Wellness Exam 2 Book/ATI Questions

A nurse if discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicated culturally responsive care to the client

"I will ask the client if they want to schedule some times to pray during the day"

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

"Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?

Administering oxygen by nasal cannula

A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains

Affective

How best can a nurse evaluate goal attainment for a patient with a culturally diverse background?

Base decisions on feedback from the patient and the nurse's professional judgment.

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the levels of critical thinking

Basic

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients?

Chamomile

What is the best method for the nurse to ensure that a Croatian patient's nutritional needs are met during hospitalization?

Check with the patient on admission to determine dietary limitations and preferences.

During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking?

Clarity

On what premise is a nursing diagnosis identified for a patient?

Clustered data

In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias?

Collecting the patient's medical history

What is the primary purpose of the nursing diagnosis?

Communicating patient needs

The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do?

Consider the possibility of health literacy limitations and assess further.

The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action?

Decision making

What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?

Defining characteristics are not part of a risk diagnosis.

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client

Determine what the client knows about stress incontinence

A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?

Discipline

Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient's short-term goals?

Documenting patient assessment findings in the patient's chart

Which nursing intervention is most important to complete before giving medication to a patient?

Double-check the patient's allergies before giving the drug.

Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued?

Encourage the patient to rest between bathing activities

Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer?

Encouraging the patient to explore options for care

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

Ensure no visitors or staff enter the room for a short period

Which statement best serves as a guide for nurses seeking to learn more about ethnicity?

Ethnicity is based on cultural similarities and differences in a society.

Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"?

Goal met; patient ambulated three times in the hallway without SOB.

Which situation indicates the greatest need for collaborative interventions provided by several health care team members?

Hospice referral

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process

I will determine the most important client problems that we should address

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?

Identify reasons the patient is unable to sleep.

Which nursing diagnosis is most appropriate for a young Middle Eastern immigrant who expresses concern for the safety of his family members who were unable to relocate with him out of a war zone?

Impaired family process

Which phrase best represents a related factor in an actual nursing diagnosis?

Ineffective adaptation to recent loss

The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain?

Interpretation

Which nursing action is critical before delegating interventions to another member of the health care team?

Know the scope of practice and competency of the other team member.

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication info

Knowledge

What is the most significant problem that may result from improperly written nursing diagnostic statements?

Lack of direction for formulating patient plans of care

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?

Listening to the patient's concerns and beliefs about proposed treatment

Which statement illustrates a characteristic of goals within the care planning process?

Long-term goals are helpful in judging a patient's progress.

Which resource is most helpful when prioritizing identified nursing diagnoses?

Maslow's hierarchy of needs

Which statement best describes the relationship of medical diagnoses and nursing diagnoses?

Medical diagnoses may be interrelated to nursing diagnoses.

What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?

Monitor patient urine output to evaluate the need for the current plan of care.

A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?

Offer information on a relaxation technique and ask the client if they are interested in trying it

What is the purpose of the nursing process?

Organizing the ways nurses think about patient care

A nurse is performing an admission for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse

Orient the client to their room

The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session?

Other members of the health care team need to know the patient's progress.

An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?

Patient

What should be the primary focus for nursing interventions?

Patient needs

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?

Patient safety

Which statement is an appropriately written short-term goal?

Patient will walk to the bathroom independently without falling within 2 days after surgery.

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery?

Patient's white blood count will remain within normal range throughout hospitalization.

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?

Perform the steps of the nursing process related to the patient's current condition.

Which is true about patient teaching sessions?

Present the patient with one idea at a time.

What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?

Provide evidence-based research to support nursing care

Teaching a patient to use an incentive spirometer by demonstration, with return demonstration by the patient is an example of teaching based on which domain of learning

Psychomotor

Written instructions showing pictures of the steps necessary to test a blood sugar, along with demonstration and a return demonstration of the steps, would most benefit which learners?

Pyschomotor

Which action would the nurse undertake first when beginning to formulate a patient's plan of care?

Rank patient concerns from assessment data

Which nursing diagnosis is appropriate if a patient expresses an interest in learning?

Ready to learn

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Reassess the client to determine the reasons for inadequate pain relief

A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. What should the nurse do before placing the NG tube?

Request an interpreter per facility protocol

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse check the client's medical record, discovers the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate

Responsibility

The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first?

Review data about the medical diagnosis and routine management

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?

Severity and duration of the nausea and vomiting

What aspect of culture is a full-time employed granddaughter of an elderly Asian female exhibiting if she asks the social worker to place her grandmother in an extended-care facility against the wishes of her parents?

System change

The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.)

