ADN 140 Exam 1 Prep-U's

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which risk factors for falls should the nurse identify? Select all that apply. 1. Client climbs two flights of stairway to get to his bedroom 2. Client prefers to use the bathtub when taking a bath 3. Client has two alcoholic beverages before dinner 4. Client takes a diuretic early in the morning 5. Client uses non-skid socks all day

1, 2, 3, 4

A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase? A. The client will express feelings and concerns to the nurse. B. The nurse and client will determine where and when they will meet. C. The client and nurse will establish goals of the relationship. D. The client will identify the goals that have been accomplished during the relationship.

A

A nurse has drafted an SBAR communication before contacting the primary care provider of a patient whose condition has worsened. How should the nurse best conclude this communication? A. Ask the care provider to come and assess the patient. B. Provide the patient's most recent vital signs. C. Ask the care provider if he or she is familiar with this patient. D. Provide the most likely diagnosis of the problem.

A

During the hospital admission interview, a client begins to cry when asked about number of pregnancies. Which communication technique would the nurse employ during this interaction? A. Use of silence B. Rescue feelings C. Offering reassurance D. Being moralistic

A

The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented? A. Wait with the client until the medications are taken. B. Allow the client to sign for the medication and keep the medications on a bedside table until ready to take them. C. Ask the client's family to confirm that the client has swallowed the medication. D. Have the unlicensed assistive personnel (UAP) to monitor the client until medication is taken.

A

The nurse is beginning to administer oral medications to a client. The client states, "I haven't taken that pill before. Are you sure it's right?" The nurse rechecks the CMAR/MAR and finds that the medication is indeed scheduled to be administered. Which response is most appropriate? A. "Don't take that pill yet. I will verify the medication order." B. "Go ahead and take it, and then I'll check with your primary care provider about it." C. "I can show you where it's listed on your medication administration record." D. "Are you certain that you haven't taken this before?"

A

Which is a characteristic of a person-centered or helping relationship? A. An unequal sharing of information B. Spontaneous occurrence with random individuals C. A focus on the needs of the helping person D. The accountability of the person being helped for the outcomes of the relationship

A

Which is an example of a nontherapeutic communication technique? A. Giving approval B. Summarizing C. Silence D. Voicing doubt

A

Which technique would a nurse employ when using listening skills appropriately when interviewing a client? A. The nurse would listen to the themes in the client's comments. B. The nurse would try to avoid body gestures when listening to the client. C. The nurse would stand close to the client and maintain eye contact. D. The nurse would not allow conversation to lapse into periods of silence.

A

Which nursing actions help improve listening skills when conversing with clients? Select all that apply. A. Listening for themes in the client's comments B. Thinking before responding to the client, even if this creates a lull in the conversation C. Sitting with the arms crossed D. Always maintaining eye contact with the client in a face-to-face pose E. Pretending to listen to the client while performing a task rather than interrupting the client's conversation F. Using facial expressions and body gestures to indicate attention to what the client is saying

A, B, F

The unlicensed assistive personnel has bathed the client who is in restraints. Upon assessing the client on hourly rounds, the nurse determines the client's restraints pose a risk for injury to the client. What assessment(s) represents a rationale for removal or adjustment ? Select all that apply. A. Two fingers cannot be inserted between the restraint and the client's extremity. B. The client's extremities are in normal anatomic positions. C. The restraint is tied to the side rail of the bed. D. A quick-release knot is used to secure the restraint. E. The restraint is tied out of the client's reach.

A, C

Which activities take place during the working phase of the nurse-client relationship? Select all that apply. A. The client participates actively in the relationship. B. The client genuinely expresses concerns to the nurse. C. The client identifies the goals accomplished in the relationship. D. The client describes the role that the nurse plays in the relationship. E. The client and nurse identify goals of the relationship.

A,B

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply. A. Reduce stimulation, noise, and light a few hours prior to bedtime. B. Provide low lights in the rooms in which the client may wander. C. Encourage the client to toilet prior to bedtime. D. Have the client exercise in the evening to ensure the client is tired at hours of sleep. E. Place locks on any doors to the outside that the client would be able to open.

