Fundaments Exam 1

The patient post-total knee replacement is preparing to be discharged. The patient tells the case manager, "I feel pretty good, but I am having a hard time getting in and out of the bathroom." What is the case manager's most appropriate response?

"An occupational therapist can be ordered to assist you in this area."

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting?

"Charting communicates to members of the healthcare team the patient's care and responses during my shift."

Bryan decides to advance his practice and begins applying to nurse practitioner education programs. During an interview, he is asked which factors are most influential in changing the face of healthcare. Which of the following answers is correct?

"Consumers are becoming more educated and demanding more choices."

An older client with a history of congestive heart failure was just admitted to the hospital for chest pain. The patient asks a nurse, "Why did the chest pain begin after I thought someone was trying to break into my house?" What is the nurse's best response?

"Fear causes an increase of the body's heart rate and blood pressure, which can place additional stress on your damaged heart and cause chest pain."

Which of the nurse's questions demonstrates critical thinking?

"Have I gathered enough data to make a decision?"

The nurse is documenting the vital sign assessment. Which statement would be a correct description?

"Hyperthermia, tachycardia, bradypnea."

An elderly client has an appointment with his or her physician. The nurse is conducting an assessment. Which statement represents the greatest safety concern?

"I almost missed the office. I couldn't see the sign for the entrance."

Which statement by the client indicates emotional distress from immobility?

"I don't even care if I get cleaned up or not."

The nurse is educating a group of clients about risks for food poisoning. Which statement made by a client indicates understanding?

"I should not consume raw cookie dough."

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process?

"I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."

The nurse is discussing the benefits of exercise with a client who has a history of hypertension and atherosclerosis. The client expresses hesitancy about beginning an exercise program while having heart disease. What is the nurse's best response?

"It is healthier for your heart to exercise than to be sedentary."

The client is being educated about the use of crutches after a cast was applied to his left ankle. What directions by the nurse are most important before discharge?

"Let me see you use the crutches to walk around the nurses' station."

An elderly patient is covered under Medicare. She is scheduled for discharge and tells the nursing student that several therapists will come to her home to help her regain functional abilities. The patient then asks, "Why can't I just stay in the hospital and receive this type of care?" What is the nursing student's best response?

"Once you have reached your reimbursable length of stay and your condition is stable, it is more cost effective to provide you with home healthcare."

A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following?

"Thank you; however, I have to refuse, even though the thought is appreciated."

Over dinner one evening, Bryan asks his grandmother whether she was ever a member of the American Nurses Association (ANA). She responds by saying, "I'm not sure what that is." What is Bryan's best response?

"The ANA focuses on the political process as a way of improving healthcare legislation"

Which statement best reflects a critical thinking philosophy being taught to a nursing student?

"Think about different interventions that can be used with this client."

Which statement best reflects a critical-thinking philosophy being taught to a nursing student?

"Think about different interventions that can be used with this client."

The patient in the ambulatory clinic asks the nurse in the billing office, "Why do I have to pay $10.00 for this visit when I have insurance?" What is the nurse's most appropriate response?

"This a co-payment you are required to pay per clinic visit as described in your insurance plan."

The 75-year-old patient is preparing for discharge and tells the case manager, "I don't know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me." What is the case manager's most appropriate response?

"We can have a social worker see you when you get home."

A client is scheduled for a major surgery the next morning and appears anxious that family has not visited. Which question by the nurse would help to determine the level of anxiety that the client is experiencing?

"Would you like for me to call a family member to come support you?"

The nurse is presenting a workshop on stress and adaptation to a group of teenagers. A teenager approaches the nurse and says, "Sometimes I feel stressed when I have to take a test. I feel my heart is going faster and I have a hard time focusing. I'm scared I'm going to fail. Do you think that is normal?" What is the most appropriate response by the nurse?

"You may need to develop some additional stress-reducing activities."

An older adult has a terminal cancer and has been in the hospital for 4 days. Her daughter visits and says to the nurse, "My mother claims she has an infection, but I know she is not telling me the truth." The daughter asks the nurse to tell her what is really happening. How should the nurse respond?

"You need to speak to the primary healthcare provider in charge of your mother's care."

The registered nurse is discharging a patient to an assisted living facility. Which instruction below is most appropriate for the patient?

"You will have assistance with meals and housekeeping tasks."

A teenage client was hospitalized 3 weeks ago after a motor vehicle accident in which he crushed his pelvis. He remains on bedrest. His parents tell the nurse, "Our son is just staring off into space and won't talk to us. He doesn't want to listen to his music or watch television. That is so unlike him." What is the nurse's best response?

"Your son had a major injury, and his immobility might be causing him to feel isolated and depressed."

Which statements should be included in the assessment of a wound? Select all that apply.

- "Cloudy drainage from site." - "4 cm tunneling around wound." - "Nickel-sized area on left ankle." - "No pain at site." - "High-protein drinks requested."

The nurse is discussing sleep patterns with a client who reports sleep disturbances. Which questions should the nurse ask the client to determine the cause of the sleep problem? Select all that apply.

- "Do you include exercise in your daily life?" - "What is a typical 24-hour food intake for you?" - "How many caffeinated beverages do you drink each day?"

A client is given a diagnosis of terminal cancer, and the health-care provider suggests hospice services for the family. The family is hesitant and asks the nurse what hospice can provide. Which responses given by the nurse are appropriate? Select all that apply.

- "Hospice services ensure the client is comfortable and the pain is controlled." - "Hospice services allow the client to preserve dignity during the dying process." - "Hospice services provide spiritual care for the client within the client's culture." - "Hospice services assist the family with funeral planning" - "Hospice services can provide chemotherapeutic medications for treatment."

Which statements by a nurse are correct when preventing needlesticks and blood exposure? Select all that apply.

- "I only recap with a needle guard when available." - "I always place my used needles into a puncture-proof, labeled container." - "I confirm that the sharps container is not overfilled before placing the syringe inside."

The nurse is documenting in a health record at the client's bedside. The client says, "It seems like nurses spend most of the day documenting. What a waste of time!" Which statements would provide a correct response? Select all that apply.

- "The written documentation can serve as a legal record for the healthcare provider." - "Written documentation is to serve as a record of accountability for accreditation." - "Written documentation serves as a record of accountability for quality assurance and improvement." - "Written documentation is important in communicating pertinent data to the healthcare team."

The nurse is admitting a new client to an acute rehabilitation facility and is completing the paperwork. The client is getting frustrated with the amount of time it is taking. What information can the nurse provide about the admission assessment to help the client understand the process? Select all that apply.

- "We use this information to determine how you progress as you go through therapy." - "This information allows us to identify any needs you will have when you are discharged." - "It provides all health-care providers necessary information including allergies, needs, and abilities."

In which clients would the nurse find elevated pulse rates? Select all that apply.

- A 3-month-old infant - A client with a temperature of 101.0°F - A client with chronic obstructive pulmonary disease (COPD)

Which scenarios support the use of restraints in a hospital? Select all that apply.

- A confused client who continuously pulls out his or her IV line - An alert client who is ventilator dependent who is pulling at the endotracheal tube

Which are examples of negligence? Select all that apply.

- A nurse not turning and repositioning a bedridden client, resulting in the development of bedsores - A nurse not administering pain medications as needed for a hospice client - A client falling after the client has called for assistance in getting up, for which nobody responded after 25 minutes

Which are examples of beliefs? Select all that apply.

- A person should not accept blood or blood products from another person. - Arriving 15 minutes before shift will give the appearance of dedication. - Elderly people cannot provide a good medical history.

Which are examples of client uniqueness that could cause challenges or differences in care and must be considered when creating a nursing plan? Select all that apply.

- A single mother recovering from a fall at work - An elderly Native-American admitted for malignant hypertension - A client living below the poverty line, admitted with pneumonia

The nurse is performing an assessment on a client. What should be included in this process? Select all that apply.

- Ability to function - Cultural needs - Collection of vital signs - Auscultation of the lungs - Readiness to learn

The nurse is assessing a client with a high fever and chills. What should be included in the assessment? Select all that apply.

- Abnormal white blood cell count - Risk for compromised immune system - Drainage from wounds

A postsurgical client has a new nursing diagnosis of "Constipation related to immobility and decreased gastrointestinal (GI) motility secondary to narcotic analgesics." Which are appropriate nursing interventions for this client?

- Administer laxative or stool softener as prescribed. - Encourage increased fluid intake, including warm liquids. - Educate the client about and encourage a high-fiber diet.

Which of the following nursing activities represent direct care? Select all that apply.

- Administering a medication - Teaching a patient how to change a wound dressing - Bathing a patient

A client is asking the nurse how he contracted a multidrug-resistant microorganism in his foot wound. What factors likely contributed? Select all that apply.

- Advanced age - Previous use of antibiotics - Chronic illness

Which factors impact a client's normal body temperature? Select all that apply.

- Age - Gender - Exercise - Environment

A client with restless leg syndrome reports difficulty sleeping. Which factors may be the cause? Select all that apply.

- Age - Low iron levels - Antidepressants

Which interventions can the nurse include in the plan of care to reduce a client's feeling of isolation related to being on transmission-based precautions? Select all that apply.

- Allow electronics in the client's room. - Instruct family members on transmission-based precautions to allow visits. - Spend time with the client

The nurse is educating a client with a new diagnosis of sleep apnea regarding consistent use of the continuous positive airway pressure (CPAP) machine. Which complications should the nurse instruct the client about that can occur with untreated sleep apnea? Select all that apply.

- Angina - Arrhythmias

At the time of Bryan's graduation with his BSN degree, Kathy decides to enroll in an RN to BSN program to obtain her degree. What new opportunities will be available for Kathy with this additional education? Select all that apply.

- Applying for graduate school - Providing direct client care - Applying research findings

Which are examples of appropriate medication orders? Select all that apply.

- Aspirin 325 mg by mouth every morning - Rocephin 200 mg IV q6h - Ibuprofen 200 mg q4h prn fever or mild pain

The nurse is bathing a client with a raised red rash on the shoulders and back. What should be the nurse's next actions? Select all that apply.

- Assess for further inflammatory reactions. - Ask whether the client has any allergies.

An older adult client suffered left-sided paralysis from a stroke. Which are the best actions for this client? Select all that apply.

- Assess the extremities for swelling and muscle atrophy. - Teach the use of a two-point crutch technique for ambulation.

What does the nurse know is true about conducting the nursing assessment?

- Assessments must be completed within 24 hours of inpatient admission. - Assessment cannot be delegated to others. - All clients are assessed for pain, nutritional status, and risk for falls.

Which represent the main groups of pathogenic microorganisms seen in a health-care setting? Select all that apply.

- Bacteria - Viruses - Fungi

The nurse is educating a group of nursing assistants regarding proper body mechanics. Which key concepts should the nurse include in the presentation? Select all that apply.

- Balance - Coordination - Joint mobility - Body alignment

The nurse asks the unlicensed assistive personnel to complete morning care for an older adult. What is included with this request? Select all that apply.

- Bathing - Oral care - Hair care - Toileting

A registered nurse (RN) is developing a plan of care for a client admitted with pneumonia. Which tasks can the RN delegate to the nursing assistive personnel (NAP)? Select all that apply.

- Bathing the client - Shaving the client - Providing oral care - Administering lubricating eye drops - Performing a sterile dressing change

The nurse's obligations in ethical decisions include which of the following? Select all that apply.

- Be a patient advocate. - Involve institutional ethics committees. - Improve one's own ethical decision making. - Respect patient confidentiality.

The nurse's obligations in ethical decisions include which roles? Select all that apply.

- Being involved in institutional ethics committees - Improving one's own ethical decision making - Functioning as a team member - Being a patient advocate

Which are causes of obstructive sleep apnea? Select all that apply.

- Being overweight - Enlarged tonsils - Deviated nasal septum

The nurse is caring for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient says, "I can still bathe myself," but the nurse performs the bath to make certain the patient gets clean. What ethical principles is the nurse violating with this behavior? Select all that apply.

- Beneficence - Autonomy - Nonmaleficence

What are the primary vital signs of the nursing assessment? Select all that apply.

- Blood pressure - Pulse - Respiratory rate - Temperature

A 44-year-old female client who was just admitted states, "I must be under too much stress at work and home. I just do not feel well." Which physical findings are consistent with the client's statement? Select all that apply.

- Blood pressure is 178/96 mm Hg. - Palms of her hands are sweaty. - Legs are continually moving in the bed. - Mucous membranes are dry.

The nurse is directing unlicensed assistive personnel in providing morning care to a comatose client. Besides a bed bath, what care should be provided? Select all that apply.

- Brushing teeth - Cleaning fingernails - Moisturizing skin

Which are elements of the Good Samaritan law? Select all that apply.

- Care was provided in an emergency situation. - Care was voluntary and payment was not provided. - Care is provided in a reasonably competent manner.

