, focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy of the organization. Magnet status is awarded by the American Nurses Credentialing Center, recognizing healthcare organizations for their excellence in nursing. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 16: Evaluating, p. 317.
How can a nurse obtain additional information about a client? a) Call the client's family. b) Review nursing literature. c) Read the client's history and assessment. d) Ask the client's sister about the family history.
Read the client's history and assessment. Explanation: Nurses and other team members gather assessment data from the client record. By reading about the client's history and initial assessment and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 336.
A nurse is working as a case manager, and in this role she audits charts. Audits of client records are performed primarily for quality assurance and a) Staff development b) Reimbursement c) Change of mechanisms d) Research
Reimbursement Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 329.
During the admission assessment of a 40-year-old female patient with a suspected mandibular fracture, the patient discloses to the nurse that her injury came as a result of her husband hitting her. Which of the following actions should the nurse prioritize when responding to this disclosure? a) Performing an assessment to confirm the patient's statement b) Ensuring the patient's statement is confirmed by another nurse c) Informing the patient of her right to keep this information private d) Reporting the abuse to the appropriate authorities
Reporting the abuse to the appropriate authorities Explanation: Nurses have a legal and ethical obligation to report cases of abuse. It would be inappropriate and likely unethical to require a third party witness to the statement or to withhold action pending assessment results. The nurse's obligation to report abuse legally supersedes the patient's right to privacy. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 131.
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? a) Provide preoperative education b) Resolve the client's anxiety c) Evaluate the need for antibiotics d) Prepare the client for surgery
Resolve the client's anxiety Explanation: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 281.
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? a) Provide preoperative education b) Resolve the client's anxiety c) Prepare the client for surgery d) Evaluate the need for antibiotics
Resolve the client's anxiety Explanation: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 281.
When assessing a patient's vital signs, a nursing student has explained each of her next actions prior to assessing the patient's temperature, pulse, and blood pressure, but has not announced her intention to assess the patient's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision? a) Temperature, pulse, and blood pressure are more volatile than respiratory rate. b) The nurse likely assessed the patient's respiratory rate simultaneous to heart rate. c) Respirations have both autonomic and voluntary control. d) Tachypnea is an expected finding among hospitalized individuals.
Respirations have both autonomic and voluntary control. Explanation: Because respiratory rate is under both autonomic and voluntary control, making the patient conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate and tachypnea is not an expected finding. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 528.
Which of the following nursing diagnoses has the highest priority when caring for an elderly client with Alzheimer's disease? a) Self-care deficit b) Risk for injury c) Impaired physical mobility d) Impaired memory
Risk for injury Explanation: Clients with Alzheimer's disease are highly prone to injuries. Risk of injury may also be precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in older age groups. Consequently, it is very important for the nurse to provide a safe and secure environment. Impaired physical mobility, self-care deficit, and impaired memory are also present but are not the highest priority. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 253.
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? a) PIE charting b) SOAP charting c) Narrative charting d) Focus charting
SOAP charting Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 17: Documenting, Reporting, Conferring, and Using Informatics, p. 335.
When assessing a patient on PCA therapy, the nurse finds the patient to be somnolent, with minimal or no response to physical stimulation, scoring a 4 on the sedation scale. What is the recommended intervention in this situation? a) Stop the infusion and report the incident to the nurse manager in charge; follow the protocol of oxygen and naloxone administration. b) Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and a narcotic antagonist, such as naloxone (Narcan). c) Stop the PCA infusion, check the medication level, and restart the infusion at a lower dose. d) Stop the PCA infusion, increase the frequency of sedation and respiratory rate monitoring to every 15 minutes, arouse the patient, and encourage deep breathing.
Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and a narcotic antagonist, such as naloxone (Narcan). Explanation: If a patient receiving a PCA infusion becomes somnolent, with a sedation score of 4, the nurse should stop the medication infusion immediately and notify the primary care provider. The nurse should prepare to administer oxygen and a narcotic antagonist, such as naloxone (Narcan). (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 35: Comfort, p. 1134.
The nurse is assessing a male patient with a diagnosis of vascular dementia. As a result of his cognitive deficit, the patient is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? a) Obtain the patient's records from admissions to other institutions. b) Supplement the patient's information by speaking with family or friends. c) Limit the assessment to objective data. d) Perform the assessment in several short episodes rather than at one sitting.
Supplement the patient's information by speaking with family or friends. Explanation: Family and friends can be an invaluable source of assessment data, especially in the care of patients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Utilizing previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 12: Assessing, p. 223.
