Fundamentals Study Exam Set

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?

"To preserve the client's functional ability to grasp and pick up objects."

Which is an open-ended question?

"Why did the health care provider prescribe this medication for you?"

Which situations observed by a nurse should the nurse report to the nurse manager for quality assurance? Select all that apply.

A nurse assesses a client after sneezing into the nurse's hands. A nurse administers medications to the wrong client. A nurse delays answering call lights to an abusive client. A nurse refuses to provide care to a client with HIV.

Which is the purpose of a focused assessment?

Adds depth to existing information

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

Which are components of an evaluative statement? Select all that apply.

Description of how the client outcome was met Client data that support how the outcome was met

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

Which nursing diagnosis has priority?

Ineffective Airway Clearance related to retention of secretions

Which is true of the Occupational Safety and Health Act?

It helps to reduce workforce injuries and illness in the workplace.

A client informs the nurse that the client wants to discontinue treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

Let the client go after signing a document stating that the client is going against medical

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

Which action should the nurse perform in the evaluation phase?

Revise the plan of care.

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

Which nursing action reflects evaluation?

The nurse assesses urine output following administration of a diuretic.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?

Tracheobronchial suctioning

What are standards for decision-making that endure for a significant time in one's life?

Values

A client requests that the nurse allow the client 15 minutes two times a day for prayer during hospitalization. What value does this represent?

Foundation value

The nurse has an ethical dilemma and is using the ethical decision-making steps to guide to a correct decision. Place in order the steps the nurse uses in this process.

Gather data and assess the situation. Identify the ethical problem. Identify and weigh the alternatives. Implement the decision. Evaluate the decision.

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating?

Integrity

A nurse working in a critical care unit has experienced personal tragedy, extreme shortage of staff in the work environment, and health issues. The nurse has overcome much of these hardships and is now mentoring other nurses in similar situations. What behavior is this nurse demonstrating?

Moral resilience

A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief?

Personal moral

A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment?

Pull the curtain dividing the two beds.

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship?

Reviewing health changes

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

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.

The nurse shows patience with the client and gives the client time to respond. The nurse maintains eye contact with the client. The nurse keeps communication simple and concrete.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate the quality of care provided and assess the potential risks for injury to the client

A client tells the nurse that the client does not want to have a painful procedure. By respecting and supporting the client's right to make decisions, the nurse is demonstrating:

advocacy.

To practice ethically, the nurse should avoid:

allowing the nurse's own judgment to guide practice.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible.

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:

invasion of privacy.

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have:

personal values.

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:

recommend 40 mg of furosemide be administered because the client had improvement with past administration.

An informatics nurse is part of a team working on developing a clinical information system for a facility. The team is working on ensuring that the system supports usability. During which phase of the system development lifecycle would the team integrate the principles of usability as a priority?

Design

An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research?

Design and build

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem?

Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses.

A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated?

Discuss the occurrence with the coworker.

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair

A nurse is named as a defendant in a malpractice lawsuit. Which action would be recommended for this nurse?

Do not volunteer any information on the witness stand.

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness Headache Vomiting

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns.

A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept?

Efficient interactions

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?

Evaluate the use of current pain relief measures.

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse?

Firmly grasp the gait belt and gently lower the client into bed.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply.

For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

Fowler Semi-Fowler Upright

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Professionalism Caring

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

Which action should the nurse take when client data indicate that the stated goals have not been achieved?

Review each preceding step of the nursing process.

A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client?

Risk for Interrupted Family Processes

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 nurse implementing?

SOAP charting

Several nurses on the same hospital unit communicate on the same social networking site. A nurse posts the following statement to the social networking page, "The lady in room 34 with heart failure was a train wreck!" In which manner has the nurse failed to apply the principles of confidentiality?

Sharing information about a client beyond the area of client care is unacceptable and breaches the client's confidentiality rights.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

Short bones contribute to movement.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort?

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?

Slander

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

Speak directly to the client.

A nurse is attempting to communicate with a client who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process?

Speak slowly and distinctly, but not loudly.

A hospital is evaluating its policies and procedures. What type of evaluation is the hospital conducting?