Teamwork Conflict Management Advocacy

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place

The client is able to demonstrate the appropriate technique

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention?

Transporting a patient to the hospital entrance for discharge

Which of the following actions reflects inductive reasoning?

Using subjective and objective data to confirm a diagnosis

If a patient's primary language differs from that of the health care professionals providing care, which action is most appropriate for the nurse to take?

Verify patient understanding of questions asked when the patient responds with continuous affirmative answers

The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching?

Wait until 10 to 15 minutes after his next intravenous pain medication

Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data?

What are the most significant factors in the problem?

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include (Select all that apply)

-Show a client how to use progressive muscle relaxation -Performing a daily bath after the evening meal -Repositioning a client every 2 hr to reduce pressure injury risk

Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)

-Thoroughly review the patient's medical history -Analyze the nursing assessment data to determine whether information is complete -Consider potential complications to which the patient is susceptible

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take (Select all that apply)

-Use a journal to write about the outcomes of clinical judgments -Review articles about evidence-based practice -Make quick decisions when unsure about a client's needs

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility (Select all that apply)

-Ensure that the client has possession of their valuables -Confirm that the rehab center has a room available at the time of transfer -Give a verbal transport report via telephone -Complete a transfer form for the receiving facility

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure (Select all that apply)

-Explain the roles of other care delivery staff -Begin discharge planning -Document the client's wishes about organ donation -Introduce the client to their roommate

If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)

-Expressed desire to eat -Report that food smells good -Preparation of home-cooked meals for self and family

A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary (Select all that apply)

-Follow-up care -Instructions for diet and medications -Contact information for the home health agency

A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use (Select all that apply)

-Guided imagery -Meditation -Music therapy

Which of the following questions is/are appropriate to ask during a transcultural assessment? (Select all that apply.)

-How do you act when you are angry? -What is your role in your extended family? -When communicating with friends, how close do you stand?

Which statement(s) reflect/s the practice of transcultural nursing? (Select all that apply.)

-May be considered a general and specialty practice area -Challenges traditional ethnocentric nursing practice -Aims to identify individual patient care preferences

What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.)

-Patient's treatment preferences -Cultural and ethnic influences -Professional level of expertise -Current evidence-based research

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)

-Potential communication barriers -Diverse cultural practices -Scope of nursing practice -Functional status of the patient

Which nursing diagnosis is appropriately written? (Select all that apply.)

-Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication -Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status -Risk for Bleeding with the risk factor of prolonged clotting time

Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.)

-Ready to learn -Literacy problem

Which action is a part of the evaluation step in the nursing process? (Select all that apply.)

-Recognizing the need for modifications to the care plan -Reviewing whether a patient met their short-term goal

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data (Select all that apply)

-Respiratory rate is 22/min with even, unlabored respirations -The client's skin is pink, warm, and dry -The assistive personnel reports that the client walked with a limp

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn

"Can you tell me about how long the surgery will take"

In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking?

"What additional details do I need to gather?"

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family

-Any difficulty swallowing

A nurse if reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies (Select all that apply)

-Art therapy -Yoga -Biofeedback

A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.)

-Asking someone in the waiting area to read the forms to her "because I need to get new glasses—these just don't work" -Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms -Returning the forms only partially filled out, with missing or inaccurate information

Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.)

-Auscultating lung sounds -Monitoring skin integrity -Applying heel protectors

What situations would necessitate modification of a patient's care plan (Select all that apply)

-Decrease in patient's level of orientation -Discharge of patient to rehab facility -Sudden onset of shortness of breath in patient receiving oxygen

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members (Select all that apply)

-Determine client understanding several times during conversation -Use lay terms if possible -Do not interrupt the interpreter and the family as they talk

What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)

-Elevated pulse rate auscultated at 140 BPM -Continuous foot tapping throughout intake interview -Patient states, "I feel nervous all the time, especially when I am alone."

If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?

Acute Pain

A nurse is evaluating how well a client learned the information presented in instructional session about following a heart-healthy diet. Which of the following actions should the nurse take to evaluate client's learning

Ask the client to explain how to select or prepare meals

A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention

Ask whether the client is comfortable with using prayer

Which action taken by a nurse would reflect application of an appropriate generalization in a patient care setting?

Asking dietary intern to verify with Middle Eastern patients whether or not they eat pork

Culturally competent care would encourage which action by a patient's family?

Asking the family's spiritual advisor to visit the patient

The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. )

Assessing the patient for symptoms of hypoxia Providing oxygen according to standing orders Elevating the head of the bed, if not contraindicated

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process

Assessment

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

The same religious beliefs can influence individuals differently