PREP U PRACTICE QUIZZES

A client who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the client to expand on this and express concerns in more specific terms?

"Feel like a woman . . ."

A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response?

"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."

The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply.

"I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn." "I can be charged with negligence if I notify the health care practitioner about a change in a client's status but do not follow up or document.

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client?

orthostatic hypotension

A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?

Autonomy

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data?

Subjective

Which question or statement would be appropriate for eliciting further information when conducting a health history interview?

"Tell me more about what caused your pain."

A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. The nurse conveys caring by saying:

"Tell me what is on your mind."

A client is questioning the need for surgery. The client asks the nurse, "What should I do?" Which answer by the nurse is based on advocacy?

"Tell me why you do not want the surgery."

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide?

"Try to bear your weight on your hands, not your armpits."

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."

A client is admitted to the hospital and the nurse is attempting to complete an admission assessment. The client reports that the spiritual healer will be coming in soon and is upset by the admission questions. What is the most appropriate response by the nurse?

"We can wait for your healer to come and then work together to answer these questions."

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 is completing a health history with a client being admitted for a mastectomy. During the interview, the client states, "I don't know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening

"You seem unsure. Tell me your concerns about your surgery."

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response? Select all that apply.

-"Flossing removes plaque and food debris that a toothbrush may miss." -"The chance of tooth and gum disease can be reduced by flossing."

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

-Approach the client from the front. -Use the client's name. -Smile and maintain eye contact.

The nurse is educating a client with poor peripheral circulation about the importance of caring for their feet. What should the nurse provide regarding foot care in order to prevent complications? Select all that apply.

-Avoid crossing your leg and feet. -Inspect feet daily.

The nurse is providing care to a client's eyes. What actions are appropriate when providing eye care? Select all that apply.

-Clean the eye from the inner canthus to the outer canthus using a wet, warm washcloth; cotton ball; or compress. -Use a protective shield if necessary to keep the lids closed when the blink reflex is absent. -use a different section for each stroke until the eye is clean

A nurse is making an unoccupied bed for a hospitalized client. Which actions are appropriate steps for the nurse to perform? Select all that apply.

-First, adjust the bed to the high position and lower the side rails. -Fold reusable linens on the bed in fourths and hang them over a clean chair. -Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. -Tuck the bottom sheets securely under the head of the mattress to form a corner, according to agency policy.

A nurse has finished providing morning care for the client. Which safety measures should the nurse employ prior to leaving the client's room? Select all that apply.

-Place the bed in the lowest position. -Test the functioning of the bed and bed controls. -Place the call light near the client within reach. -Ensure the bed is locked.

A nurse is asked to serve on an ethics committee. Which roles would the nurse be required to fill on the committee? Select all that apply.

-Presenting explanations about technical terminology -Advocating for the client's wishes -Serving as a liaison between the family and the committee members

A nurse is performing an admission assessment with a non-English speaking client. Which actions can the nurse take to enhance communication? (Select all that apply.)

-Request assistance from an agency interpreter. -Contact a telephone-based medical interpreter. -Use an electronic translator.

Which actions by the nurse demonstrate the ethical principle of fidelity? Select all that apply.

-Taking an extra client assignment so that the client will be cared for -Maintaining current nursing registration and meeting continuing education requirements -Performing an intervention for a client at the time that was promised

Nurses are working in an emergency department (ED). Which nurses are acting in a moralizing manner? Select all that apply.

-The client frequently visits the ED for various reports of pain. The nurse tells another nurse, "That client is drug seeking." -The client is found to be at fault in a motor vehicle accident in which others are injured. The nurse delays treatment for this client.

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.

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

The nurse is using nonverbal communication when caring for a group of clients. Which situation reflects nonverbal communication? Select all that apply.

-The nurse is maintaining eye contact when changing a client's dressing. -The nurse has a smile when being thanked for caring for a family member. -The nurse is using a quiet tone of voice.

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice? Select all that apply.

A nurse threatens to hit an older client who has dementia and is screaming. A nurse seeks employment in a hospital after falsifying credentials on a resume. A nurse places a client who is a fall risk in restraints without an order from the health care provider. A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI).

A nurse is assigned the care of a client who speaks a nondominant language. The nurse does not understand the client's language. Which agency resource is best for the nurse to use in this case?

A professional interpreter.

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

Advocacy

During a nursing shift, which events warrant completion of an incident report? Select all that apply.

An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. A visitor slipped and fell in the hallway, but was not injured. A client falls while being transferred from the bed to the chair.

A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication?

Ask the care provider to come and assess the client.

An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?

Asking the LPN/LVN to teach a new diabetic client how to administer insulin

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Assault

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which action?

Battery

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

The nurse inserts a prescribed urinary catheter into the client's urethra after the client has refused the procedure. The client suffers an injury. The client may sue the nurse for which type of tort?

Battery

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

The evening nurse received a change-of-shift report from the day nurse. The day nurse's report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F (39.4°C). A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability? Select all that apply.