Which of the following statements accurately represents a consideration when using an epidural analgesia for patient pain management? a) If the patient develops a headache, a mild analgesic may be administered along with the epidural. b) The anesthesiologist/pain management team should be notified immediately if the patient exhibits a respiratory rate below 10 breaths/minute. c) If a patient is experiencing adverse effects, a peripheral IV line should be installed to allow immediate administration of emergency drugs, if warranted. d) Slight resistance should be felt during the removal of an epidural catheter.
The anesthesiologist/pain management team should be notified immediately if the patient exhibits a respiratory rate below 10 breaths/minute. Explanation: The anesthesiologist/pain management team should be notified immediately if the patient exhibits a respiratory rate below 10 breaths/minute or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.
A pulse deficit is the difference between a) Palpated and auscultated blood pressure readings b) The radial pulse and the ulnar pulse rates c) The systolic and diastolic blood pressure readings d) The apical pulse and the radial pulse rate
The apical pulse and the radial pulse rate Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate. Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 24: Vital Signs, p. 527.
Which of the following aspects of nursing would be most likely defined by legislation at a state level? a) The criteria that patients must meet in order to qualify for Medicare or Medicaid. b) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). c) The process that nurses must follow when handling and administering medications. d) The criteria that a nurse must consider when delegating tasks to unlicensed care providers.
The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). Explanation: The scope of practice defines the parameters within which nurses provide care and is established by state legislation, most commonly in the form of a Nurse Practice Act. The criteria and due process for delegation in the clinical setting is addressed by a state board of nursing. Qualification criteria for programs such as Medicare and Medicaid are established by federal legislation while the process for safe and appropriate medication administration is defined and monitored by a state board of nursing. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 7: Legal Implications of Nursing, p. 112.
Which of the following reflects the diagnosis phase? a) The nurse sets a tolerable pain rating with the client. b) The nurse identifies that the client does not tolerate activity. c) The nurse documents the client's response to pain medication. d) The nurse performs wound care using sterile technique.
The nurse identifies that the client does not tolerate activity. Explanation: Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client's response to pain medication is an example of evaluation. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 243.
The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? a) The diagnoses present significant risks for the development of medical diagnoses. b) The diagnosis has yet to be confirmed by another practitioner. c) The patient is more vulnerable to certain problems than other individuals would be. d) The data necessary to make a definitive nursing diagnosis are absent.
The patient is more vulnerable to certain problems than other individuals would be. Explanation: Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. They do not denote a particular link to medical diagnoses nor do they require independent confirmation. Missing data are associated with possible nursing diagnoses. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 254.
Besides controlling pain of the post-abdominal surgery client with narcotics, the nurse suggests to the client that he a) Describe the pain b) Use distraction c) Think about the next dose d) Focus on pain relief
Use distraction Explanation: Distraction is useful when clients are undergoing brief periods of sharp, intense pain such as dressing changes, wound débridement, biopsy, or incident pain from shifting positions. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 35: Comfort, p. 1130.
A student nurse is performing a sterile dressing change on a patient's abdominal incision. While establishing her sterile field, the nurse drops her forceps on the floor and is unable to continue with the dressing change because she has no extra supplies in the room and no one in the room to assist her by bringing new forceps. The student has failed to organize: a) equipment and personnel. b) logistics and planning. c) environment and patient. d) skills and assistance.
equipment and personnel. Explanation: A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 15: Implementing, p. 294.
Which of the following best defines nursing diagnoses? a) Identification of patient problems that require collaboration with other healthcare professionals b) Identification of actual patient problems not including potential problems c) Identification of patient problems that nurses can treat independently d) Identification of signs and symptoms that identify diseases
identification of patient problems that nurses can treat independently Explanation: Nursing diagnoses are written to describe patient problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other healthcare professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential patient problems. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 246.
The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from: a) assessment data gleaned from the physician's progress notes. b) assessment data provided by the multidisciplinary team. c) the defining characteristics in the nursing diagnosis statement. d) the problem statement of the nursing diagnosis.
the problem statement of the nursing diagnosis. Explanation: Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based upon independent nursing actions. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 14: Outcome Identification and Planning, p. 264.
The nurse is providing care for a patient who experienced an ischemic stroke 5 days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this patient? Select all that apply. a) Dysphagia b) Impaired Physical Mobility c) Risk for Hemiparesis d) Bowel Incontinence e) Impaired Swallowing
• Bowel Incontinence • Impaired Swallowing • Impaired Physical Mobility Explanation: Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all health problems that can be independently prevented or resolved by nursing practice. Dysphagia and hemiparesis are medical diagnoses. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2011, Chapter 13: Diagnosing, p. 252.