As a new grad on the acute-care floor, Madge worked diligently to obtain patient information and supplies in preparation for the healthcare provider's rounds. She cared for each of her patients and knew them well. How did Madge's actions meet the ANA standards of nursing? Select all that apply.

- Caring is central to practice - Nursing practice is individualized - She plans care for each of her patients

Which are examples of never events, or Serious Reportable Events? Select all that apply.

- Catheter-associated urinary tract infection - Stage IV pressure ulcer that develops during hospitalization - Foreign object left in client after surgery

Which structures are involved in physical coordination? Select all that apply.

- Cerebral cortex - Cerebellum - Basal ganglia

Which actions by the nurse are considered "skilled nursing care"? Select all that apply.

- Changing a wound dressing - Monitoring an IV antibiotic - Teaching a patient how to use a blood glucose monitor

A nurse can delegate assessment of vital signs to a UAP for which clients? Select all that apply.

- Client who will be discharged to home the next day - Client who is 4 hours post laparoscopic cholecystectomy - Client with diverticulitis and taking prednisone

A posttraumatic sexual assault victim has a nursing diagnosis of Rape-Trauma Syndrome r/t sexual assault AEB guilt and embarrassment, physical trauma, fear, and self-blame. What nursing outcomes would be appropriate for this client? Select all that apply.

- Client will have a resolution of embarrassment, self-blame, guilt, and fear. - Client will state the results of the physical examination completed in the emergency department. - Client will discuss the need for follow-up crisis counseling and other supports.

Which information should always be included in a report in which a client is transferred from one unit to another? Select all that apply.

- Client's name, age, and diagnosis - Last set of vital signs - Tubes, lines, or IV therapy

Which intervention can the nurse include in the plan of care for a client in the hospital to promote sleep and rest?

- Clustering activities

Which interventions promote nighttime sleep in the hospitalized client? Select all that apply.

- Clustering care - Back massage - Aromatherapy

Which are ways health providers use documentation to provide quality care? Select all that apply.

- Communication tool - Continuity of care - Legal record

The nurse is preparing to give a bath to an older adult who is unconscious and has had a fever and night sweats. Which type of bath would be the best option?

- Complete bed bath

What are the components of a theory? Select all that apply.

- Concept - Definition - Phenomenon - Proposition

Which findings in the immobile client are complications related to immobility? Select all that apply.

- Constipation - Decreasing appetite - Bladder infection - Lung fluid

Which are the recommendations from the Centers for Disease Control for use of water in caring for contact lenses? Select all that apply.

- Contact lenses should be removed before showering or swimming. - Water can cause soft lenses to swell and stick to the eye. - If water touches the lens, the user should discard them.

What factors influence hygiene practices?

- Culture - Developmental level - Personal preference - Economic status - Knowledge level

The nurse is teaching a group of parents of toddlers about safety. What should be included in the presentation? Select all that apply.

- Cut food into small, bite-size pieces. - Keep the telephone number of the poison control center accessible. - Encourage child to sleep on his/her back at night. - Have self-closing, locking swimming pool gates.

What skin conditions should be monitored for in a client with Risk for Impaired Skin Integrity? Select all that apply.

- Dampness - Dehydration - Inadequate circulation - Nutritional status

A registered nurse notices an increase in the unit of injuries related to anticoagulation therapy in elderly clients and wishes to conduct research. The nurse chooses a qualitative research design. What will be the characteristics of this design? Select all that apply.

- Data is derived from interviews and observations. - Data is objective and analyzed with statistical methods. - Data is gained from using small numbers of participants. - Data is obtained from the researcher's workplace or home setting. - Data is numerical and obtained through using questionnaires.

Which of the following exemplify critical thinking? Select all that apply.

- Decision making following data evaluation - Accounting for patient considerations

The client's spouse is concerned about the fatigue her husband is experiencing from inadequate sleep. What are some complications that can occur? Select all that apply.

- Decreased activity - Falls - Poor coping skills - Decreased mental focus

Which are common responsibilities of the state boards of nursing? Select all that apply.

- Describing a level of competency for nursing care - Providing approval for nursing education programs - Funding research for nursing education - Enforcing rules that govern nursing practice - Developing criteria that permit someone to be licensed as a registered nurse (RN) or as a licensed practical or vocational nurse (LPN/LVN)

Each U.S. state has its own state board of nursing responsible for protecting the health, safety, and welfare of the general public. The state board of nursing meets these responsibilities by performing which of the following functions? Select all that apply.

- Determining the nurse's scope of practice - Enforcing the rules that govern nursing

The nursing student is preparing a presentation on health promotion. Which of the following activities are included in the presentation? Select all that apply.

- Developing a list of stress-management strategies - Identifying calorie counts on all food choices in restaurants

A nurse works three 12-hour shifts each week from 7 p.m. to 7 a.m. He finds that during his days off he wants to sleep all day, then he's up most of the night. What could improve his sleeping pattern? Select all that apply.

- Developing a regular sleep routine - Sleeping in a dark room

Which factors increase the susceptibility of a host to infection? Select all that apply.

- Developmental stage - Illness or injury - Substance abuse

When comparing the roles of Madge and Bryan as new nursing grads, which roles and functions would they have in common? Select all that apply.

- Direct care provider - Communicator - Client/family educator - Counselor - Leader

Which are appropriate instructions to give to children if they encounter a firearm? Select all that apply.

- Do not touch it - Leave the area. - Tell an adult.

Which nursing degrees are research-focused? Select all that apply.

- Doctor of Nursing Science (DSN/DNSc) - Doctor of Philosophy (PhD)

Which describes components of implementation in the nursing process? Select all that apply.

- Doing - Delegating - Documenting

What are steps to help avoid malpractice? Select all that apply.

- Don't blame or criticize other health-care providers. - Recognize "problem" clients. - Recognize significant assessment cues. - Know and follow standards of care.

The nurse is caring for a client who is being treated for pneumonia and develops clostridium difficile from the antibiotic therapy. The client is placed on contact precautions. What interventions should the nurse perform? Select all that apply.

- Double-bag all trash and label it as contaminated. - Provide a disposable blood pressure cuff, thermometer, and stethoscope.

Which statements about bed making are correct? Select all that apply.

- Draw sheets are used to help lift and turn heavier patients. - A poorly made bed can contribute to the development of pressure ulcers.

A client reports performing intense cardiovascular workouts every day for 45 minutes. Which information should the nurse include to prevent dehydration in the client? Select all that apply.

- Drink 8 ounces of fluid prior to exercise. - Continue to drink water throughout exercise.

Which factors lead to increased numbers of injuries in children and younger adults related to motor vehicle accidents?

- Driver distraction - Failure to use car seats - Improperly placed car seats

The nurse enters the room of a client to perform wound care and administer medications. When should the nurse apply clean gloves? Select all that apply.

- During medication administration - Prior to removing soiled dressings - Before applying clean dressings - Before treating a new patient

What are the elements that the plaintiff must establish in a malpractice lawsuit? Select all that apply.

- Duty - Breach of duty - Causation - Injury

What types of scheduled hygiene are provided in healthcare facilities?

- Early Morning Care - Morning Care - Hourly Rounds - Afternoon Care - Hour of sleep care

A nurse is working at a clinic and wants to focus on primary health care in the community. Which interventions would be included in the nurse's plan? Select all that apply.

- Educating children on appropriate hand hygiene. - Administering flu shots to elderly clients in an independent living center. - Presenting information at a senior center regarding ways to prevent diabetes mellitus.

When working with a postoperative bariatric client, how can the nurse promote client participation and adherence to the nursing plan?

- Ensure the client feels comfortable asking questions. - Keep the instructions simple, clear, and as specific as possible. - Determine if the client's goals for weight loss are the same as those in the nursing plan. - Help the client set realistic goals.

Which concepts must be present in nursing theories? Select all that apply.

- Environment - Health - Person - Nursing

A posttraumatic sexual assault victim has a nursing diagnosis of Rape-Trauma Syndrome r/t sexual assault AEB guilt and embarrassment, physical trauma, and self-blame. What nursing intervention would be appropriate for this client? Select all that apply.

- Establish trust and rapport. - Provide strict confidentiality. - Do not use judgmental language and tone. - Encourage verbalization.

Which behaviors are consistent with adaptive coping behaviors? Select all that apply.

- Exercising each day to relieve tension - Going to a movie with friends - Seeking a support group

The steps of critical thinking include which of the following? Select all that apply.

- Explore - Identify - Analyze

The nurse is cleaning a wound using a wet-to-damp dressing, making sure to clean each new section with a new piece of gauze. What should the nurse be assessing for during the wound cleaning? Select all that apply.

- Exudate - Odor - Type of tissue present

The nurse understands that the electronic health record (EHR) has which advantages over paper charting? Select all that apply.

- Facilitates evidence-based nursing practice - Ensures improved client safety and outcomes - Promotes efficient use of the nurse's documentation time

You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is higher than it was on the previous day, when the level was within normal limits. You page the patient's provider, but he does not return your call right away. You become busy with another patient and forget to notify the provider again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Select all that apply.

- Failure to implement a plan of care - Failure to evaluate - Failure to assess and diagnose

When educating student nurses on self-care and sleep hygiene, what information should be included? Select all that apply.

- Fatigue can cause impaired judgment and decision making. - If possible, take frequent breaks (e.g., every 1 to 2 hours) during the night shift. - Be smart about your caffeine use. - Plan rest days in between consecutive work days.

What are primary causes of maceration? Select all that apply.

- Fever - Incontinence

Which are considered secondary defenses? Select all that apply.

- Fever - Phagocytosis - Inflammation - Complement cascade

An older adult is admitted to the care center for a skin assessment. What areas would the nurse assess using the Braden Scale for Predicting Pressure Sore Risk? Select all that apply.

- Friction and shear - Moisture - Activity - Sensory perception

Which type of data should be included in the discharge planning?

- Functional and self-care limitations - Emotional stability and ability to learn - Family or other caregivers available - Use of community services before admission

A client has a diagnosis of insomnia. Which factors can create this disorder? Select all that apply.

- Generalized pain - Severe anxiety - Chronic stress - Chronic depression

The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? Select all that apply.

- Get additional help. - Clear area of obstacles. - Apply a lift belt.

The nurse is teaching a group of elementary students about infection prevention. Which factors should be included in the discussion? Select all that apply.

- Getting an annual influenza immunization - Importance of washing hands - Sleeping 6 to 9 hours a night - Regular physical activity

Which are examples of a direct-care nursing intervention? Select all that apply.

- Giving medication - Obtaining vital signs - Giving a bedside bath

At which levels of education is a person eligible to take the National Council Licensure Examination (NCLEX®)? Select all that apply.

- Graduate degree - Associates degree - Bachelor's degree - Practical nursing - Diploma nursing

The charge nurse is helping another nurse care for a client whose condition is deteriorating. Without knowing the client, which portions of the health record should the charge nurse access first in this emergency situation? Select all that apply.

- Graphic data and vital signs - Advance directive

Which are tools for recording assessment data? Select all that apply.

- Graphic flow sheet - Intake and output sheet

A client presents to the clinic requesting medication to help him or her sleep. The health-care provider diagnoses the client with insomnia. Which criteria would the nurse expect to be present related to this diagnosis? Select all that apply.

- Happens three days per week - Happens for at least three months

Which are examples of cue clusters for a nursing diagnosis?

- Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin - Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis - Urinary incontinence, lower abdominal pain, bladder spasm

While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Select all that apply.

- He may change his advance directive by telling his physician or by making changes in writing. - An advance directive will ensure he gets as much or as little care as he wishes.

Which are primary purposes of nursing care? Select all that apply.

- Health promotion - Illness prevention - End-of-life care

Which objects are at greatest risk for infection transfer in the healthcare environment? Select all that apply.

- Healthcare workers - Artificial fingernails - Vital sign equipment

During a client's appointment at the women's clinic, she states her menstrual flow is very heavy, occurs about every 3 weeks, and is accompanied by severe abdominal cramping. The breast exam is normal, and the results of the Pap smear are normal. However, the client's hemoglobin level is low, and the nurse suspects the heavy menstrual bleeding may be causing anemia. Which information is considered primary data?

- Heavy menstrual flow every 3 weeks with severe abdominal cramping - Evidence of link between anemia and heavy menstruation

Which expectations are covered by the American Hospital Association Patient Care Partnership? Select all that apply.

- High-quality care - Involvement in care - A clean and safe environment

A home health nurse receives a referral to provide care to a client in his or her home. According to the Center for Medicare and Medicaid Services, what should the nurse document in the client's medical record? Select all that apply.

- Homebound status of the client - Ongoing need for skilled services

Clinical practice theories are instrumental in day-to-day nursing practice. Which are examples of theoretical practice? Select all that apply.

