N126 HESI - Elsevier Adaptive Quizzing #4
Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised? Justice Fidelity Veracity Nonmaleficience
Fidelity Rationale: Fidelity involves being loyal by keeping promises, doing what is expected, performing duties, and being trustworthy. Justice refers to fair treatment and fair distribution of resources. Veracity involves being truthful to the client. Nonmaleficence refers to acting in ways that prevent harm or risk of it.
Which of these stages of health behavior will the nurse suspect in a client who is in a state of ambivalence? Preparation Maintenance Contemplation Precontemplation
Contemplation Rationale: The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude toward a change; the client is most likely to accept that change in the next 6 months. The stage of preparation is exhibited when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about changes in his or her behavior.
Which factor is used to assess the quality of health care provided to a client? Fall prevention measures employed for the client Functional health status of the client after discharge Hand hygiene practiced by the health care personnel Teamwork and coordination among health care personnel
Functional health status of the client after discharge Rationale: Health care providers determine the quality of care provided to the client by measuring outcomes that show how the client's health status has changed. One method of measuring the quality of health care provided to the client is the functional health status of the client after discharge. The nursing staff would take necessary fall-prevention measures for the client; however this is not a measurable outcome. All health care personnel would practice hand hygiene to prevent infection, which is a quality measure, not an outcome of health care. Teamwork and coordination among health care personnel are important to provide efficient health care to the client. They are not outcomes of health care.
Which is true about prescriptive theory? It is nonspecific. It focuses on medication. It is seen in the Neuman systems model. It focuses on the phenomenon of an event.
It focuses on medication. Rationale: Prescriptive theory is focused on the prescribed medication under particular circumstances. Prescriptive theory is nursing-intervention specific and does not cover a wide range of nursing practices. The Neuman systems model is an example of a grand theory. Prescriptive theory is focused on a client's abilities to cope with situations.
Which action would the nurse team leader take when discovering a nurse is coming to work after drinking alcohol? Counsel the nurse about the problem. Ignore the problem until it happens again. Notify the nurse manager about the problem. Resolve the problem by sending the nurse home.
Notify the nurse manager about the problem. Rationale: The assessment phase of problem-solving consists of collecting data. The next step involves exploring options to address problems; this is best accomplished in collaboration with the nurse manager. Counseling the nurse about the problem is not the role of a nurse; the nurse who has been drinking needs professional counseling. Ignoring the problem until it happens again is unsafe; clients may be placed in jeopardy. Resolving the problem by sending the nurse home delays addressing the problem.
Which activity can be performed by infants aged 6 to 8 months? Holding a pencil Showing hand preference Placing objects into containers Transferring objects from hand to hand
Transferring objects from hand to hand Rationale: Infants aged 6 to 8 months may be able to transfer objects from hand to hand. Infants aged 10 to 12 months may be able to hold a pencil. Infants aged 8 to 10 months may show a hand preference. Infants aged 10 to 12 months may be able to place objects into a container.
Which of these databases would the nurse use to obtain a broad view of biomedical and pharmaceutical studies? PubMed EMBASE MEDLINE PsycINFO
EMBASE Rationale: The EMBASE database is a good source of biomedical and pharmaceutical studies. PubMed is the health science library at the National Library of Medicine; this database offers free access to many journal articles. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. PsycINFO is a good resource for psychology and psychology-related health care disciplines.
Which documentation is most informative for an assessment of drainage on a surgical dressing? 'Moderate amount of drainage.' 'No change in drainage since yesterday.' 'A 10 mm-diameter area of drainage at 1900 hours.' 'Drainage is doubled in size since last dressing change.'
'A 10 mm-diameter area of drainage at 1900 hours.' Rationale: A 10 mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. 'Moderate amount of drainage,' 'No change in drainage since yesterday,' and 'Drainage is doubled in size since last dressing change' are not specific, objective, or measurable.
Which statement about a case manager is correct? 'A case manager identifies and implements new and more effective approaches to problems.' 'A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families.' 'A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems.' 'A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families.'
'A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families.' Rationale: A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families.
Which point listed by the nursing student is accurate regarding the loss of a client's medication records? 'Loss of medical records may lead to libel charges.' 'The registered nurse would maintain accurate nursing records.' 'There is an assumption that the care provided to the client was negligent.' 'The health care facility needs to demonstrate why the medical records were lost.'
