Fundamentals exam 3

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? A) Perform the focused assessment as this is an independent nurse-initiated intervention. B) Request an order from Jill's physician since this is a physician-initiated intervention. C) Request an order from Jill's physician since this is a collaborative intervention. D) Request an order from the nutritionist since this is a collaborative intervention.

A

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A) A patient problem list B) Narrative notes describing the patient's condition C) Overall trends in patient status D) Planned interventions and patient outcomes

A) A patient problem list

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A) Cognitive B) Psychomotor C) Affective D) Physical changes

A) Cognitive

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. A) The nurse carefully removes the bandages from a burn victim's arm. B) The nurse assesses a patient to check nutritional status. C) The nurse formulates a nursing diagnosis for a patient with epilepsy. D) The nurse turns a patient in bed every 2 hours to prevent pressure injuries. E) The nurse checks a patient's insurance coverage at the initial interview. F) The nurse checks for community resources for a patient with dementia

A,D,F

A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate? A) Normal body temperature f B) Decreased body temperature C) Increased body temperature D) Fluctuating body temperature

Ans: A

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Ans: A Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework

The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures? A) The nurse will use the arm with the highest reading. B) The nurse will use the arm with the lowest reading. C) The nurse will average the two blood pressures and document this average. D) The nurse will obtain a blood pressure on the client's leg.

Ans: A Feedback: An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10-mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following? A) A dysrhythmia B) Tachycardia C) Bradycardia D) Hypertension

Ans: A Feedback: An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.

When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision? A) Respirations have both autonomic and voluntary control. B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate. C) Temperature, pulse, and blood pressure are more volatile than respiratory rate. D) Tachypnea is an expected finding among hospitalized individuals.

Ans: A Feedback: Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured? A) Rectal B) Oral C) Skin surface D) Axillary

Ans: A Feedback: Core temperatures are measured by nurses rectally. Surface body temperatures are measured at oral (sublingual), axillary, and skin surface sites.

The nurse at the beginning of the shift plans to see which client first, based on the following vital signs? A) The client age 2 years whose respiratory rate is 16 breaths/minute B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC) C) The client age 7 years whose pulse is 120 beats/minute D) The client age 10 years whose blood pressure is 102/62 mmHg .

Ans: A Feedback: Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits

The nurse at the beginning of the shift plans to see which client first, based on the following vital signs? A) The client age 2 years whose respiratory rate is 16 breaths/minute B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC) C) The client age 7 years whose pulse is 120 beats/minute D) The client age 10 years whose blood pressure is 102/62 mmHg

Ans: A Feedback: Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits.

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition? A) Orthostatic hypotension B) Orthostatic hypertension C) Ambulatory bradycardia D) Ambulatory tachycardia

Ans: A Feedback: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.

An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment? A) Assess the client's temperature by axilla. B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile. C) Use a disposable mercury thermometer to take the client's temperature. D) Take the client's temperature rectally. .

Ans: A Feedback: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? A) Reading is erroneously high B) Reading is erroneously low C) Pressure on the cuff with be painful D) It will be difficult to pump up the bladder

Ans: A Feedback: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery

Which of the following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C

Ans: A Feedback: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C

Which of the following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C

Ans: A Feedback: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.

Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

Ans: A, B, D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Normal pulse

Ans: B Feedback: Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse rate.

What anatomic site regulates the pulse rate and force? A) Thermoregulatory center B) Cardiac sinoatrial node C) Cardiac atria and valves D) Peripheral chemoreceptors

Ans: B Feedback: The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial node. The other anatomic sites may affect, but do not regulate, the pulse rate and force.

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Bigeminal

Ans: B Feedback: The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.

The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

Ans: B Feedback: The researchers involved in the development of NICs are also committed to developing a classification of client outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators.

Which of the following clients should the nurse monitor vital signs every four hours? A) A client in a critical care unit B) A client hospitalized for high blood pressure C) a resident in a long-term care facility D) a long-term care resident on Medicare A

Ans: B Feedback: Vital signs are assessed at least every four hours in hospitalized clients with elevated temperatures, with high or low blood pressures, with changes in pulse rate or rhythm, or with respiratory difficulty. In critical care settings, technologically advanced devices are used to continually monitor clients' vital signs. Regulations require monthly vital sign measurements in long-term care residents, but if the resident is classified as Medicare A (meaning discharged from the hospital and Medicare is paying for the stay to receive skilled nursing care) vital signs are taken daily.