- Hospice nurse working with a newly widowed client - Basing the care plan for a 2-year-old client on the autonomy versus shame and doubt stage

The nurse is developing a plan of care for a client in the intensive care unit with fluid volume overload related to congestive heart failure who is receiving diuretics. Which factors can lead to altered sleep patterns for this client? Select all that apply.

- Hospitalization in an intensive care unit - Frequent urination related to diuretic use - Repeated interruptions throughout the day and night

Which are measures that can support defenses to make a host less susceptible to infection? Select all that apply.

- Hygiene - Eating vegetables - Immunizations

Which scenarios are considered collaborative problems?

- Hyperglycemia with type 2 diabetes - Infection in a postsurgical client - Hemorrhage in a postpartum client

What are considered "never events"? Select all that apply.

- Hypoglycemic episode after insulin administration - Sponge left in a client after a hysterectomy - Blood clot in the lungs after an orthopedic surgery

In which situation would hand hygiene with alcohol-based hand sanitizer not be appropriate? Select all that apply.

- If hands are visibly soiled - When there is a possibility of contact with bacterial spores

How is critical thinking used in nursing other than in the nursing process? Select all that apply.

- In determining how many nurses to staff during a shift - When creating a list of inventory needed for the unit

The nurse is caring for a client after abdominal surgery. The client is afraid of having pain and experiences physiological changes when the stressor of pain is introduced. Which changes are a result of this stressor? Select all that apply.

- Increased blood pressure - Vasoconstriction of the skin - Increased glucose in the blood

The nurse is educating a group of teenagers regarding obtaining sufficient amounts of sleep. Which consequences of sleep deprivation should the nurse include in the presentation? Select all that apply.

- Increases sensitivity to pain - Intensifies insulin resistance - Increases the appetite and intake

While creating a plan for client care, the nurse should include which considerations? Select all that apply.

- Individual client needs - Realistic expectations - Colleagues' input - Client needs upon discharge

Which are appropriate client teaching topics for nurses to provide to clients regarding nail care? Select all that apply.

- Inspect nails daily. - Clip toenails straight across. - Use moisturizing lotion to soften cuticles.

When educating a client on nail care of the feet, what important aspects should be included? Select all that apply.

- Inspect nails daily. - Trim with clippers, or file if diabetic. - File nails straight across, slightly rounding edges.

The nurse is preparing to administer morning medications to a client. As the nurse reviews the electronic medication administration record, which medications require an assessment prior to administration? Select all that apply.

- Insulin - Digoxin - Antihypertensive - Chemotherapy drugs

A client who has just changed to working third shift is concerned about getting enough sleep. What is the probable cause for this?

- Interrupted circadian rhythm

What were the greatest contributions of Florence Nightingale? Select all that apply.

- Introduced hygiene by washing sheets and cleaning the wards - Set up tents near battlefield to expedite care - Advanced the education of nurses

When creating a nursing diagnosis for a client with renal failure, what questions should the nurse ask during the assessment process?

- Is the client still producing urine? - What is the client's oral intake? - Does the client exhibit signs of edema? - Can the client engage in activities of daily living?

An older adult is tearful, shaky, withdrawn, tachycardic, and sleepless. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." Which statement can be made about this anxiety reaction? Select all that apply.

- It concerns future or anticipated events. - It concerns anticipation of danger rather than a present danger. - There is a psychological rather than a physical threat. - She lacks adaptive coping mechanisms.

The nurse is caring for an older adult at risk for falls. What should be included in the plan of care? Select all that apply.

- Keep call light within reach. - Clear floor of obstacles. - Provide nonskid footwear. - Keep bed wheels locked.

What eye care interventions should a nurse make for a comatose client? Select all that apply.

- Keep eyes lubricated every 2 to 4 hours with saline. - Use a protective eye shield to keep eyes closed. - Instill eye ointment on lower lids as prescribed.

The nurse is working with an elderly client and designs a care plan to reduce the risk of infection. Which nursing interventions should the nurse include? Select all that apply.

- Keep the skin clean and dry. - Offer foods high in protein.

When using the MORAL model for ethical decision making, what principles will help the nurse to function effectively as an advocate?

- Know and document facts. - Know the argument. - Avoid getting into a power struggle. - Be aware of client vulnerability.

Which are functions of a client's medical record? Select all that apply.

- Legal record - Communication - Continuity of care - Quality improvement

Which factors affect respiration? Select all that apply.

- Level of carbon dioxide tension in the blood - Central chemoreceptors in the medulla and pons - Peripheral chemoreceptors located in the carotid and aortic bodies

A nurse is assigned a client who is temporarily nonambulatory and with a nursing diagnoses including Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. What information should be provided when delegating assistance? Select all that apply.

- Limitations and restrictions - Specific safety precautions - Presence of obstacles - Observations to make during the procedure and why they are important.

A client is concerned about the cost of ongoing treatment and has asked about treatments that may be more affordable. What resources and information can the nurse provide to this client? Select all that apply.

- Listing of nurse practitioners who can provide equal care - Information on complementary and alternative medicine (CAM) - Eligibility criteria for Medicaid

The client has developed kidney infection following a bladder infection from the urinary catheter. How would the nurse describe this? Select all that apply.

- Local - Secondary - Healthcare-related

A client reports a pain rating of 9 on a scale of 1 to 10. The nurse administers an intravenous narcotic analgesic to the client. What will the nurse include when documenting this task? Select all that apply.

- Location and characteristics of the pain - Client's pain level 30 to 60 minutes after the medication is given - Administration of the intravenous narcotic analgesic medication

The nurse tries some relaxation techniques with the client to promote sleep. Which would be appropriate? Select all that apply.

- Massage - Aroma therapy

An impoverished 55-year-old client has accrued a large hospital charge after emergency surgery and is unable to pay the bill. What insurance can the nurse recommend to the client to help with the cost? Select all that apply.

- Medicaid - Charitable organization

At which points of client care must the nurse complete a discharge summary? Select all that apply.

- Moved to an acute rehabilitation unit - Transferred to a long-term skilled facility - Allowed to leave the hospital and go home

Which changes can be noted during the deepest stage of non-REM sleep? Select all that apply.

- Muscles relax. - Heart rate lowers. - Respirations decrease.

A registered nurse is instructing nursing students about incorporating critical thinking into client care. Which attributes will the registered nurse include during this lesson? Select all that apply.

- Need to find the truth - Openness to other options - Use of reasoned thinking - Capacity to reflect on situations

What do negligence and malpractice have in common? Select all that apply.

- Negligence and malpractice are unintentional torts. - Malpractice is the professional form of negligence.

Which are examples of primary defenses of the body against infection? Select all that apply.

- Normal flora - Skin - Saliva

Which statements are accurate regarding normal flora? Select all that apply.

- Normal flora synthesizes vitamin K. - Normal flora aids in the digestive process. - Normal flora release vitamin B vitamins when they die.

Under the American Nurses Association (ANA) Code of Ethics, the nurse has the professional responsibility to uphold ethical behavior. Choose the statements below that are accurate about the Code of Ethics. Select all that apply.

- Nurse actions are to be at the level expected by the profession. - Nurses do not need to collaborate to meet a patient's healthcare needs.

Which statements are correct about critical thinking and the nursing process? Select all that apply.

- Nurses use critical thinking for decisions unrelated to the nursing process. - Nursing process is a form of critical thinking. - Some nursing decisions do not require critical thinking.

To reflect the changes in healthcare and nurses' expanded roles, the International Council of Nurses revised the definition of nursing. Which statements are consistent with the revised definition of nursing?

- Nursing encompasses the autonomous and collaborative care of others. - Nursing includes the care of ill, disabled, and dying people. - Participation in shaping health policy is a nursing role.

Which characteristics of registered nursing are identified by the American Nurses Association (ANA)? Select all that apply.

- Nursing practice is individualized - Nurses coordinate care by establishing partnerships.

According to the American Nurses Association (ANA), which statements best describe the characteristics of registered nursing? Select all that apply.

- Nursing practice is individualized. - Caring is central to the practice of the registered nurse. - Nurses coordinate care by establishing partnerships.

Which of the following are unique to the Scientific method of acquiring knowledge? Select all that apply.

- Objectivity - Use of Empirical data

A student nurse is bathing an obese client for the first time. What intervention could be suggested for bathing this client? Select all that apply.

- Offer a handheld shower with a long-handled brush. - Apply moisture barrier creams after bathing. - Separate skin folds with towels. - Rinse and dry the skin well.

Tom, an 84-year-old with arthritis and lung disease, takes a diuretic twice a day to remove the fluid from his lungs. He lives alone and wonders what will become of his cat once he's gone. What factors can impact his sleep? Select all that apply.

- Old age - Anxiety - Frequent urination - Pain - Difficulty breathing

At what times should a client's vital signs be measured and documented? Select all that apply.

- On admission to a hospital or clinic visit - After certain medications have been administered - Whenever the client's condition changes

The nurse is assessing a patient with a stage 2 pressure injury. What sign is the nurse likely seeing? Select all that apply.

- Open, shallow wound with red pink wound bed - Partial thickness loss of dermis

Which gases are primarily exchanged during respiration? Select all that apply.

- Oxygen - Carbon Dioxide

Which sleep disorders are considered secondary and are caused by underlying health disorders? Select all that apply.

- Pain - Depression - Hyperthyroidism

Which health factors affect a person's self-care ability? Select all that apply.

- Pain - Limited mobility - Cognitive impairment

The nurse in a long-term care facility is caring for a 70-year-old client who has a history of type 2 diabetes mellitus, hypertension, and Parkinson disease. The client takes antihypertensive medications, insulin, and carbodopa/levodopa. The client has functional incontinence due to a shuffling gait and uses a wheeled walker for ambulation. Which factors place the client at risk for falls?

- Parkinson disease - Wheeled walker use - Functional incontinence - Antihypertensive medications

Which of the following are emphasized in Benner's expert nurse theory? Select all that apply.

- Patient - Environment - Health

A nurse is assisting a morbidly obese client with bathing. Which specific considerations should be taken? Select all that apply.

- Pay special attention to drying skin folds. - Provide a trapeze to assist with movement. - Provide a long-handled shower head or brush.

What are the most important considerations when performing oral hygiene for an unconscious critical client? Select all that apply.

- Perform oral hygiene at least twice a day. - Moisturize lips every 2 hours. - Use a padded tongue blade when providing oral care.

Which physiological processes occur when the hypothalamus is stimulated due to a client being warm? Select all that apply.

- Peripheral vasodilation - Perspiration

What are disadvantages of charting by exception? Select all that apply.

- Pertinent information could be omitted because it is not considered significant. - It is difficult to capture the skilled judgment of nurses. - It can lead to errors because nurses may conclude that care has been done when it has not.

Which are secondary defenses of the body? Select all that apply.

- Phagocytosis - Inflammation - Fever

Which nursing interventions are considered direct-care interventions?

- Physical care - Emotional support - Client education

A nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are actions the nurse can take when caring for this client? Select all that apply.

- Place call light within reach. - Repeat fall risk assessment every 8 hours. - Identify medications that increase falling risk.

How can a student develop critical-thinking skills? Select all that apply.

- Play "what if?" multiple times a day. - Question each test item, asking why it was incorrect.

Which are care and hygiene challenges nurses must consider when providing care for morbidly obese clients? Select all that apply.

- Pressure - Friction and shear - Moisture

The nurse is working with an older client who wants to begin an exercise regimen. The client asks the nurse about the benefits of moderate walking 30 minutes per day. What would be the nurse's best response? Select all that apply.

- Prevents falls - Improves memory - Reduces depression - Lowers risk of Alzheimer's

The nurse contacts the primary health-care provider about a change in a client's status. The primary health-care provider in turn gives the nurse orders over the telephone. What are the nurse's responsibilities related to accepting these orders? Select all that apply.

- Pronouncing numerical digits separately - Spelling out any unfamiliar names or words - Repeating what was stated before hanging up - Having a second nurse listen to verify the orders

What are the goals of infection prevention and control in health care? Select all that apply.

- Protect clients from contagions. - Lower the cost of health care services. - Meet professional standards and guidelines. - Protect employees from contracting infections.

Which are the purposes of the Health Insurance Portability and Accountability Act of 1996? Select all that apply.

- Protect health insurance benefits for workers who change jobs. - Establish standards to protect client privacy and confidentiality. - Protect coverage for individuals with preexisting conditions.

The nurse is explaining the Health Insurance Portability and Accountability Act to a group of new employees. What should the nurse include when explaining its purpose? Select all that apply.

- Protects health insurance benefits - Protects those with preexisting conditions - Provides personal health information privacy

Which falls prevention measures can a nurse delegate to nursing assistive personnel?

- Provide nonskid slippers. - Lock beds and wheelchairs. - Keep room free of clutter

Which would be considered critical thinking skills when assessing a newly admitted client who has Alzheimer's disease and pneumonia? Select all that apply.