'There is an assumption that the care provided to the client was negligent.' Rationale: In case a client's medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary health care providers need to demonstrate why the medical records were lost.
Arrange the order of critical thinking for an existing problem. Making a conclusion Evaluating the information Recognizing the existing issue Analyzing information about the issue
1. Recognizing the existing issue 2. Analyzing information about the issue 3. Evaluating the information 4. Making a conclusion Rationale: When a problem exists, the nurse first recognizes the existing issue, then analyzes information about the issue and evaluates the collected information about the issue. After evaluating, the nurse would make a conclusion.
According to Freud's developmental theory, which age is considered the phallic stage? Birth to 18 months old 18 months to 3 years old 3 to 6 years old 6 to 12 years old
3 to 6 years old Rationale: According to Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage. Eighteen months to 3 years of age is the anal stage. Six to 12 years of age is the latent stage.
Which point requires correction regarding the use of restraints? Less restrictive interventions must have been unsuccessful before applying restraints. All other alternatives must have been tried and exhausted before applying restraints. Restraints may be applied to ensure the physical safety of the resident or other residents. A written order for restraints is not required.
A written order for restraints is not required. Rationale: Restraints can be used only on the written order of a health care provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.
Which describes the role of the nurse in the situation where the nurse informs the client's family that the client does not wish to proceed with chemotherapy? Manager Educator Caregiver Advocate
Advocate Rationale: The nurse acts as the client's advocate by communicating the client's concern to the family. As an advocate, the nurse protects the client's human and legal rights. The nurse manager coordinates the activities of health care personnel in delivering quality health care. The nurse acts as an educator while explaining concepts and facts about health or demonstrating procedures for self-care activities. The nurse also acts as a caregiver by providing measures to restore a client's physical, emotional, spiritual, and social well-being.
Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? Attempt to identify the client's concerns. Reassure the client that the surgery is routine. Report the client's anxiety to the health care provider. Provide privacy by pulling the curtain around the client.
Attempt to identify the client's concerns. Rationale: The nurse would assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the health care provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.
How would the nurse prepare a factual record when performing client documentation? By providing a logical order for the communication By using exact measurements for each activity of the client By providing complete and appropriate information in each client record By recording descriptive and objective information of what he or she sees, hears, feels, and smells
By recording descriptive and objective information of what he or she sees, hears, feels, and smells Rationale: A factual record contains descriptive and objective information about what the nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a comprehensive record that includes all essential information.
The nurse is helping a client maintain and regain health, manage his or her disease and symptoms, and attain a maximal level of function and independence through the healing process. Which role is the nurse playing? Manager Advocate Caregiver Communicator
Caregiver Rationale: As a caregiver, the nurse helps clients maintain and regain health, manage diseases and symptoms, and attain a maximal level of function and independent through the healing process. As a manager, the nurse coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. As a client's advocate, the nurse protects the client's human and legal rights and provides assistance in asserting these rights if the need arises. As a communicator, the nurse learns about a client's strengths and weaknesses and his or her needs through effective communication.
Which factors may help in providing excellent health care services to the client? Select all that apply. One, some, or all responses may be correct. Cultural sensitivity High client literacy Competent health care One-way communication Interprofessional teamwork
Cultural sensitivity Competent health care Interprofessional teamwork Rationale: Excellent health care services can be provided through competent health care that helps in reaching the client's goals. Interprofessional teamwork helps provide comprehensive care to the client. Cultural sensitivity helps provide health care while keeping in mind the client's cultural background and attitude. Communication should not be one-way; rather, it should be comprehensive to include all the team members and the client. The literacy level of the client is unrelated to quality health care.
The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with client care, remove the gown first and then remove the gloves.
Don an N95 respirator mask before entering the room. Rationale: An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.
To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care? Increase fluid intake. Restrict fluids. Encourage early mobility. Elevate the knee gatch of the bed.
Encourage early mobility. Rationale: In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk of thrombophlebitis.
The nurse should expect to take which action to help alleviate anxiety for a client scheduled for a colostomy? Administer the prescribed as-needed (PRN) sedative. Encourage the client to express feelings. Explain the postprocedure course of treatment. Reassure the client that there are others with this problem.