A,B,C,E

Which of the following populations would benefit from fall prevention strategies based on their developmental stage? Select all that apply. A. Newborns B. Toddlers C. Adolescents D. Adults E. Older Adults

A,B,E

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply. A. Spoken words B. Intuition C. Sight D. Telepathy E. Touch F. Observation

A,C,E,F

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A. Glasgow scale B. Braden scale C. FLACC scale D. Morse scale

B

A registered nurse (RN) working with an experienced licensed practical/vocational nurse (LPN/LVN) delegates the task of administering oral medications to a group of clients. The LPN/LVN documents a client's medication administration before entering the client's room. What action will the LPN/LVN anticipate? A. The RN will check all client's medication records to make sure the appropriate drugs were given. B. The RN will stop the LPN/LVN immediately and discuss the possible consequences of this action. C. The RN will contact the nurse manager to discuss the actions of the LPN/LVN. D. The RN will continue to supervise the LPN/LVN as medications are being administered.

B

Nurse A receives an urgent phone call and hands several medications to Nurse B stating "Please give these to my client. I will be right back." What is the rationale behind Nurse B's response not to administer the medication to the client? A. The client's allergies are unknown to Nurse B. B. It violates the rights of medication administration. C. It violates the rights of the client's privacy. D. It is not Nurse B's responsibility to administer medications for Nurse A's clients.

B

The nurse performs an assessment on a newly admitted older adult client and the client is assigned a high score on the Braden scale. What is the nurse's best action? A. Assess the client's pain every two hours B. Act to prevent pressure injury C. Create a dietitian referral D. Document a risk for substance misuse

B

The nurse therapist calls a client to reschedule their appointment for the following week. When the client arrives at the appointment, the client is uncommunicative and avoids eye contact with the nurse. When asked how things have been going, the client answers, "Fine." How should the nurse confront this behavior? A. "You seem angry, and I understand that you have been depressed, but I feel like you are avoiding speaking to me. Can you explain why you're acting this way?" B. "You appear to be angry. Perhaps you are angry with me for rescheduling our appointment or something else has happened. Tell me more about what you are feeling." C. "You seem angry. Would you like to talk more about how you're feeling?" D. "I'm sorry I had to reschedule our appointment. It really couldn't be helped. Is that what's bothering you?"

B

A nurse is performing an admission assessment with a client who does not speak the dominant language. Which action(s) can the nurse take to enhance communication? Select all that apply. A. Ask the client's adolescent daughter to interpret. B. Contact a telephone-based medical interpreter. C. Use an electronic translator. D. Request assistance from an agency interpreter. E. Speak loudly and slowly.

B, C, D

The client is 61 years old, tripped over a sidewalk curb, and incurred a fractured leg. The client denies any previous falls. The client is prescribed oxycodone every 4 hours as needed for pain and has received one dose. Vital signs are pulse 88 and regular, respirations 20, and blood pressure 126/78. The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply. A. age of 61 years B. history of a fall C. fractured leg D. administration of oxycodone E. vital signs

B, C, D

The nurse is interviewing a client with a complex medical and psychosocial history For which purposes would observing silence be appropriate? Select all that apply. A. To allow the nurse time to think of something to say when the nurse doesn't know the answer to a question To allow the client time to compose oneself when the client is upset B. To allow the client time to reflect on communication that has occurred C. To allow the client time to reflect on the client's thoughts D. To allow the client time to formulate an answer after asking the client a question

B, C, D

Following surgery, a client is receiving morphine 5 mg IV every 2 hours as needed (PRN) for pain. To ensure safe medication administration when administering this drug, the nurse should take which action(s)? Select all that apply. A. Assess the client's pain level 45 to 60 minutes after giving the medication. B. Check the medication administration record to see when the last dose was administered. C. Consult a drug manual to determine whether the amount prescribed is safe. D. Document the reason the medication was given in the client's electronic health record. E. Use two identifiers to confirm that the medication is given to the correct client.

B, C, D, E

Which characteristics would indicate a professional relationship? Select all that apply. A. The focus being on both parties involved B. An emphasis on addressing the client's needs in the current situation C. Open self-disclosure by the nurse D. The relationship ending with goal achievement E. Assessment of how each member's needs for enjoyment are being met

B, D

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What guidance should the manager provide? Select all that apply. The incident report should be placed with the client's health records. A. It should provide a clear, concise recording of the situation B. It should include factual information about the incident. C. The nurse should document the suspected root causes of the incident D. Completion of the incident report should be noted in the nurse's notes.