- Questioning the client's family or caregivers as well as the client for clarification of information - Separating random information from pertinent information - Carefully reading the physician's notes and orders and prioritizing how to proceed with the nursing plan

What information is needed when assessing the respiratory vital signs? Select all that apply.

- Rate - Depth - Rhythm - Effort

What should the nurse include when trying to motivate a group of adolescents to include exercise in their daily regimen? Select all that apply.

- Recognize barriers to exercise. - Reward yourself when goals are met. - Tailor the exercise regimen to meet needs.

The nurse is educating the parents of a toddler about medication safety in the home. What should the nurse include in the teaching plan?

- Refrain from calling medications candy. - Avoid taking medications in front of children. - Store all medications in child-resistant containers.

Which interventions should the nurse include in the plan of care for a postmenopausal client with osteoporosis? Select all that apply.

- Refrain from cigarette smoking. - Perform weight-bearing exercises - Include vitamin D and phosphorus in daily intake.

Which nursing interventions are important for the home health nurse to perform to promote safety when caring for elderly clients?

- Removing throw rugs - Moving electrical cords - Changing positions slowly - Using visual and hearing aids

Which of the following is an example of whistleblowing? Select all that apply.

- Reporting fraudulent billing practices - Reporting unsafe work practices - Reporting a coworker for working under the influence of drugs

What is the correct procedure for responding to small fires?

- Rescue the clients - Activate the alarm - Confine the fire - Extinguish the fire

The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure, 107/66 mm Hg. Which findings are abnormal? Select all that apply.

- Respiratory rate - Temperature - Pulse

A nurse is enrolling a client into a research study and is going over the paperwork. Which rights should the nurse review with the client before obtaining informed consent? Select all that apply.

- Right to full disclosure - Right to confidentiality - Right to self-determination - Right to not be harmed - Right to knowledge of placebo administration

Which are examples of nursing diagnoses?

- Risk for impaired skin/tissue integrity - Ineffective impulse control - Insufficient breast milk

Which of the following are examples of invasion of privacy by nurses? Select all that apply.

- Searching a patient's belongings without permission - Reviewing the plan for patient care in the lunchroom - Releasing patient health information to local newspaper reporters

Which criteria must be present for an occurrence to be labeled a never event?

- Serious - Preventable - Measurable

Which neurotransmitters are related to excitatory and inhibitory sleep mechanisms? Select all that apply.

- Serotonin - Histamine - Prostaglandins - Acetylcholine

Which recommendations to redesign the health-care system does the American Nurses Association's Health System Reform Agenda include? Select all that apply.

- Shift the priority from illness care to health promotion. - Establish health policies that support safe, effective, patient-centered care. - Provide universal access to essential health-care services for all citizens and residents.

Which questions are examples of bioethics considerations? Select all that apply.

- Should a client be allowed to die? - Should a nurse question an order? - Should a client be told about a medical error?

Which describe types of muscle? Select all that apply.

- Skeletal - Smooth - Cardiac

The nurse's documentation of a wound states, "Round stasis ulcer on right ankle, no tunneling. Clear serous drainage present. Dry dressing applied." What additional documentation is needed? Select all that apply.

- Skin around wound - Pain and nutritional status - Size - Condition of wound bed

What must the nurse consider in regards to the integrity of the aging adult's skin? Select all that apply.

- Skin is thinner and more fragile. - Glandular activity decreases. - Collagen and elastin fibers weaken and become less elastic.

An adolescent reports constant fatigue and an inability to stay awake in school. Which factors should the nurse assess for that could be interfering with sleep? Select all that apply.

- Smart phone use - Drug and alcohol use - School work and studying - Caffeine consumption

Which are common causes of fire in a health-care setting?

- Smoking - Anesthesia - Malfunctioning electrical equipment

The occupational health nurse is educating a group of workers who do heavy lifting. Which safety aspects should be included in the session? Select all that apply.

- Squat to lift objects. - Spread legs apart when lifting. - Use thigh muscles when lifting.

Strategies to improve the status of nursing include which of the following? Select all that apply.

- Standardizing the educational requirements for entry into practice - Enacting uniform continuing education requirements - Encouraging participation in professional organizations

Which guidelines are established for nursing practice? Select all that apply.

- Standards of Practice - Patient Care Partnership - Nurse practice acts

Which aspect of the exercise regimen should the nurse refrain from including when developing an exercise program for an older client with arthritis?

- Standing on one foot, then the other, to improve balance

What benefits can the client experience from bathing? Select all that apply.

- Stimulates depth of respirations and provides sensory input. - The warmth and friction dilate blood vessels near the surface of the skin, increasing the circulation. - It can be a time to strengthen the nurse-client relationship. - It promotes relaxation and comfort, enhances well-being, and improves self-image.

Which are modifiable risk factors for preventing hypertension? Select all that apply.

- Stress - Smoking - Salt and alcohol intake

Which statements about stressors are accurate? Select all that apply.

- Stressors can be different, depending on the situation. - Stressors change throughout the life span.

The U.S. Department of Health and Human Services (USDHHS) is working to reduce which health-care-related infections? Select all that apply.

- Surgical site infections - Multidrug resistant bacteria - Ventilator-associated pneumonia - Catheter-associated UTIs

Which type of exercises should the nurse recommend to an obese client to reduce pain and increase compliance? Select all that apply.

- Swimming - Using a rowing machine - Riding a recumbent bike

In which ways can anxiety interfere with a client having a restful night's sleep? Select all that apply.

- Tachycardia - Increased respirations - Increased gastric secretions

What suggestions can the nurse make to help improve an adult client's sleep? Select all that apply.

- Take a warm bath or shower before bedtime. - Consume a small glass of warm milk at bedtime.

Which factors can affect geriatric clients' ability to obtain adequate sleep at night? Select all that apply.

- Taking longer to fall asleep - Awakening for longer periods during the night - Nocturia interfering with sleep

Which are components of an effective culture of safety on a nursing unit? Select all that apply.

- Team empowerment - Transparency - Accountability

Which statements about documentation are correct? Select all that apply.

- The chart is a legal document and is admissible in court. - Standardized nursing language provides a clear picture of client outcomes.

Which chart entry would be part of SOAP (subjective, objective, assessment, plan) documentation? Select all that apply.

- The client complains of pain at the incision site. - Redness and edema is noted at the incision site. - The physician was notified about signs of infection at the incision site.

Which precautions and considerations should a nurse take when bathing a client with dementia? Select all that apply.

- The client may experience fear and loss of control. - Clients who are agitated during a bath my stay agitated for hours. - Prepackaged bathing products can help complete the bath faster and more comfortably.

Which circumstances would qualify a client for a move into an independent living center? Select all that apply.

- The client must be autonomous in all activities of daily living. - The client must have a desire to live with other senior citizens. - Client must be over age of 55

The nurse is caring for a patient diagnosed with a brain tumor who is about to undergo surgery to have the tumor removed. Before the surgery, the patient signs a document giving instructions to his family regarding the level and extent of life-prolonging treatments he desires. Which of the choices below describe this legal directive? Select all that apply.

- The document is a living will. - The family can make decisions that are consistent with the document if the patient is incompetent. - The family has guidance on the treatments the patient wants.

When arriving to take a client's blood pressure, a nurse witnesses an argument between the client and spouse. Recognizing that stress can alter blood pressure, the nurse encourages the spouse to step out and get something to drink, giving the client an opportunity to calm down. The nurse returns later to take the client's blood pressure after the client has had time to settle down. What is true about this situation? Select all that apply.

- The nurse used theoretical knowledge by recognizing the argument would raise blood pressure. - The nurse used ethical knowledge by returning to get an accurate reading instead of just assuming the client's blood pressure would return to normal. - The nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading.

The nurse arrives at work to find the unit will be short staffed for the shift because a nurse called in sick at the last minute, leaving no time to find a replacement. What factors contribute to the dilemma faced by the nurse working this shift? Select all that apply.

- The nurse's multiple obligations and relationships - Value conflicts and lack of clarity within the profession - Caring versus the decreased time to spend with patients

The health-care team is determining discharge plans for a client admitted after involvement in a motor vehicle accident. The client requires intravenous antibiotics as well as physical and occupational therapy and wants to receive these services in the home. Which factors determine if this is appropriate? Select all that apply.

- The presence of help in the client's home - The coverage provided by the client's insurance carrier - The availability of a home health-care agency to provide the required services. - Complexity of the care required by the client - The ability of the client to be transported to and from health-care provider appointments

Which factors determine if a client would develop an infection? Select all that apply.

- The quantity of organisms - The host's ability to fight off infection - The virulence of organisms - The ability to survive in the host

Which of the following are part of informed consent? Select all that apply.

- The right to know what is expected - The right to be provided written information - The right to provide written consen

Which statements describe theories? Select all that apply.

- Theories help find meaning in our experiences. - A theory organizes thinking around an idea. - Theories assist in the development of ideas or insight into work performed.

Which of the following are true about Conceptual Frameworks? Select all that apply.

- They have not been tested in Practice - They are broader than a theory - They contain a set of concepts

The nurse is conducting an educational session on stress with a group of executives. Which type of stressors would most likely be problems for this population? Select all that apply.

- Time stressors - Situational stressors - Anticipatory stressors

Which are benefits of large systems using electronic health records (EHRs)? Select all that apply.

- To develop better disease treatment methods - To understand disease causes and progression - To determine outcomes for various populations

Which terms are commonly used to describe types of baths delivered in healthcare?

- Towel bath - Therapeutic bath - Bed bath - Partial bath - Assist bath

What should the nurse use prior to moving a client who needs an assist device to help move from the bed to a chair?

- Transfer belt

Which are contributing factors for escalation of violent behavior? Select all that apply.

- Under the influence of drugs or alcohol - Chaotic environment - History of violent behavior

What should the nurse educator include when giving a presentation to a group of nurses about ways to prevent nurse back injuries while transferring a patient? Select all that apply.

- Use electric or mechanical lifts for transfers. - Obtain assistance from other staff members. - Lock wheels and furniture and equipment before moving clients.

The home health nurse is instructing the family of an elderly client about safety precautions that should be taken in the bathroom. Which information should the nurse provide?

- Use raised toilet seats. - Set up grab bars in the shower. - Purchase a sturdy shower chair for the client.

What factors contribute to a person's ethical beliefs? Select all that apply.

- Values - Attitudes - Morals - Beliefs

Which critical thinking skills will a nurse utilize when reviewing the health record of a new client to prepare a nursing diagnosis? Select all that apply.

- Visualizing potential solutions to a problem - Prioritizing or ranking data as needed - Separating relevant from irrelevant data

A 38-year-old client is asking for medication for trouble falling asleep and staying asleep. The client also feels groggy and unrested during the day. What should the nurse assess for as possible etiologies? Select all that apply.

- Watching TV while in bed - Sleeping with smart phone nearby - Caffeine consumption - Current medications

Which are measures that should be taken by health-care workers to decrease radiation exposure for a client with a radioactive implant? Select all that apply.

- Wear the lead apron - Limit the amount of time spent with the client. - Perform care near the client only when necessary.

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply.

- Weather - Pollutants - Financial strains

The nurse knows that falls most often occur in hospitals and long-term care facilities during which time frames? Select all that apply.

- Weekends - Nights - Holidays

While reflecting and determining what should be done, which questions might help focus thinking? Select all that apply.

- What else might work in this situation? - What was done? Why was it done? - What rationale do I have for my decisions?

The nurse is caring for a client who fell while trying to get out of bed without assistance. As the nurse is completing the incident report, what should the nurse include in the documentation? Select all that apply.

- What happened in an objective manner - Actual statements from the client - The date, time, and location of the incident

In which situation would standard precautions be adequate? Select all that apply.

- While assisting a client with oral care - While ambulating a client after a procedure - While inserting an intravenous catheter

Which are guidelines for good body mechanics? Select all that apply.

- Wide base of support - Chest high - Abdominal muscles tight

Which roles are commonly used by nurses during a given shift? Select all that apply.

- advocate - educator - case manager - leader

What are the components of safe, effective care? Select all that apply.

- informatics - evidence-based practice - quality improvement - patient-centered care

Which factors control the growth of microorganisms? Select all that apply.

- pH - Light - Oxygen - Temperature

A student nurse is learning how to take manual blood pressure. Put the following steps in order for this procedure.

1. Clean the stethoscope with a 70 % alcohol pad. 2. Positon the client. 3. Fully expose the arm. 4. Place the cuff around the bare upper arm. 5. Palpate the brachial artery. 6. Place the stethoscope ear pieces in the ear. 7. Inflate the cuff. 8. Place the stethoscope over the brachial artery. 9. Deflate the cuff slowly. 10. Auscultate accurate Korotkoff sounds. 11. Remove the cuff from the client's arm. 12. Document findings in the medical record.

Place the action involved in the step of the nursing process in the order in which it occurs.

