PrepU questions for Exam 4

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 mostappropriate response by the nurse?

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

The nurse is educating a client on vitamin and mineral intake. Which statement by the client indicates a need for further teaching?

"Taking megadoses of vitamins will help me increase muscle mass quickly."

Which statement by the nurse is an example of deception?

"This injection of procaine will feel like a little pinch."

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."

Nursing practice consistent with the Code of Ethics for Nurses includes which actions? Select all that apply.

Delivering culturally safe care Acknowledging that the client is the focus and center of care and remains a part of the treatment team Protecting the client's right to confidentiality and privacy

Which example most accurately depicts the ethical principle of autonomy?

Describing a surgery to a client before the consent is signed

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

The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding?

Iron

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?

"According to research, vegetarians have a higher incidence of obesity than others."

A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?

"Can you share an example of what you ate yesterday?"

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality."

A nurse is planning a high-energy diet for a client. Which statement by the nurse best describes the types of foods the client should include in the diet?

"Include plenty of grains, fruits, and vegetables in your diet."

The nursing student is describing moral values to another student. Which statement is correct?

"Moral values give individuals some sense of what is right and wrong."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?

"My husband and I are ordering a product that has megadoses of vitamins."

A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?

"Obesity is closely linked with vegetarianism."

The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?

"When I take my medication, I will eat a banana or take it with a glass of orange juice."

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."

A client is 6 weeks' pregnant and is in a clinic for her first prenatal exam. The client asks the nurse how her nutritional needs have changed now that she is pregnant. Which is the nurse's best

"You will need an increase in calories, protein, calcium, folic acid, and iron."

The nurse attempts to notify a health care provider about a client's elevated temperature but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation?

1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified.

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

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. 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 options.

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

Which example best describes feminist ethics?

An approach critiquing existing patterns of oppression and domination in society

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.

Which action constitutes battery?

An older adult client refuses an intramuscular injection, but the nurse administers it.

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

Accreditation

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply.

Adolescents, pregnant or lactating woman, strict vegetarians

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals.

A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle?

Autonomy

Which ethical principle is related to the idea of self-determination?

Autonomy

The nurse is assessing adequate nutrition for residents of a long-term care facility. Which strategies are recommended to address age-related changes affecting nutrition? Select all that apply.

Avoid cold liquids with decreased peristalsis in the esophagus. Serve one food at a time rather than mixing foods. Avoid eating right before bedtime for gastroesophageal reflux. Eat a high-fiber diet for slowed intestinal peristalsis.

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

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

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing?

Certification

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?

Check the medical record for the client's prescribed diet.

Which traits are examples of virtues that can exemplify character and conduct as a professional nurse? Select all that apply.

Compassion Trustworthiness Humility

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet?

Cranberry Juice

Which is true of the Occupational Safety and Health Act?

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

The nurse is managing the care for a postoperative client. How does the nurse demonstrate advocacy?

Limiting visitors due to the client reporting pain

A nurse knows that the expression "Do not cause harm" refers to which ethical principle?

Nonmaleficence

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the mostappropriate action of the nurse?

Obtain a medical order.

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

Overweight

A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?

Overweight

A client continues to complain of pain despite receiving medication. The family states, "In our culture it is acceptable to complain out loud." What would be the best response by the nurse?

Tell me more about your cultural beliefs.

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.

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

A client who is new to the clinic is suspected of having a vitamin A deficiency. Which assessment finding would most clearly support this potential diagnosis?

The client cites difficulty seeing at night

During a general survey, the nurse documents the waist circumference of an overweight female client as 43 in (109 cm). Which teaching should the nurse include about the risks associated with this waist circumference?

The client is at risk for diabetes

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

A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse confirms that the client's family has signed the consent form.

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

The nurse should ask the health care provider to come back and write the order.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the health care provider. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?

The nurse should call and inform the nursing supervisor of the situation

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.

Which are examples of a nurse appropriately protecting a client's privacy? Select all that apply.

With the client's permission, the nurse explains the client's diagnosis to the client's spouse. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data.

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.

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

adolescent who is in the second trimester of pregnancy

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.

A nurse is caring for a client who had an appendectomy earlier in the day. The client now has bowel sounds and is passing flatus. Which food is appropriate for the nurse to serve to the client at this time?

apple juice

Ethical distress is:

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

A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?

low prealbumin levels

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet?

maintenance of normal bowel elimination

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?

serum albumin

Which laboratory test is the best indicator of a client in need of TPN?

serum albumin

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

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

After a teaching session regarding dietary choices of carbohydrates, which client responses indicate correct understanding of the foods to limit in the diet? Select all that apply.

wheat germ corn on the cob apple rice

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 nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?

Drink juice for majority of fluid intake.

A nurse is being sued for malpractice in a court of law. What elements must be established to prove that malpractice or negligence has occurred? Select all that apply.

Duty Breach of duty Causation

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws?

Emergency care for a choking victim in a restaurant

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog.

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 is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability?

Filling out an occurrence report and notifying the healthcare provider

The nurse is preparing to educate a pregnant client who is in the clinic for the first prenatal appointment. Which vitamins or minerals will the nurse include in the teaching to prevent neural tube defects in the fetus?

Folic acid

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

Personal values

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?

Psychological reasons for overeating should be explored, such as eating as a release for boredom.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is represented by what value?

Recommended dietary allowance

A nurse is providing care to an older adult client who was just diagnosed with cancer. The client together with the immediate family discuss their preferences with the health care providers involved. The health care providers offer their clinical recommendations about possible treatments. Ultimately, the group arrives at a decision. The nurse interprets this decision-making process as reflecting which type?

Shared

A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing the nurse's own judgments based on the nurse's expertise. Which type of healthcare decision making does this represent?

Shared decision making

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What is an example(s) of legal safeguards for the nurse? Select all that apply.

The nurse confirms informed consent was give by the client to perform a procedure. The nurse educates the client about what to expect during the hospital stay. The nurse documents all client care in a timely manner.

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.

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

To protect the safety of the public

A health care provider orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN)

Ethical practice is evaluated as a portion of the nurse's annual review. Which practice(s) would cause the evaluator to reduce the nurse's score on this section of the review? Select all that apply.

The nurse often speaks harshly to cleaning staff and transport workers. The nurse is frequently late to work.

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

The promotion of the dignity and respect of clients as people

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.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care

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

Values

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

Vitamin K

A client who has bleeding tendencies has a deficiency in which vitamin?

Vitamin K

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

An older adult was just diagnosed with stage 4 pancreatic cancer. The client states, "I am so overwhelmed and I feel like everyone has already decided that I need to be put in hospice care." Complete the following sentence by choosing from the lists of options. The nurse upholds the principle of autonomy by

offering to answer questions the client may have about care and treatment options, and providing the client with the information needed to obtain a second opinion

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

The State Board of Nurse Examiners

After caring for a pediatric client, the nurse is surprised to learn about being named in a malpractice lawsuit. Select the four actions that meet the legal requirements of malpractice.

The client suffered an injury. The nurse has the duty to care for the client. The nurse failed to provide appropriate care. The nurse's lack of action directly resulted in harm. The nurse does not have a professional liability insurance.

A nurse is checking a client's capillary blood glucose level. Which nursing action is mostappropriate?

Touch the test strip directly to a drop of blood.

A client is brought to the emergency department by an adult child, who states, "I am unable to care for my parent anymore. Although I would like to, financially and physically I cannot do it anymore." What ethical problem is the adult child experiencing?

moral distress

The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?

older adults living on a fixed income