Breach of duty has occurred.

A nurse is taking care of an older adult client who was admitted for pneumonia. The client feels very weak and tired but has soiled the linens with urine and feces. What would be the mostappropriate action by the nurse?

Cleanse the perianal area and change the linens with the client in the bed.

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice?

Code of ethics

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?

Cognitive

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?

Collect data about client responses.

Which is the nurse's best legal safeguard?

Competent practice

Which term is most appropriate for describing a healthcare practitioner who is respectful of the healthcare traditions of other cultures?

Culturally sensitive

A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. Which element of liability does this description of the client's injuries represent in terms of proof of malpractice?

Damages

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care?

Discuss any lack of progress with the client.

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.

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated?

Duty

Which elements are necessary to prove malpractice? Select all that apply.

Duty Breach of duty Causation Damages

A nurse learns to adopt behavior modeled by a charge nurse. What ethical principle or behavior is the nurse most likely to learn through this process?

Ethical conduct

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when reflecting on the decision-making process and the role it will play in making future decisions?

Evaluating

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

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 restaraunt 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?

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

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?

Invasion of privacy

The nurse is reviewing charges to clients for surgical procedures and observes different charges dependent upon insurance status. The nurse immediately reports this bias in charges to the supervisor for action. What principle of bioethics is the nurse demonstrating?

Justice

A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?

Laboratory data

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments?

Libel

A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report?

Mental status

A nurse is educating an older woman on how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan?

Minimize stress on the wife's joints.

An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, the client has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse bestrespond to this situation?

Modify the plan of care to better reflect the client's current functional ability

A home health nurse performs a careful safety assessment of the home of a frail older adult client to prevent harm to the client. The nurse is acting in accord with which principle of bioethics?

Nonmaleficence

Which statement about laws governing the distribution of controlled substances is true?

Nurses are responsible for adhering to specific documentation about controlled substances.

The nurse is preparing to call a health care provider to report a significant decrease in a client's oxygen saturation level. What action should the nurse take first?

Obtain all needed information to give report.

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

Paternalism

A nurse is going to bathe a client who is confined to bed. What does the nurse do first?

Perform hand hygiene.

In SBAR, what does R stand for?

Recommendations

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?

Sacrum

A nurse is collecting data from a home care client. In addition to information about the client's health status, which is another critical observation the nurse should make?

Safety of the immediate environment

When analyzing an ethical dilemma according to the ethical framework, what is most important for the nurse to take into consideration?

Standards of conduct

The labor and delivery nurse is getting report from the previous shift regarding a client with Asian heritage. The nurse is told that the client did not ask for pain medication because "Asian people can handle pain." The nurse receiving report understands that this an example of what?

Stereotyping

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.

Injuries related to lifting or transferring clients occur in the health care setting and may be considered a work-related injury. Which law was intended to reduce work-related injuries and illnesses?

The Occupational Safety and Health Act of 1970

Which organization has established safety standards about the use of electrical equipment, isolation techniques, and toxic chemicals?

The Occupational Safety and Health Administration (OSHA)

What is always the primary concern when performing the evaluating step of the nursing process?

The client

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?

The condition of the skin over bony prominences

A client is being prepared for an elective surgical procedure and the consent form has not been signed. Who should the nurse have obtain consent for the procedure?

The health care provider performing the surgical procedure

Why is communication important to the "assessment" step of the nursing process?

The major focus of assessing is to gather information.

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with suspected MIs.

Which nursing intervention is the most clear and well-written?

The nurse will offer the client 100 mL of water every 2 hours while the client is awake.

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

To protect the safety of the public

A client is requesting to view all medical record information regarding the care received while hospitalized. What rights does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply.

To see the health record To copy the health record To restrict certain disclosures of the health record

A nurse is educating an adolescent regarding care of acne that is present on the face and neck. What actions should the nurse educate the client about that will promote healing and prevent outbreaks?

Use oil-free, water-based moisturizers and makeup.

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care?

Use small amounts of water and an oral suction device.

The client demonstrates stair climbing using a quad cane. This is an example of:

a psychomotor outcome.

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is:

an advance directive.

The nurse directs the nurse aide to assist a client with eating. Into which position will the nurse delegate the UAP to place the client?

high Fowler's

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should:

clean the dentures over a plastic basin or towel.

A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. Now the client is no longer able to express wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may involve:

ethical distress.

A client is hospitalized with orthostatic hypotension from dehydration. A nurse must delegate the task of hygiene and morning care to an unlicensed assistive personnel (UAP). What type of bath should the nurse instruct the UAP to provide to the client?

partial bath

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.

A nurse is reviewing the medical orders for a client who has had a stroke and is at high risk for aspiration. The orders state to place the client in a high Fowler position for eating and drinking. How would the nurse position the client?

sitting upright at 90 degrees

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides. The nurse informs the group that back stress and injury can be prevented by:

spreading the feet shoulder width apart to broaden the base of support.

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will:

terminate the plan of care.

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

traditional bed bath with linen change