Structure

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

A client comes to the health care provider's office for a follow up. The client was recently hospitalized for heart failure. The nurse reviews the client's discharge plan, which included the client being supplied with telecommunications technology for monitoring daily weights and blood pressure. Then each day, after completing those tasks, the client would receive a phone call from the nurse practitioner about the results and adjust the client's medication schedule. The nurse identifies this specifically as reflecting which type of care?

Telemedicine

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case?

The Good Samaritan law will provide legal immunity to the nurse.

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color.

Which are cognitive client outcomes? Select all that apply.

The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?

The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.

Which are psychomotor outcomes? Select all that apply.

The client will safely ambulate using a walker. Accurately drawing up insulin

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

The importance of consistent seat belt use

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?

The nurse should gently slide the client down his or her body to the floor.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

A client who gave birth yesterday refuses to eat the food provided by the hospital. The client reports needing special food brought from home by family. How would the nurse most appropriately address this situation?

The nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

"All of the people got themselves out of the car?"

It is time for a nurse to renew licensure. The nurse says, "I need some really easy and quick continuing education hours. I don't understand why we have to do these every year." What is the nurse's coworker's best response?

"Life-long learning is part of the code for nurses."

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?

"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."

Which is an example of an unintentional tort?

A nurse gives the client a medication, and the client has an adverse reaction to it.

Which scenario is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special testing

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf?

A surrogate decision maker

Which process evaluates and recognizes educational programs as having met certain standards?

Accreditation

Which word is best described as protection and support of another's rights?

Advocacy

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?

Assist in decision making based on the client's best interests.

A client has been in the emergency department for 3 hours for treatment of a migraine headache. Care has been delayed due to a multicasualty car accident. The client gets up to go to the bathroom unattended, faints, and suffers a subdural hematoma. The family threatens to sue for malpractice. Which element of malpractice will be the most difficult for the attorney to prove?

Causation

Which nursing situation is an example of an ethical dilemma?

Deciding whether to perform cardiac compressions against a client's wishes

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission

A client's record can be more accurate if the nurse:

uses point-of-care documentation.

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

A nurse from the postanesthesia care unit (PACU) transports a client in the elevator with a nurse from the intensive care unit (ICU). There are staff members and visitors in the elevator as well. Which response from the ICU nurse is appropriate when the PACU nurse begins the report?

"Wait and give me a report in the room at the bedside."

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

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?

Giving false reassurance

A nurse talks with family members about an AIDS client from the clinic where the nurse works. Which tort has the nurse committed?

Invasion of privacy

Which are areas of potential liability for the nurse? Select all that apply.

The nurse fails to document refusal by the client to ambulate following surgery. The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour.

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances?

The nurse is legally held to the same standards of care as when staffing levels are normal.

Which action would cause a charge nurse to have concerns about a nurse's moral agency?

The nurse was seen at a grocery store after calling in sick.

A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client?

The student nurse, the nurse instructor, and the hospital

Nurses who value client advocacy follow what guideline?

They give priority to the good of the individual client rather than to the good of society in general.

A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

Tort

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature?

Witnesses to a signature do not need to read the will.

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the client to explain the statement.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

A nursing student administers an overdose of a narcotic to a client and the client arrests. When discussing the incident with nursing faculty, which statements made by the student indicate the need for further teaching? Select all that apply.

"I am glad I am a student because nursing faculty will be blamed, not me." "I cannot be held liable because this is only my second time at this facility."

A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy?

"I see you are upset. Would you like to talk?"

A pregnant client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed, and the health care provider informs the client that there are normal fetal heart tones noted. The client begins to tear-up and has a worried appearance. To facilitate therapeutic communication, what statement would the nurse make after observing the client's nonverbal communication?

"Take your time and tell me how you are feeling. I have plenty of time to answer your questions and discuss any thoughts or feelings with you."

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment."

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"What did your health care provider tell you about your need to be admitted?"

Which scenario is an example of the laissez-faire approach to value transmission?

Allowing a child to decide not to have an intravenous line inserted

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

Analyze and Plan

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

Which ethical principle refers to the obligation to do good?

Beneficence

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure.

An informatics nurse is demonstrating how to use an updated version of an electronic documentation system to a group of staff nurses. The nurse shows the staff that they can follow the same steps that they used with the previous system but need to add one additional final step to the process. The informatics nurse's actions reflect which concept of usabilty?

