Full Fundamentals Exam 2 Review

A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation?

"Atrial fibrillation is caused by electrical signals outside of the SA node."

A nurse is reinforcing teaching with a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?

"Cover your nose with the CPAP mask."

A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?

"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level."

A nurse is reinforcing teaching with a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

"Take a deep breath" "Hold your breath for several seconds" "Exhale slowly" "Brace the incision with a pillow and try to cough deeply"

A nurse is teaching a newly licensed nurse about the purpose of peer review in scholarly publications. Which of the following statements should the nurse make?

"This process ensures scientific quality and rigor."

A nurse is teaching a class about searching the internet for research articles to use for evidence-based changes. Which of the following information should the nurse include?

"Use Quackwatch to verify credible websites."

A nurse is reinforcing teaching with a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include?

"Use the incentive spirometer every hour while awake."

A nurse is speaking with a client who is noncompliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make?

"What is preventing your consistency with your daily blood glucose checks?"

A nurse is teaching a class about citing references to use for evidence-based changes. Which of the following requires citing a reference to avoid plagiarism?

1) Direct quotations from a journal article 2) A photograph depicting equipment 3) Ideas published in a theoretical paper 4) Paraphrased sentence from an article

A nurse is preparing to perform a procedure on a client. Which of the following resources should the nurse use to meet the standard of care? (Select all the apply)

1) The health care organization policy and procedure manual 2) Information from a governmental website 3) Article published by a peer-reviewed journal

A nurse is planning to use evidence-based practice (EBP) to determine the best practice for dressing changes for clients. According to EBP, in what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1) The nurse notices another nurse changing a dressing and recognizes that they perform the same procedure differently. 2) The nurse asks a clinical question about methods to perform a dressing change. 3) The nurse conducts a literature search to determine the presence of nursing literature on how to perform dressing changes. 4) The nurse reads, organizes, and compares the results of the scientific literature search. 5) The nurse develops recommendations about dressing changes to present to an interdisciplinary team in order to update the policy and procedure. 6) The nurse implements changes for performing dressing changes and collects data to determine client outcomes.

A nurse is caring for a client during a prenatal visit. The client states, "now that I'm pregnant. I drink wine with dinner. I've given up hard alcohol. Which of the following responses should the nurse make?

A. "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby." Scientists have not yet determined if there is a safe amount of alcohol to drink during pregnancy. Therefore, clients who are pregnant are advised to abstain from drinking alcohol during pregnancy altogether

Which of the following support the integration of informatics into nursing practice to support safety in client care? (Select all that apply) ​1) Embedded medication alerts for side effects in an electronic health care record ​2) Immediate access to digital X-rays ​3) Use of phones that connect directly to an assigned nurse for clients ​4) Integration of telehealth to follow up with clients in rural locations ​​5) Wireless Internet access for clients from the health care facility

1,2,3,4 Embedded medication alerts for side effects in an electronic health care record is correct. This promotes safe, effective nursing care through notifications to prevent medical errors and enhanced communication within and outside the health care facility. ​Immediate access to digital X-rays is correct. This promotes safe, effective nursing care through notifications to prevent medical errors and enhanced communication within and outside the health care facility. ​Use of phones that connect directly to an assigned nurse for clients is correct. This promotes safe, effective nursing care through notifications to prevent medical errors and enhanced communication within and outside the health care facility. ​Integration of telehealth to follow up with clients in rural locations is correct. This promotes safe, effective nursing care through notifications to prevent medical errors and enhanced communication within and outside the health care facility.

A nurse needs to determine the use of technology as an assistive device to facilitate discharge teaching for a client. Which of the following represents an appropriate application of technology in this situation? (Select all that apply) 1) Using translation software for a Spanish-speaking client who has a new diagnosis of acute renal failure ​2) Providing instruction for access to the facility's free wireless Internet ​3) Supplying the link to a website with a video demonstrating home care for a client after a knee arthroplasty ​4) Explaining the use of automatic email reminders to increase medication compliance ​5) Accessing an iPad to review side effects of medications with a client

1,3,4,5 ​Using translation software for a Spanish-speaking client who has a new diagnosis of acute renal failure is correct. ​Supplying the link to a website with a video demonstrating home care for a client after a knee arthroplasty is correct. This facilitates nurse and client communication regarding discharge teaching through integration of technology. ​Explaining the use of automatic email reminders to increase medication compliance is correct. This facilitates nurse and client communication regarding discharge teaching through integration of technology. ​Accessing an iPad to review side effects of medications with a client is correct. This facilitates nurse and client communication regarding discharge teaching through integration of technology.

A nurse is reinforcing teaching with a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk for this condition?

A client who has an enlarged prostate

A nurse is assisting with planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first?

A client who reports dyspnea when walking to the bathroom

A nurse is collecting data from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply.)

A diet high in saturated fats A history of smoking for 25 years A sedentary lifestyle

A nurse is teaching a newly licensed nurse about using credible databases for research studies. Which of the following sources should the nurse include?

A peer-reviewed journal

A nurse is providing an in-service about research methods for a group of nurses. Which of the following methods provides the most credible evidence to support practice changes?

A systematic review summarizing findings of studies.

A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statments by the newly licensd nurse indicates an understanding of the concept? (Select all that apply)

A. "Both males and females experience a change of life referred to as climacteric." B. "Climacteric in females is referred to as menopause." D. "Climacteric changes in males occur gradually over a number of years." E. "Climacteric in females can manifest as heart palpitations."

A nurse is providing an educatinal session on cognitive development at a community event. Which of the following statements by the nurse are consistent with Piaget's theory of cognitive development? (Select all that apply)

A. "Individuals acquire knowledge, intellect and cognition over time." B. "Intelligence is a natural ability that develops as a child grows and adapts to their environment." C. "Children construct knowledge that evolves and changes over time." D. "Children construct knowledge in new ways at critical points during development."

A nurse is caring for a client who is 4 days postoperative following a below-the-knee amputation related to a work injury. The nurse should identify that which of the following are components of the client's self-concept that this injury can impact? (Select all that apply.) A. Body image B. Role performance C. Identity D. Health promotion E. Self-esteem

A. Body image B. Role performance C. Identity E. Self-esteem Body image is correct. The four main components of self-concept include body image, self-esteem, role performance, and identity. Role performance is correct. The four main components of self-concept include body image, self-esteem, role performance, and identity. Identity is correct. The four main components of self-concept include body image, self-esteem, role performance, and identity. Health promotion is incorrect. While health promotion is a focus of nursing interventions within the plan of care, it is not considered a component of self-concept. Self-esteem is correct. The four main components of self-concept include body image, self-esteem, role performance, and identity.

A nurese is planning an educational session about human growth and development for a group of clients who are pregnant. Which of the following universal principles should the nurse include in the discussion? (Select all that apply)

A. Cephalocaudal principle C. Simple to complex D. Continuous process E. Individual rates

A nurse is reviewing factors that can affect a client's self-concept. The nurse should identify that empathy, motivation, and self-awareness are domains of which of the following factors? A. Emotional intelligence B. Body image C. Self-efficacy D. Role performance

A. Emotional intelligence The nurse should identify that social skill, self-awareness, self-regulation, motivation, and empathy are domains of emotional intelligence, which is a factor that can affect a client's self-concept.

A nurse is reviewing the plan of care for a client who was recently divorced. Which of the following interventions should the nurse include to promote the client's positive self-concept? (Select all that apply.) A. Encourage the client to identify past and current accomplishments. B. Contact delivery services to provide the client with in-home meals. C. Encourage the client to verbalize perceptions that indicate a healthy self-esteem. D. Assist the client to identify healthy coping strategies and support systems. E. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

A. Encourage the client to identify past and current accomplishments. C. Encourage the client to verbalize perceptions that indicate a healthy self-esteem. D. Assist the client to identify healthy coping strategies and support systems. E. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care. Encourage the client to identify past and current accomplishments is correct. The plan of care is designed to prevent, promote, maintain, and restore mental and physical client health. One intervention that can promote a positive self-concept includes encouraging clients to identify past and current accomplishments. Interventions that promote a positive self-concept include encouraging clients to identify accomplishments, verbalize perceptions that indicate a positive self-concept, identify coping strategies, and identify support systems. Contact delivery services to provide the client with in-home meals is incorrect. At-home delivery food service is not indicated. Encourage the client to verbalize perceptions that indicate a healthy self-esteem is correct. The plan of care is designed to prevent, promote, maintain, and restore mental and physical client health. One intervention that can promote a positive self-concept includes encouraging the client to verbalize perceptions that indicate a healthy self-esteem. Assist the client to identify healthy coping strategies and support systems is correct. The plan of care is designed to prevent, promote, maintain, and restore mental and physical client health. One intervention that can promote a positive self-concept includes assisting the client to identify healthy coping strategies and support systems. Collaborate with the client, family, and members of the health care team to ensure successful implementatio