B,C

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply. A. Restraints may be used to prevent a client from falling if the facility is short-staffed. B. The client's family must be involved in the decision and care plan. C. Alternatives to restraints and less restrictive interventions must have been implemented and failed. D. The benefit gained from using a restraint must outweigh the known risks for that client. E. A health care provider or licensed independent practitioner must reevaluate and assess the client every 48 hours. F. The client's vital signs must be assessed and the medical client must be visually observed every 4 hours.

B,C,D

The nurse is performing an assessment of a client to determine risk for skin breakdown. Which areas will the nurse include with use of the Braden scale? Select all that apply. A. The client is 80 years old. B. The client is unable to turn in the bed independently. C. The client has reduced sensation in the lower extremities. D. The client is NPO (nothing by mouth). E. The client is occasionally incontinent of urine. F. The client is drinking 6-8 ounce glasses of water per day.

B,C,D,E

When administering medication, the nurse ensures client safety by following the rights of medication administration. Identify the "rights of medication administration." Select all that apply. A. right room B. right client C. right dose D. right medication E. right time F. right route

B,C,D,E,F

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options. E. Secure restraints to the bed frame with quick-release knots. D. Pad bony prominences. B. Explain rationale for use to the client and family. A. Ensure that two fingers fit between the restraint and the client's skin. C. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. F. Position limbs in normal anatomic position.

B,D,C,A,F,E

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? A. "Do you feel like you are not a woman?" B. "Do you want more children?" C. "Feel like a woman . . ." D. Remaining silent

C

Which of the following is an example of nonverbal communication? A. A nurse says, "I am going to help you walk now." B. A nurse presents information to a group of patients. C. A patient's face is contorted with pain. D. A patient asks the nurse for a pain shot.

C

Which of the following statements is true of factors that influence communication? A. Nurses provide the same information to all patients, regardless of age. B. Men and women have similar communication styles. C. Culture and lifestyle influence the communication process. D. Distance from a patient has little effect on a nurse's message.

C

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor? A. Noise B. Ambience C. Experience D. Privacy

C

Which statements describe the qualities of a helping relationship? Select all that apply. A. The helping relationship occurs spontaneously. B. The helping relationship is characterized by an equal sharing of information. C. The helping relationship is built on the client's needs, not on those of the helping person. D. A friendship must develop from an effective helping relationship. E. A helping relationship is dynamic. F. A helping relationship is purposeful and time limited.

C, E, F

A client begins discussing frankly the client's history of sexual abuse as a child. The nurse listens for awhile and then asks the client about the client's stressful job situation. The nurse does this for what reason? A. To make sure the nurse understands other problem areas in the client's life B. To model social skills C. To help the client understand appropriate boundaries D. To reduce the nurse's own anxiety

D

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? A. Skin color B. Tissue perfusion C. Drainage D. Moisture

D

A staff member says she is really busy and asks the charge nurse to double-check a dose of insulin which she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. This nurse has made multiple medication errors and the charge nurse is concerned that she isn't safe. What should the charge nurse do? A. State that she can't check the dose unless she sees the nurse draw it up. B. Ask the nurse which bottle of insulin she used to draw up the client's dose. C. Ask to see the original order, then determine if the dose is correct. D. Tell the nurse that she'd like to start at the beginning to be on the safe side.

D

The nurse is preparing to administer medications to a client. The client asks, "Why are you using this to give me my medication?" After reviewing the image above, what is the best response by the nurse? A. "Sometimes I use this to double check that you are receiving the appropriate medications and if you are not I can notify your doctor." B. "This device can help me check to see when you received medications earlier today." C. "It is important to use this device as a workaround to improve efficiencies so everyone can get their medications on time." D. "I am using this machine to scan the code on your wrist to identify and verify the medications prescribed for you before you receive them."

D

A nurse who is discharging a patient is terminating the helping relationship. Which of the following actions might the nurse perform in this phase? Select all that apply. A. Making formal introductions B. Making a contract regarding the relationship C. Providing assistance to achieve goals D. Helping patient perform activities of daily living E. Examining goals of relationship to determine their achievement

E