Consistency

Which is a characteristic of the care-based approach to bioethics?

The promotion of the dignity and respect of clients as people

What is the term for the beliefs held by the individual about what matters?

Values

An informatics nurse specialist is engaged in evaluating a clinical information system. At which time would the nurse specialist anticipate the need to obtain help from a statistician?

When determining the data collection method

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase

The nurse has established client outcomes and outcome criteria. What should the nurse do next?

Write a client plan of care

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome.

An informatics nurse specialist is working on a team that is considering a new technological system for the facility. Which aspect would be most important for the team to do as the first step?

Determine the need or problem to be solved

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed.

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment?

Safety

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and security

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.

"We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive." "This system fits nicely into how we work."

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology.

A nurse shows client advocacy by:

offering a hospice consultation to a client who is terminally ill.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

Cognitive

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

When documenting client care in the client's health record, which abbreviations would be appropriate for the nurse to use? Select all that apply.

PO mL

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed:

Peer review

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement?

Physical changes

Which organization audits charts regularly?

The Joint Commission

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease.

Which client outcome is an example of a physiologic outcome?

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula

A nurse becomes concerned that a coworker may have a substance use disorder. Which behaviors by the coworker would increase this concern? Select all that apply.

The last two times the nurse has needed help turning a client, the coworker could not be found. The coworker has needed to leave early "to pick up my kids" several times in the last 2 months. The coworker has stopped eating lunch in the breakroom with other nurses.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A female client is brought to the emergency room with matted hair, bruising, and malnutrition. The nurse suspects physical abuse and neglect. The nurse states, "This happens to many women." Which type of ethical approach is the nurse exhibiting?

Feminist

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

outcome evaluation.

A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:

remain honest, open, and frank.

A mother brings an infant into the clinic for a well-baby visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding. and the nurse finds that the baby is gaining weight appropriately. Which is an appropriate evaluative statement for this client?

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

An informatics nurse specialist teaches a group of staff nurses how to document client care in the new electronic health record. To document assessment findings, the nurses are to select the correct information from a drop-down list. During the teaching session, one of the nurses asks, "Why do we have to use this list. Why can't we just type in what we want to say?" Which response by the informatics nurse specialist would reflect the most important reason for documenting in this way?

"Documenting this way allows nurses' actions to be measured."

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Does it hurt when I touch you here?" "Are you ready to get out of bed?" "Is there any chance you might be pregnant?" "Do you smoke cigarettes?"

An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply

"Have you experienced any falls and hit your head?" "Are you having any dizziness?" "Is the headache affecting your vision?"

An informatics nurse specialist is presenting an in-service program for a group of staff nurses on using the electronic health record. As part of the presentation, the nurse specialist is emphasizing the need for maintaining security and privacy of the record. During a break in the program, the nurse specialist overhears a conversation among several of the staff nurses. Which statement would the nurse specialist identify as a cause for concern?

"I always put a sticky note on the computer terminal with my password on it in case I forget it."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

A client comes to the primary care provider's office for a routine follow-up visit. While completing the assessment, the nurse tells that client about a new patient portal that the office has begun to use. The client asks the nurse, "I guess this is a good thing, but what is it and what does it do?" Which response by the nurse would be appropriate? Select all that apply.

"It's a site you can access through your home computer or smartphone." "It allows you to get information about your health status and care." "You can communicate with your provider through the system." "It allows you to request refills for your prescriptions."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

"Only certain members of the health care team can extinguish a fire."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

An informatics nurse specialist is working with a team designing an update to a clinical information system being used by the nursing staff. When selecting the language to be used with the system, which characteristic would be most appropriate to address? Select all that apply.

Terminology is clear and concise for the nurses Terminology is familiar to the user Terminology reflects the users work context

An informatics nurse is participating in an online continuing education course about informatics, health information technology, and the use of standard terminology. The informatics nurse demonstrates understanding of the information presented in the course by identifying which aspect as a characteristic of nursing standard terminologies? Select all that apply.

The terminology identifies concepts related to the delivery of nursing care. The terminology is structurally organized to reflect nursing knowledge. The terminology provides a means to code the delivery of nursing care. The terminology aids in promoting interoperability.

