NUR2220 Exam 1

Which element is least likely to be a characteristic of an expected outcome of a nursing intervention? A) Measurable B) Realistic C) Behavior-centered D) Nurse-centered

D) Nurse-centered

The following nursing diagnoses are formulated with a client: constipation, acute pain, and caregiver role strain. During the planning phase of the nursing process, the nurse will prioritize the diagnoses in what order? A) Acute pain, constipation, caregiver role strain B) Constipation, acute pain, caregiver role strain C) Caregiver role strain, acute pain, constipation D) Caregiver role strain, constipation, acute pain

A) Acute pain, constipation, caregiver role strain

The nurse obtains a client's oral temperature reading of 36.8°C. How should the nurse proceed? A) Document the client's temperature result as obtained. B) Retake the client's temperature to make sure the measurement is accurate. C) Turn the heat up in the client's room. D) Notify the physician to obtain orders for an antipyretic medication.

A) Document the client's temperature result as obtained.

A community health nurse is helping develop teaching on the role of the community health nurse and how this discipline can help the community. What does the nurse describe as a key component of community-based care? A) Improving quality of life B) Improving hospital compliance C) Improving hospital payer reimbursement D) Improving quality improvement

A) Improving quality of life

A client is being treated for injuries resulting from a skateboarding accident and is very agitated as the nurse cleans several gashes on the client's head. Which of the nursing responsibilities outlined by the American Nurses Association is the nurse fulfilling? A) administering medications, wound care, and numerous other personal interventions B) Interpreting patient information and making critical decisions about needed actions C) providing health promotion, counseling, and education D) performing physical exams and health histories

A) administering medications, wound care, and numerous other personal interventions

A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document? A) advance directive B) consent form C) durable power of attorney D) do-not-resuscitate order

A) advance directive

A nurse is employed by a community organization engaged in health promotion. In this role, the nurse teaches clients steps they can take toward achieving wellness. The nurse would explain "wellness" to a client as: A) an ongoing and intentional effort to achieve the highest potential for total well-being. B) the absence of disease. C) a state of complete physical, mental, and social well-being. D) viewing one's health in terms of a balance of body, mind, and spirit, which means being open to alternative treatment options.

A) an ongoing and intentional effort to achieve the highest potential for total well-being.

Which tools do case managers commonly rely on to plan and coordinate client care? A) clinical pathways, practice guidelines, and standards of care B) clinical pathways and drug formularies C) standards of care, HIPAA regulations, and electronic medical records D) practice guidelines, outcome data, and staff rosters

A) clinical pathways, practice guidelines, and standards of care

The fifth step of the nursing process is evaluation. As part of this step, the nurse: A) compares actual client outcomes to the expected outcomes. B) sets priorities and defines expected outcomes. C) observes and documents the client's health status. D) carries out the written plan of care and monitors the client's status.

A) compares actual client outcomes to the expected outcomes.

Several times, family members have asked a nurse to share personal prescriptions when they were in need of pain medication or antibiotics. Which type of rules or standards should govern the nurse's moral decision? A) ethics B) administrative law C) common law D) civil law

A) ethics

Which of the following is involved in the implementation step of the nursing process? A) Selecting nursing interventions B) Documenting nursing care and client responses C) Documenting the plan of care D) Identifying measurable outcomes

B) Documenting nursing care and client responses

A nurse working in the community is involved in secondary prevention. Which activity would most likely apply? A) Teaching about a nutritious diet B) Health screening for diabetes risk C) Assisting with bowel retraining D) Providing rehabilitation exercises

B) Health screening for diabetes risk

Which setting has been the traditional site for the nursing work force? A) Industrial environments B) Inpatient units C) Same-day surgery units D) Clinics

B) Inpatient units

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement? A) Assessment B) Planning C) Implementation D) Evaluation

B) Planning

A home care nurse is planning to visit a 60-year-old client diagnosed with heart failure for the first time. Which of the following would be most appropriate for the nurse to do? A) Contact the client to say that the nurse is coming out to visit. B) Telephone the client to obtain permission to visit. C) Ask the client if he lives alone or with someone else. D) Obtain information about the client's health insurance.

