NUR 315 review material 1

components of discharge planning

*Assessing strengths/limitations of the patient, family/support person, and environment *Implementing and coordinating the care plan *Considering individual, community, and family resources *Evaluating the effectiveness of care

Nursing Diagnosis vs Medical Diagnosis

*Nursing Diagnosis: Focus on patient response & Identify potential problems *Medical Diagnosis:Disease process , can have multiple nursing diagnosis

A pediatric client has a fever for which the provider has prescribed ibuprofen 200 mg orally every 6 hours. The instructions on the bottle indicate there is 100 mg/5ml. How many milliliters should the nurse give? Record your answer using a whole number.

10 mL

The nurse has a prescription to administer 25 mg of furosemide IV to a client. The drug is supplied in a vial 40 mg/4 ml. How many milliliters will the nurse administer of the medication? Record your answer using one decimal place.

2.5 mL

patient protection and affordable care act (PPACA)

2010 federal legislation designed for comprehensive health reform, with an intent to expand coverage, control health care costs, and improve the health care delivery system

clinical nurse leader

A nurse with an advanced degree who is a clinical expert in the care of a distinct group of patients, and who may provide direct patient care

Nurse Entrepreneur

A nurse, usually with an advanced degree, who may manage a clinic or health-related business, conduct research, provide education, or serve as an adviser or consultant to institutions, political agencies, or businesses

love and belonging needs

A person's need to have affectionate relationships with people and to have a place in a group

Which instruction should the nurse give to a client to ensure that a nasal medication is deposited within the nose rather than into the throat? A. "Aim the tip of the container toward the nasal passage." B. "Breathe through your mouth as the drops are instilled." C. "Place a rolled towel beneath the neck if you are unable to sit." D. "Remain in the sitting position for 5 minutes."

A. "Aim the tip of the container toward the nasal passage."

The nurse is assessing a client's postoperative pain. Which statement demonstrates accurate documentation of subjective pain assessment? A. "Client rates pain 4 on a scale of 0 to 10." B. "Client does not appear to be in pain." C. "Client seems irritated but states pain is around a level 5." D. "Client is smiling and talking with visitors—pain scale not used."

A. "Client rates pain 4 on a scale of 0 to 10."

The nurse is caring for a client who requests to see their medical record since admission to the hospital. What is the appropriate response by the nurse? A. "I will have to review the policy that determines what procedure is in place for client access." B. "You may not understand all of the information and it will confuse you, so I will help you decipher it all." C. "Let me open up the computer access so that you can see what information is of interest to you." D. "The hospital owns your records and does not have to allow you access while you are a client here."

A. "I will have to review the policy that determines what procedure is in place for client access."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? A. "Legal policy requires nursing practice to be permanently integrated into the client record." B. "The facility requires us to document client care this way because of the computer application used." C. "It would be easier to do it that way. You could develop a tool to use." D. "The electronic health record we use does not allow us to use different formats."

A. "Legal policy requires nursing practice to be permanently integrated into the client record."

The nurse is teaching a client about metformin SA. When the client asks, "What does the SA mean?" what is the appropriate nursing response? A. "sustained action" B. "extended release" C. "sustained release" D. "continuous release"

A. "sustained action"

What is aseptic technique? A. All activities to prevent infection or break the chain of infection B. Strict sterile technique always C. The proper way to make and maintain a bed D. A way to safely administer medications to prevent infection

A. All activities to prevent infection or break the chain of infection

For a patient on any type of precautions, when is hand hygiene supposed to be completed? A. Before entering or exiting the room B. Only when hands are visibly soiled C. Before getting report in the morning D. When wearing sterile gloves

A. Before entering or exiting the room

What is the best way to alert other staff that a patient is at risk for falls? A. By placing a sign on the patient's door and in their chart B. By making an announcement each shift to the whole floor C. By putting their name on a list at the nurse's station D. By documenting in the electronic medical record that the patient is at risk

A. By placing a sign on the patient's door and in their chart

The nurse is administering an oral opioid medication to a client who reported pain. The client dropped the medication on the floor. What actions would the nurse take now? Select all that apply. A. Discard the pill in an appropriate container with a witnessing nurse present. B. Wipe off the pill with dry gauze and administer to the client. C. Ask the health care provider to prescribe the opioid medication in a liquid form. D. Search for the pill on the floor until the pill is found. E. Obtain another dose of the medication for the client.