Which is not a purpose of the client care record?

To serve as a contract with the client

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device?

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

administering medications to the client

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

charting by exception

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize:

equipment and personnel.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

transfer belt

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

trapeze bar

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

tremor

The nurse is caring for a client who is on bed rest. After reviewing the image above, which is the most appropriate reason for the nurse to observe this client perform the activity?

"A client can perform this activity to prevent a permanent a condition in the feet caused by bed rest."

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps"

An informatics nurse is heading a team working on evaluating a newly implemented nurse-driven protocol for urinary catheter care. The team has completed the evaluation and is now ready to document the findings. One of the team members asks, "Why do we need to document this information. Isn't the fact that we evaluated the protocol enough?" Which response by the informatics nurse would be most appropriate as the priority reason for this documentation?

"Documentation helps ensure that any practice improvements needed can occur."

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with peforming activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower."

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?"

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?

"Legal policy requires nursing practice to be permanently integrated into the client record."

The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?

"Myocardial infarction."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

"What day of the week is it?"

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply.

Analyzing data Identifying patterns Identifying indicators of potential dysfunction

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

A nurse threatens to restrain a verbally abusive client if the abuse continues. Which legal tort has the nurse committed?

Assault

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

Battery

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplary team?

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

Which is the best source of information for the nurse when collecting data for an assessment?

Client

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

Which is the primary purpose of client records?

Communication

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

An informatics nurse is evaluating a new clinical information system for usability. The nurse notes that the system requires the user to complete a maximum of 3 steps to complete a task. The system also provides shortcuts to frequent users of the system. The nurse would determine that which concept of usability is being addressed?

Efficient interactions

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached?

Empathy

Which piece of client information is subjective?

Generalized myalgia or muscle pain

Which are models used in nursing to assist in clustering data? Select all that apply.

Human Needs Functional Health Patterns Human Response Body Systems

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

Which nursing skill uses all five senses?

Observation

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

Obtain order from a licensed provider within minutes of restraint application. Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal

Which client outcomes are psychomotor outcomes? Select all that apply.

The client measures capillary blood glucose level. The client self-catheterizes using clean technique.

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed?

The client pushes the walker ahead, following behind it.

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

The client will ambulate with assistance by the nurse to a bedside chair.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

Usability

A parent teaches a child not to drink and drive; however, the parent does drink and drive. This action results in:

a failure to model one's own values.

A nurse is caring for an 18-month-old client after a tracheostomy. The client is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to:

ask why the client thinks the client will wake up during surgery.

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of:

ataxia.

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet.

"Measurable qualities, attributes, or characteristics that identify knowledge or health status" defines:

criteria.

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?

decrease in flexibility

An informatics nurse specialist is describing the role of informatics in health care to a group of staff at a facility. The nurse specialist determines that the teaching was successful when the group identifies which as a core practice area?

electronic health record

The purpose of obtaining a nursing history is to:

identify actual and potential health problems

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

Ethical distress is:

knowing the correct action but being unable to perform it due to constraints

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?

leave the friction-reducing sheet in place once the client is transferred

During a recent visit to the clinic, a client tells the nurse, "I've been using my cell phone to track and record the foods that I eat so that I can better understand if I'm making healthy food choices." The nurse interprets the client's statement as reflecting which technology?

mHealth

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

Adduction

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

An informatics nurse specialist is working with a group of nurses who are tasked to test a new electronic health record system. Which phase would the group be involved with as the last phase of testing?

User acceptance

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

"Check breathing and heart rate."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse's friend states, "I admire you so much. I would love to be a nurse, but I don't think I have the courage." Which response will the nurse make?

"You can work on being more courageous as you learn to be a nurse."

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document?

A living will

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

The nurse is evaluating risk factors for a developmentally diverse group of clients. Which client(s) is at risk for safety? Select all that apply.

A toddler allowed to crawl in a house that has not been childproofed An older adult client with a shuffling gait

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

Acts to prevent injury to the client and/or nurse

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client?

Address the collaborative problem PC: Hypertension.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?

Assess the client's blood pressure to determine if the medication is indicated.

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys.

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?

Narcotic analgesic to treat pain

An informatics nurse specialist is interviewing several nurses who have participated in testing a new electronic assessment tool. The nurses report that the tool "feels so familiar, like we know exactly what it is that we're supposed to do." The nurse specialist interprets this as indicating which concept?

Naturalness

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and the members of other health disciplines.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance?

Quality by inspection

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy

A nurse has completed 4 hours of an 8-hour shift on a medical-surgical unit when the nursing supervisor calls. The nursing supervisor directs the nurse to give a report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with client assignments and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources

A client is scheduled to have an elective surgical procedure performed but cannot decide whether to go forward with the procedure or cancel it. The client asks the nurse to help make the decision because the client lacks knowledge about the procedure. Which action by the nurse is the best way for this nurse to advocate for the client?

Allow the client to verbalize feelings, and provide information to help the client assess

A nurse is providing care to a client and is preparing the client for breakfast. The nurse assists the client out of bed to the chair and then helps the client open the items on the breakfast tray. The client begins to eat breakfast. The nurse tells the client, "I'll be back in about 10 minutes to check on you. In the meantime, here is your call light in case you need me." About 10 minutes later, the nurse returns to check on the client. The nurse is demonstrating which ethical principle?

Fidelity

A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case?

The agency's risk manager

An informatics nurse specialist is using data visualization to present information about client populations admitted to the health care facility. Which type of format would the nurse most likely use? Select all that apply.

Bar graphs Infographics Pie charts

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

Battery

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

Breach of duty

An informatics nurse is preparing a training program for staff nurses in the facility. The facility will be implementing a new electronic health record. To ensure the best results, which type of training would the informatics nurse most likely use?

Classroom education

Which is an appropriate expected outcome for a client?

Client will independently follow transplant medication schedule 1 week after surgery.

What is likely to have the greatest influence on an adolescent's formation of values during this developmental stage?

Peers

Which statement on a plan of care should a nurse identify as a nursing intervention?

Perform range-of-motion exercises to all of the client's joints each morning.

An informatics nurse specialist has received an update from the vendor who is providing the electronic health record. During which phase of the system development lifecycle would this update be made?

Maintain

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?

Make changes in the plan of care based upon assessment data.

While caring for an infant, the nurse hears another child screaming in the next room and rushes there, forgetting to put the side rails up on the infant's crib. The nuse returns to the room to find that 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?

Malpractice

A nurse is conducting a client assessment and documenting the findings in the client's electronic health record (EHR). Which description would the nurse most likely enter as data in the system to document the client's activity level?

Walks without assistance

The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?

Watching client walk into room

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually

does not contain documented scientific rationales.

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

progress notes

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

prone

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should:

provide the client with an overhead trapeze.

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to help prevent motor vehicle accidents? Select all that apply.

Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

"I am concerned that the small rugs in your home can be a tripping hazard."

What dual purpose does an audit serve?

Quality assurance and reimbursement

A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach?

"Surgery is your only option. You need this operation."

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:

a guideline.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent the legs from rotating outward."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear."

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

An informatics nurse specialist is conducting a discussion with a group of staff nurses who have been participating in the implementation of an updated electronic protocol system. The informatics nurse specialist is gathering information about the system's optimization. One of the participants asks, "Why is this information important?" Which response by the informatics nurse specialist would be appropriate?

"We can make improvements to the system to improve our delivery of care."

The nurse has been assigned to a group of clients. Which client should be the nurse's priority?

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Provide the client with assistance in transferring to the bedside commode.

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

What is a benefit of regular exercise over time?

decreased heart rate

An informatics nurse specialist is talking with a group of health care providers at a local clinic about implementing a patient portal system. During the presentation, one of the providers asks the nurse specialist, "I understand what this portal is, but how will it help our clients?" Which response by the nurse would be appropriate? Select all that apply.

"Your clients will be able to actively participate in their care." "Your clients will be more motivated to get preventive care." "Your clients will be more likely to seek out care if needed." "Your clients will be able to manage their chronic problems better."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches."

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?

4/10 pain on pain scale, epigastric pain; with reports of nausea

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation?

A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

Affective

A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome?

Affective

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

An informatics nurse specialist is involved in the development of a clinical system in a facility. As part of this process, the nurse is applying the system development lifecycle. Place the phases of the system development lifecycle in the order that they would occur from first to last.

Analyze and plan Design and build Test Train Implement Maintain and evaluate

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?

