Fundamentals PrepU
Invasion of privacy
An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed?
To protect the safety of the public
A student is preparing to graduate from nursing school and understands that professional regulations and laws that govern nursing practice are in place. These regulations and laws are in place for which reason?
A psychosocial risk factor
An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health?
Preventing illness
Then nurse is providing flu shots to older adult clients at a nurse-managed wellness center. This is an example of which aim of nursing?
"Cheer up. Tomorrow is another day." "Your doctor knows best." "Don't worry. You will be just fine in another day or two." "Everything will be all right."
A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply.
"Is that a new shirt you're wearing?"
A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?
Administering bedside blood glucose testing
A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?
"Sir, I understand this is uncomfortable but I assure you I am experienced with this task and would like to continue."
A client comes into the urgent care center to have sutures removed on his right arm. The nurse assesses the sutures and finds significant crusting along the suture line. The client indicates he didn't have time to get his sutures removed a week prior as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls his arm away and tells the nurse, "you do not know what you are doing." In response, the nurse should answer:
Shared decision making
A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing her judgments based on her expertise. Which type of health care decision making does this represent?
The nurse is careful what is said in the client's presence since hearing is the last sense to go. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. The nurse speaks with the client before touching him.
A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply.
applying for a reciprocal license in the new state
A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?
Communicator Counselor Teacher
During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.
close-ended questions
Each of the following facilitates a therapeutic nurse-client relationship except:
The Grey Nuns of Montreal
Of the following orders, which is considered to be the first to provide visiting nurses in Canada?
Work effectively in interdisciplinary teams
The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?
Homeostasis
The body's attempt to restore balance through self-regulatory mechanisms is termed:
Physical changes
The mother brings her infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states "The infant will double birth weight by 6 months of age." This is an example of what type of outcome statement?
World War II
The need for university-based nursing education programs was brought to light during which important historical time?
Outcome evaluation
The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?
Communicate with the physicians to coordinate their orders.
The nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client while another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?
Art of nursing
The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?
A client with a leg amputation who performs activities of daily living with a prosthesis
The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?
Educator
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
avoid allowing her judgment to guide practice.
To practice ethically, the nurse should:
*Telling a client their blood pressure *Calling a physician about a client's blood pressure *Informing the physical therapist that the client's therapy was discontinued *Discussing laboratory values with a client
What are the best examples of the role of the nurse as a communicator? Select all that apply.
Values
What is the term for the beliefs held by the individual about what matters?
Obtain continuing education credits.
What might a nurse need to do to ensure the continuation of his or her nursing license?
Illness Prevention
When administering immunizations, the nurse is engaged in:
Malpractice
While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for?
To set standards for nursing education and practice
Why are nursing organizations important for the continued development and improvement of nursing as a whole?
Encouraging a group of junior high school students to engage in regular physical activity
Which nursing action best exemplifies the nurse's role in promoting health?
Setting up parenting classes
A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?
Giving false reassurance
A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?
Slander
A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged?
Licensed or vocational nursing program
A prospective nursing student desires a career that will allow him to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
They are responsible for the continued development and advancement of nursing.
A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?
Control the tone of the voice to avoid hidden messages.
A student nurse is attempting to improve their communication skills. Which therapeutic communication skill is appropriate?
Written communication
The nurse is providing education to a client who sometimes has difficulty remembering information. Which form of communication will be most helpful for this client?
*The nurse should assess the clients for risk factors for infection when planning nursing care. *The nurse should consider the client's family history and age when assessing risk factors for infection. *The nurse should examine environmental stressors in clients' lives to see how these stressors might affect their recovery and ability to ward off infection.
The nurse is using Leavell and Clark's Agent-Host-Environment Health Model to help plan nursing interventions for clients in a hospital setting. Which examples of nursing actions to prevent hospital-acquired infections (HAIs) best illustrate the principles of this model? Select all that apply.
The nurse is maintaining eye contact when changing a client's dressing The nurse has a smile when being thanked for caring for a family member The nurse is using a quiet tone of voice
The nurse is using nonverbal communication when caring for a group of clients. Which situation reflects non-verbal communication? Select all that apply.
process evaluation
The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation?
Health is a state of complete well-being.
The nursing instructor is teaching the students about health and wellness and identifies which definition of health as the best?
Assess Plan Implement Evaluate
The nursing process includes step(s)? Select all that apply.
Structure
The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:
Health promotion
The primary aim of the Healthy People 2020 initiative is:
help the client achieve optimal levels of health.