1. Gather data. 2. Identify strengths and needs. 3. Developing outcomes and interventions. 4. Carry out interventions.

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority.

1. Ineffective airway clearance 2. Ineffective breathing pattern 3. Deficient fluid volume 4. Risk for fall 5. Wandering 6. Impaired memory

Chain of infection

1.) Pathogen exists 2.) Pathogen multiplies 3.) Portal of exit & contact with another organism 4.) Mode of transmission/contact with a susceptible person 5.) Susceptible host/Pathogen is no longer contained

The nurse is working with a 57-year-old client who is worried about exercising too hard. What would be this client's maximum heart rate for high-intensity exercise? Insert numeral only.

138

How many hours of sleep per day does a newborn need?

16 to 20

Which blood pressure Korotkoff sound represents the systolic reading?

1st sound

A nurse is calculating the pulse pressure for a client who has a blood pressure of 150/80. What is the pulse pressure?

70 mm Hg

Which client would the nurse consider to be at the highest risk of developing a nosocomial (happens in hospital) infection?

A 65-year-old client with an indwelling urinary catheter

Which client is using conversion as a defense mechanism?

A client who is overwhelmed with stress and experiences nausea and vomiting

A nurse has received shift reports on several clients. Which client should the nurse see first?

A client with heart failure with a respiratory rate of 42 breaths per minute

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently.

Which is the best example of intellectual courage?

A nurse fairly examines his or her own values and beliefs even when uncomfortable.

Which nurse would fall into Benner's stage of being an expert nurse?

A nurse who assesses a client and believes that something is not right and notifies the health-care provider

Which represents an Americans with Disabilities Act (ADA) accommodation?

A nurse who has had a stroke is not physically able to perform client care and is given a position in scheduling, with an associated pay cut.

Which describes an ethical dilemma?

A pregnant woman may miscarry if she takes a strong chemotherapy agent, but if she doesn't, her cancer will progress quickly.

Which type of immunity is present when the body makes its own antibodies or T cells to protect the body against a pathogen?

Active immunity

A nurse is assisting a client to a standing position. The client requires frequent breaks and is unable to catch his or her breath. After standing for a few seconds, the client states he or she is exhausted and needs to lie down again. Which is an appropriate priority nursing diagnosis for this client?

Activity intolerance

Which of the following is considered a primary care service?

Administering childhood immunizations

Which of the following is an example of an illness prevention activity?

Administering immunization for HPV

A nursing student recognizes that a client's laboratory results are abnormal but does not know the reason why. In which stage of informal learning is this student?

Advanced beginner

Bryan finds himself feeling unprepared and frustrated in his new grad role. He tells his mom, "I do fine when I've done something before, but every day there seems to be a new skill that I haven't performed yet." His mom reassures him that things will get easier as he becomes exposed to more experiences. Which stage of Benner's model is Bryan demonstrating?

Advanced beginner Bryan is an advanced beginner, an individual who improves performance with multiple exposures to new experiences. The novice stage begins with the onset of education. The competence stage is when an individual is able to handle the patient load and prioritize situations, even if complex. A proficient individual serves as a resource for less experienced nurses. A nurse at the expert level is able to identify and achieve objectives.

The parents of a 12-year-old boy refuse chemotherapy to treat the child's leukemia, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution to this ethical dilemma would demonstrate compromise, maintaining the integrity of all involved?

Agreeing to administer the chemotherapy agent with the fewest side effects.

A client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately?

Airborne

A nurse works night shift in an intensive care unit. After a night of multiple clients developing abnormal heart rhythms, and alarms going off continuously, the nurse does not notice that a client has developed a potentially lethal rhythm and the alarm is sounding. What does this describe?

Alarm fatigue

A client has been brought in from a motorcycle accident in which he or she has suffered deep track-like injuries with debris that can be only partially removed. What type of dressing should be applied to this client's wounds?

Alginate

Which is the appropriate procedure for disposal of used isolation supplies?

All supplies are bagged inside the room by a health-care worker wearing appropriate PPE, and a second health-care worker outside the room contains the waste in a separate bag.

The nurse is reviewing electroencephalograph results for a client who reports sleep difficulty. Which waves would the nurse expect to disappear when the client is asleep?

Alpha

Which is not a professional value identified by the American Association of Colleges of Nursing (AACN)?

Altruism

Harriet accepted money from a client as a "thank you" gift. Her employer found out and fired her. What is this an example of?

American Nurses Association Code of Ethics

The nurse, Suzie, has an allergy to latex. Her employer replaced all latex products used on the unit with non-latex substitutions so Suzie will not get sick.What is this an example of?

Americans With Disability Act (ADA)

A nursing unit is receiving report for five clients being newly admitted. Which client is at the highest risk for injury and best to place close to the nurse's station?

An 87-year-old patient who is confused

The client asks the nurse whether he should create an advance directive. What information should the nurse share when replying?

An advance directive will ensure he gets as much or as little care as he wishes.

A UAP has been assigned to take vital signs on four clients. Which temperature should be reported immediately to the nurse?

An oral temperature of 104.9°F for a client who is 40 years old

The registered nurse is educating a student nurse about critical thinking when caring for clients. Which action made by the graduate nurse indicates the use of critical thinking?

Analyzing a client's temperature changes and assessing for signs of infection

The diagnosis step of the nursing process includes which activity?

Analyzing data

How should the nurse deliver the breakfast tray to the bedside of a client in airborne isolation?

Apply respirator mask and gloves, then place the tray on the client's nightstand.

The nurse is caring for a client who has recently immigrated to this country. The interpreter shares that the client usually bathes once a week. When your assessment is finished, the nurse plans to have the client shower. What additional information needs to be gathered?

Ask about hygiene customs in the client's native land.

The nurse is working at a health fair providing blood pressure and pulse screenings. The nurse finds a young adult client has an apical pulse of 44 bpm. What would be the nurse's first action?

Ask the client if he or she is an athlete or runs every day.

The nurse enters a client's room to obtain a fasting blood glucose reading and notices the breakfast tray is in front of the client. Which action best indicates the nurse using critical thinking?

Asking the client if he or she has eaten any food yet

The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of:

Assault and battery

Which describes the use of the Morse scale?

Assesses a client's likelihood of falling

Which describes the type of bath in which a client does as much as possible, but the nurse assists with hard-to-reach areas, such as the back, feet, and legs?

Assist bath

How could a nurse reduce a confused client's risk of falls?

Assist with toileting frequently.

An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him?

Assisted living facility

Confidentiality will be maintained by a nurse who believes in and values the ethical principle of:

Autonomy

The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patient's case?

Autonomy

Which nursing value describes the right to self-determination and to choose and act on that choice?

Autonomy

The emergency department nurse cares for a 17-year-old adolescent who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment, saying, "I don't want my parents to know I have been sexually active, and if they find out about the cancer, they'll figure out the rest of it." The nurse explains the risk of death if the cancer is not treated, but the patient continues to refuse therapy. What conflicting principles is this nurse facing as the result of this patient's choices?

Autonomy versus nonmaleficence

Which client teaching would be most therapeutic for someone with a sleep disturbance?

Avoid eating carbohydrates before going to sleep.

A client is discussing an extended family-related conflict with the nurse and states he is tired of the problem and does not participate in family get-togethers because of it. Which ego defense mechanism will the nurse document that the client is using?

Avoidance

A client begins experiencing chest pain off and on for a few days and continues to work without seeking medical attention. Which response to stress is this client demonstrating?

Avoiding the stressor

Martha is stressed from the overwhelming amount of work she is responsible for since her charge nurse quit her position. She has spoken with her director but nothing seems to change. She decides to apply for another position within the hospital. Which coping approach is Martha using?

Avoiding the stressor

Correct body mechanics should be utilized by nurses to prevent which type of injury?

Back injury

Which is the cause of body odor?

Bacteria

The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursing plan?

Basic three-part statement

Which term describes a type of bath in which a client is in bed but able to bathe himself or herself?

Bed bath

Which describes the intentional release, or threat of release, of disease-producing organisms with the intent of causing illness, fear, or death?

Bioterrorism

While palpating Mrs. Wong's pulse, you find a rate of 40 beats/min. This finding is _________.

Bradycardia

A client has a respiratory rate of 8 breaths per minute. What is this rate called?

Bradypnea

A client has a high risk of gum bleeding due to painful mouth lesions. What might the nurse consider as a precaution?

Brush teeth with a foam or cotton mouth swab.

A home care nurse is teaching a client and his wife about taking digoxin. What is the most important teaching intervention?

Call the primary care provider if the pulse is less than 60

A client is brought by ambulance to a hospital after being found in a closed garage with the car running. The physician orders 100% humidified oxygen. Which type of poisoning does this client have?

Carbon monoxide inhalation

A nurse becomes irritated with a client who is requesting more ice chips and refers to the client as "the ice man in 201" to other nursing staff. In which important component of nursing has the nurse failed to engage?

Caring

The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following?

Case method

Which fire extinguisher classification is approved for use with combustible metals?

Class D

While conducting research on weight management among Native Americans, what information would be integral in developing a theory?

Client preferences regarding weight management (timing, location, and costs) and how meeting these preferences will influence success

Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of "lower abdominal pain r/t uterine contractions and hyperextension of cervix"?

Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period

Which is the most important factor a nurse should consider when planning a client's hygiene care?

Client's needs

How has the vast amount of information available on the Internet affected client-nurse relationships?

Clients actively participate in discussions about health issues and treatment options more often than in the past.

What is meant by full-spectrum nursing?

Clients are treated by nurses who use well-rounded skills such as critical thinking and communication in addition to technical skills and safe and effective care.

Using the nursing process to carefully consider a client's condition is an example of which skill?

Clinical judgement

After a year as a medical-surgical nurse in an acute care facility, Bryan tells his mom that he's more passionate about preventive care than he is about health restoration. To which care location should Kathy direct him?

Community health

A nurse who has been practicing for 3 years in an acute care facility is caring for a post-hip surgery patient. The nurse observes an abnormal change in vital signs and associates these changes with a postoperative bleeding problem. The nurse is demonstrating which proficiency level?

Competent

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse do first?

Complete a physical assessment of the child.

A nurse provides a bath in which the nurse washes the client's entire body. The client is unable to assist. Which type of bath is this?

Complete bath

A nurse who has worked on a medical-surgical unit for 4 years wishes to learn how to become a school nurse. Which is the recommended next step?

Completion of a BSN and other state requirements

Which of the following describe the decision-making process of a nurse?

Complex maze of alternatives

Which information is needed to record an evaluative statement?

Conclusion and supportive data

The nurse is facing a moral dilemma and applies the MORAL model to decision making. After writing down all the possible options to solve the problem, what will the nurse do next?

Consider all the options and choose the best one.

Which is the appropriate initial action if a client has a possible poisoning?

Contact the nearest poison control center.

If a written order is confusing or unclear, what action should the nurse take?

Contact the provider for clarification.

Clients with private insurance pay for services in the form of deductibles, premiums, and co-payments in which method of financing health care?

Cost sharing

The nursing supervisor has developed a new protocol for implementing family support through family-centered care. The majority of the staff is apprehensive about trying the new procedure. If the supervisor continues with implementing the plan, which critical thinking attitude is he or she displaying?

Courage

When checking on a postoperative client, the nurse notices evisceration. What should immediately be done?

Cover the wound with sterile towels or dressings soaked in sterile saline solution.

What should the nurse do for a client with orthostatic hypotension who is preparing to get out of bed to walk for the first time in several days?

Dangle the client's legs off the side of the bed.

What would be an appropriate nursing diagnosis for a client who is uncertain about which course of action to take in his or her treatment?

Decisional conflict

How are critical thinking skills used when following hydration recommendations for two different clients with dehydration issues, one due to a gastrointestinal virus and one with kidney dysfunction?

Decisions are geared toward individual differences.

At the end of a meditation session, which physical assessment finding would suggest that the relaxation technique was successful?

Decreased blood pressure

What is a contributing factor to foot problems in elderly clients?

Decreased circulation to lower extremities

A student nurse asks the nurse the difference between dehiscence and evisceration. Which would be the best explanation?

Dehiscence is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

Which of the following is the most important reason to develop a definition of nursing?

Differentiate nursing activities from those of other health professionals

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation?

Disciplinary action against the nurse's license to practice

The nurse notices a blood pressure cuff in the client's room with spots of dried blood on it. What should be the nurse next action?

Disinfect it with a chemical cleaner.

The nurse needs an IV pole to begin a new medication for a client. There is a pole in another client's room that is not in use. What should be the nurse's next action?

Disinfect the pole and begin using it.

Which is the best method of preventing needlestick injuries and exposure to bloodborne pathogens while providing client care?

Dispose of the needles in a sharps container.

Which safety precaution should the nurse take when preparing to administer an injection to a client?

Disposing of the needle immediately in the sharps container

When washing a client's legs, which direction is correct?

