FON exam 2

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?

Evaluating

A nursing student has established a strong therapeutic rapport with a patient who was admitted to the hospital with a perforated appendix. The patient is similar in age to the student and is interested in a career in nursing. Before being discharged, the patient asks if she can add the student as a contact on a social networking site in order to ask her more questions about nursing. How should the student respond to the patient's request?

Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged.

A client, who is scheduled for coronary angioplasty, is concerned if the procedure is safe. Which nursing diagnosis relates most directly to this client's condition?

Fear related to potential risk and surgical outcomes

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

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization?

Gently pull the pinna down and back.

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?

Physiological

A nurse is preparing to weigh a client. What actions should the nurse complete before assisting the client onto the scale? Select all that apply.

Place a paper towel on the scale. Ask the client to remove shoes. Check to see that the scale is calibrated at zero.

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval

A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

Which documentation example best reflects the complexity of client teaching by the nurse?

"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning?

"I'm starting to see how my lifestyle has caused me to end up here."

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

"Let me tell you what I will be doing. It should not be painful."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment?

"Unable to palpate femoral pulse in left leg."

A nurse is preparing to conduct the health history for a client new to the clinic. Which question would the nurse likely ask first?

"What brings you here today?"

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information?

6 units of insulin administered

Which statement describes the person who is likely the most motivated to learn?

A 70-year-old female who is the client's spouse and is learning the care so the client can come home

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

The 40-year-old client is admitted for repair of a femoral fracture. The client discloses a history of an addiction to painkillers and asks that the nurse assist in adhering to the recovery from this addiction by not administering any opioids. As the nurse reviews postoperative prescriptions for the client, the nurse notes that the health care provider has prescribed codeine 30 mg p.o. q6 hours for pain. How does the nurse best approach this situation?

Ask the health care provider to remove this prescription from the client's chart.

A client aged 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. The nurse communicates the client's wish to the family and health care team. This is an example of what ethical principle?

Autonomy

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

Which types of data would be collected during a physical assessment?

Color, moisture, and temperature of the skin

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input

The client is newly diagnosed with type 2 diabetes. After teaching the client about diabetes and how to self-administer insulin, the nurse identifies which client response as a need for additional education?

During the return demonstration, the client draws up insulin, leaving tiny bubbles in the syringe.

A hospital client has expressed dissatisfaction with the quantity and quality of care that they have been receiving since admission. The client has told the nurse that they would like to read their medical record. How should the nurse best respond to the request?

Grant the client access to the health record in accordance with the hospital's policies.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session.

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized?

Include educational strategies that encourage clients to be active participants.

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients?

Include the child in the education; ask questions of both the mother and the child.

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?

Ineffective Coping; verbalizes support systems.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

Integrity

Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?

Invasion of privacy

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed?

Invasion of privacy

An older adult client suffered a stroke a short time ago and has experienced dysphagia (difficulty swallowing) consequent to neurological damage. The nurse has thus identified the nursing diagnosis of Risk for Imbalanced Nutrition: Less than Body Requirements. What action should the nurse first take after identifying this diagnosis?

Liaise with nurses and members of other health disciplines to create a plan for promoting the client's nutrition.

The nurse is preparing to auscultate the lung sounds of a client with asthma. How should the nurse complete the assessment?

Listen to at least one full respiration in each location

What is the nurse accountable for, according to state nurse practice acts?

Making nursing diagnoses

A woman always thanks clerks at the grocery store. The woman's daughter, age 6 years, echoes the thank you. The child is demonstrating what mode of value transmission?

Modeling

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?

Observing a mother expressing the breast milk

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation?

Palpate the pulse for 1 minute.

A client with a body mass index (BMI) of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time?

Past interventions for weight loss

Upon entering the hospital system, the nurse discusses the rights and responsibilities that the client is entitled to in the institution. The information the nurse discusses is commonly referred to as:

Patient's Bill of Rights.

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?

Positive feedback

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations.

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?

Preparation

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

A nurse has a duty of nonmaleficence. Which action would be considered a contradiction to that duty?

Refusing to administer pain medication as prescribed

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

Return demonstration

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

A nurse witnesses a 50-year-old woman go into cardiac arrest while traveling in a train and attempts to resuscitate her. In spite of the nurse's efforts, the woman dies, and the family members file a suit against the nurse. Which of the following statements about Good Samaritan laws is applicable here?

The Good Samaritan law will likely protect the nurse because she acted in the woman's best interests.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants.

Which observation during the nursing assessment of a client supports the documentation of low health literacy?

The client avoids health care screenings and seeks care in the local emergency department.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

A nurse in the cardiac care unit needs to check the potassium level of the client prior to giving furosemide Where is the best place to find up to date client laboratory data?

The electronic health record (EHR)

A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions?

The nurse

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind?

The nurse and client relationship is based on mutual sharing and negotiation.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

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 physician. 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

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

To protect the safety of the public

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

A client coming in to the outpatient clinic for a follow up visit has a note regarding human immunodeficiency virus (HIV) testing. There is no record of the results of the HIV test in the computer. The nurse asks the secretary and unlicensed assistive personnel if they know whether the client is HIV positive. What is the primary ethical issue?

Violation of client privacy

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

a referral.

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.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

A nurse has encouraged a bedridden hospital client to perform deep breathing and coughing exercises each hour to prevent respiratory complications. After performing this intervention, the nurse should

assess the client's lungs to determine the effectiveness of the intervention.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

auscultation

Which type of learner processes information more adequately by listening or reading facts?

cognitive

The nurse is performing the positions test on a client following a head injury. Which assessment would the nurse interpret as a normal finding?

coordinated movement of both eyes

Two children need a kidney transplant. One is the child of a famous sports figure, whereas the other child comes from a low-income family. What ethical consideration is relevant to the nurse as an advocate for these clients?

cost-effectiveness and allocation

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:

critical thinking.

A nurse uses percussion to assess a client's liver. What is the normal tone that should be heard in this situation?

dull

When percussing the liver, the sound should be

dull.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

A nurse educator is teaching a group of nurses about various aspects of care for clients who have experienced a stroke. What activity most clearly reflects the affective domain of learning?

having a person who had a stroke talk about her experiences as a client

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:

invasion of privacy.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

A client is brought to the health care center in a semi-conscious state following a suicide attempt. The nurse is assisting the physician in resuscitating the client. The client's skin appears to be bluish. What should the nurse document as the cause for this coloration?

low tissue oxygenation

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?

moisture in air passages

The nurse palpating the skin of a client documents a firm 1.5-cm mass on the lower right leg. What type of skin lesion does this describe?

nodule

A group of nurses working in a long-term care facility fails to keep the opioid medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the:

nurses' licenses.

A nurse practitioner is preparing to examine a child with a suspected otitis media. Which instrument will be required?

otoscope

A nurse is using inspection as an assessment technique. What does the nurse use during inspection?

senses of vision, hearing, and smell

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

symmetry (comparison of bilateral body parts)

A nurse is performing a general survey of a client admitted to the hospital. Which action is an element of this procedure?

taking vital signs

Which information is the nurse expected to find on the nursing Kardex? Select all that apply.

the level of activity for the client the current medical order for the client the client's preparedness for an investigation

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

wheezes

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan