Fundamentals Exam 2 prep

A nurse is planning care for a client who has tb. the nurse should use which of the following pieces of PPE when providing care for a client - gown N 95 shoe covers surgical cap

N 95

a nurse notifies their supervisior that they accidentally administered the wrong med to a client. the nurse is demonstrating which of the following professional values integrity human dignity alturism social justice

integrity

A nurse is providing equal care to a group of clients who have varying economic statuses. which of the following ethical principles is the nurse demonstrating? fidelity autonomy justice veracity

justice

nonassertive communication

providing information to the healthcare provider in an indirect manner without telling the healthcare provider what to do

15 mL to teaspoons

3 teaspoons

A nurse is preparing hearing infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescript reads: 25,000 units of hep in 0.9% solution sodium chloride 250 ml to infuse at 800 ml/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole # )

8 ml/hr (800 x 250)/25,000 = 8

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? (SATA) check the cord routinely for frays and tears - keep the unit at least 1.2 (4 ft) m away from a fast stove -conseride purchasing a generator for power backup observe signs of hypoxia select synthetic clothing and bedding

check cords consider buying generator observe signs of hypoxia

A nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first? - check the client for injuries - move hazardous objects away from the client -notify the provider -ask the client to describer how she felt prior to the fall

check the client for injury assess the client for injuries

A nurse is discussing the model of professionalism with another nurse. which of the following concepts should the nurse include as an outer process? trustworthiness clear communication self awareness capacity for reflection

clear communication bc it is a behavior or action that the nurse performs

Transfer reports

given when a patient is transferred from unit to unit or from facility to facility. If the patient is being transported to another unit in the same facility, you will need to transport his paper medical records unless the receiving unit can electronically access the records.

Face-to-face oral report

may involve only the outgoing and oncoming nurse or may include the entire oncoming shift

A nurse is reviewing a clients med prescription that reads "digoxin 0.25 by mouth every day" which of the following component t of the prescription should the nurse verify w the provider - med name route of admin medication dose frequency of admin

medication dose the medication dose is not complete thee number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer

A nurse is caring for a client who is post operative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client''s vital signs every 15 min and to report back in 1 hr. which of the following actions should the nurse take 1st? - document the provider's statement in the med record - complete an incident report - consult the facilitys risk manager - notify the nurse manager

notify the nurse manager the greatest risk to the client is not receiving timely intervention for a deterioration in physiological status therefor the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary cary

Graphic data

numerical data collected over time and displayed visually to allow analysis of trends. Examples include intake and output (I&O) records, vital sign flow sheets, rating scales, and checklists of client activity, dietary intake, and activities of daily living (ADL)

veracity

nurses obligation to provide truthful info to the client, provider or the nursing supervisor

channel

the way the message is sent

benefits of larges systems using Electronic health records

- develop. better disease treatments methods - to understand disease causes and progression - to determine outcomes for various populations

Electronic Health Record Systems disadvantages

- expensive -downtime -diffculties associated with change -lack of integration

A nurse has accepted a verbal eprfcrip "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema. how should the nurse transcript the dosage of the medication

0.3 mg

240 ml to cups

1 cup

15 mL = ? Tbsp

1 tbsp

30 mL = ? tablespoons

2 tablespoons

1 kg = ? lbs

2.2 lbs

1 tbs to teaspoon

3

240 mL is how many oz?

8 oz

A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of the following priority setting frameworks should the nurse use to prioritize client assessment? acute vs chronic ABBCDE least restrictive/least invasice survival potential

ABCDE

A nurse is discussing the use of herbal supplements for health promotion with a client which of the following client statements indicates an understanding of herbal supplement use? - I can take echinacea to improve my immune system 0 I can take feverfew to reduce my level of anxiety - I can take ginger to improve my memory - I can take ginkgo bi;oba to relieve nausea

I can take echinacea to improve my immune system

A nurse is reviewing documentation guidelines with a newly licensed nurse. which of the following abbreviations should the nurse not as being on the joint commission Do not use list (Select all that apply) MSO4 IU PO ohs NKA

MSO4 IU qhs

A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicated the medication can be taken as needed ? _ PRN - NPO -AC _ad lib

PRN

Events Requiring an Occurrence Report

Patient fall or other injury Medication error Incorrect implementation of a prescribed treatment Needlestick injury or other injury to staff Loss of patient belongings Injury of a visitor Unsafe staffing situation Lack of availability of essential patient care supplies Inadequate response to emergency situation

PACE

Patient/Problem Assessment/Actions Continuing/Changes Evaluation

SOAR analysis

Strengths, Opportunities, Aspirations, Results

a nurse manager is reviewing the documentation of four newly licensed nurses. which of the following medication entries should the nurse identify as being written correctly Synthroid 100 mg PO every morning ac Enocaparin 75 mg SQ bid digoxin 0.24 mg PO qd Metformin 500.0 mg PO with evening meal

Synthroid 100 mg PO every morning ac

Bioethics

The study of ethics related to issues that arise in health care. - should a client be allowed to die?? should a nurse question an oder? should a client be told about a medical error?

DO NOT USE THIS ABBREVIATION

U" or "u" Unit "IU" International Unit Q.D., QD, q.d., qd Daily Q.O.D., QOD, q.o.d., qod Every other day MS, MSO4, and MgSO4 Either morphine sulfate or magnesium sulfate The trailing zero for medications (X.0 mg) X mg (e.g., 10 mg) Lack of leading zero (.X mg) 0.X mg (e.g., 0.1 mg)

spinal cord

a central receiver for nervous stimulation but it is not involved in coordination

problem list

a concise listing of actual and resolved problems identified from the database

atrophy

a decrease in the size of muscle tissue due to lack of use

A nurse follows the six rights of med admin when caring for a client. which of the following concepts is the nurse demonstrating? Laissez-faire advocacy professional identity accountability

accountability

A nurse is teaching a newly license nurse about ethical principles. the nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles? veracity beneficence autonomy fidelity

autonomy

a charge nurse is planning to discuss factors that can influence the clinical decision- making process in client care with a newly licensed nurse. which of the following factors should the charge nurse include? (SATA) - appropriate delegation - close of client care -available resources -awareness of client status -support from other staff

available resources awareness of client status support from other stand

A nurse is caring for a client who is alone and has just received a serious diagnosis. the client asks the nurse if they can pray together, and the nurse agrees. the nurse is demonstrating which of the following ethical principle s autonomy beneficence nonmalefinece justice

benedicence

a nurse is assessing a client using the ABCDE approach. the nurse has already assessed the client's airway and breathing status. which of the following assessments should the nurse perform next? - body temperature - abdominal contour -skin integrity - blood pressure

blood pressure next is circulatory system, can include BP, checking peripheral pulses and measuring capillary refill time

mobility

body movement

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide? - admitting diagnosis - breath sounds - body temp -diagnostic test results

breath sounds

audio recording

can use to verbalize end of shift reports about the client in the break room , not at the client bedside

a nurse is discussing nursing roles with a newly licensed nurse. the nurse should include that which of the following is a role of a nurse? (SATA) - diagnostician - caregiver -advocate change agent dispenser of meds

caregiver advocate change agent

a nurse is caring for a client who is in an acute care facility. the nurse should recognize that the client's care requires clinical reasoning when it is complicated y which of the following factors (SATA) complex clinical situations -ongoing client and family concerns - cost of healthcare - decreased need for advanced practitioner intervention -availability of computerized med records

complex clinical situations ongoing client and family concerns

problem list

contain medical diagnoses and problems for which the client is receiving treatment

DAR format

data, action, response

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

intestinal motility and peristalsis __ with immobility

decrease

flaccid

decrease in or absence of muscle tone

a nurse is caring for a client who is immobile. the nurse should recognize that immobility places the client at risk of which of the following health alterations increase intestinal motility respiratory alkalosis decreased cardiac output hypocalcemia

decreased cardiac output during immobility, the client's HR increases to compensate for increased venous pooling. the reduction in circulating volume increase the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output

articulation

describes the movement of the joints

data base

dpi;d contain demographic data, as well as history and physical data

Admission data

emographic information, insurance data, contact information

A nurse is planning a teaching for a client about wound care. which of the following actions should the nurse take? use medical term during teaching - sit across the client at a table in the car during teaching ensure the client is wearing their glasses during teaching use the communication tech of probing during teaching

ensure the client is wearing their glasses during teachings

Exudate

fluid, such as pus, that leaks out of an infected wound

synovial joint

freely moving joints

a nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. which of the following selections by the client indicates an understanding of the teaching cream of rice cottage cheese gelatin ice cream

gelatin

source oriented med records

have separate areas for information from various sources including testing, nurses notes and progress notes

A nurse is providing privacy for a client who is incontinent. the nurse is demonstrating which of the following professional values? human dignity alturism social justice autonomy

human dignity

Benefience

implement actions that minimize harm and benefit the client

plan of care

include healthcare provider orders, as well as the nursing care plan

a nurse is caring for a client who has a prescription for 5 until of regular insulin and 10 nits of NPH insulin to mix tg and administer subcutaneously. Determine the correct order of steps for this procedure

inject air into the vial of NPH insulin w/o touching the needle to the solution inject air into the vile of regular insulin withdraw correct amount from regular insulin insert needle into the NPH insulin vial and withdraw the correct amount of NPH insulin

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. which of the following skills should the nurse plan to include in the discussion? (SATA) inspection implementation inference creativity inductive reasoning

inspection inference creativity inductive reasoning

respiratory acidosis

low pH, high CO2

spasticity

motor disorder characterized by increased muscle tone, exaggerated tendon jerks, and clonus

A nurse is assessing a client who came to the ED reporting of chest pain. the client tells the nurse they have hearing loss and forgot to bring their hearing aid with them which of the following action should the nurse take to improve comm with the client? (SATA) - move the client to a quieter area or private room - speak at a slower pace -delay the assessment until the client's family member brings the hearing aid - have a sign language inter translate convo w client - stand next to client when speaking -avoid med term

move to quit area or private room speak at a slow pace avoid using med term

nonmaleficence

not doing harm

fidelity

nurses obligation to keep a promise

place the regulation of practice from highest to lowest

nursing regulatory board nursing practice act organization policies and procedures individual self regulation

A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take? - pad the client's wrist before applying restraints. - evaluate the client's circulation every 8 hr after application - remove the restorations every 4 hours to evaluate the client status secure the restrain to the beds side rails

pad the client's wrist before applying restraints. without can abrade the client's skin resulting in injury

a middle adult client tells the nurse, I feel so useless now that my children do not need me anymore. which of the following responses should the nurse make? - most people are happy when their children grow up and leave home - you should be proud that your children are booming independent - maybe you should consider why you are feeling useless -people in middle adulthood often find satisfaction in nurturing and guiding young people"

people in middle adulthood often find satisfaction in nurturing and guiding young people"

human dignity

recognizing that all human life has value and should be treated equally with respect, regardless of race, religion, gender, sexual orientation, culture, ethnicity or socioeconomic status

narrative chart entry

tells the story of the client's experience in the order that it happens.

fitness

the ability to perform ADLs without undue fatigue

endurance

the ability to withstand periods of exercise and activity

A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority ? - the client who reports dizziness when standing - the client has not had a bowel movement in 3 days - the client has non-pitting edema in the lower extremities - the client has several scratch marks on their abdomen

the client report dizziness when standing greatest risk of fall therefore is a priority finding

alturism

the desire and motivation to help others, without any regard to self or wanting anything in return

utilization review

verify that medical treatments are necessary and appropriate

message

what is being states

A nurse is caring for a client who has a new diagnosis go cancer. the client states " I don't understand what my treatment options are" which of the following statements y the nurse demonstrates advocacy? - I will contact your provider to review your treatments options - why don't you understand your options - your provider thinks you need an operation - you will need to cut living costs so you can pay for the treatment

I will contact your provider to review your treatments options

A nurse at a provider's office is reviewing the records of several clients. which of the following clients should the nurse recommend as the priority for treatment? - a client who has a history of hypertension and requires a yearly checkup - a client who reports new chest pain - a client who reports increased joint stiffness due to arthritis - a client who has diabetes mellitus and needs dietary instruction

a client who reports of new chest pain

basal ganglia

assist with coordination of movement

Progress notes

chronological documentation by healthcare team members including client examinations, problem identification, and response to therapy

Discharge planning

includes data from utilization review, case managers, or discharge planners on anticipated client needs after discharge

a nurse is caring for a client who reports pain. when documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements - im having mild pain - pain is like a dull ache in my stomach - pain gets worse when i eat - makes me feel nauseous

pain like like a dull ache in my stomach describing the quality of the pain, which if who it feels in the clients own words

paresis

partial or incomplete paralysis

Documentation

the act of recording patient status and care

quality improvement programs

used to determine effectiveness of care

A nurse truthfully answers a clients question about their lab results. the nurse is demonstrating which of the following ethical principles justic e nonmaleficence fidelity veracity

veracity

point of origin

where a muscle is attached to a stable bone

A change nurse is discussing health records with a newly licensed nurse. which of the following information should the nurse identify as a component of a health record - immunization data - record of client health care payments - complete medical info for household members - facility policies

Immunization data

justice

an obligation of the nurse to treat all clients the same regardless of age, sex, race, sexual orientation, or economic status

hypertrophy

increase in muscle size

Advance directive

information on client's wishes for end-of life care

Priority oder of clients needs using Maslow's hierarchy of needs in order of priority

physiological safety love and belonging esteem self actualization

proteolytic enzyme

apply to an unstable ulcer to facilitate debridement and to softer eschar

cerebral cortex

initiates voluntary movement

paresthesia

numbness and tingling or burning resulting from injury of the nerves

A nurse is caring for a client who refused to have a biopsy. the client states, "I don't need the biopsy; I wouldn't do anything about it anyways if its cancer" the nurse replies " you don't want to have the biopsy bc you wouldn't seek treatment if it was cancer. is that correct? which of the following therapeutic comm tea is the nurse using? affirmation open ended ? reflection restating

restating

Maceration

softening or dissolution of tissue after lengthy exposure to fluid

Focus Charting®

uses assessment data to evaluate client care concerns, problems, or strengths. It also identifies necessary revisions to the care plan as you record each entry. The focus is often nursing diagnosis, a sign or symptom, client behavior, special need, acute change in condition, significant event dar format

A nurse is caring for a client who requires an informed consent for a surgical procedure. which of the following actions is the nurses' responsibility - describe the procedure to the client 0witness the clients signature on the consent form - inform the client of alternatives to the procedure - tell the client which team member will assist w the procedure

witness the signature of the consent form confirm that the client appears competent to give consent and that the client understands the procedure

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? - ensure sterilization of nondispoable items with ethylene oxide - wrap monitoring cords with stockinette and tape them in place - cleanse latex ports on IV tubing with chlorhexidine before injecting med - wear hypoallergenic latex gloves that contain powder

wrap monitoring cords with stockinette and tape them in place many cords contain latex should prevent contact w these cords and devices with the clients skin by covering them w a non latex barrier material

a nurse is caring for a client who asks why they chose the nursing profession. the nurse states that it was bc they wanted to help others. the nurse is referring to which of the following professional values? human dignity alturism social justice autonomy

alturism

a nurse at an urgent care clinical is auscultating the lungs of a client who reports a cough and SOB. which of the following steps in the nursing process is the nurse using? eval implementation analysis assess

assessment

tremor

involuntary quivering movement of the body part

Diagnostic studies

reports detailing the findings of tests that have been performed, such as x-ray examination, ultrasound, or pulmonary function tests

autonomy

respecting the client's right to make their own decisions regarding their health care, including the right to refuse

A nurse is providing education on priority setting framework to a group of newly licensed nurses. which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework? - when using this framework, clients are prioritized using a color coded system - this framework uses the least restrictive measures first as long as the clients safety is maintained - when using this framework, the nurse will encourage the client to have social relationships through group interactions - this framework assigns the highest priority to the situation that poses a threat to the client's physical well being

this framework assigns the highest priority to the situation that poses a threat to the client's physical well being

Rehabilitation and therapy notes

chronological charting by therapists (e.g., physical, occupational, respiratory) about assessments, treatment plan, and client response to therapy

A nurse is obtaining a health history from a client who is newly admitted. the nurse notices that the client does not make eye contact and their arms are folded across their chest. the nurse should recognize that the client is using which of the forms of communication? auditory nonverbal emotional energetic

nonverbal

A nurse suspects their coworker might be under the influence of a chem substance. which of the following actions should the nurse take? - console the coworker about substance abuse -report the coworker to the ethics committee at the facility - ask the coworker how long they have been using substances - tell the charge nurse that the coworker might be impaired

tell the charge nurse the coworker might be impaired

A nurse is caring for a client who has terminal diagnosis and whose health is declining. the client requests information about advanced directives. which of the following responses should the nurse make? - we can talk about advances directive, I can also give you some brochure about them - you should set up a time to talk with your provider about that - lets discuss how you are feeling today, and well save the planning for when you are feeling a little better - why do you want to discuss this without your partner here to plan this with you

we can talk about advances directive, I can also give you some brochure about them

A nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching? - when descending stairs, I will first shift my weight to my right leg I should place my crutches 12 inches in front of my and to the side of each foot - as I sit down, I will hold one crutch in each hand - I will make sure the should rests snug against my arm pits

when descending stairs, I will first shift my weight to my right leg first shift weight to right, unaffected leg crutches should be 6 inches in from and to the side sitting down hold both crutches in 1 band avoid injury the should should rest 1-2 inches below armpits

A nurse in a clinic is caring for a middle adult client who states "the Md says that since im at an av risk for colon cancer, I should have a routine screening. what does that involve? " which of the following responses should the nurse make? - ill get a blood sample from u and send it for screening - beginning at age 60, you should have a colonoscopy - you should have a fecal occult blood test every year - the rec is to have a sigmoidoscopy every 10 years

you should have a fecal occult blood test every year

A nurse is reviewing protocol for suctioning section from a client who has a new tracheostomy. which of the following actions should the nurse plan to take ? - use a resuscitation bag w 80% oxygen prior to the procedure - select a suction Cath that is 1/2 the size of the lumen - place the end of the suction Cath in a water-soluble lubricate 0 adjust the wall suction apparatus to a pressure of 170 mm HG

select a suction Cath that is 1/2 the size of the lumen to prevent hyperemia and trauma to the mucosa

A nurse is caring for a client who has a NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take 1st? - since the feeding bags w water btwn feedings - tell the client to keep the head of the bed el at least 30 deg - make sure the enteral formulae is at room temp - wipe the top of the formula can w all

tell the client to keep the head of the bed el at least 30 deg prevent reflux of the formula into the esophagus

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? - ensure the room is well lit - have soft music playing in the background - hand out samples of products during the teaching - speak quickly during the teachings

ensure the room is well lit

A nurse at the end of their shift realizes they forgot to give their scheduled vitamins. the nurse decides to document that the vitamins were administered. which of the following describes the nurse's actions? HIPAA violation falsification of records assault defamation

falsification of records

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? - dissolve each med in 5 mL sterile water - draw up medications tg in the syringe -push the syringe plunger gentle when feeling resistance - flush the tube w 15 mL of sterile water

flush the tube w 15 mL of sterile water

A nurse enters a client's room and stands near the client to ask them if they need anything. the client continues to watch the TV, which is at a loud volume. Which of the following actions should the nurse take? leave the clients room and go check on others ask the client why they are ignoring the question repeat the question in a loud voice lower the volume on the TV

lower the volume on the TV

A nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make? - drink a cup of hot cocoa b4 bedtime - maintain a consistent time to wake up each day -exercise 1 hr before going to bed - watch a TV program in bed b4 going to sleep

maintain a consistent time to wake up each day

A nurse is initiating a protective environment for a client who has\d an allofernic stem cell transplant. which of the following precautions should the nurse plan for this client? - make sure the client's room has at least 6 air exchanges per hour - make sure the client wears a mask when outside her room if there is constructive in the area. - place the client in a private room w the negative-pressure airflow - wear a N95 respirator when giving the client direct care

make sure the client wears a mask when outside her room if there is constructive in the area. compromises clients immune system, greatly increasing the risk for infection. the client will need protection from breathing in any pathogens in the environment has at least 12 air cexhanges - should be in positive pressure room - N 95 only for airborne precautions

A nurse is teaching a newly licensed nurse about professional competence. which of the following examples should the nurse include in the teaching? - documenting client care before it is done - reviewing the charts of clients not assigned to the nurse - presenting a summary of an evidence-based journal -performing a surgical procedure under the direction of a surgeon

presenting a summary of an evidence-based journal

A nurse is completing an admin assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following should the nurse expect? - neck vein distention -uring specific gravity 1.010 - rapid heart rat e - blood pressure 144/82

rapid heart rate

A nurse is documenting in a client's chart and makes the entry "the client reports abdominal pain on exertion" which of the following documentation formats describes this entry the I in PIE - the S in SOAP the R in DAR - the E in PIE

the S in SOAP subjective -> client is reporting their feelings of pain

Electronic Health Record Systems advantages

- enhance communication and collaboration -improved access to info -time savings -improved quality of care -information is private and safe

the nurse include to promote effective communication with the healthcare team

-report any concerns to the proper person - discuss any clinical errors with coworkers 0 question the healthcare provider regarding unclear orders

MBAR

Medication Background Assessment Recommendation

client rounding

a collaborative approach that allows nurses and healthcare providers to equally discuss the plan of treatment and client goals at the bedside

History and physical

a detailed summary of the current health problem; past medical, surgical, and social history; medications taken; allergies; review of systems; and physical examination data

occurrence report, or incident report

a formal record of an unusual occurrence or accident. It is an organizational report used to analyze the event, identify areas for quality improvement, and formulate strategies to prevent future occurrences.

moral judgment

a person own standards of right and wrong

ethical distress

a situation in which a nurse observes or even participates in a violation of ethics

whistleblowing

a type of ethical distress signal in which a nurse observes and reports an immoral or unethical behavior

hypercalcemia occurs with immobility because

bones demineralize from lack of weight being. the excess can deposit in joints, causing stiffness and pain

traits of transformational leeaders

empower employees to share idea s for how to improve client care, ideas embraced and appreciated - bottom up - flexible - creativity

nursing managers

ensure continuity of care when determining when work schedules and client assessments, providing appropriate client care

interventions the nurse should include when performing a procedure within the client's intimate space

explain to the client about the procedure - inform the client when the nurse will touch the client -acklowledge that it is uncomfortable

A nurse is teaching a client who is newly diagnosed with diabetes mellitus, the client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the schramm model of communication, the nurse should recognize the client's statement as? sender channel feedback reciever

feedback demonstrated when the receiver (person who receives the message as the decider) is allowed to let the sender (the person initiating the communication) know that the message was properly received

factors take into account when interviewing clients?

gender personal space developmental level sociocultural factos

A nurse is caring for a client who has a stage II pressure ulcer. which of the following wound dressings should the nurse apply to the ulcer? hydrocolloid collagen calcium alginate proteolytic enzyme

hydrocolloid this type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin

factors that affect the perception of a stimulus

location of the receptors # of receptors activated frequency of action potentials generated changes in frequency, location and # stimuli

environmental factors the nurse should consider when interviewing a client

noise odors room temperature

SOAP format

often used to write nursing and other progress notes. It can be used in source-oriented, problem-oriented, and EHRs. The following list explains the acronyms SOAP, SOAPIE, and SOAP(IER). subjective, objective, assessment, plan, interventions, evaluation, revision

Problem-oriented records (PORs)

organized around the client's problems. There are no separate sections for each discipline. The POR consists of four parts: database, problem list, plan of care, and progress notes.

problem-intervention-evaluation (PIE) system

organizes information according to the client's problems. It requires keeping a daily assessment record and progress notes. problem, intervention, evaluation

A nurse calls the unit to tell say that they will be late for their shift. the charge nurse responds "Don't worry, take your time and be safe" after hanging up the phone, the charge nurse then says to the staff at the nurses station "Im tired of that nurse always being late. I wish someone would do something about that tardiness " which of the following communication styles is the charge nurse demonstrating assertive aggressive passive aggressive passive

passive aggressive

Provider's prescriptions

plan of care that includes medications, treatments, and activities

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. which of the following actions should the nurse take? - ask a staff member who speaks the language as the client to interpret - as a family member of the client to interpret the information - search the internet for an electronic application to use for translating - request assistance from the facilities interpreter

request assistance from the facilities interpreter ensures that the information is correct and gives both the nurse and the client opp to ask questions

Laboratory data

results from diagnostic tests, such as complete blood count (CBC)

transactional leaders

rules-based and employees are rewarded with a salary and benefits. expected to follow rules with little variance directive and task focused

handoff report

s to promote continuity in care. The nurse is alerted to the client's status, recent status changes, planned activities, diagnostic tests, or concerns that require follow-up. A handoff report may be given at the bedside or in a conference room, using paper notes or an EHR device.

frontal lobe

sensory receiver and has cognitive function

Calcium alginate

should apply to stage IV pressure ulcer. this type of dressing is used for sounds with significant exudate and must be covered with a secondary dressing

bedside report

standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

Charting by exception (CBE)

system of charting in which you only document significant findings or exceptions to standards and norms of care. To use the CBE effectively, you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions

contrast

the amount od physical contrast the stimulus produces affects the response

ethical agency

the application of ethical principles to professional practice

progress notes

the nurse and all other healthcare professionals would document the care provided in the progress notes

health records system

the overall process by which to create, store, and retrieve client records in an organization

encoding

the way a message is sent, this includes verbal and nonverbal communication

A nurse is teaching a newly licensed nurse about professional values. the nurse should include that which of the following is an example of autonomy - a nurse provides the same quality care for every client - a nurse maintains client confidentiality - a nurse admits they forgot to change a clients dressing - a client respects a client's wish to discontinue a treatment

- a client respects a client's wish to discontinue a treatment

a nurse is reviewing the concept of critical thinking with a newly licensed nurse. which of the following statements should the nurse make? - critical thinking is the foundation for clinical decision making - critical thinking takes into conisideration nursing, scientific and technological knowledge in client situations - critical thinking is the visible or observed outcome whole using evidence-based practice -critical thinking is necessary for the nurse to collect objective client data

- critical thinking is the foundation for clinical decision making

a nurse is discussing leadership styles with a newly licensed nurse. which of the following characteristics should the nurse identify as describing a bureaucratic leaders? (SATA) - decisions are controlled by policies - enforcers the rules - inflexible to creative suggestions -uses a variety of strategies based upon the circumstance - motivates staff w use of rewards or punishments

- decisions are controlled by policies - enforcers the rules - inflexible to creative suggestions

A nurse is preparing a poster about professional accountability for an in-service. which of the following examples should the nurse include? (SATA) - informs a client's family that the assistive (AP) failed to get the client out of bed during the day - lowers a clients bed to the lowest position after assisting the clients to lay down - administers pain medicine to a client 30 min b4 the client is scheduled for PT - provides instructions to AP on how to provide culturally competent care to a client - documents a dressing change on a client's wound prior to completing it

- lowers a client's bed to the lowest position after assisting the client to lie down admin pain med to client 30 min b4 PT is scheduled provides instructions to AP on how to provide culturally competent care to a client

a nurse is discussing professional commitment with their supervisor during an annual performance review. which of the following actions by the nurse demonstrates professional commitment? - the nurse attends an educational course to learn about the treatment and prevention of pressure ulcers - the nurse tries to improve their skills by starting an unnecessary IV on client who has dementia - the nurse covers for another nurse who the nurse suspects is chemically impaired - the nurse withholds information from a client to reduce the client's stress level

- the nurse attends an educational course to learn about the treatment and prevention of pressure ulcers

3840 mL = __________ gallon

1 gallon

180 ml to teacup

1 teacup

5 mL = ? tsp

1 tsp

3840 = quarts

4

180 ml =? ounces

6

180 mL = ? oz

6 oz

A nurse is calculating a client's fluid intake over the past 8 hr. which of the following items should the nurse plan to document intake and output record as 120 mL of fluid - 2 cups of coup - 1 qt of water 8 oz of ice chips 6 oz of tea

8 oz of ice chips 2 cups - 480 mL 1 qt water - 960 to 1,000 ml 4 oz of liquid water = 120 ml 6 oz = 180 mL

A nurse is reviewing documentation principles with a group of newly hires AP. which of the following information should the nurse include? - providers designate to other staff which abbreviations cannot be used - a nurse who delegates a task to an AP will review the charting for that task -providers read and cosign nursing documentation for accuracy - license personnel should document out of range vital signs for AP

A nurse who delegates a task to an AP will review the charting for that task

Documentation ABCs

AccurateEasy to readBias-freeFactualCompleteGrammaticalDetailedHarmless (legally)

A nurse is discussing computerized provider order entry (CPOE) systems with staff. which of the following statements from a staff member indicates an understanding of a CPOE system - Cpoe systems are associated with a slightly higher error rate -CPOE use foes not include medication prescriptions -CPOE systems can increase the speed of care delivery -CPOE use is mandated by HIPAA under the privacy rule

CPOE systems can increase the speed of care delivery

FACT documentation model

Flow sheets individualized to specific services Assessment features standardized with baseline parameters Concise, integrated progress notes and flow sheets documenting the client's condition and responses Timely entries documented when care is given FACT documentation includes only exceptions to the norm or significant information about the client. It eliminates the need to document normal findings.

A nurse receives a phone call from a client who was discharged yesterday. the client asks the nurse to email them a copy of their discharge instructions. which of the following responses should the nurse make ? - The nurse manager will need to email the discharge instructions to you" - I am unable to send you instructions via email due to the HIPAA Privacy act - you will need to ask your provider to email the discharge instructions to you - sending the discharge instructions to you via email would be a violation of the affordable care act

I am unable to send you instructions via email due to the HIPAA Privacy act

A staff nurse is evaluating a newly licensed nurse's understanding of the telephone prescriptions. which of the following statements by the newly licensed nurse idicates an understanding of the info? - I can take a tele prescriptivists if a provider is making routine rounds in anothe area of the facility - I can take a tele prescriptivists if a provide is directing a code for an unresponsive client - if a client requires an OTC medicine for relief of nausea, it is ok to accept a tele prescrip - if a client requires pain control for a terminal condition, it is ok to accept a tele prescrip

I can take a tele prescriptivists if a provide is directing a code for an unresponsive client use only in emergency situations

A nurse is caring for a client who requires 24 hr using collection. which of the following statement by the client indicates an understanding of the teachings? - I had a bowel movement but I was able to save the urine - I have a specimen in the bathroom from about 30 min ago 0 flushed what I urinated at 7 am and have saved all the muring side - I drink a lot, so I will fill up the bottle and complete the test quickly

I flushed what I urinated ta 7 am and have saved all urine since for 24 since should discard the first voiding and save all subsequent voiding

A nurse is talking with a client about their electronic health record (EHR) at the facility. which of the following client statements indicated an understanding of the EHRs - I wil be able to track my health information - my personal info will be entered into a national data base - I will have one EHR that will encompass the health care I've received over my lifetime - the goal of EHRs is to improve insurance coding

I will be able to track my health info

IPASS

Illness Severity Patient Summary Action List Situation Awareness and Contingency Planning Synthesis by Receiver

flow sheets and graphic record

Perform and document care activities. Document assessments and care that are performed frequently, on a recurring schedule, or as a part of unit routines Allow you to see patterns of change in client status

point of insertion

the attachment of a muscle to a moveable bone

A nurse is assisting with client triage at the scene of a mass casualty event. which of the following clients should the nure=se recommend for transport first? - a client who reports a possible sprained wrist and is walking around - a client who has an open forearm fracture without visible drainage - a client who has a respiratory rate of 6/min and no pupil response - a client who has an abdominal wound that is actively bleeding

a client who has an abdominal wound that is actively bleeding requires immediate intervention for survival, therefore, when using the survival approach to client care, the nurse should recommend this client for 1st transport to a health care facility, a client who is hemorrhaging has an immediate threat to life

A nurse has received change of shift report on four clients. which of the following clients should the nurse plan to see first? - a client who is scheduled for an abdominal ultrasound - a client who needs a urine specimen sent to the lab - a client who has audible wheezing during respirations - a client who requests their routine pain med

a client who has audible wheezing during respirations

A nurse has received change of shift report for a group of clients. which of the following clients should the nurse plan to see first? - a client who is receiving a blood transfusing and reports urticaria - a client who has back pain and is requesting a muscle relaxant medication - a client who has an ankle Spain and requests toileting assistance - a client who has chronic migraines and reports a headache

a client who is receiving a blood transfusing and reports urticaria is unstable bc this is a manifestation of anaphylaxis

A nurse is reviewing the medical records of 4 clients. which of the following clients should the nurse identify as the priority for care? - a client who received digoxin and has a HR of 48/min - a client who received pain medication and has a respiratory rate of 14/min - a client who has a UTI and temp of 37.9 C (100.2 F) - a client who has anemia and a BP of 118/78 mm HG

a client who received digoxin and has a HR of 48/min unstable, the HR is below the expected range and check for manifestations of decreased cardiac output

a nurse is planning a presentation about shared governance, which of the following examples should the nurse plan to include? - a supervisor at a home health agency makes a unilateral decision to cut staff - 2 assistant directors at an ambulatory care center write the policy manuals for the center - a group of staff nurses in a clinic work tg to recommend the equip purchases for the unit - nurses on a med surgery floor follow instructions made by the charge nurse

a group of staff nurses in a clinic work tg to recommend the equip purchases for the unit

a charge nurse is observing a newly license nurse prepare a sterile field dressing change. which of the following actions by a newly license nurse requires intervention by the charge nurse - a newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field - the NLN holds places sterile objects 2.5 cm ( 1 in within the border of fiel d - holds the bottle of saline outside the edge of the field when pouring sterile field is positioned at the NLN waist

a newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field place cap on clean surface bc the outer edged are unsterile and will contaminate the sterile field

A nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines. - is caring for a client review the client medical chart with a nurse student who is working w the nurse e - asks a nurse from another unit to assist with documentation for a client - who is caring for a client returns a call to the person appointed din the health care proxy to discuss the clients care - discussies a client's status w the physical therapist who is caring for the client

a nurse asks a nurse from another unit to assist with documentation for a client

A nurse is reviewing standards of care with a group of newly hired nurses. the nurse should include which of the following incidents as an example of a breach of standards of care? - a nurse did not read back a verbal med prescription to a provider 0 a nurse did not return to a client's room with a promised blanket - a nurse documents client care as soon as it is completed - a nurse forgot to call a client's family after performing a procedure

a nurse did not read back a verbal med prescribed to a provider standards of care guide nursing practice to perform safe and effective care. failing to verify a med prescription can result in harm to a client and is therefore a breach of the standard of care

A nurse is teaching a newly licensed nurse about ethical principles. the nurse should include which of the following situations is an example of fidelity - a nurse involves a client in making decisions about their care - a nurse implements fall precautions for a client who is at risk of falling - a nurse tells the truth about forgetting to perform a proceeder for a client - a nurse keeps a promise to the client not to tell their family about their diagnosis

a nurse keeps a promise to the client not to tell their family about their diagnosis

A nurse is planning on educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? - even exam every 2 years - tents booster every 5 years - shingles when 70 - pneumococcal vaccine when 65 yrs old

a pneumococcal vaccine when 65 recent 1 of the 2 vaccine when 65, can given to clients who are 19 or older and have certain conditions such as chronic heart, lung or liver disease, diabetes and alcohol disease or smoke cigs

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. which of the following information should the nurse include? - a problem-oriented medical record is created using the PIE model for documentation entries - a problem oriented medical record contains speeerate sections for lab and diagnostic info - a prob or med rec promotes information sharing among members of the interdisciplinary team - prob or med rec is rarely used in acute care settings

a problem oriented medical record promotes information sharing among members of the interdisciplinary team uses progress notes, which promotes info sharing among members of the interdisciplinary teams SOAP format more organized than traditional source-oriented med records , useful in acute care settings

A nurse in an ER is caring for 4 clients. which of the following clients requires mandatory reporting? - an adolescent who has a fractured tibia following a football game 0 a young adult who is + for Tb - an older adult who has dementia, a history of falls and bruising on their knees - a preschooler who has freuuent enuresis

a young adult client who has a positive TB diseases and illnesses that are considered a threat to public health, such as TB, HIV, and flu require mandatory reporting to the health department to track and develop prevention and protective protocols

a nurse is discussing leadership styles with a newly licensed nurse. the nurse should include that which of the following is a characteristic of situational leadership? - follows leadership directives exactly as stated - controls situations by paying attention to details - adjusts quickly to different circumstances - refuses to allow staff to make exceptions to establish guidelines

adjusts quickly to different circumstances

a nurse is preparing to delegate client care tasks to an assertive personnel (AP). which of the following tasks should the nurse delegate? - ambulating a client who is postoperative - inserting an indwelling ur cash for a client -demonstrating the use of an incentive spirometer to client - confirming that a clients pain has decreased after receiving an analgesic

ambulating a client who is postoperative

A nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractors - place pillow under clients knees - position a trochanter roll under each of the clients hips -advise the client to wear rubber soled slipper - apply an ankle-foot orthotic device to clients feet

apply an ankle-foot orthotic device to clients feet

A nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding? - assign a staff member to feed the client -provide small-handed utensils for the client - thicken liquids on the clients tray - arrange food in a consistent pattern on the clients plate

arrange food in a consistent pattern on the clients plate `

A nurse is caring for a client who is scheduled fo surgery. before the client has signed the uniformed consent form, the client states " id dint really understand what the doctor said" which of the following actions should the nurse take - explain the procedure in detail to the client - ask the provider to discuss the procedure with the client - encourage the client to reread the consent form before signing - tell the client that the surgeon will explain it to them in the operating room

ask the provider to discuss the procedure with the client

A nurse is caring for a group of clients. which of the following actions by the nurse demonstrated professionalism? - asks the client their name, DOB, and scans their med ID bracelet before admin meds - determines that the client's rash is a sreponsse to being overly stressed about new diagnosis - suggests a clients fam member translate med info to a client who speaks a diff lang - documents that a clients med was admin when retrieving the med from the pharm

asks the client their name, DOB, and scans their med ID bracelet before admin meds

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? - rock the client up to a standing position - pivot on the dot that is the farthest from the chair - assesses the client for orthostatic hypertension - apply a gait belt to the client

assess the client for orthostatic hypotension

A nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessment should the nurse identify as the priority osculate lung sounds measure urine output monitor BP reading monitor electrolyte levels

auscultate lung sounds

A nurse is preparing to administer morphine 15 mf PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the med? by mouth intramuscularly per rectum intravenously

by mouth

a charge nurse uses a transformational leadership style when working with other staff on the unit. which of the following actions by the charge nurse demonstrates transformational leadership? - tells assistive personnel if the morning care for a group of clients is completed by noon they will receive a free lunch - challenges a nurse to investigate evidence based approaches to reduce the client fall rate on the unit - provides a nurse with the written protocol for changing a dressing and encourages them to work independently - adjusts direction to nursing staff based on the nurses' experience and client needs

challenges the nurse to investigate evidence based approaches to reduce the client fall rate on the unit focuses on a person's willingness to change and stimulates them to review current structures and come up with fresh ways to improve them, such as finding a way to decrease client falls

A newly licensed nurse is orienting to a facility's documentation system. the facility requires staff to only document variations from an expected set of findings when performing a physical assessment. the nurse should identify this system as which of the following documentation methods? - charting by exception - subjective, objective, assessment, plan format - problem, intervention, evaluation model, - data, action, response charting

charting by exception - only chart unexpected findings , can be done on a flowsheet or through narrative notes

A nurse is discussing responsibility with a newly licensed nurse. which of the following actions should the nurse include as an example of responsibility - informs. social worker that a client will require financial assistance with prescriptions at discharge - supports a client's decision to stop chemo - checks tp determine how well a pain med worked - ensures a client understands their treatment options

checks a client to determine how well a pain med worked identified a client need, interfered and is now determining the outcome of the intervention

A nurse in a provider's clinic is teaching a female client about how to collect a clean-catch muring specimen at home. which of the following information should the nurse include in the teaching? - use sterile gloves when collecting your urine specimen - you may refrigerate your specimen for up to 12 hrs before bringing it to the lab collect your specimen as soon as you start your stream clean your vaginal area from the front to back

clean your vaginal area from front to back

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? - history of abuse - permanent pacemake -ulcerative colitis -asthma

client who has asthma bc they can cause broncospasm

a nurse is reviewing methods created to assist nurses in using evidenced based practice. which of the following is aa NCSBN model that can assist the nurse when critical thinking and decision making? clinical judgment critical thinking clinical reasoning SMART goals

clinical judgment was developed to assist nurses in using evidenced based practice to think critically and make decisions

A nurse on a medical unit is preparing to discharge a client to home. which of the following actions should the nurse take as a part of the medication reconciliation process? - seal unused medications from the facility in a plastic bad - escalate the clients ability to self admin medications - report an identified discrepancy to the joint commission 0 compare prescriptions with medications the client received while at the facility

compare prescriptions with medications the client received while at the facility

an individuals response to stimuli is based on

contrast adaptation previous experience intensity

cerebellum

coordinates movement and is responsible for posture, movement and position sense

A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take 1st? - apply soft limb restraints to the client's wrists -admin an anti anxiety med to the client intramuscularly (IM) - cover the IV site with an elastic bandage - request a prescription for a central venous catheter

cover the IV site with an elastic band will hide the IV from the clients vision while at the same time allowing the nurse easy access to the site

a hospice nurse is caring for a client who states that they want to have their last rites before they die. the nurse recognizes that which of the following factors is influencing the clients request? cultural developmental environmental psychological

cultural factor

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term facility. which of the following documentation should the nurse include? -client flow sheet - acuity rating - current medications - incident reports

current medications to ensure client safety and continuity of care

A nurse is caring for a client who has been wheezing. the nurse asks an assist personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. this is an example of which of the following concepts? - delegation of the right circumstanc e del of the wrong task del ro the right person del to the wrong time

delegation of the wrong task

A nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as indication of fluid volume excess ? -hypotension -weak, thready pulse -slow cap refil -distended neck veins

distended neck veins can also include edema, tachycardia, crackles in lungs, dyspnea, bounding pulse and increase in BP

A nurse is preparing to administer a PRN pain med to a client but withholds the med c the client is sleeping. which of the following actions should take to provide the expected standard of care -document that the med was not administered - document that the client is not experiencing pain - contact the provider to change the PRN prescript - fill out an incident report about the situation

document not administered

Nurses' notes

documentation of client care and response to treatment recorded by nurses (usually chronological)

A nurse manager is observing a newly licensed nurse provide care for a client. which of the following actions by the newly liscensed nurse should the manager identify as unprofessional behavior (SATA) documents in advance to save time - stays logged into the client's electronic health recordd while obtaining supplies from the supply room - contacts a client on social media to become friends - informas a provider that a requested action is outside the nurses' scope of practice - provides a certified med translator for a client who speaks a different language than the nurse

documenting in advance stays logged in contacts a client on social media

A client who is non ambulatory notifies the nurse that his trash can is on fire. gayer the nurse confirms the presence of the fire, which of the following actions should the nurse take next? - activate the emergency fire alam - extinguish the fire -evacuate the client -confine the fire

evacuate the fire RACE mnemonic

A nurse is instructing a client regarding heart-healthy activities. the action represents which of the following phases of the client-nurse relationship? identification orientation exploitation resolution

exploitation actively coaching the client toward a healthier lifestyle

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel. which of the following information should the nurse include? - American nurse association standards prevents client records from being used for legal proceedings - HIPAA regulations cary from one state to another - privacy regulations apply to electronic data transfer rather than verbal communication - facilities can establish their own rules for documentation methods

facilities can establish their own rules for documentation methods

A charge nurse is overseeing an AP who has been assigned care for a group of clients. which of the following actions by the charge nurse demonstrates accountability - assigns the AP to provide care for clients who are in rooms next to each other - files an incident report when the AP performs a task that is outside their scope of practice - promises to write a letter of recommendation for the AP id they complete all their assigned tasks - discusses advancing their ed w the AP

files an incident report when the AP performs a task that is outside their scope of practice

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? - gently shake the container of med prior to admin - transfer the med to a med cup - place the client in a semi-fowlers position period to med admin - verify the dosage by measuring the liquid before admin it

gently shake the container of med prior to admin ensure mixed

A nurse stops at the side of the road to provide care to a person involved in a motor vehicle crash. which of the following protects the nurse from liability when administering care at the scene of an accident whistleblower protection Good Samaritan laws torts emergency medical treatment and labor act

good samara tin law

A nurse is discussing shared governance with a newly licensed nurse. which of the following components should the nurse include in the discussion (SATA) - guides decisions toward accountability - improves client outcomes - assures money's being used for its intended purpose - promotes professional development - monitors activités of directors

guides decisions toward accountability improves client outcomes promotes professional development

A charge nurse is discussing the responsibility of nurses caring for clients who have c diff infection. which of the following should the nurse including the teaching? - assign a room # w neg airflow system - use all based hand Sani when leaving room clean contamination surfaces in the room phenol solution - have fam members wear a gown and gloves when visiting

have fam members wear a gown and gloves when visiting

A nurse is performing a Romberg test during a physical assessment of a client. which of the following techniques should the nurse use? - touch the face w a cotton ball - apply a vibrating turning fork to the clients forehead - have the client stand w their arms at their sides and their feet tg - perform direct percussion over the area of the kidneys

have the client stand w their arms at their sides and their feet tg helps identify alterations in balance, stand like that to observe for swaying and loss of balance

A nurse is teaching a group of newly licensed nurses about professional values. which of the following statements by a newly licensed nurse demonstrates an understanding of social justice? - healthcare should be a right for everyone - all clients should have a private room in a health care facility - I plan to volunteer at the local homeless shelter on my days off - I will respect a clients right to refuse a procedure

health care should be a right for everyone social justice is the recognition of and fighting for equality of every individual for equal access to healthcare, food, housing, educational opportunity, and far and equal treatment in all aspects of life

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appt and is focusing on the client's ability to make healthy behavior changes. which of the following statements by the nurse is an examp of the use of affirmations? im glad you decided to continue your fit routine - you could achieve better results if you applied yourself more - you are adjusting very well for your age - reducing your caffeine intake is good, but you really need to stop completely

im really glad you decided to continue your fitness routine

A nurse who has been working 12 hr shift on a busy unit is experiencing nurse fatigue. which go the following effects can result from nurse fatigue - increase in communication - increase in effective clinical judgment 0 increase in med error - increase in productivity

increase in med errors

A nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? - insert an implanted port - close a laceration with sutures - place an endotracheal tube -initiate an internal feeding through a gastrostomy tube

initiate an internal feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. which of the following actions should the nurse take? - instruct the family to refrain from pushing the button while she is asleep inform the client that bc she is one PCA, vital signs will be taken every 8 hr - teach the client to avoid pushing until pain is above a 7 on a scale of 0 to 10 - increase the basal rate and shorten the lock-out interval time if the clients pain is too high

instruct the family to refrain from pushing the button for the client while from she is asleep

A nurse is preparing a poster describing leadership styles for a unit in service. which of the following terms should the nurse use to describe a nurse manager who exerts little control over the decisions made by the charge nurse bureaucratic transactional transformational laissez-faire

laissiez-faire

A nurse is teaching a client about advance directives. which of the following client stamens indicates an understanding of the teaching? - I need to choose a family member as my health care surrogate - once I sign my advance directives, I cannot change my decisions - my health care surrogate will make health care decisions for me if I am unable - I need to have an attorney present to complete my advanced directives

my health care surrogate will make health care decisions for me if I am unable

A nurse is caring for a client who has TB. which of the following actions should the nurse take? (SATA) place client in a neg pressure room - wear gloves when assisting w client with oral care -limit each visitor to 2 hr increments 0 wear surgical mask when providing client care - use antimicrobial sanitizer for hand hygiene

negative pressure room wear gloves when assisting w oral care antimicrobial sanitizer

A nurse is assessing a client using the ABCDE property setting approach. which of the following actions should the nurse take when completing the exposure component of this priority setting method (SATA) - observe the client's lower extremities for indications of deep vein thrombosis - obtain a respiratory rate for a full minute -measure the client's temp -check client for bruising - obtain a blood pressure measurement

observe the clients lower extremities for indications of deep vein thrombosis check the clients temperature check the client for bruising

source-oriented records

paper format in which each health care group keeps data on its own separate form

hemiplegia

paralysis of one side of the body

A nurse is admitting a client who has hypertension. using the nursing process, which of the following should the nurse take first? - develop nursing diagnosis - perform a physical assessment -administer prescribed medications -develop goals and outcomes

perform a physical assessment

A nurse is preparing an in-service about HIPPA> which of the following information should the nurse plan to include? - accessing the medical record of clients on units other than were you are assigned is allowed - there are large financial penalties for charity vital signs you obtain for another nurse's client -personnel can be terminated for breaching a clients confidentiality - once you have cared for a client, it is acceptable to look at their medical record on the subsequent health care visits

personnel can be terminated for breaching a clients confidentiality

exercise

planned and purposeful repetitive movement to improve physical fitness

immobility decreases respiratory movement, leading to __

poor oxygenation and carbon dioxide retention, if not corrected, the hypoventilation can eventually cause an immobile client to develop respiratory acidosis

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a psychomotor approach to learning? - role play group discussion question-answer meet gins practice sessions

practice sessions

a nurse is preparing for a presentation on professional identity in nursing. which of the following statements should the nurse use to describe professional identify - professional identity is how one describes themselves at work - professional identity refers to the public image about the role of nurses - professional identity is a term describing the belief and acceptance of the standards and values of the profession - professional identity being with licensure and training within a healthcare stepping

professional identity is how one describes themselves at work

A nurse is caring for a client who has a new prescription for dialysis 3x a week. the client avoids eye contact while talking to the nurse and explains that they work 2 jobs to support their partner and 2 kids. the client also states " idk how im going to have time for dialysis" which of the following factors are influencing the clients comm (SATA) physchosocial factors cognitive factors situational factors environmental factors physiological factors

psychosocial situational

A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. which of the following chart entries should the nurse include as an example of objective data? - the client states "I've had abdominal pain for the past 3 days" - the client reports consuming aout 1500 mL of water per day - rebound tenderness noted in LQ of the abdomen - recommend client referral to RD

rebound tenderness noted in RLQ of the abdomen

a nurse is preparing to obtain a client's BP. which of the following actions should the nurse plan to take? = place the lower border of the cuff slightly over the antecubital space - record the diastolic # as the last heart sound heard - release the air from the cus so the pressure decreases at 5 mm Hg per second - use a bp cuff with the ladder is that of 50% of the clients arm circumference

record the diastolic # as the last heart sound heard

A charge nurse is reviewing characteristics of the electronic documentation with staff at a providers office. which of the following characteristics should the charge nurse plan to include? (SATA) - reduces medical errors - improves listening skills among interdisciplinary team members - less convenient than paper based charting - makes client medical history more easily available - increases accuracy of coding procedures

reduces medical erros makes client medical history more easily available increases accuracy of coding procedures

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. which of the following statements should the nurse include? (SATA) - interrupt the client occasionally during the conco - respect the client during the convo - used complex terms when explaining with client - allow time. for reflection during the conversation with the client - show empathy during the conversation with the client

respect the client allow time for reflection show empathy

A nurse manager is planning to introduce a new scheduling policy to the unit staff. which of the following methods of communication should the nurse mamanger use? send an email to staff via the facility's email system - schedule a fact to face unit staff meeting - place a copy of the policy on a bulletin board in the hallway. - leave a vm on each staff memeers phone

schedule a fact to face unit staff meeting in person comm of this important policy would permit both verbal and nonverbal modes of communication between he sender and receiver

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. they nurse should recognize that these feelings fall under which of the following categories of Maslow's hierarchy of needs? - love and belonging -self-actualization - safety -self-esteem

self-esteem

A nurse is providing discharge instructions to a client during a follow-up telephone call. based on the shannon-weaver communication model. which of the following components of the model is the nurse demonstrating receiver sender channel recorder

sender the nurse is imitating the message

intefrity

showing honestly and choosing to do what is right and fair even when he situation is difficult

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration? -purulent exudate -warmth -skin blanching -bleeding

skin blanching skin black, edema and coolness at IV site indicate infiltration warmth indicates phlebitis eceudate indicates infection

a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension? - a client who is 52 yrs old - a client who smokes 1 pack of cigarettes each day - a client who walks for 30 min every day - drinks one glass of wine 3x per week

smokes 1 pack of cigs each day

Clonus

spasmodic contraction of opposing muscles resulting in tremorous movement

A nurse is caring for a client who has dementia. which of the following communication strategies should the nurse implement to communicate with the client? -explain the daily schedule to the client in detail -turn on the overhead lights on the client's room when speaking with them -speak in a loud voice to the client - speak to the client clearly and at a slow pace

speak to the client clearly and at a slow pace simple instructions and explanations, avoid complicated terms or medical terminology

A nurse in an E overhears a provide say they will not accept any more clients who do not have health insurance.which of the following is the provider violating ? - the emergency medical treatment and labor act (EMTALA) - HIPAA - tort law - good Samaritan law

the EMTALA was enacted to allow clients access the ER of hospitals for equal care regardless of their ability to pay

A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first (SATA) the admitting provider the charge nurse on the unit the clients siblings the client the client's spiritual advisor

the admitting provider the charge nurse on the unit the client

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication for elder abuse - the caregiver is the clients financial power of attorney 0 the client is in the wheelchair w the wheels locked - the client reports receiving a full bath 2 x each week - the caregiver insists on remaining in the room

the caregiver insists on remaining in the room can be an indication of potential mistreatment of client and should evaluate for additional signs of potential mistreatment though the admission assessment

A nurse is discussing chains of command with a newly licensed nurse. which of the following statements by the newly licensed nurse indicated an understanding of the discussion? - the use of the chain of command is reserved for natural disasters or acts of terroism - the steps for the chain of command consist of notifying my superiors stating from the top to the bottom - I will wait to document the communication I used while following the chain of command until the end of the process - the chain of command clarifies the steps I need to take when I have a concern about a client's care

the chain of command clarifies the steps I need to take when I have a concern about a client's care

A nurse is caring for a client who is postoperative and has sanguineous drainage on their dressing. the nurse is unable to reach the client's provider. which of the following members of the chain of command should the nurse contact next? the charge nurse the nursing supervisor divisional director chief of medical staff

the charge nurse

A nurse is performing a skin assessment for a client using the Braden scale. which of the following findings should the nurse identify as increasing the risk for skin breakdown? - ambulates independently 3x during the day - consumes 75% of each meal - reports pain in the right foot - is incontenet of urine and feces

the client is incontinent of urine and feces

A nurse is reviewing the documentation of a newly licensed nurse. which of the following entries should the nurse identify as meeting the American nurse association (ANA) standards for documenting - the client is now asleep, and they ate most of their breakfast a few hours ago - the client omitted 240 mL of clear emesis but denies pain or nausea - the client reports not feeling good, they look fine - the client has 8 to 10 sores on their body

the client omitted 240 mL of clear emesis but denies pain or nausea factual and complete, includes measurements, visual observations and client data

A nurse is discussing the history of the electronic health records during a staff in-service. the nurse should identify that which of the following agencies advocated for the nationwide use of EHRs - the insitute of medicine -dep of veteran affairs - American hospital associate -the joint commission

the institute of medicine the agency that recommended the nationwide use of EHRs in 97 ,the rec was driven by the belief that it would increase safety in client health care

A nurse is exploring leadership styles of nurse managers as a part of the quality improvement project. which of the following statements by a nurse manager should the nurse identify as an example of transactional leadership - you are a star and high competent team. I will let you do what you do best -we've agreed to provide excellent client care and brainstormed the steps we will take to meet our objective 0 I appreciate your suggestion but each of you will wash your hands before exiting a client's room - the staff members who complete their online learning courses before the deadline will receive a gift card

the staff members who complete their online learning courses before the deadline will receive a gift card

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. which of the following info should the nurse include as a benefit of electronic documentation - the system alerts providers of possible actions that could cause client harm - an electronic system prevents breaches of confidentiality of client data -poviders cna document client info in electronic record during system downtime - system encryption eleimnates the need for security firewalls

the system alerts providers of possible actions that could cause client harm

A nurse is caring for a group of clients on a med surg unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity? - unaware of her recent cancer diagnosis asks the nurse if she has cancer, the nurse responds affirmatively - has a prescript for a nasogastric tub refuses it, and the nurse complies w the clients wishes - a client who has a DNR order has a cardiac arrest, and the nurse does not perform CPR despite the requests from the clients fam - a client who is about to undergo a painful procedure receives pain med 30 min before procedure that the nurse previously promised to admin

unaware of her recent cancer diagnosis asks the nurse if she has cancer, the nurse responds affirmatively

A nurse is caring for a client who reports onset of abdominal pain. the nurse should assign the client's condition to which of the following categories when prioritizing care? - chronic -minimal -urgent - expectant

urgent urgent category have a greater probability of poor outcomes if prompt actions are not taken, abdominal pain can be caused by non lifetreatening problems such as gas and constipation but can also be a manifestation of more significant illness such as bowel obstruction or appendicitis's, the nurse should assess further to determine the cause of abdominal pain

A nurse in the PACU is determining if a client has pain. the client is drowsy and opens their eyes to verbal stimulation but is unable to communicate their pain level. which of the following actions should the nurse take? admin an antagonist ot reverse the effect of the anesthesia - use an alternative method for determine the client's pain level -admin a pain med as prescribed for severe pain - wait until the client is awake, alert and able to vocalize their pain level

use an alternative method for determining the client's pain level

ways to facilitate communication with a child

using words and phrases the child understands

A nurse is planning to teach new assistive personal (AP) how to use a bedside glucose monitor to check a client's bgl. the nurse will include a 30 min face-to-face lecture and a written copy of the step - by-step procedure. which of the following modes of communication is the nurse using in the teaching plan - verbal - written - electronic - nonverbal -assertive

verbal written nonverbal

A nurse is assessing an olde adult client's risk for falls. which of the following assessment should the nurse use to identify the client's safety needs (SALTA) - lacrimal appartus - pupil clarity -appearance of bulbar conjunctivae -visual fields -visual acuity

visual fields -visual acuity pupil clarity

a nurse is teaching an older adult client who is at risks for osteoporosis about beginning a program of regular physical activity. which of the following types. of activity should the nurse recommend? - walking briskly - riding a bike - performing isometric exercises -engaging in high impact aerobics

walking briskly

a nurse is planning care for an adult client who has fluid volume excess. which of the following interventions should the nurse plan to. include to monitor the clients weight? calibrate the scales weekly use a different scale each time weight the client on arising weigh the client without clotting

weigh the client on arising weigh on arising each day, after voiding and before breakfast. an accurate weight rehires the client to be weighed wearing the same garments and on the same carefully calibrated scale (balanced to 0 before each use) accurate daily weights provide the easiest measurement of volume state . an increase of 1 kg (2.2lb) is equal to 1,000 mL (1L) of retained fluid and same type of clothing to provide accurate reading and avoid embarrassment

A nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? - what could I have done to deserve this illness - I blame medical science for not curing me - where is my daughter at this time - will I ever begin to feel in charge of my life again

what could I have done to deserve this illness

feedback

what the receiver gives to the original sender of the message

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? - ask the client to consider a direct donation 0wthhold the blood transfusion - request a consultation with the ethics committee - ask the clients family to intervene

withhold the blood transfusion

A nurse is conducting a preoperative assessment of a client. which of the following statements is an example of the nurse sing motivational interviewing? _ you said that your sad, what is making u sad? - if you want to lose weight, why do you keep eating fast food - have you always struggled with depression - do you have any health problems

you said that youre sad. what is making you sad uses OARS (open ended questions, affirmations, reflective listening, summarizing)

A nurse is teaching a client who requires the intention of a feeding tube in the jejunum. which of the following instructions should the nurse include in the teaching? - you should tilt your head forward when the tube is 1st inserted into your nostril - you will need an X-ray to check the location of the tube after it is inserted you should cough forcefully as the tube is passed through the back of your throat - this tube will e placed in your large intestine

you will need an X-ray to check the location of the tube after it is inserted