Distal to proximal

Fair access to care and allocation of resources are examples of what type of justice?

Distributive

A client with rheumatoid arthritis (RA) informs the nurse he or she wants to begin an exercise program to prevent the disease from getting worse. What should the nurse instruct the client?

Do your exercise in the afternoon or evening.

Which elements of documentation can be delegated to unlicensed assistive personnel?

Documentation of vital signs and activities of daily living (ADLs)

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD), becomes fatigued easily, and is unable to perform all activities of daily living (ADLs). The work of which nursing theorist would best help the nurse plan care for this client?

Dorothea Orem

What is important to remember when conducting perineal care for a client?

Drape the client appropriately to protect modesty.

Which describes the ethical concept of fidelity?

Duty to keep promises

A 49-year-old uninsured and unemployed client arrives at the emergency department of the local private hospital closest to home complaining of chest pain radiating between the shoulder blades, tightness in the neck, and nausea. The triage nurse calls the on-call provider, who instructs the nurse to send the client to the county hospital several blocks away. What federal law protects this client against refusal of care at the private hospital?

EMTALA (Emergency Medical Treatment and Labor Act)

What should be considered when using abbreviations in nursing documentation?

Each facility should have a list of approved abbreviations, and those that should not be used.

In which capacity would a clinical nurse specialist best serve a health-care facility?

Educating clients and families on disease management

An experienced nurse signs up for a class on a new electronic health record system. Which of the American Nurses Association Standards of Professional Performance does this most exemplify?

Education

A nurse visits a high school to give a presentation on HIV prevention. In what role is this nurse acting?

Educator

Which is the single most important activity for preventing and controlling infection in a health-care setting?

Effective hand hygiene

A nurse is a new employee in a facility learning about The Joint Commission's Patient Safety Goals. What is in included within these goals?

Elimination of never events

Jason just vomited blood but is hesitant to go to the emergency department because he does not have insurance. He tells this to the admitting nurse, who assures him he won't be turned away from medical care.What is this an example of?

Emergency Medical Treatment and Active Labor Act

Which regulation requires health-care facilities to provide emergency care to clients who seek health care regardless of ability to pay?

Emergency Medical Treatment and Active Labor Act

Which phase of wound healing describes collagen fibers breaking down and remodeling?

Epithelialization

What is the primary goal of the National League for Nursing?

Establish and maintain standards for nursing education

Which is a description of nurses being able to apply standards of ethical conduct to professional practice and participate in ethical decision making?

Ethical agency

A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n):

Ethical dilemma

Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios?

Ethical dilemma

A nurse taking care of a client who has been involved in a motor vehicle accident while intoxicated is an example of which principle?

Ethics

The care plan for a client includes ambulating for 10 minutes every hour, but the client has been unable to achieve the full amount of time. What is the next step in the nursing process?

Evaluation

How often must a long-term care facility complete the Minimum Data Set for Resident Assessment and Care Screening (MDS) after initial admission?

Every 3 months

A research-based method for judging and choosing nursing interventions is referred to as what?

Evidence-based practice

According to the Institute of Medicine, which competency best promotes nursing research?

Evidence-based practice

A pregnant 16-year-old girl is admitted to the emergency department in active labor. Her mother says she has no money or insurance. What should the nurse do next?

Examine her to determine whether her condition is stable or whether she requires immediate medical attention.

An experienced seasoned nurse uses her knowledge of patient medical conditions and intuition to identify patient problems. She is often the resource for other nurses on the unit. What stage of proficiency has this nurse achieved?

Expert

A client is being transferred from the bed to a stretcher for surgery using a transfer board. What should be the nurse's first action?

Explain the procedure to the client.

A nurse discharges a client without answering any questions or teaching her how to treat a wound at home. What type of malpractice claim could be brought against this nurse?

Failure to implement a plan of care

The nurse enters a patient's room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient's chart and begins to question the nurse about the patient information. This is an example of:

Failure to maintain patient confidentiality

A client is processing information regarding a new diagnosis and the treatment the physician has recommended. The client's family has provided excessive input and are attempting to have the nurse "convince" the client to see things their way. Which critical thinking attitude should the nurse present?

Fair-mindedness

A client has called the nurse to the room several times over the course of the past hour because he or she keeps getting up and wandering and is having difficulty getting back into bed. On the last visit to the client, the nurse gives the client a sedative to cause drowsiness. What can this treatment be considered?

False imprisonment

A client is placed under involuntary confinement for suicidal ideation. During this time, the nurse applies restraints to insert a urinary catheter. Which situation has occurred?

False imprisonment

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." To keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following?

False imprisonment

A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will return to explain the results. After assisting the other patient to the bathroom, the nurse returns to explain the results to the patient. What ethical principle has the nurse displayed?

Fidelity

When taking a manual blood pressure, the nurse listens for Korotkoff sounds. What numbers of Korotkoff sounds produce the systolic and diastolic numbers?

First and fifth

Which describes the ability to carry out activities of daily living with vigor and alertness, without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies?

Fitness

Which type of exercise program does a nurse recommend to an older adult to prevent injury and muscle strain?

Flexibility

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected?

Focused assessment

A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate?

Follow the patient's wishes and do not administer a blood transfusion.

A client is admitted to the hospital with chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen via nasal cannula. Which position will best assist his breathing?

Fowler's

A nurse is recently hired at an acute care facility. During orientation to her unit, she is given a role chart describing each person's role on the unit. The chart reflects that the registered nurses are responsible for all admission and discharge assessments and patient treatments. The licensed practical nurses are responsible for administering all medications and the certified nursing assistants obtain all vital signs and administer baths. The nurse recognizes this practice as which model of care?

Functional

What is the correct technique for palpating the carotid pulses?

Gently palpate both carotid pulses one side at a time.

Henry, a nurse, is driving home from work when there is a major motor vehicle accident in front of him. He runs to the side of the driver, finding him bleeding from the nose and mouth. Henry calls 911 and begins treating the driver after receiving consent.What is this an example of?

Good Samaritan laws

The nurse performs care on an unconscious person at the grocery store. What law protects the nurse in this situation?

Good Samaritan laws

Which is an inflammatory response to high levels of uric acid in the blood, resulting in severe pain and limited activity levels?

Gout

Which of the following best describes the legal definition of a nurse? Assume all education programs are accredited.

Graduate of a nursing education program and has passed the National Council Licensure Exam

The nurse is caring for a client following a surgical procedure. The health-care provider's orders include vital signs every 15 minutes for one hour, every 30 minutes for two hours, then every hour for four hours. Which type of document would best serve this nurse?

Graphic chart

When is a back massage typically offered as part of scheduled care?

H.S. care

Which statement best describes how Florence Nightingale's theory benefits nursing today?

Hand hygiene greatly decreases nosocomial infections.

Which describes the universal symbol for choking?

Hands clutching the neck

The physician wants to monitor a client who has been having difficulty falling and staying asleep and feels unrested during the day. What intervention could be used to do this?

Have the client complete a sleep diary for 14 days.

The nurse is assessing the sleep patterns of a client who has not been sleeping well, leading to fatigue and frustration. How could the nurse best evaluate the situation?

Have the client keep a sleep diary

Michelle is in grave condition after an automobile accident. The nurse knows he cannot give a status update to her sister calling from out of state. What is this an example of?

Health Insurance Portability and Accountability Act (HIPAA)

The charge nurse uses a whiteboard located at the nurse's station to write the nurses' patient assignments and the patients' diagnoses. This is a violation of which of the following?

Health Insurance Portability and Accountability Act (HIPAA)

Pulse oximetry is a noninvasive method to assess a client's oxygen level in what part of the blood?

Hemoglobin

Which of the following is an example of a complementary and alternative form of treatment or medicine?

Herbal medicines

Going beyond administering medication and direct care to treat the client as a whole is considered which type of theory-based intervention?

Holistic nursing care

The nurse is explaining that she works with homebound clients who cannot get to ambulatory care for treatment. Which health care setting is the nurse working in?

Home care

Which is the leading cause of complications of hospital care?

Hospital-acquired infections

A client in a group setting begins to kick a trash can and yell at other clients. Which behavior would the nurse note in the client's medical record?

Hostility

Which disorder can cause an increase in the basal metabolic rate (BMR) and thus raises body temperature?

Hyperthyroidism

Which somatoform disorder would the nurse expect to find in the medical record of a client who is constantly fearful of becoming ill?

Hypochondriasis

Which part of the brain controls circadian rhythms?

Hypothalamus

A nurse caring for a client with peripheral neuropathy secondary to uncontrolled diabetes suggests acupuncture because the client has trouble sleeping and is showing signs of daytime drowsiness, irritability, and restlessness. The client does not want to take medication for pain but is willing to try alternative therapies. What component of the PICOT model addresses acupuncture in this situation?

I

A graduate nurse from an Associate's degree in nursing (ADN) program asks the nurse manager what the expectations are for ADN nurses in research. What responsibility should the nurse manager include in the explanation?

Identifying problems in practice

A nurse is presenting a workshop on how to avoid the development of high blood pressure to a group of older adults in a community senior center. Which role is the nurse assuming?

Illness prevention

The nurse begins a shift, performs a client assessment, and then proceeds to prepare to administer medications. At what point should the nurse document the assessment?

Immediately after the assessment

What skin integrity issue should the nurse be aware of when working with a client diagnosed with Alzheimer's disease?

Impaired cognition can lead to pressure injuries.

Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare?

Improved patient compliance with prescribed treatments

In which sleep stage would a client's EEG show beta waves?

In periods of wakefulness

Which is a major disadvantage of the electronic health record (EHR)?

Incapability to integrate records from multiple locations

A nurse is working in a health-care facility with a protocol of having clients who have pneumonia turn, cough, and deep breathe. This nurse is assigned to care for a client admitted with pneumonia but does not encourage the client to cough because the client also has esophageal varices from cirrhosis. Which aspect of critical thinking is this nurse using to guide client care?

Individual differences

Which of the following best demonstrate nurse's critical thinking skills?

Individualized patient care plans

A client with peripheral vascular disease has weak pedal pulses and the right foot is cool and pale. Which nursing diagnosis has the highest priority?

Ineffective tissue perfusion

Which level of contamination describes a wound with bacteria in excess of 100 000 organisms per gram of tissue?

Infected

Three days after abdominal surgery, the nurse notes a 2-cm area of erythema and swelling at the proximal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Temperature is 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication?

Infection at the incisional site

The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen?

Inflammatory phase

A nurse has concerns that an order written on a client is not appropriate. She contacts the physician, who insists the order is correct. The nurse still has reservations about carrying out the order. What is the appropriate course of action?

Inform her supervisor about her concerns regarding the order.

When a client is hospitalized, at which point in the treatment regime should discharge planning begin?

Initial assessment

Asking questions that begin with "What if ...?" or "How can we ...?" are characteristic of a nurse who has which critical thinking quality?

Intellectual curiosity

A nurse with several years of experience in the intensive care unit obtains a new job in the newborn nursery at the health-care facility. Which critical thinking attitude would be best for the nurse to employ in this new setting when asking for guidance?

Intellectual humility

Which organization represents nurses around the world to ensure quality nursing care for all?

International Council of Nursing

The nurse is caring for a client admitted with abdominal pain, nausea, and a bowel obstruction. The client states, "I feel nauseous, and I am going to vomit." The nurse administers an antiemetic after the client vomits 200 mL of greenish-brown fluid. In the SOAPIE documentation system, under which aspect would the administration of the antiemetic be documented?

Interventions provided

The Code of Ethics for Nurses:

Is not legally binding

What should the nurse monitor in a client who is taking blood pressure medication?

Ischemia

A client who is bedridden asks the nurse what exercises can be included to prevent muscle atrophy. What is the nurse's best response?

Isometric

Weight training with free weights is an example of which type of exercise?

Isotonic

Why is the diagnosis step critical to the nursing process?

It connects the assessment with planning, interventions, and follow-up evaluation.

What is the mission of the Patient Care Partnership?

It encourages health-care providers to be more aware of the need to treat clients in an ethical manner and to protect their rights.

What is one major drawback of applying the Golden Rule way of thinking when addressing a client's wishes?

It is presumptuous in that nursing actions may not really be what the client wants.

What is the most effective way for a new nurse to influence health-care policy and become involved in legislation on the local, state, and national levels?

Joining and becoming involved in a professional nursing organization

Which type of joint is a synovial joint?

Knee joints

Tuberculosis that is acquired by an individual who has no symptoms for several years is an example of which type of infection?

Latent infection

The patient is struggling with a decision whether or not to receive experimental treatment. What is the nurse's role when caring for this patient?

Listen to the patient's thoughts, ask questions, and provide support.

The nurse is preparing to administer an insulin injection to a client with an elevated blood glucose level. What should the nurse check in the electronic medication administration record prior to giving the dose?

Location of last injection

When trying to identify a concept in research, which is considered an operational definition?