The primary purpose of nursing implementation is to:
They must take a licensure exam.
The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?
The RN coordinates care delivery.
The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?
Another registered nurse with critical care certification
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?
tell herself to "remain calm" and remember that she was trained to perform this skill.
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:
"What day of the week is it?"
A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask the client in order to assess the her orientation?
Modify the plan of care
A client has come into the clinic for a postoperative visit. The client states that the postoperative pain continues to be 6 on a 0 to 10 rating scale. The nurse evaluates the client and the current plan of care. Based on the information provided by the client, the nurse should:
Safety
A client has just been admitted to the clinical unit. The nurse is providing her with the expectations she may have of the health care she will receive. She is told that she will not be harmed by any errors that might be made and she can expect to be safe in the facility. This assurance represents which expectation of the health care environment?
Coordinating
A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention?
asking if the client feels less anxious 30 minutes after administering the medicine
A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?
Facilitating coping
A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
"Were you tired and depressed before starting the new medication?"
A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:
Children are kept inside the home on a sunny summer day because of lack of recreational opportunities.
A home health care nurse who works in a low-income community assesses the risk factors for clients being serviced. What is an example of a community risk factor?
A nurse researches the culture of a Muslim client when planning care.
A nurse demonstrates the professional value known as altruism when caring for clients in a long-term care facility. What nursing action demonstrates this behavior?
Aggressive
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
It is the role of nursing to provide a caring relationship that facilitates health and healing.
A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?
Nursing process
A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case?
swaddling the child and gently stroking its head.
A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:
The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.
Be silent and allow the client to continue speaking when ready.
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?
"Have you ever thought of laser surgery?"
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?
The nurse devises a postdischarge questionnaire to evaluate client satisfaction.
A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?
"I understand you have four kids; how many times have you actually been pregnant?"
A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?
Clinical nurse specialist
A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?
The client receiving the care
A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?
An audiologist
A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:
have group members confront the dominant member to promote the needed team work.
A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:
the presence of a disease with the absence of symptoms.
Chronic illness may be characterized by periods of remission. Remission is best defined as:
managing a health-related business
In the role of entrepreneur, the nurse's primary responsibility is:
18th to 19th century
In what time period did nursing care as we now know it begin?
A nurse is calling a physician to report a client's new onset of chest pain.
In which of the following situations would the SBAR technique of communication be most appropriate?
Assess the client to determine the cause of the pain.
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?
*knowledge about the value of the food pyramid *understanding food preferences of clients from the Jewish community *information on the client's financial status related to meal provisions *ability of the client to prepare food at home
Patient care dealing with nutrition and metabolism should include which factors? Select all that apply.
RN to BSN
The diploma nurse is considering obtaining a baccalaureate degree. Which degree should the nurse investigate?
American Journal of Nursing
The first nursing journal owned, operated, and published by nurses was:
Mary Breckinridge
The nurse going back to school for nurse midwifery can trace education for nurse midwifery to which nursing leader?
Associate degree
The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification?
"Keep all medications in a locked cabinet."
The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?
"Could you tell me more about how you are feeling right now?"
The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?
Discard the sterile field and prepare a new one
The nurse is preparing a sterile field for a procedure. While opening an instrument, the outer wrapper of the sterilized instrument touchs the extreme edge of the field. Which of the following should the nurse do next.
Medical terminology
When communicating with clients nurses need to be very careful in their approach. This is particularly true when communicating using:
Demonstrated Steps
When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?
"The thought of having surgery is keeping you awake."
When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:
Well-funded school systems and inadequate childcare services.
Which are stressors that affect the health of the family?
ANA Standards of Nursing Practice
Which authoritative statements guide current professional nursing practice?
An approach critiquing existing patterns of oppression and domination in society
Which example best describes feminist ethics?
The LPN/LVN should work under the supervision of an RN.
Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)?
Ambulate 30 ft (9 m) twice a day with the assistance of a walker.
Which is an appropriately stated nursing intervention?
American Nurses Association (ANA)
Which nursing group provides a definition and scope of practice for nursing?
Refer the mother for a home care visit.
Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?
Empathy
Which qualities in a nurse help the nurse to become effective in providing for a client's needs while remaining compassionately detached?
A nurse who demonstrates advanced expertise in a content area of nursing through special testing
Which scenario is an example of certification?
Providing nutrition teaching to a client with diabetes
Which scenario is the best example of a nurse implementing care according to the ANA standards of practice?