Nursing Fundamentals

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 An older adult with pneumonia who is being discharged to the son's home tomorrow A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall An adult client who is being treated for kidney stones

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

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 the client how the bag is changed. Read the policy and procedure manual. Ask a skilled nurse to assist with the procedure. Determine the necessity of the bag change.

Ask a skilled nurse to assist with the procedure.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Bed bath for the newly admitted client who has multiple skin lesions Preparation of insulin for the diabetic client with an elevated blood glucose level Ambulation of the client with a history of falls for the first time after surgery Insertion of a urinary catheter in a client with benign prostatic hypertrophy

Bed bath for the newly admitted client who has multiple skin lesions

The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply. Confirming that the UAP has successfully passed this skill competency Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Transferring accountability and responsibility for the client to the UAP Confirming that the UAP has repeatedly completed similar tasks

Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Confirming that the UAP has repeatedly completed similar tasks

Which parties are essential for the nurse to include in the implementation of a client's plan of care? Client, family, and physician Client, physician, and hospital director Client, physical therapist, and nursing staff Client, surgeon, and physician

Client, family, and physician

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? Assess the client to determine whether the client is capable of ambulation. Instruct the client to ask the physicians for clarifications of instructions. Communicate with the physicians to coordinate their orders. Collaborate with the physical therapist to determine the client's ability.

Communicate with the physicians to coordinate their orders.

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 The client's condition Time and resources Feedback from the family

Finances of the client

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Request that the UAP place the steps of the task in the framework of the nursing process. Inform the UAP of the importance of following each step listed in the procedure manual. Ask another UAP to observe and assist the UAP in performing the task.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply. Psychosocial Supportive Physical Coordinating Technical

Psychosocial Supportive Physical

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? Educational Psychomotor Maintenance Surveillance

Surveillance

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 asks the nurse to repeat the instructions. The client tells the nurse that the client's spouse will handle the care. The client discusses the specifics of what was taught during the session.

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.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom.

The client with continuous pulse oximetry who requires pharyngeal suctioning.

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 explains each procedure twice to prevent client questions from wasting time. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine.

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

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? Medications used to treat diabetes mellitus Risk factors for and prevention of diabetes mellitus The severity of the client's disease The cellular metabolism of glucose

Risk factors for and prevention of diabetes mellitus

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? Remind the client that the client is responsible for the client's own health care decisions. Ask the client whether the client is afraid that the spouse will be angry. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form.

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

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? Providing medication for agitation Repositioning to prevent pressure injuries Ensuring that the endotracheal tube is secure Changing the dressing to prevent infection

Ensuring that the endotracheal tube is secure

What is the priority goal of interventions for a risk diagnosis? Reduce or eliminate contributing factors Prevent an actual problem Collect additional data Promote higher level wellness

Prevent an actual problem

Which nursing interventions are appropriate to perform when addressing a risk nursing diagnosis? Select all that apply. Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status. Promote a higher level wellness. Collect additional data to rule out the diagnosis.

Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status.

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? Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction. Revise the plan to include the inclusion of a support group. Report the client's inability to learn to the case manager.

Reassess the appropriateness of the method of instruction.

Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Reassess the client to determine whether the action is needed. Ask the client whether this is a good time to do the intervention. Record the planned intervention in the client's medical record.

Reassess the client to determine whether the action is needed.

Which nursing action can be categorized as a surveillance or monitoring intervention? Auscultating of bilateral lung sounds Providing hygiene Administering a paracetamol tablet Use of therapeutic communication skills

Auscultating of bilateral lung sounds

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? Discuss the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the physician. Discuss the client's options with other church members. Discuss the client's refusal with hospital risk managers.

Discuss possible alternatives to a blood transfusion with the physician.

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? Review with the client the risks and benefits of surgery. Ask the client to discuss the decision with family members. Discuss with the client the reasons for declining surgery. Notify the physician of the client's refusal.

Discuss with the client the reasons for declining surgery.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? Does this task fall within the scope of a UAP? What is the client's condition? How can I supervise the completion of this task? How can I explain the task to the UAP?

Does this task fall within the scope of a UAP?