A nurse is assessing an adolescent who reports feeling "very depressed". The nurse should recognize that which of the following are signs of increased risk for suicide? (Select all that apply)

A. Expressing feelings of gloom and helplessness B. Expressing loss of interest in activities once considered important C. Making threats of self-harm D. Having access to weapons

A nurse is providing discharge teaching to parents of a preschooler who was admitted due to a severe asthma exacerbation. Which of the following instructions should the nurse include? (Select all that apply)

A. Instruct on the use of a metered-dose inhaler (MDI). B. Have family memebers smoke tobacco products outside of the house. C. Make changes in the home environment to reduce dust mites. D. Share the plan for managin gan asthma attack with the child's preschool teachers.

A nurse is caring for a client who has diabetes mellitus and does not adhere to the prescribed diet

Requesting a referral to a dietitian to work with the client

A nurse is meeting with a client at a community health center to assess their self-concept. Which of the following factors should the nurse consider during the assessment? (Select all that apply.) A. Life experiences B. Societal and cultural attitudes C. Health status D. Academic achievement E. Meditation

A. Life experiences B. Societal and cultural attitudes C. Health status D. Academic achievement Life experiences is correct. Self-concept is impacted by life experiences, cultural and societal attitudes, academic achievement, and health status. Societal and cultural attitudes is correct. Self-concept is impacted by life experiences, cultural and societal attitudes, academic achievement, and health status. Health status is correct. Self-concept is impacted by life experiences, cultural and societal attitudes, academic achievement, and health status. Academic achievement is correct. Self-concept is impacted by life experiences, cultural and societal attitudes, academic achievement, and health status. Meditation is incorrect. Meditation is considered a healthy coping strategy, not a factor of self-concept.

A home health nurse is planning care for an older adult client who has hypertension and is living alone. Which of the following health promotion topics should the nurse include in the client's plan of care? (Select all that apply)

A. Maintaing functional capacity B. Encouraging the use of free-weight exercises C. Participating in social functions D. Installing grab bars in the shower

A nurse is planning a health class at a local middle school about puberty during adolescence. Which of the following pieces of information should the nurse include in the discussion? (Select all that apply)

A. Primary sex organs mature during puberty. B. Puberty begins with a growth spurt in height and weight. C. Onset of puberty is influenced by genetics, environment factors, and gender. D. Secondary sex characteristics emerge during puberty .

A school nurese asks a first grader about rules at school. The child responds, "we need to wash our hands before lunch, be respectful to the teacher, and pay attention in class. If we don't we'll get into big trouble." The nurse should recognize that the child is in which of the following of Kohlberg's stages of moral development?

A. Punishment and obedience The Punishment and Obedience stage is a part of the first level of Kohlberg's moral development theory, referred to as the preconventional reasoning level, and occurs in children between the ages of 4 and 10 years. During the Punishment and Obedience stage, rules are viewed in terms of positive or negative consequences to action. In the punishment and obedience stage, rules are obeyed to avoid punishment. A child who is in the first grade would be in this stage.

A nurse is meeting with a client who is recovering from a bilateral mastectomy. Since being discharged, the client has changed dressings as prescribed and completed arm exercises. The client tells the nurse, "I'm pleased with my postoperative progress." The nurse should identify that the client is displaying which of the following self-concept characteristics? A. Self-efficacy B. Emotional intelligence C. Self-awareness D. Generativity

A. Self-efficacy Clients who have a higher level of self-efficacy are more effective in the self-management of various health conditions, are more confident when dealing with stressful situations, and engage in behaviors to preserve or restore health.

A nurse is planning discharge teaching for a client who is newly diagnosed with type 2 diabetes mellitus. Which of the following topics should the nurse include in the teaching? (Select all that apply)

A. Weight management C. Glucose testing D. Daily exercise E. Foot care

A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?

Administer 100% oxygen before the procedure.

A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations?

Alveoli

A nurse is reinforcing teaching for a client who has an ileostomy. The nurse should identify that which of the following is true regarding an ileostomy?