Another registered nurse with critical care certification

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate?

Assess the triggers from the data.

A facility plans to implement a new electronic medication documentation system. An informatics nurse specialist conducts a focus group with staff nurses to gather information. The nurse specialist asks the group about the current system being used, including a step-by-step account of the actions they perform. The nurse specialist also asks the nurses how they see this new system affecting this process and their overall daily tasks. The informatics nurse specialist is demonstrating which ANA informatics competency?

Assessment

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household?

Avoid stuffed animals and blankets in the crib.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?

Client's record and occurrence report

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use?

Cllinical pathway

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

Clustering significant data cues

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

An informatics nurse specialist working at an ambulatory care center is interviewing clients about their experiences in using the center's patient portal. A majority of the clients have voiced dissatisfaction, stating that they "find the display screen confusing and are not sure what to click on to get the necessary information." They also talk about difficulties in trying to find their test results. Based on this information, the nurse specialist identifies a need to talk with the information technology team about ways to make the portal easier for clients to use. The informatics nurse specialist is demonstrating which ANA informatics competency?

Collaboration

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

Comfort the client and family.

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?

Continue the plan of care.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

A nurse is documenting a client's vital signs, height, and weight in the electronic health record. Applying the framework for informatics practice, the nurse would identify these values as which component of the framework?

Data

An informatics nurse is applying the informatics framework to a clinical situation. Which component of the framework would the nurse apply first?

Data

An informatics nurse specialist is describing the framework underlying informatics practice. Which component of the framework would the nurse specialist describe as discrete entities without interpretation?

Data

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply.

Demonstrate Choose

An informatics nurse specialist is participating in evaluating the a new clinical information system being used at a provider's office. The nurse specialist has determined what is being evaluated and the question being asked and has completed the literature search. Which action would the nurse specialist do next?

Determine the data elements to be collected

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?

Discovering a problem

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

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?

Effective decision making

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength

The nurse works as a client advocate for an older adult client admitted with hyponatremia. Which action can the nurse take to help the client advocate for oneself?

Encourage the client to ask questions.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint

A nurse is completing the assessment of an 85-year-old client who is being admitted to a memory care home for progressing dementia. The client is unable to answer some of the questions or provide some of essential information that the nurse needs to create the best nursing care plan for this client. Which source will be the best for the nurse to consult to gain this missing information?

Family member

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

Florence Nightingale

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

An informatics nurse is teaching a clinic staff about a newly implemented patient portal being used. The informatics nurse determines that the teaching was effective when the staff identify which aspect as being the focus of this technology?

Greater client engagement

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

Health teaching and health promotion

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold your cane on the right side.

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

An informatics nurse specialist is working as part of a team to develop and implement a new electronic documentation and reporting system at the clinic. The team has analyzed the situation, created a plan based on supporting evidence, created a design, built the program, and has worked out issues with the system. Staff who will be using the system have received education about the system and how it works, as well as how to use it. The team would proceed to which phase of the system development lifecycle next?

Implement

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.

Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm.

A client comes to see the cardiologist for a routine follow-up visit. At the visit, the nurse reviews the client's electronic health record. The nurse is able to access a report from the client's last visit to the primary care provider last month and the report from an emergency department visit two weeks ago for reports of shortness of breath. The record also lists two changes in the client's medication based on the emergency department visit. The nurse's ability to access this information reflects which concept?

Interoperability

A nurse working in a primary care provider's office is using the clinical information system to review a client's health information. The nurse is able to review the client's last visit to the primary care provider as well as information from a recent hospitalization, and also a visit that the client made to the cardiologist last week. The nurse's ability to review this information is based on which aspect of the clinical information system?

Interoperability

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Meeting the care needs of clients

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care?

Nursing diagnosis

Which is most important for the nurse to include in a client's plan of care?

Nursing interventions

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable?

Omitting documentation of blood pressure at the end of the shift

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

An informatics nurse specialist is involved with implementing strategies to improve the performance of the clinical information system being used. As part of this process, the nurse specialist is working on updating the plans of care in the system to reflect changes to a procedure based on new evidence. The nurse is also working to streamline the display screens to reduce the need to document the same information in three different areas. The nurse specialist is addressing which aspect of the system?