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

Ans: C Feedback: Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations

A client in a physician's office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension? A) It depends on the time of day the BP was taken. B) It depends on whether the client is male or female. C) No, a single BP reading should not be used. D) Yes, this reading is high enough to be significant. .

Ans: C Feedback: The American Heart Association recommends that blood pressure readings be averaged on two or more subsequent occasions before diagnosing hypertension

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate? A) The radial pulse is more rapid than the apical pulse. B) This is a normal finding and should be ignored. C) The client's arteries are very compliant. D) Not all of the heartbeats are reaching the periphery.

Ans: D Feedback: A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned? A) An older adult B) A pregnant adolescent C) A junior high football player D) An infant 2 months of age

Ans: D Feedback: A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms

A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer? A) Evaporation B) Radiation C) Conduction D) Convection

Ans: D Feedback: Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.

An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

Ans: D Feedback: Nurses must carefully document each intervention. The legal truth is "if it wasn't documented, it wasn't done."

What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record .

Ans: D Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements

A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use? A) Femoral B) Temporal C) Pedal D) Radial

Ans: D Feedback: The radial artery is the site most commonly assessed in a clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior medial aspect of the thigh, just below the inguinal ligament, about halfway between the anterior superior iliac spine and the symphysis pubis. The pulsation of the temporal artery is palpated in front of the upper part of the ear; however, it is not the site most commonly assessed in the clinical setting. The pedal pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the dorsalis pedis pulse may be congenitally absent in some

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? A) Erase or use correcting fluid to completely delete the error. B) Mark the entry "mistaken entry"; add correct information; date and initial. C) Use a permanent marker to block out the mistaken entry and rewrite it. D) Remove the page with the error and rewrite the data on that page correctly.

B) Mark the entry "mistaken entry"; add correct information; date and initial

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? A) Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B) Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C) A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D) A complete list of reimbursable charges for each nursing intervention

B) Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A) Quality assurance B) Quality improvement C)Process evaluation D)Outcome evaluation

B) Quality improvement

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? A) Administer pain medication. B) Reassess the patient. C) Prepare the equipment. D) Explain the procedure to the patient

B) Reassess the patient

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: A) a physiologic outcome. B) a cognitive outcome. C) a psychomotor outcome. D) an affective outcome.

B) a cognitive outcome.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? A) State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." B) Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. C) State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." D) Try calling another resident for the order or wait until the next shift.

C) State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly."

A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem? A) The client expresses a desire to change the way that he eats and the amount of exercise he performs. B) The client can demonstrate the correct technique for using his new glucometer. C) The client is able to explain when and why he needs to check his blood sugar. D) The client's blood sugars have been maintained within acceptable range in the days prior to discharge.

C) The client is able to explain when and why he needs to check his blood sugar.

In order to successfully implement the plan of care, what parties are essential for the nurse to include? A) client, physical therapy, and nursing staff B) client, physician, and hospital director C) client, family, and physician D) client, surgeon, and physician

C) client, family, and physician

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A) A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. B) A nurse consults with a psychiatrist for a patient who abuses pain killers. C) A nurse checks the skin of bedridden patients for skin breakdown. D) A nurse orders a kosher meal for an orthodox Jewish patient. E) A nurse records the I&O of a patient as prescribed by his health care provider. F) A nurse prepares a patient for minor surgery according to facility protocol.

C,D,F

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A) "Outcome not met." B) "1/21/20—Patient reports no change in diet." C) "Outcome not met. Patient reports no change in diet or activity level." D) "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

D) "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? A Explain to the client the benefits of ambulation. B Ambulate the client and medicate later. C Emphasize to the client the importance of following the treatment plan. D Medicate the client and wait to ambulate later.

Medicate the client and wait to ambulate later

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? A) Report the findings to the physician for further plans. B) Reinforce the instructions for the treatment regimen to the client. C) Inform the client that the blood pressure medication will have to be changed. D) Interview the family to determine if the client is giving accurate information.

Report the findings to the physician for further plans

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When does the nurse collect information to evaluate this outcome? at the client's direction on 3/2 on 3/3 at the completion of each meal

at the completion of each meal