An ileostomy can allow the colon time to heal from surgery

Which of the following electronic resources should a nurse use to obtain clinical practice guidelines and interventions to reduce the risk of negative client outcomes while in a hospital? A) Centers for Disease Control (CDC) B) Agency for Healthcare Research and Quality (AHRQ) C) Quality & Safety Education for Nursing (QSEN)

B ​AHRQ supports research designed to improve the quality of health care, including providing evidence-based guidelines.

Which of the following legislative acts stipulate that clients be allowed to see and make corrections to their health care records? A) Health Information Technology for Economic and Clinical Health (HITECH) Act B) Health Information Portability and Accountability Act (HIPAA) C) American Recovery and Reinvestment Act (ARRA)

B ​One privacy rule of HIPAA is to establish client ownership of the health care record and allow for client-initiated corrections and amendments.

which of the following illustrates the integration of informatics into a health care system to support cost containment? A) Offering free wireless Internet access to clients and visitors B) ​Installing bar codes on medications with alerts for low supplies C) ​Integrating an electronic health care record on a platform compatible with computers and tablets

B ​This illustrates cost containment by allowing inventory management related to supply and demand, directly affecting management of medication and supply costs.

A health care facility recently opened a research department to collect and analyze data related to improved client outcomes. Which of the following examples represents integration of technology to support creation of scholarly knowledge? ​A) Administration of an online survey for new nurses post-orientation regarding satisfaction with teaching methods B) ​Electronic collection of healing times of sacral wounds post-hyperbaric treatment, with and without antibiotic administration C) ​Piloting an instant messaging system between hand-held computers for nursing and pharmacy

B ​This supports research through data collection examining and intervention and comparison intervention. Technology supports the timely and accurate collection and analysis of data related directly to client outcomes. This helps support the creation of scholarly knowledge.

Which of the following illustrates the use of technology to improve communication with a client who is cognitively impaired? ​A) Provide the client with an online video as a teaching aid that allows multiple viewings. B) Use an electronic drawing screen allowing the client to create pictures during an assessment. ​C) Offer translation software for the client.

B ​When a client has a cognitive impairment, understanding and reactions are often diminished. Allowing the client to communicate through use of pictures is effective.

During a wellness visit for a 4-year-old preschooler, a parent explains that their child enjoys playing games on a computer and asks the nurse about an acceptable amount of screen time for their child. Which of the following responses should the nurse make?

B. "An acceptable amount of screen time is 1 hour per day." Screen time for preschoolers should be limited to no more than 1 hr per day of programming at home, school, or afterschool care.

A nurse is caring for adolescents in a school-based health clinic. Which of the following client statements should the nurse recognize as an indication that the client is experiencing Erikson's stage of identity versus role confusion?

B. "I think I might be gay." Identity vs. Role Confusion is the stage of Erikson's theory related to adolescence that involves forming an identity and answering the central question of "Who am I?" Questions about sexuality, developing a sense of identity, and finding their place in society are issues the adolescent addresses during this stage.

A nurse is preparing an educational session about school-age children to a group of caregivers. Which of the following characteristics should the nurse include in the teaching? (Select all that apply)

B. Egocentrism decreases C. Begins to understand reversibility D. Understands evens can be interpreted in different ways

A nurse is caring for an adolescent client who plans to attend the same law school their parent attended and work at their parent's law firm upon graduation. The client has never questioned their academic and career pathway and states, "If it's good enough for my parent, it's good enough for me." The nurse should identify that which of the following identity statuses describes the client's position? A. Identity achievement B. Foreclosure C. Identity diffusion D. Moratorium

B. Foreclosure Individuals whose identity status is foreclosure have adopted beliefs and values without question, which are often imposed upon them by authority figures. Their belief system is generally carried forward from childhood into adulthood without challenge.

A nurse is providing prenatal education to a client who is in the first trimester of pregnancy. Which of the following teratogens should the nurse instruct the client to avoid during pregnancy due to the risk to fetal development? (Select all that apply)

B. Hyperthermia C. Uncontrolled glucose levels D. Rubella E. Smoking

A nurse is teaching an in-service about zero-tolerance for bullying and incivility in the health care facility

Bullying can result in an increase in nursing turnover

A nurse off duty receives a photo on her cell phone from a fellow nurse who is at work. The photo shows a celebrity receiving physical therapy. Which of the following actions should the nurse take first? A) ​Make factual notes of the event that has occurred. ​B) Notify nursing administration, explaining who sent the photo. ​C) Delete the photo.

C ​Deleting the photo is the correct action to prevent further violation of HIPAA and is the first action for the nurse to take.

The Centers for Medicare and Medicaid Services electronically reports specific quality outcomes measures based on data collected from hospitals. These data allow the public to compare hospitals that A) have the best health care providers. ​B) have the most up-to-date surgical services. C) have a higher percentage of hospital-acquired infections.

C ​Hospital-acquired infection is one of the quality outcome measures publicly reported by the Centers for Medicare and Medicaid Services (CMS). These measures hold hospitals accountable for client care and provide useful information to health care consumers when choosing hospital care.

Which of the following uses of technology would constitute a violation of HIPPA? ​A) Sharing a client's lab results with a consulting provider via email on the health care facility intranet ​B) Charting client data on an electronic health care record while at the bedside with family members present ​C) Texting a picture of a client's wound from one nurse to another nurse related to wound care protocol

C ​This is a violation of client confidentiality due to identifiable client assessment data shared outside the health care facility. Even though the nurse sent the photo to another nurse related to wound care protocol, this is not acceptable use of technology and violates HIPAA.

A nurse is assessing the self-concept of a client who recently lost their job and, as a result, might lose their home to foreclosure. Which of the following questions should the nurse ask the client when gathering information regarding self-concept? A. "What did your partner say when you lost your job?" B. "Why do you think that you were fired?" C. "How would you describe yourself and your situation?" D. "What are you going to tell your friends about losing your job?"

C. "How would you describe yourself and your situation?" By asking the client to describe their self and their situation, the nurse is assessing the client's identity, which can be a self-concept stressor.

A nurse is interviewing a client to assess their self-concept and asks, "What are some of the accomplishments that make you feel good about yourself?" The nurse is assessing which of the following components of self-concept? A. Body image B. Role performance C. Self-esteem D. Identity

C. Self-esteem Self-esteem is an individual's generalized sense of self-worth and is measured by how much value a person places on themselves.

A nurse is using evidence-based research to care for a client who has diabetes mellitus. Which of the following resources should the nurse use to manage the delivery of care?

Clinical practice guidelines

A nurse is collecting data from a client who has COPD. The nurse should identify that which of the following is an expected finding?

Clubbing of the fingers

A nurse is caring for a client who has a history of irritable bowel syndrome and report that their last bowel movement was 5 days ago. The nurse should identify this is which of the following types of altered elimination pattern?

Constipation

A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding?

Consuming alcohol

A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?

Continuity of care

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Crackles in the lungs

A nurse is collaborating with an interdisciplinary team to develop a plan of care for a client. Which of the following tools should the nurse use to guide the delivery of care?

Critical pathway

A nurse is reinforcing teaching with a client about diagnostic urinary testing. Which of the following should the nurse recognize is consistent with cystometric testing?

Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins

A nurse is meeting with a client who was recently diagnosed with rheumatoid arthritis. The client tells the nurse, "I'm never going to be able to do anything fun." Which of the following questions should the nurse ask to assess the client's identity? A. "Can you describe one of your primary roles?" B. "How do you respond when you feel you have failed?" C. "What aspects of your body would you like to change?" D. "How do others' opinions impact the way you see yourself?"

D. "How do others' opinions impact the way you see yourself?" By asking the client how others' opinions impact the way they see themselves, the nurse is assessing the client's identity.

A nurse is caring for a 10-year-old child who is newely diagnosed with diabetes mellitus. Which of the following actions by the child should the nurse recognize as characteristic of Erikson's stage of industry versus inferiority?

D. Expresses confidence in their ability to self-administer insulin. Industry vs. Inferiority is Erikson's stage of development occurring during the school-age years. During this stage, children work at learning complex skills, problem-solving, and gaining a sense of self. Successes in these areas, along with support from those around them, promotes a sense of accomplishment and confidence in their endeavors.

A nurse is caring for a client who reports enjoying retirement because they are reading more, visiting with children and grandchildren, and playing bridge with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development? A. Trust vs. mistrust B. Autonomy vs. shame and doubt C. Identity vs. role confusion D. Integrity vs. despair

D. Integrity vs. despair Integrity is achieved when older adults reflect on life and feel a sense of fulfillment and accomplishment.

A nurse is preparing to discharge a client following a bilateral below-the-knee amputation

Determine whether the client's home is wheelchair accessible

A nurse is preparing to collect a urine sample for urinalysis a reagent strip. The nurse should identify that the reagent strip can detect substances that are consistent with which of the following conditions?

Diabetes

A nurse is caring for a client with suspected dehydration. For which of the following findings should the nurse monitor this client?

Dry mucous membranes

A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first?

Ensure client is in a sitting position

A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering?

Fecal occult blood test

role of social worker

Help find solutions to client challenges and advocate for resources to help resolve issues. Clinical social workers can also diagnose, treat clients, and provide psychotherapy services.

A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for?

Hernia

A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow?

High fiber

A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?

Make a list and prioritize a plan.

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (Select all that apply.)

History of frequent respiratory infections Consumes large amounts of dairy in their diet Currently taking cephalexin for pneumonia

A nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information?

I can develop a kidney infection called pyelonephritis

A nurse is caring for a female client who has a prescription for a clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen?

I need to wipe from front to back with a sanitary wipe

A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?

I should try to escape or put a barrier between myself and the client

A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct the use of the IDEAL method?

I will include the client and caregivers in the discharge discussion

A nurse is teaching about what to include in a medication reconciliation form for a client who is being transferred to a new facility

Include medications the client took at home

A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution?

Instruct the client to lie on their left side with their right leg pulled up to their chest

A nurse is reinforcing teaching with a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse identify will help facilitate urinary elimination for this client?

Intermittent catheter

A nurse and assistive personnel disagree about how to move a client from the bed to a stretcher. Which statement to promote conflict resolution?

Let's discuss how we can work together

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?

Listen for a hollow sound when performing chest percussion therapy.

A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence?

Loss of bladder tone

A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

Monitor the client for subcutaneous emphysema.

A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following?

Murmur

A nurse is reviewing a client's list of medications and supplements. Which of the following medication classifications increases the risk of constipation?

Narcotic pain medications

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use?

Nasal cannula

A nurse is collecting data from a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?

Normal breathing

A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nurses will pair together to care for an assigned group of clients."

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first?

Obtain the oxygen saturation.

A nurse is reinforcing teaching with a client about foods that can irritate the bladder. Which of the following foods should the nurse identify as being a bladder irritant?

Oranges

A nurse is collecting data from a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings?

Pale yellow, clear urine

A nurse is reinforcing teaching with a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply.)

Post a "No Smoking" sign inside the home Attach oxygen containers to a fixed object Notify the fire department that oxygen is used in the home

A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function?

Preform colostomy irrigation

A nurse is using evidence-based practice to reduce pain during venipunctures for adolescent clients by asking a PICOT question: "Does providing music to adolescent clients during venipunctures decrease their discomfort compared to those clients who do not listen to music?" Which of the following is a component of the "I" in this PICOT question?

Providing music

A nurse is collecting data from a group of clients regarding their feelings and experiences of living with congestive heart failure. In which of the following types of research studies is the nurse participating?

Qualitative

Advanced Practice Registered Nurse (APRN)

RNs with specialized training and advanced degrees

A nurse is teaching about receiving and transcribing verbal prescriptions

Read back the prescription to the provider after transcribing

A nurse has created a table of evidence to organize findings from a literature search. Which of the following components of the table provides information for implementing a change in practice?

Recommendations

A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?

Right task

A nurse is collecting data from a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity?

Ringing in the ears

A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

SA node is the first step. AV node is the second step. Bundle of His is the third step. Right and left bundle branches is the fourth step. Purkinje fibers is the fifth step.

A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use?

Simple face mask

A charge nurse is teaching about the collaborative teamwork skill of situation monitoring

Situation monitoring focuses on the awareness of the team's performance on client outcomes

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia?

Smoke inhalation

A nurse is admitting a client who has heart failure. Which of the following tools should the nurse use to implement nursing interventions for the client?

Standard of care

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect?

Stenosis

A nurse is assisting with planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output?

Stroke volume

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis?

Surfactant

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea?

The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow

Which statement by the newly licensed nurse demonstrates Incivility

The charge nurse called me stupid in front of the team

A nurse is using (I-SBAR-R) when contacting a provider about a client with COPD. Which should be included in the assessment component

The client has a respiratory rate of 38/min

A nurse is caring for a client who is establishing a bladder training program. Which of the following indicates that the bladder training is successful?

The client has less than one urinary accident per week

A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?

The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues.

A nurse is using (I-SBAR-R) when contacting a provider about a client who has Parkinson's disease. Which of the following statements by the nurse is included in the situation component

The client is coughing while eating Situation: pertinent data required to provide effective and prompt care

A nurse is using evidence-based practice to develop a PICOT question. Which of the following describes the "O" in PICOT?

The desired result of the intervention to the problem.

A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body.

The large intestine

A nurse is reinforcing teaching with a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity?

The maximum volume of air that is expired after a maximum inspiration.

A charge nurse is supervising a nurse providing care to several clients. For which of the following actions by the nurse should the charge nurse intervene?

The nurse alters the steps in a procedure established in the clinical practice guidelines.

A nurse assigned to care for a client and the provider is known to become angry and yell at the nurse. Which actions by the nurse demonstrates the use of cognitive rehearsal

The nurse mentally practices in advance what to say to the provider

Nurse is teaching a client who has end-stage kidney disease and a new sacral pressure injury. The client's provider requests a plastic surgery consultation

The plastic surgeon might change my wound care treatment

A nurse is reinforcing instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements should the nurse identify is true regarding a nephrostomy tube?

The tube is temporary

A nurse is reviewing the primary function of they urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include?

The urinary tract eliminates waste and excess fluid from the body

A nurse is caring for a group of client who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (Select all the apply) Uncircumcised infants School-age children Middle adults Older adults Young adults

Uncircumcised infants School-age children Older adults

A nurse is teaching about barriers to interprofessional collaboration between health care professionals

Unresolved conflicts between team members

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need?

Ureteral stent

A nurse is planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis?

Urine culture

A nurse is collecting data from a client who has stress incontinence. Which of the following findings should the nurse expect with this client?

Urine leakage following coughing

A nurse is teaching about change-of-shift report with a newly licensed nurse

Using I-SBAR-R during change of shift report decreases the risk of missing information

Client asks nurse "Why do I have to talk to so many people before i can go home? Don't these people communicate?"

You health care team works together so you can safely go home

Diagnosis-related group (DRG)

a fixed payment system for reimbursement for health care services based on the clients diagnosis and procedures performed

Hospital Consumer Assessment of Healthcare Providers and Systems

a survey instrument and data collection method to measure clients perceptions of their inpatient experience s

A nurse is preparing to teach a client how to ambulate with crutches and is determining the client's readiness to learn. Which of the following factors should the nurse include in this assessment? select all that apply a. Client's cognitive ability b. Client's current physical needs c. Client's level of motivation d. Client's developmental stage e. Client's preferred learning style

a. Client's cognitive ability An important component of assessing a client's readiness to learn is the client's cognitive ability b. Client's current physical needs An important component of assessing a client's readiness to learn is the client's physical needs. c. Client's level of motivation An important component of assessing a client's readiness to learn is the client's level of motivation. d. Client's developmental stage An important component of assessing a client's readiness to learn is the client's developmental stage.

Which of the following should the nurse take into consideration when selecting an environment to provide client education? a. Noise level b. Size of space c. Lighting d. Pain level e. Temperature

a. Noise level The environment should have minimal noise distractions. b. Size of space The environment should provide an appropriate space for the type of content. c. Lighting The environment should provide adequate and appropriate lighting. e. Temperature The environment should be a comfortable temperature for the client.

A nurse is evaluating a client's ability to self administer insulin. Which of the following behaviors is reflective of the mechanism level of the psychomotor domain? a. The client demonstrates confidence in a performing an insulin injection. b. The client demonstrates an insulin injection with the nurse's guidance. c. The client demonstrates how to hold the syringe depending on the injection site.

a. The client demonstrates confidence in a performing an insulin injection.​ The psychomotor domain consists of seven levels of behavior. The mechanism level refers to the client's ability to perform a skill with confidence.

A nurse is preparing a toddler for surgery. Which of the following is appropriate for the nurse to take into consideration when developing the teaching plan? a. Toddlers depend on their senses to learn. b. Toddlers view their illness as a punishment. c. Toddlers see themselves as individuals.

a. Toddlers depend on their senses to learn. ​Toddlers are in the sensorimotor cognitive stage, which means that they learn through their senses.

sentinel event

an event that results in client death of permanent or severe temporary harm

role of occupational therapist

assist clients to either recover or develop new skills to maintain daily living and return to work

A nurse is preparing an adult client's teaching plan and gathering information about the client's culture. Which of the following client statements helps the nurse understand the client's social organization? a. "I would feel most comfortable if I had an interpreter present during the teaching." b. "My mother needs to be present for any teaching." c. "It is hard for my family to understand the concept of long-term goals."

b. "My mother needs to be present for any teaching." The client's comment, indicating a matriarchal family structure, is a component of cultural social organization.

A nurse is preparing an educational lecture for bariatric clients. Which of the following should the nurse take into consideration when developing the lecture? a. The content should focus on a limited amount of information. b. Audiovisuals should be used during the lecture. c. The content should apply to all lecture participants. d. The nurse should focus on the psychological effects of obesity. e. Lecture is effective because participants find it fun and interactive.

b. Audiovisuals should be used during the lecture. Audiovisuals are an important component of the lecture format in order to engage the audience and increase attentiveness. c. The content should apply to all lecture participants. Due to the large number of participants in a lecture, the content should be relevant for everyone in attendance.

A nurse asks a client how he learns best. The client states. "I think I learn the best when I can discuss the information with a group of people." This indicates the client has a performance for which of the following learning styles? a. Kinesthetic b. Auditory c. Visual

b. Auditory ​Group discussion is an effective teaching strategy for auditory learners. This strategy allows the client to listen to the comments of others, which improves understanding and retention for the auditory learner.

A nurse is providing discharge teaching for an adolescent client. Which of the following teaching strategies is appropriate for the nurse to use when teaching this client? select all that apply a. Focus teaching toward the client's parents. b. Talk to the client as if he is an adult. c. Provide time to teach the client privately. d. Use audiovisuals as a teaching tool. e. Use reminiscence when discussing information.

b. Talk to the client as if he is an adult. Talking to an adolescent client as if he is an adult shows an understanding of the client's ability to use logical reasoning and helps gain the client's respect and trust. c. Provide time to teach the client privately. Respect and trust is further gained by allowing time to teach the client privately. d. Use audiovisuals as a teaching tool. Adolescent clients are receptive to audiovisuals, and therefore these should be incorporated into the teaching plan.

three hospital acquired infections

c-diff, SSI, CAUTI

A nurse is teaching a client who has a new diagnostic of diabetes mellitus type 1. Which of the following questions by the nurse addresses the client's affective domain? a. "Are you ready to learn how to give yourself insulin injections?" b. "What information do you already know about diabetes?" c. "How do you feel diabetes will affect your lifestyle?"

c. "How do you feel diabetes will affect your lifestyle?" One of the focuses of the affective domain is the client's feelings.

A nurse is caring for a client who has a new prescription of digoxin (Lanoxin). Which of the following should the nurse first teach the client? a. "You should call your provider before taking this medication if your pulse is below 60/min." b. "You may be experiencing toxicity to this medication if you experience nausea or changes in your vision." c. "Your provider is prescribing this medication to strengthen your heart's contractions."

c. "Your provider is prescribing this medication to strengthen your heart's contractions." ​Knowledge is the first level of cognitive behavior. Identifying the purpose of the medication is an example of providing basic knowledge information and is the first thing the nurse should teach.

long-term care facility

cares for clients who do not need specific nursing skills but rather a place to live

five social determinants of health

economic stability, education, social and community context, health and health care, neighborhood and built environment

role of case manager

facilitate treatment plan and look for most cost-effective care in the least restrictive setting while maintaining client self-determination and culturally appropriate care

Goal of the ACA

improve health care quality and increase access to services

Role of a naturopathic doctor

prescribe natural and alternative treatment options such as lifestyle changes, exercise, herbs, and acupuncture

health care disparities

social, economic, and environmental differences that affect health status

skilled nursing facility

sometimes referred to as a nursing home or long-term care; may provide short-term rehab care such as occupational and physical theory as well as oversight for ADLS

long-term care hospital

specializes in caring for clients who require hospitalization for long-term illnesses such as severe burns, trauma, or ventilation needs