A. Discard the pill in an appropriate container with a witnessing nurse present. D. Search for the pill on the floor until the pill is found. E. Obtain another dose of the medication for the client.

What is the proper order for donning personal protective equipment? A. Gown, mask, goggles, gloves B. Gloves, gown, goggles, mask C. Mask, gown, gloves goggles D. Goggles, mask, gown, gloves

A. Gown, mask, goggles, gloves

Which are appropriate actions for protecting clients' identities? Select all that apply. A. Have conversations about clients in private places where they cannot be overheard. B. Orient computer screens toward the public view. C. Document all personnel who have accessed a client's record. D. Ensure that clients' names on charts are visible to the public. E. Place light boxes for examining X-rays with the client's name in private areas.

A. Have conversations about clients in private places where they cannot be overheard. C. Document all personnel who have accessed a client's record. E. Place light boxes for examining X-rays with the client's name in private areas.

When is hand hygiene not appropriate? A. When in a sterile environment B. Prior to entering a room C. Prior to exiting a room D. When hands are visibly soiled

A. When in a sterile environment

A client reports itching and shortness of breath 15 minutes after receiving ceftriaxone 500 mg intravenously. The nurse recognizes that the client is experiencing which type of reaction? A. allergic reaction B. toxic effect C. idiosyncratic effect D. synergistic reaction

A. allergic reaction

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client: A. breathes through his or her mouth until all the medication has been inhaled. B. takes rapid, shallow breaths until the medication is complete. C. rinses his or her mouth with water before the medication is administered. D. coughs intermittently while the medication is being administered.

A. breathes through his or her mouth until all the medication has been inhaled.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A. interpretation of data. B. factual statement. C. important information. D. relevant data.

A. interpretation of data.

The Z-track technique is utilized during drug administration by which route? A. intramuscular B. intravenous C. intradermal D. subcutaneous

A. intramuscular

Why is it important to know surgical asepsis? A.To know how to act around a sterile environment B. To understand how to handle bed linens C. To know why informed consent is essential D. To know how to clean a patient for good hygiene

A.To know how to act around a sterile environment

nursing process ADPIE

Assess Diagnose Plan Implement Evaluate

nurse navigator

Attempts to eliminate barriers. Serves as an advocate for the client. makes moving through the treatment phase easier. Similar to a case manager. Focuses on one specialty, like cancer. Helps reduce the client's anxiety and depression.

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? A. "Client has a history of recent abdominal pain." B. "Client is reporting abdominal pain is rated at 8/10." C. "2 mg hydromorphone hydrochloride PO was administered with good effect." D. "Client is guarding the abdomen and occasionally moaning."

B. "Client is reporting abdominal pain is rated at 8/10."

Which are examples of breaches of client confidentiality? Select all that apply. A. A nurse checks the health record of a client to see who is the contact person for an emergency. B. A nurse updates the employer of a client regarding the client's date of return to work. C. A nurse discusses information about a client with a coworker in the elevator. D. A nurse uses a computer to document a client's response to pain medication. E. A nurse shares his or her computer password with another nurse who was unable to log in to the system.

B. A nurse updates the employer of a client regarding the client's date of return to work. C. A nurse discusses information about a client with a coworker in the elevator. E. A nurse shares his or her computer password with another nurse who was unable to log in to the system.