Encourage the client to express feelings. Rationale: Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus would be on the client, not others. Reassurance may cut off communication and deny emotions.
Which statement indicates that the nurse is in the advanced beginner stage of Benner? Learns about the profession through a specific set of rules and procedures Identifies the basic principles of nursing care through careful observation Understands the organization and specific care required by certain clients Assesses the entire situation and transfers knowledge gained from multiple previous experiences
Identifies the basic principles of nursing care through careful observation Rationale: According to the levels of proficiency set forth by Benner, the nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.
Which statement regarding an interpreter is correct? Relatives or friends of the client can serve as interpreters. The interpreter would be able to make literal, word-for-word translations. Interpreting not only the language but also the culture is important. As long as the health care provider is caring for the client, the interpreter should be available.
Interpreting not only the language but also the culture is important. Rationale: The health care facility should be able to provide interpreters to the clients who cannot speak English or do not speak English well enough to meet their communication needs. The interpreter should be able to interpret not only the language but also the culture. Health care facilities should not rely on relatives or friends of the client for interpreting, because they may not be as open as needed during the encounter. Literal translations are not necessary; words in one language can carry many different connotations in another language. The interpreter should be available at all points of contact but not when communication between the client and the health care provider is not occurring.
Which statement defines information gathered by the nurse? It is an individual piece of reality. It is a combination of pieces of reality. It is the organization and interpretation of data. It is the identification of relationships of various data.
It is the organization and interpretation of data. Rationale: Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge.
What is the definition of descriptive research? It tests how well a program, practice, or policy is working. It measures the characteristics of persons, situations, or groups. It is designed to establish facts and relationships concerning past events. It explores the interrelationships among variables of interest without any active intervention.
It measures the characteristics of persons, situations, or groups. Rationale: Descriptive research is defined as a study that measures the characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Evaluation research tests how well a program, practice, or policy is working. Historical research is designed to establish facts and relationships concerning past events. Correlational research explores the interrelationships among variables without any active intervention by the researcher.
Which action by a home care nurse would be considered an act of euthanasia? Implementing a 'do not resuscitate' order in the home health setting Abiding by the decision of a living will signed by the client's family Encouraging a client to consult an attorney to document and assign a power of attorney Knowing that a dying client is overmedicating and not acting on this information
Knowing that a dying client is overmedicating and not acting on this information Rationale: In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a 'do not resuscitate' order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse.
Which possible legal complication might the nurse face in a situation in which intravenous (IV) therapy was administered to the wrong client? Assault Battery Malpractice False imprisonment
Malpractice Rationale: If the nurse administers IV therapy to a wrong client, the nurse may face the charge of malpractice. Assault is any action that places the client or the nurse in fear of harmful or offensive contact without consent. Battery is any intentional touching without consent. False imprisonment occurs with unjustified restraint of a person without legal warrant.
The nurse adheres to which ethical principle when withholding a prescribed opioid medication from a client requesting to be treated for pain for fear the client will become addicted? Veracity Autonomy Paternalism Beneficence
Paternalism Rationale: Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices; the client has requested to be treated with a medication that has been prescribed by the health care team, and the nurse is refusing to give it because of unfounded personal beliefs. The client's priority is pain relief, and the nurse would be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Beneficence commonly is referred to as 'doing good'; it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety.
Which of these is a part of the health belief model? Behavioral outcomes Behavior-specific knowledge Perception of susceptibility to an illness Individual characteristics and experience
Perception of susceptibility to an illness Rationale: The health belief model is divided into three components. The first component is an individual's perception of susceptibility to an illness. The second component is an individual's perception of the seriousness of an illness. The third component is the preventive actions taken by a person. The health promotion model focuses on behavioral outcomes, behavior-specific knowledge and effect, and individual characteristics and experience.
To ensure client and visitor safety during transport of a client with influenza A (H1N1) for a computed tomography, the nurse would take which precaution? Place a surgical mask on the client. Other than standard precautions, no additional precautions are needed. Minimize close physical contact. Cover the client's legs with a blanket.
Place a surgical mask on the client. Rationale: Nurses would provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their rooms. Special precautions such as face masks would be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client wit ha blanket is for comfort and privacy, not because of a transmission precaution.