Optimization

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient portal

An informatics nurse specialist is preparing a presentation about patient portals for a group of primary care providers in an office practice. When describing the tasks that can be accomplished by clients using the portal, which activity would the informatics nurse specialist include? Select all that apply.

Paying their bill Checking their lab test results Scheduling appointments Receiving screening reminders

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?

Perform hourly neurovascular assessment.

A nurse is reviewing the medical record of a client at the clinic. The nurse notes that the medication and dosage prescribed for the client was based on information gathered about the client's genetic makeup from the electronic health record. The nurse interprets this as:

Pharmacogenomics

A mother brings an 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 which type of outcome statement?

Physical changes

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply.

Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe

A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance? Select all that apply.

Plan a strategy using indicators. Assess the change. Discover a problem. Implement a change.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in the client's care.

An informatics nurse specialist is extracting data from the facility's electronic health record in an attempt to identify clients at risk for developing catheter-related bloodstream infections. When gathering this data, the nurse specialist is using which technique?

Predictive analytics

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

An informatics nurse specialist is conducting a seminar on the emergence of telehealth and its importance in health care delivery. The nurse specialist determines that additional discussion is needed when the group identifies which aspect as an advantage of this technology?

Promote the development of new health care services

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing?

Psychomotor

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions.

In SBAR, what does R stand for?

Recommendations

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

The nurse is preparing to assess a new client just admitted to the unit. The nurse prepares to interview the client and complete an assessment. Place the following steps in the order in which the nurse will complete them. Use all options.

Reviews the client's past medical history Introduces oneself to the client Asks pertinent questions Establishes goals of care to best help client

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Which roles are a responsibility of the nurse in the nurse-health care team relationship? Select all that apply.

Serve as a liaison between the client and family and the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

Simplicity

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims'

The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position?

Sims'

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

Which are areas of focus in quality improvement? Select all that apply.

Systems Processes Data use

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk gently to her.

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing.

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

An informatics nurse specialist is involved in the testing of a new clinical information system that is being planned for use by the health network. The system is currently undergoing unit testing. Which information would be addressed during this phase? Select all that apply.

The correct information appears on the screen. All information is included. There are no typographical errors. Information is in its proper location on screen.

Which nursing actions would take place during the diagnosis stage of the nursing process? Select all that apply.

The nurse asks, "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" The nurse identifies that the client has effectively coped with health stressors in the past. The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. The nurse determines that the client needs to have a decrease in activity.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?

The nurse devises a postdischarge questionnaire to evaluate client satisfaction.

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

An informatics nurse specialist is involved in evaluating a new electronic documentation system being used by the facility. The nurse specialist has collected the necessary data, analyzed it, and is now preparing to display the data using a bar graph to present the information. When displaying the data, which information would be important for the nurse specialist to include? Select all that apply.

Title of the graph Date range Sample size Legends for colors

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms.

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent?

True collaboration

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

Use minimum disclosure policy to release the information.

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

Use of strong passwords

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

a referral.

What ensures continuity of care?

communication

The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

is demonstrating a common gait for the older adult.

As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise?

isometric

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise?

isometric

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?

move the client to edge of the bed opposite the side that client will be turning

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

near the client's hip, with legs shoulder width apart and one foot near the head of the bed

The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply.

nursing care provided physical assessment nursing diagnoses client teaching

An informatics nurse specialist is conducting an in-service program for a group of informatics nurses. The nurse specialist is reviewing the components of the system development lifecycle and determines that the education was successful when the group identifies the phases of the lifecycle as similar to the:

nursing process.

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

A client requires frequent turns but is unable to assist by grasping the side rail. The nurse will place the client in which positions for a turn to the client's left? Select all that apply.

on the right side of the bed right leg crossed over the left leg

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of:

outcome evaluation.

An informatics nurse is teaching a client recently diagnosed with heart failure how to use a web-based tool to learn more about this condition. The tool is provided by the client's primary care provider. The informatics nurse is teaching the client about:

patient portal.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

pull the shoulder blade forward and out from under the client

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

retrieval of information is more efficient.

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

revise or modify the client care plan.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

scoliosis

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

shortness of breath after walking up five stairs

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

slight Trendelenburg

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

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:

structure.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

supine

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.