Lumbar pain is a verbal statement denoting a client's pain.

A client that has urinary incontinence is susceptible to what type of skin issue?

Maceration

The nurse is packing a wound during a wet-to-damp dressing change. She avoids applying the moist dressing to the surrounding tissue to prevent what complication?

Maceration

What is an appropriate nursing intervention to prevent dehiscence in an obese client who is recovering from abdominal surgery?

Maintain bed rest with the head of the bed elevated at 20° and the knees flexed.

A nurse encourages a client who has suffered a left brain ischemic stroke to participate in rehabilitation. The nurse reminds the client of his or her family and grandchildren who are a large part of his or her life. The nurse is engaging in which component of caring?

Maintaining belief

According to Maslow's hierarchy of needs theory, which basic level of physiologic need must be met before higher level needs can be addressed?

Making sure the client has food

The nurse cares for a patient who is diagnosed with a sexually transmitted infection (STI). The patient is upset and asks the nurse not to share this information with anyone. The nurse explains to the patient that this must be reported to the local Health department based on which regulation?

Mandatory reporting

Upon initial assessment of an older adult, the nurse discovers bruises and scratches on the client's arms, legs, and trunk in various stages of healing. The supervisor is notified that physical abuse is suspected. With which of the following is the nurse in compliance?

Mandatory reporting laws

What is the significance of using standardized reporting formats?

Many serious errors occur as a result of miscommunication between caregivers.

Which would be the most appropriate way of moving a client who is very obese and immobile?

Mechanical lift

____________________ is a health program, administered by the state and funded by federal and state governments, to provide care for low-income people.

Medicaid

Hand hygiene, environmental cleanliness, standard precautions, and protective isolations are components of which infection prevention strategy?

Medical asepsis

____________________ is a federal insurance program designed to fund healthcare for people aged 65 years and older, the disabled, and those with end-stage renal disease.

Medicare

What is the hormone that naturally controls sleep?

Melatonin

The nurse is working with a client newly diagnosed with narcolepsy. Which treatment regimen would the nurse expect to be prescribed for this client?

Methylphenidate (Ritalin)

The nurse receives a prescription to begin a morphine drip for a patient who is to be taken off the ventilator, and to increase the infusion rate as needed to maintain the patient's comfort. The nurse refuses to carry out the order because the morphine will depress respirations and the nurse believes this is equivalent to killing the patient. Which concept best describes what this nurse is demonstrating?

Moral agency

The nurse is assigned a 39-year-old client with the nursing diagnoses Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. When would be the most appropriate scheduled care time to address the bathing needs of this client?

Morning care

Which is the restful phase of sleep in which physiological function is slow?

NREM

12/23/21 0200 Received patient from the E.D. BP 85/62, HR 118, RR 24, temp 102°F, sats 94%. Arouses to verbal stimuli but drifts back to sleep. Normal saline infusing in left arm via 20-gauge IV catheter at 200 mL/hr. Urinary catheter draining scant dark amber urine. O2 at 4 L/min via nasal cannula. Lungs with coarse crackles bilaterally. Loose cough present, unable to expectorate secretions. Nasotracheal suctioning x 1 for thick green sputum. Sats increased to 96% —Mary Jones, RN

Narrative

Which would be considered a bloodborne pathogen exposure?

Needlestick injury

The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following?

Negligence

Which sleep disorder involves a person suddenly waking up thrashing about and hallucinating?

Night terrors

A client has a wound that has been allowed to heal through secondary intention due to excessive loss of tissue. The physician is planning to suture the tissue together when the wound is ready. What should the nurse be monitoring to determine the readiness for delayed primary closure?

No evidence of edema, infection, or foreign matter

Annie is planning to move to another state. She looks at the Board of Nursing website to explore that state's regulations for registered nurses. What is this an example of?

Nurse practice acts

The nurse documents, "Anxiety related to change in health status and situational crisis." This is an example of which step in the nursing process?

Nursing diagnosis

The nurse believes that abortion is murder of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient?

Nursing ethics

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this?

Objective

The nurse uses the SOAP format for documentation and types in a client's medical record, "The left coccyx wound is reddened and measures 1 cm x 2 cm x 0.2 cm and is without drainage." Which aspect of the SOAP format is this considered?

Objective

Which development-related safety issue should the nurse include when educating the parents of a 6-month-old infant?

Objects being placed in the mouth

The nurse is assessing a client with congestive heart failure and notes 3+ bilateral pitting pedal edema. The nurse is unable to palpate the pedal pulses. What would be the best intervention?

Obtain a portable Doppler and check for pedal pulses.

Which nursing action is part of the evaluation phase when performing wound care for a client?

Obtaining wound measurements once a week

A nurse working in a rehabilitation facility has a physician's prescription to contact other therapists as required by patient need. A patient has started to have difficulty with bathing and grooming. Which therapist should the nurse contact to assist the patient to regain these skills?

Occupational therapist

The nurse is caring for a client who is in the alarm stage of a stress response. Which clinical finding corresponds to the production of aldosterone, antidiuretic hormone, and renin?

Oliguria

Which type of evaluation is performed while implementing care, immediately after an intervention, and at each client contact?

Ongoing evaluation

A client admitted 2 days ago has not slept well due to pain from injuries. The nurse recognizes this and adjusts the client's nursing diagnosis to reflect the change in status. The nurse then creates a new plan to address the change. What type of planning is this considered?

Ongoing planning

A nurse who is obtaining a health history through an interview asks, "What can you tell me about your previous knee replacement surgery?" Which type of question is this?

Open-ended

Which type of communication would the nurse be using when giving a bedside change of shift report to another nurse?

Oral communication

Which is the best term for the nurse to include in his or her assessment documentation to note that a client is unable to lie flat without becoming short of breath?

Orthopnea

In which position should the nurse place the client with chronic obstructive pulmonary disease (COPD) who is short of breath?

Orthopneic

Which is the most prevalent type of degenerative disease that can severely limit a person's ability to perform physical activity?

Osteoarthritis

According to Leap Frog Hospital Safety Guide (2018), approximately how many avoidable deaths occur in U.S. hospitals each year?

Over 200,000

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each other's opposing views. Which step of the MORAL model does this illustrate?

O—Outline the options

In addition to the four major vital signs, the Joint Commission added a fifth vital sign. What is the fifth vital sign?

Pain

When assessing pallor in a light-skinned client, how does the skin appear?

Pale without underlying tones of pink

Which statement best describes parasomnia?

Parasomnia is a pattern of waking behavior that involves sleepwalking.

A nurse is caring for a 25-year-old client who is quadriplegic. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility?

Passive ROM

A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed?

Paternalism

Johnston would like to better understand his hospital bill. He calls the hospital and the billing department suggests he meet with a representative and have it explained.What is this an example of?

Patient Care Partnership

A client is asking about developing a living will. What act protects this right?

Patient Self-Determination Act

Josephine wants to make her own decisions about her end-of-life care. She talks to her significant other about creating a living will and durable power of attorney. What is this an example of?

Patient Self-Determination Act

On a patient's admission to the hospital, a nurse asks the patient whether he has a living will or durable power of attorney for healthcare. He states he does and provides a copy for the chart. The basis for the nurse's inquiry is which of the following?

Patient Self-Determination Act (PSDA)

Nursing codes of ethics support which of the following?

Patients have the right to dignity, privacy, and safety.

The nurse is working at a hospice organization in her area. Which of the following best describes the patients for whom she will be caring?

Patients who are terminally ill and their family members

A registered nurse forgot to put the siderails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurse's situation is that her insurance policy will do which of the following?

Pay $2 million

Which intervention in the immobile client's plan of care best helps develop muscle strength?

Perform AROM each hour.

Which is the most common cause of tooth loss in adults over 35?

Periodontal disease

A nurse is assisting a client who has had a stroke that caused the loss of use of the left side with activities of daily living. What actions can the nurse take to encourage self-care and as much independence as possible?

Place all hygiene items on the client's right side and assist with what the client cannot reach.

The parents of a toddler report difficulty getting their child to sleep at night. The child wants to play and not go to sleep. Which intervention suggested by the nurse would be most effective?

Plan sedentary activities the last hour before bed.

In a client's health record, the nurse documents, "Nutritional status will improve as evidenced by a weight gain of 3 lb (1.4 kg) by July 1." This statement is an example of which step of the nursing process?

Planning

Which describes the attachment of a muscle to a more stable bone?

Point of origin

Which is the leading cause of unintentional deaths in the United States?

Poisoning

Which diagnostic test involves measuring brain wave activity, oxygen and carbon dioxide levels, and vital signs?

Polysomnography

The nurse on the medical-surgical unit has noticed a client has edema. Why should the nurse address this issue in the care plan?

Poor oxygen diffusion to the cells can cause skin breakdown.

A client has decreased mobility to her left side from a stroke. The nurse discovers a stage 1 pressure injury on the patient's left heel. What should the nurse do next?

Position the heel off the bed using pillows

A nurse has been caring for a client and appears to make excessive visits to the client's room. The nurse states he or she has the best understanding of the client's needs while behaving as if no one else can care for the client. When asked about this behavior, the nurse becomes defensive. What could possibly be the issue in this scenario?

Potential boundary issues

A nurse is caring for a client with a history of diabetes and feels as if something is "not right." The nurse takes the client's blood glucose level. The nurse is acting on which type of knowledge?

Practical

Which type of managed care allows patients the greatest choice of providers, medications, and medical devices?

Preferred provider organization

Which characteristic of the electronic health record (EHR) helps prevent medication errors?

Preventing medications from being administered to clients with allergies

A nurse assesses the client and develops a plan of care in which type of model of care?

Primary nursing

The nurse is working in a mental health clinic and a client states, "My coworker did not do well on our joint presentation, and that's why I got fired!" As the nurse documents the findings, what defense mechanism is this client using?

Projection

Which nursing action reflects the nurse assisting the client in maintaining belief?

Providing encouragement to a client with a new amputation

Which type of research strives to look at the lived experience of the patient?

Qualitative

According to the Institute of Medicine, which competency best promotes the concept of providing safe, quality client care?

Quality improvement

Which factor most decreases adverse outcomes in a health-care facility?

Quality nursing care

A registered nurse (RN) is interviewing for a new staff position at a hospital and asks about staffing and client assignments. The interviewer explains nurses work in a functional nursing role. Which statement best explains this approach?

RNs provide compartmentalized care, perform complex treatments, and are in charge

A nurse is learning about the processes of heat exchange between the body and the environment. What is this process that accounts for almost 50% of body heat loss called?

Radiation

A nurse is in charge of a client with multiple challenges who is not responding to care as predicted. Upon evaluating the care plan and outcomes the nurse realizes the interventions should be altered. What is the next step in the nursing process?

Reassess the client, create a new nursing diagnosis if needed, and plan for new outcomes with new interventions.

The nurse completes the critical-thinking process but the client's care outcome has been only partially met. What should be the nurse's next action?

Reevaluate the plan to determine whether it was realistic.

While helping a postsurgical client ambulate, the nurse notices the client becomes short of breath with little exertion. Which is the next step in the nursing process for this client?

Reevaluating and creating a new nursing diagnosis and outcome

The scientific basis for client care is ever-changing. What can a nurse do to stay current with this multifaceted information?

Refine critical thinking skills as well as update knowledge and skills frequently.

Which localized physiological response would the nurse anticipate a client may experience during an intravenous insertion?

Reflex pain response

Which member of the healthcare team typically serves as the case manager?

Registered nurse

An 80-year-old patient fell and fractured her hip and is now in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred?

Rehabilitation center

Which health-care setting would the registered nurse (RN) recommend for a client who needs further inpatient therapy after sustaining a stroke?

Rehabilitation center

The nurse is performing an assessment on a client. What should be included in this process?

Religious and spiritual needs

The nurse responds to a client's call light to find a fire in the bathroom trashcan. The client yells, "I just wanted a cigarette; I didn't think this would happen." What should be the nurse's first action?

Relocate the client away from the fire.

A nurse is about to plug in an IV pump and notices that the electrical cord is frayed. What action should the nurse take?

Remove the pump from service and submit a work order for repair.

The nurse is assigned a 39-year-old client who is temporarily nonambulatory due to a car accident that resulted in a fractured pelvis and femur. One nursing diagnosis is Self-Care Deficit: Bathing. Using the NOC ranking system for self-care, which category would this client fall into?

Requires assistive person

Which stage of General Adaptive Syndrome (GAS) would a client be in if he or she was failing to adapt to the point that exhaustion will occur if left unresolved?

Resistance

Identify the third step in the MORAL decision-making model.

Resolve the dilemma. M - Massage the dilemma O - Outline the options R - Resolve the dilemma A - Act by applying the chosen option L - Look back & evaluate

Which type of isolation is indicated for a client who is immunosuppressed?