Which patient is at the highest risk for falling? A. A patient in a locked, low bed B. A patient on a new narcotic prescription C. A patient wearing nonskid socks D. A patient whose room is clear of clutter

B. A patient on a new narcotic prescription

Which patients need standard precautions? A. Patients who are immunocompromised B. All patients at all times C. Patients who need assistance with hygiene D. Patients who are visiting outpatient offices

B. All patients at all times

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action? A. Request another nurse to reteach the material. B. Give written instructions to the client and caregivers. C. Provide discharge paperwork to the client. D. Arrange for home health to see the client.

B. Give written instructions to the client and caregivers.

The nurse is educating a client on how to self-administer subcutaneous insulin injections. The client asks why the needle must be removed at the same angle as that of insertion. How will the nurse respond? A. It prevents needlestick injuries. B. It minimizes tissue trauma. C. This helps to control placement of the needle. D. This verifies correct injection of the drug.

B. It minimizes tissue trauma.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? A. It provides and refers to a client's problem by a number. B. It provides quick access to abnormal findings. C. It documents assessments on separate forms. D. It records progress under problems, intervention, and evaluation.

B. It provides quick access to abnormal findings.

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? A. standing order B. PRN order C. one-time order D. stat order

B. PRN order

A nurse needs to administer a prescribed dose of an opioid medication to a client with acute neck pain. These medications should be stored in a: A. single container. B. double-locked drawer. C. self-contained packet. D. disguised container.

B. double-locked drawer.

Which component of a syringe's needle does the nurse recognize that refers to width? A. shaft B. gauge C. lumen D. bevel

B. gauge

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A. protecting the nurse and the hospital from litigation B. identifying risks and ensuring future safety for clients C. following up the incident with other members of the care team D. gauging the nurse's professional performance over time

B. identifying risks and ensuring future safety for clients

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal? A. to administer timely emergency treatment B. to determine the extent to which the client responded to the drugs C. to prevent interfering with test results D. to implement measures to reduce the transmission of microorganisms

B. to determine the extent to which the client responded to the drugs

Which data entry follows the recommended guidelines for documenting data? A. "Client complained about the quality of the nursing care provided on previous shift." B. "Client is overwhelmed by the diagnosis of pancreatic cancer." C. "Following oxygen administration, vital signs returned to baseline." D. "Client's kidneys are producing sufficient amount of measured urine."

C. "Following oxygen administration, vital signs returned to baseline."

A student nurse asks if they can administer the intravenous lorazepam intramuscularly instead to practice injections. What is an appropriate response to this question? A. "Yes, that is fine as long as it's the same dose." B. "Yes, if that is what the patient wants." C. "No, you do not have the authority to change how the medication was ordered." D. "No, we do not have the time for you to practice injections."

C. "No, you do not have the authority to change how the medication was ordered."

A health care provider has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen? A. Before administering the first dose B. Immediately after the first dose C. 30 minutes before the next dose D. 24 hours after the last dose

C. 30 minutes before the next dose

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? A. Explain the reasons for the hospitalization, but give no further information. B. Provide the information to the parent. C. Ask the client if information can be given to the parent. D. Take the parent to the client's room and have the client give the requested information.

C. Ask the client if information can be given to the parent.

A nurse is caring for a client in the nursing unit when the health care provider, during the rounds, verbalizes a prescription for a medication. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order? A. Ask the health care provider to spell out the medication name. B. Ask the health care provider to repeat the dosage. C. Ask the health care provider to write out the order. D. Ask a second nurse to listen for accuracy.

C. Ask the health care provider to write out the order.

How can a nurse ensure that the right medication has been selected to administer to a patient? A. Ask the charge nurse. B. Ask the patient. C. Compare it to the medication administration record (MAR). D. Call the provider.

C. Compare it to the medication administration record (MAR).

What personal protective equipment (PPE) is required for a patient on contact precautions? A. N95 mask and eye protection B. Surgical mask and gown C. Gown and gloves D. Face shield and surgical mask

C. Gown and gloves

What is a component of proper respiratory hygiene? A. It is not necessary to cover a cough if no one is within 3 ft of the person coughing. B. There is no need to cover the nose when coughing. C. It is best to cough into a tissue and promptly dispose of the tissue. D. Anyone coughing should wear an N95 mask.

C. It is best to cough into a tissue and promptly dispose of the tissue.

Which action is not appropriate regarding dirty needles? A. Use the intended safety lock appropriately. B. Place them safely in the sharps container. C. Recap them as part of standard practice. D. Do not use the same needle twice.

C. Recap them as part of standard practice.

What is true regarding restraints and falls? A. Restraining patients prevents falls. B. Chemical restraints are most effective for preventing bathroom falls. C. Restraints increase the risk for falls. D. Only ankle restraints increase the risk for falls.

C. Restraints increase the risk for falls.

An unlicensed nursing personnel completed vital signs on a patient using an electric machine. What should happen next? A. They should go to the next patient. B. They should begin to bathe the patient. C. They should clean the equipment used to take vital signs. D. They should notify the RN of their scheduled break.

C. They should clean the equipment used to take vital signs.

Why is it important to follow the rights of medication administration? A. To facilitate documentation B. To prove the need for higher wages C. To ensure patient safety D. To increase the number of items to check each shift

C. To ensure patient safety

What is the goal of clean technique? A. To keep objects free of microorganisms B. To provide information on a sterile field C. To reduce the number and transfer of pathogens D. To keep the operating room floor clean

C. To reduce the number and transfer of pathogens

Which diagnoses warrant airborne precautions? A. Influenza, rubella, diphtheria B. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended spectrum beta-lactamase (ESBL) C. Tuberculosis, measles, disseminated herpes zoster D. Lung cancer, liver disease, stage IV pressure injuries

C. Tuberculosis, measles, disseminated herpes zoster

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing? A. subcutaneous B. intravenous C. intradermal D. intramuscular

C. intradermal

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): A. assessment tool. B. incident report. C. legal document. D. Kardex.

C. legal document.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? A. any family member of the client B. close friends of the client C. those directly involved in the client's care D. health care professionals of the facility

C. those directly involved in the client's care

The primary reason for the Controlled Substances Act is: A. to prevent overuse of antibiotics. B. to regulate the purchase of antibiotics. C. to prevent drug use and dependence. D. to regulate the purchase of opioids.

C. to prevent drug use and dependence.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? A. pain rating of 4 on a scale of 0-10 B. describes wound as itchy C. urine output 100 ml D. concerned with feeling tired

C. urine output 100 ml

continuity of care

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care. SBAR or ISBARQ

A client is taking numerous eye drops to prepare for cataract surgery. Which teaching about ophthalmic application will the nurse provide? A. "If you cannot instill these drops from the bottle, you will be unable to have surgery." B. "Dispose of these medications every 7 days due to possible bacterial contamination." C. "Rest the eye dropper on the inner canthus to make it easier to instill the drops." D. "Wait 5 minutes between instillation of different types of eye drops."

D. "Wait 5 minutes between instillation of different types of eye drops."

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A. One U of glucose B. 1U of glucose C. 1 bottle of glucose D. 1 Unit of glucose

D. 1 Unit of glucose

In what area would you least expect to see surgical asepsis implemented? A. The operating room B. The labor and delivery unit C. The cardiac catheterization lab D. A long-term nursing care facility

D. A long-term nursing care facility

A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation? A. Use correction fluid to cover up 86/132 in the record. B. Cross out 86/132 using a black sharpie marker. C. Erase the incorrect statement and write 132/86. D. Cross out 86/132 with a single line and place the nurse's initials above it.

D. Cross out 86/132 with a single line and place the nurse's initials above it.

In what area is medical asepsis most likely utilized? A. The operating room B. A medical-surgical unit C. An outpatient psychiatric unit D. Every area of healthcare

D. Every area of healthcare

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A. Call the pharmacy to have the order entered in the electronic record. B. Add the new order to the medication administration record. C. Write the order in the client's record. D. Inform the health care provider that a written order is needed.