Which Quality and Safety Education for Nurses (QSEN) competency would the nurse comply with when using flowcharts to determine usefulness of bed monitoring devices for checking on dementia clients? Safety Informatics Quality improvement Patient-centered care
Quality improvement Rationale: According to QSEN competencies, quality improvement takes place when the nurse uses data to monitor the outcomes of care provided to improve the quality and safety of health care systems. In the given scenario, the nurse uses flowcharts to determine the usefulness of applying a bed-monitoring device for dementia clients to improve the quality of client care.
The nurse recalls that which disease in clients includes the short period of the evident decline in disease trajectory? Heart failure Renal cancer Disabling stroke Alzheimer disease
Renal cancer Rationale: Clients with cancer follow the short period of the evident decline in disease trajectory. Clients with organ failure do not follow this trajectory; instead, these clients follow the long-term limitations with intermittent serious episodes trajectory. The prolonged dwindling disease trajectory is generally seen in clients with disabling stroke, Alzheimer disease, and frailty disease.
Which should the nurse include when teaching a client with Clostridium difficile about decreasing the risk of transmission to family members? Increased fluid intake A high-fiber diet Soap and water for hand washing Wash hands with an alcohol-based hand sanitizer
Soap and water for hand washing Rationale: Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.
What are the current leading causes of death in the United States? Select all that apply. One, some, or all responses may be correct. Stroke Cancers Dementia Accidents Infections
Stroke Cancers Accidents Rationale: Researchers revealed that conditions such as stroke, cancers, and accidents are the leading causes of death in the United States. Dementia and infections are not the current leading causes of death in the United States; they were the leading causes of death a century ago.
Which are the characteristics of an adverse hospital event? Select all that apply. One, some, or all responses may be correct. May result in death at times The client usually experiences minimal harm Human error or hospital system error is typically the cause Caused by severe variation in the standard of care A root cause analysis tool can be used to analyze the cause
The client usually experiences minimal harm Human error or hospital system error is typically the cause Rationale: An adverse hospital event is a medical error that may result in causing harm to the client. However, the harm is not too severe or life threatening to the client. Adverse events are caused by human errors made by health care professionals or error in the hospital system. Sentinel events may result in death of the client and are caused by severe variation in the standard of care. Sentinel events are analyzed using the root cause analysis tool. An adverse hospital event is analyzed using the failure mode effective analysis tool.
Which point listed about the United Network for Organ Sharing (UNOS) program is accurate? The organization has a contract with the federal government. The donor's estate is protected from liability for injury or damage. Priority is given to international clients who need organs on an urgent basis. Civil and criminal immunity is given to the hospital and the primary health care provider.
The organization has a contract with the federal government. Rationale: The United Network for Organ Sharing (UNOS) has a contract with the federal government. The National Organ Transplant Act of 1984 protects the donor's estate from liability for injury or damage. The United Network for Organ Sharing gives priority to clients in their geographical area who need organs on an urgent basis. The National Organ Transplant Act of 1984 provides civil and criminal immunity to the hospital and the healthcare provider.
Which intervention reflects the nurse's approach of 'family as a context'? Trying to meet the client's comfort Evaluating the client family's coping skills Determining the client family's energy level Trying to meet the client family's nutritional needs
Trying to meet the client's comfort Rationale: In the 'family as context' approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The 'family as a client' approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach 'family as a client' involves assessment of the family's nutritional needs.
The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. One, some, or all responses may be correct. Vasodilation Dry and flushed skin Pale and cyanotic skin Decreased capillary refill Decreased urinary output
Vasodilation Dry and flushed skin Decreased urinary output Rationale: During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result, the skin may be warm to the touch. Hyperthermia causes loss of water from the body and results in dry skin and mucous membranes, decreased urinary output, and other signs of dehydration and electrolyte imbalance. Clients with hyperthermia may not have pale and cyanotic skin; instead they have dry, flushed skin. Clients with hyperthermia may not have decreased capillary refill; instead, they have increased capillary refill.
Which services do nurse-managed clinics provide in preventive and primary care services? Select all that apply. One, some, or all responses may be correct. Crisis intervention Wellness counseling Health risk appraisal Employment readiness Communicable disease control
Wellness counseling Health risk appraisal Employment readiness Rationale: Nurse-managed clinics provide wellness counseling, health risk appraisal, and employment readiness. Crisis intervention services are provided by school health centers. Communicable disease control services are provided by occupational health centers.