Reverse isolation

A nurse is using critical thinking and clinical reasoning to evaluate the plan of care for a hospitalized client. What should the nurse do after recognizing that the goals of the care plan have not been met in a timely fashion?

Revise the plan of care with more realistic goals and time line for the client.

Which is an appropriate nursing diagnosis for a client who has had a stroke and has left-sided hemiparesis?

Risk for disuse syndrome

Which describes the process in which a safety event is analyzed to determine the underlying cause and to prevent the event from occurring again?

Root cause analysis

Which is a method of providing a complete communication during a hand-off report?

SBAR (situation, background, assessment, and recommendation)

After assessing a client who has just been weaned from the ventilator, the nurse determines the client is not yet able to ambulate and does not follow the physician's order. What protects the nurse from being terminated or disciplined for not following orders?

Safe harbor laws

A homeless client comes to the emergency room via ambulance after being found unresponsive on a park bench. The client is diagnosed with diabetes mellitus and needs his or her blood glucose levels monitored twice a day. The client is not interested in self-monitoring. According to Maslow, which type of needs must be met prior to being successful with client education about glucose regulation?

Safety and security needs

What priority nursing intervention does the nurse incorporate into a plan of care to promote sleep for a hospitalized client?

Schedule nursing care to avoid interrupting sleep.

The newly graduated nurse is supervising licensed practical nurses and certified nursing assistants. It is important to understand the role of each person. What is this an example of?

Scope of Practice

An elderly female client is admitted with pneumonia. During the course of hospitalization, she develops shingles, caused by herpes zoster virus, related to a history of varicella. Which type of infection is the shingles?

Secondary infection

A new client on the medical-surgical unit has not bathed in several days although she is fully capable of engaging in personal hygiene practices and ADLs. Upon investigation, the nurse learns she is homeless and typically utilizes the services of the homeless shelter once a week for her bathing and other hygiene needs. What is an appropriate nursing diagnosis for this client?

Self-care deficit

What is an appropriate nursing intervention for moral distress?

Self-manage emotions; discuss moral distress with a mentor if you are having difficulty

Which position is described as the client lying in a semi-recumbent position, with the head of the bed elevated to 30 degrees?

Semi-Fowler's position

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the family's wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR (AND) prescription. This is an example of which of the following?

Settlement of an issue by force

Which is the most preferred method of bathing for ambulatory clients?

Shower

Which professional nursing organization would a nurse seek to join if interested in nursing research and scholarship?

Sigma Theta Tau International (STTI)

Which nursing intervention reflects Jean Watson's caring theory, including personal presence?

Sitting down for several minutes with a client who is preparing to undergo a permanent colostomy formation

What is the difference between skilled care and custodial care?

Skilled care focuses on short-term rehabilitation, while custodial care focuses on activities of daily living and other daily needs clients would typically do themselves.

A client informs the health-care provider of increased fatigue upon return from a camping trip last weekend. What would be important to assess for this client?

Skin for bug bites

The unit manager stops you in the hallway to discuss your inability to give safe patient care. The conversation is overheard by other nurses. The manager's comments are based on false information reported to her by a patient. This is an example of:

Slander

Which factor has a positive effect on the quality of sleep?

Sleeping in a quiet environment

A client is admitted with flu and placed on droplet precautions. Which is a portal of exit for the virus that is the pathogen?

Sneeze

Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors impacting healthcare?

Social worker

Which is considered a restraint?

Soft wrist holders

If a person makes a conscious decision to bend the elbow, which nervous system is applied?

Somatic nervous system

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart?

Source-oriented

Offering to call a client's clergy member during illness is an example of which type of theory-based implementation?

Spiritual care

Which describes the stretching of a ligament that causes the ligament to tear?

Sprain

A nurse is reviewing the blood pressure log for a 57-year-old African American client. The average blood pressure for this client is 156/88. Which stage of blood pressure is this?

Stage 2 high blood pressure

Calvin is considering a transfer to the interventional radiology department. He's unfamiliar with the expectations in the nursing role within that department and looks for practice guidelines.What is this an example of?

Standards of Practice

While setting up a sterile field, a nurse opens a package of 4 X 4 gauze and drops it onto the sterile field. One corner of the gauze is outside of the sterile field. What action should the nurse take?

Start over with setting up the sterile field.

In the United States, each state enacts its own nurse practice acts. Which agency is responsible for nurse practice acts?

State Board of Nursing

Which organization can require nurses to take continuing education courses as a condition of licensure renewal?

State Board of Nursing

Nurse practice acts are an example of what type of law?

Statutory

The nurse is measuring the depth of a client's wound. What piece of equipment should she use to make this measurement?

Sterile cotton-tipped applicator

Which is a method of asepsis that involves the removal of all pathogens from an area when providing care?

Sterile technique

The nursing staff on the surgical unit complains to the manager that they do not have enough time to complete all wound care and dressing changes. What is the manager's most appropriate action to take?

Suggest a continuing quality improvement committee to assess the issue

_____________ pressure is peak blood pressure against arterial walls.

Systolic

What can the nurse include in the day at work to minimize stress and maintain health?

Take a 20-minute walk on a break.

The nurse witnesses the patient's signature on a consent form to participate in her physician's research study. After the physician leaves the room, the patient tells the nurse she really doesn't want to participate but didn't have the heart to turn down the request because of fear that the physician would be upset. What should the nurse do to advocate for this patient?

Tell the physician why the patient agreed to participate.

A client has been referred to hospice for end-of-life care. What type of care is this considered?

Tertiary care

A patient who requires long-term rehabilitation needs which type of care?

Tertiary care

The nurse assists unlicensed assistive personnel in providing morning care to a comatose client who is bowel and bladder incontinent. The nurse should intervene if which action is observed?

The UAP answers the telephone while wearing gloves.

Which represents correct documentation in the medical record of an initial nursing assessment of a client admitted with pneumonia?

The client appears short of breath, with wheezing in all lung fields.

How can a nurse recognize a client is struggling with an ethical issue?

The client experiences conflict in some form.

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information?

The client has most likely not had a recent physical examination.

Effective delegation is a vital part of the nurse's responsibilities. What factor should guide the nurse to correctly delegate a nursing task?

The education and experience of the delegatee

If an error is made in nursing documentation, what should the nurse do?

The entry is noted as being an error, and an addendum with correct information is added.

A client visits an urgent care center while on vacation in Colorado. The client reports difficulty breathing since arriving. Which factor most likely explains the client's dyspnea?

The high altitudes prevent oxygen from binding to hemoglobin.

Place in order the neuroendocrine responses that occur during the fight-or-flight response.

The hypothalamus releases CRH, which stimulates the pituitary gland to release ACTH and then ADH. ACTH in turn stimulates the adrenal glands to release cortisol and aldosterone. Then ADH causes water reabsorption in the renal tubules. Endorphins are released, causing a sense of well-being and decrease in pain. TSH is released by the pituitary gland. This increases the efficiency of cellular metabolism and converts fat to energy.

The nurse believes that abortion is wrong, but applies the MORAL model and decides that caring for patients following an abortion is her ethical duty. When evaluating the effectiveness of the nurse's decision process, what finding would indicate the nurse made the best choice?

The nurse believes quality care was delivered and feels satisfied with the decision.

According to validation theory, what is the nurse's best response when caring for an elderly client with dementia who asks when his or her mother is coming to visit?

The nurse should tell the client he or she would like to hear more information about the mother.

The nurse faces a true ethical dilemma and uses several strategies for resolving the issue. What is the likely outcome?

The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used.

Which statement is correct about critical thinking and the nursing process?

The nursing process is a critical-thinking, problem-solving model.

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient?

The patient is brought to the emergency department in cardiac arrest; no family is present.

An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse?

The patient's

The nurse is documenting client care in a medical record. The facility uses a problem-oriented record system. In which area would the nurse document the medications he or she administers?

The progress notes

Which type of bath is most likely to be a medical order?

Therapeutic bath

What is the primary purpose of swaddling a newborn for the first few weeks of life?

Thermoregulation

Which high-amplitude brain waves found during deep sleep are common in children but rare in adults?

Theta

Which statement describes the primary purpose of an incident report?

This report is used by risk management to prevent the incident from reoccurring.

What is the purpose of the nursing process?

To guide the nurse in providing goal-directed, patient-centered care

What is the purpose of the diagnosis step of the nursing process?

To provide analysis of the nursing assessment

Which statement describes the purpose of utilization review as related to documentation in the medical record?

To verify medical treatments are necessary

Which civil laws deal with wrongs done by one person to another without a contract involved?

Tort laws

Two nurses are planning to transfer a comatose client from the bed to a stretcher. Which device should be used?

Transfer board

A client who has depression with secondary insomnia is requesting "some kind of relief" to improve his or her quality of life. What type of medication would most likely be prescribed for this client?

Tricyclic antidepressant

An elderly client is ambulatory but requires assistance with bathing. The client has episodes of incontinence and his or her bed and gown is soiled. Which type of bath would be most appropriate?

Tub bath

Which is an appropriate nursing order for a client with a nursing diagnosis of "ineffective airway clearance"?

Turn, cough, and deep breathe every 2 hours.

A 70-year-old client has a nursing diagnosis of Self-Care Deficit: Dressing r/t decreased strength and endurance and loss of muscle control and coordination. What is an appropriate nursing intervention for the client?

Use Velcro fasteners instead of buttons and zippers

A nurse is performing oral care on an unconscious client. How should the nurse hold the mouth open?

Use a padded tongue blade.

The nurse is bathing a client with senile dementia. What action will optimize the chance of cooperation?

Use a quiet, calm manner, allowing for choices.

A client is providing A.M. care to a client who is on anticoagulation therapy. When assisting the client with shaving, which consideration should be taken?

Use an electric razor.

Which is an effective nursing intervention for preventing falls?

Use of bed alarms

When addressing the needs of a nonambulatory client with severe Vitamin D deficiency, what might be an appropriate intervention?

Use of ultraviolet light in the room

What is the best way for student nurses to improve critical-thinking skills?

Use the five points of the critical-thinking model

A surgeon refused a patient's request to restart a patient's total parenteral nutrition (giving nutrition through the intravenous route) because he believed that a greater good would be achieved by not using medical resources to prolong the life of a terminally ill patient when the resources could be used for other patients. Which ethical theory best explains the surgeon's rationale?

Utilitarianism

The nurse manager performs a risk-benefit analysis to determine the minimum number of staff the unit will need over the Christmas and New Year's holiday to allow as many nurses to take time off as possible while maintaining the safety of the patients. What ethical problem-solving approach is this nurse manager using?

Utilitarianism

Which consequentialist theory requires a risk-benefit analysis?

Utilitarianism

The nurse overhears a coworker say, "How can an overweight nurse teach proper nutrition? That nurse should practice what is taught." Which concept best describes what the coworker is expressing?

Values

Which describes an organism that carries a pathogen to a susceptible host?

Vector

The nurse observes a new graduate nurse preparing to place an IV catheter in the patient's arm. The new graduate tells the patient, "You won't feel a thing" before inserting the needle under the skin. What ethical principle did the new graduate violate?

Veracity

Which describes the power and ability of an organism to cause disease?

Virulence

What should the nurse do when obtaining a client's orthostatic blood pressure (BP)?

Wait 1 to 3 minutes in between each reading.

A client with dementia becomes belligerent and combative when the nurse attempts to give him a tub bath. How should the nurse proceed?

Wait for the patient to calm down, then give him a towel bath.

What has influenced the image of nursing over time? Select all that apply.

War, Religion, Media

Which action made by the parent of a 4-month-old infant indicates a need for further education?

Warming formula in the microwave

Which is the safest way to warm infant formula prior to feeding an infant?

Warming infant formula in a pan of warm water

The nurse is inserting an intravenous catheter into a client. Blood drips down from the venipuncture and lands on the nurse's arm. Which intervention should the nurse perform first?

Wash the affected area thoroughly.

A statement such as "readiness for enhanced self-care" is an example of which type of nursing diagnosis?

Wellness diagnosis

When assessing a client for sleep disturbances, what is an appropriate question to address the sleeping environment?

What room temperature do you prefer?

A nurse suspects a colleague is taking a client's narcotics. The colleague has been behaving erratically at work and his or her clients complain of uncontrolled pain. The nurse reports this concern to the colleague's supervisor. Which is this an example of?

Whistleblowing

Which of the following about the nursing process is correct?

Works alongside an individualized plan of care

What is one skin integrity issue that should be addressed with an older adult client that has been admitted?

Xerosis

A nurse who is able to identify and achieve objectives is demonstrating which aspect of Benner's model?

expert

Which of the following best explains the importance of standards of practice?

tandards of practice identify the knowledge, skills, and attitudes nurses need to provide safe care.

The American Nurses Association (ANA) believes nurses should not participate in active euthanasia (and assisted suicide) because such acts violate ____.

the Code of Ethics for Nurse