D. Inform the health care provider that a written order is needed.

What is not true regarding the patient's room and risk of falls? A. It is best to keep the bed in the lowest position. B. It is best to keep the wheels locked. C. It is best to leave a light on at night. D. It is best to keep personal items out of sight.

D. It is best to keep personal items out of sight.

The nurse is reviewing a medication prescription for a client prior to administration and observes that the route of administration is not present in the prescription. What is the appropriate action by the nurse to address this omission? A. Add the route to the prescription and administer the medication since the nurse is familiar with the drug. B. Call to ask the pharmacy how the drug should be administered. C. Omit the administration of the medication since it was written incorrectly. D. Notify the health care provider to add the route and then administer the medication when complete.

D. Notify the health care provider to add the route and then administer the medication when complete.

Which example may illustrate a breach of confidentiality and security of client information? A. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. B. The nurse provides information to a professional caregiver involved in the care of the client. C. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. D. The nurse provides information over the phone to the client's family member who lives in a neighboring state.

D. The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A patient on droplet precautions needs to leave their room for a computed tomography (CT) scan. How should the nurse address the droplet precautions? A. The patient should not wear anything additional. B. The patient must promise not to cough when outside the room. C. The patient should hold a sheet over their mouth when talking to others outside the room. D. The patient should don a surgical mask for the duration of time spent outside the room.

D. The patient should don a surgical mask for the duration of time spent outside the room.

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation? A. When preparing to discharge the client home B. When documenting the care that was provided to a client whose condition recently deteriorated C. When reporting to a client's family member or significant other D. When transferring a client from the emergency department to the acute care unit

D. When transferring a client from the emergency department to the acute care unit

Where should the patient's call bell be left? A. Hanging behind the bed B. On the floor next to the bed C. With the family member D. Within reach of the patient

D. Within reach of the patient

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? A. documenting clients' health histories and discharge planning B. recording nursing interventions C. identifying nursing diagnoses or clients' needs D. omitting clients' responses to nursing interventions

D. omitting clients' responses to nursing interventions

ISBARQ

Introduction Situation Background Assessment Recommendation Question and answer

tertiary health care

Management of rare and complex disorders

SBAR

Situation Background Assessment Recommendation

self-esteem needs

The need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

Susceptible host

a person likely to get an infection or disease

a nursing diagnosis is

a statement of clients health that nurses can identify or treat independently. Stated in terms of human responses to disease or injury

health

a subjective state of being healthy

portal of entry

a way for the infectious agent to enter a new reservoir or host

types of nursing diagnoses

actual risk (potential) wellness

portal of exit

any body opening on an infected person that allows pathogens to leave

nursing interventions

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions

infectious agent

bacteria, viruses, fungi

cellulitis

bacterial skin infection inflammation and pain mostly in lower extremities

means of transmission

direct contact indirect contact-vectors, fomites

means of transmission

direct contact, indirect contact, airborne route

transendence

helping others self-actualize

revising the careplan

if goals are met cancel and recreate a careplan, modify plan as needed to meet goals

reservoir

natural habitat of the organism

self-actualization needs

need to live up to our fullest and unique potential

vulnerable populations

people with disabilities, mental illness, minorities, those in poverty, homeless, undocumented immigrants

patient navigator

person without a clinical background (e.g., a lay person or a social worker) who assists the patient with scheduling, financial assistance, psychosocial support, and community support

safety and security needs

person's need to be protected from actual or potential harm and to have freedom from fear

nursing aims

promote health prevent illness restore health facilitate coping with death

common portals of exit

respiratory, GI, GU, skin, blood and tissue

5 rights of delegation

right task right circumstance right person right directions and communication right supervision and evaluation

physiological needs

those relating to the basic biological necessities of life: food, drink, rest, and shelter

primary health care

treatment of common health problems

secondary health care

treatment of problems requiring more specialized clinical expertise ex specialists like cardiologist