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. Determine the frequency of pain medication. Medicate the client with the ordered pain medication. Instruct the client in nonpharmacologic pain management.

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

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? Explain the effects of a high-salt diet and smoking on blood pressure. Identify what barriers the client feels are preventing adherence with the plan. Collaborate with other health care professionals about the client's treatment. Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan.

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 manager Nurse case manager Physician Insurance company

Nurse case manager

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. Instruct the client that pain medication is available at regular intervals. Notify the physician that the client has required pain medications. Perform additional nonpharmacological pain interventions.

Reassess the client to determine the effectiveness of the interventions.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? Algorithm Standing orders Protocol Order set

Standing orders

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? Supportive Surveillance Collaborative Maintenance

Surveillance

The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.

help the client achieve optimal levels of health.

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. Consult with the physician for additional pain medication. Discuss the frequency of pain medication administration with the client. Assist the client to reposition and splint the incision.

Assess the client to determine the cause of the pain.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

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

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. Instruct the client to make alternate living arrangements. Communicate with the physician about additional orders. Inform the family that it is not possible to change the discharge plans.

Collaborate with other disciplines to revise the discharge plans.

Which roles are a responsibility of the nurse in the nurse-health care team relationship? Select all that apply. Provide creative leadership to make the nursing unit a satisfying and challenging place to work. Support the nursing care given by other nursing personnel. Serve as a liaison between the client and family and the health care team. Educate the family to be informed and assertive consumers of health care. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

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.

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. The client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. The parents have comprehensive insurance coverage for their family's medical care.

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

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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.

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

Before implementing a nursing intervention, which question(s) will the nurse ask oneself? Select all that apply. "Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Do any health care provider prescriptions need to be clarified?"

"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Do any health care provider prescriptions need to be clarified?"

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? "My daughter has been staying with me the past few weeks." "I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now." "I sort my medication into an organizer every week."

"My wife's been gone for about 7 months now."

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 gastroenterologist to explain the treatment plan to the client and family again. Ask the client to verbalize the medication regimen and diet modifications required. Ask the nutritionist to give the client strict meal plans to follow. Refer the client to available community resources and support groups.

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

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply. Collecting additional client data Modifying the client plan of care Performing an initial assessment of the client Developing client outcomes and goals Measuring how well the client has achieved client goals Collecting a database to enable an effective plan of care

Collecting additional client data Modifying the client plan of care

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? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family

Discontinue the education and attempt at another time.

Which statement best explains why continuing data collection is important? It is difficult to collect complete data in the initial assessment. It is the most efficient use of the nurse's time. It enables the nurse to revise the care plan appropriately. It meets current standards of care.

It enables the nurse to revise the care plan appropriately.

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. Ask the client's family to assist the client in following the plan of care. Provide information to the client on the benefits of complying with the plan of care. Discuss the desired outcomes with the client and the importance of the outcomes.

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

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? Registered nurse Nursing assistant A senior nursing student present for clinical Licensed practical nurse

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? Registered nurse Nursing assistant who is a nursing student A senior nursing student present for clinical Licensed practical nurse

Nursing assistant who is a nursing student

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? Perform vital signs and blood glucose level. Discuss the need to change positions slowly, especially when moving from sitting to standing. Perform a full review of systems. Initiate an intravenous line and administer 500mL of normal saline.

Perform vital signs and blood glucose level.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Assess an IV site for possible infiltration Reassess the client's sacrum for redness when doing a bed bath. Provide the client with assistance in transferring to the bedside commode. Retrieve a unit of blood from the blood bank.

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

In the implementation step of the nursing process, which activity is the nurse's first priority? Reassess client's needs. Document nursing care. Prioritize evaluation of care. Differentiate between subjective and objective data.

Reassess client's needs.

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. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.

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

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. The nurse should ask another nurse who was previously assigned to the client for instruction. The nurse should request that the blood transfusions be delayed until the next shift. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

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

The nurse is discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? To help the client adhere to the plan To give the client the opportunity to actively participate in care To save the client the trouble of looking in the menu To encourage the client to make a healthy food choice

To give the client the opportunity to actively participate in care