B) Telephone the client to obtain permission to visit.

A nurse acts as preceptor to a student nurse who is performing discharge planning for a client. What statement made by the student nurse about discharge planning indicates that the student needs additional teaching? A) "Discharge planning involves a multidisciplinary team." B) "Discharge planning involves the client." C) "Discharge planning occurs when the patient is discharged." D) "Discharge planning begins once the client is on the unit."

C) "Discharge planning occurs when the patient is discharged."

Which communication technique is helpful in health teaching about relevant aspects of a client's well-being and self-care? A) Silence B) Reflection C) Informing D) Humor

C) Informing

A client had a total hip replacement earlier in the day. The nurse sits with the client to establish some goals. One goal they agree on is to ambulate 1 to 2 miles each day. This is an example of which type of goal? A) Immediate B) Intermediate C) Long-term D) Independent

C) Long-term

The hospital is having a problem with healthcare-associated infections. A committee has been established to study the problem and make recommendations. The nurse working on the committee knows that this work addresses what? A) Inpatient quality indicators B) Prevention quality indicators C) National Patient Safety Goals D) Patient safety indicators

C) National Patient Safety Goals

How should the registered nurse be responsive to the changing health care needs of society? A) Focus care on the traditional disease-oriented approach to patient care, because hospitalized patients today are more acutely ill than they were 10 years ago. B) Learn how to delegate discharge planning to ancillary personnel so that registered nurses can spend their time managing the "high-tech" equipment needed for patient care. C) Place increasing emphasis on wellness, health promotion, and self-care, because the majority of Americans today suffer from chronic debilitative illness. D) Stress the curative aspects of illness, especially the acute, infectious disease processes

C) Place increasing emphasis on wellness, health promotion, and self-care, because the majority of Americans today suffer from chronic debilitative illness.

According to the American Nurses Association (1995), the advanced practice registered nurse is distinguished from other registered nurses according to scope of practice. Select the activity that would distinguish the advanced practice nurse from other RNs. A)Interprets health care provider orders B) Develops nursing care plans C) Prescribes medications D) Reports abnormal test results

C) Prescribes medications

Nursing students are reviewing the roles that a nurse may assume. The students demonstrate understanding of the information when they identify which of the following as characteristic of the research role? A) Achieving patient outcomes through direct intervention B) Assuming responsibility for unlicensed assistive personnel C) Replicating findings to further the science of nursing D) Promoting health through screening and early detection

C) Replicating findings to further the science of nursing

The nurse is caring for a patient who is to be discharged from the acute care facility to a rehabilitation unit after having a stroke. What type of prevention is this considered to be? A) Primary B) Secondary C) Tertiary D) Rehabilitation

C) Tertiary

A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow's theories on human needs, what is the reason the client refuses to participate in activities? A) The client needs to increase feelings of positive self-esteem. B) The client eats the meals served in the room. C) The client likes to go to have a nap in afternoon and go to bed early in the evening. D) The client is adjusting to sharing a bathroom and feels in control with bowel elimination.

C) The client likes to go to have a nap in afternoon and go to bed early in the evening.

A client with newly diagnosed diabetes requests information about how to give an injection. What is the best communication technique the nurse can use with the client? A) providing a URL for a website that demonstrates proper injection technique B) demonstrating the proper injection technique C) informing about the proper injection technique D) reflecting the client's feelings about his question

C) informing about the proper injection technique

A home care nurse is visiting a new client and notes that the client's home is very messy. There are dirty dishes piled everywhere, the house smells of garbage, and there are very few surfaces that are clean. How should the nurse respond? A) Stand at the door and assess the client. B) Ask the client nicely to clean the home prior to another visit. C) Leave the home and call adult protective services. D) Enter the home and continue to treat the client.

D) Enter the home and continue to treat the client.

A group of nursing students are reviewing the various types of advanced practice nurses. The students demonstrate the need for additional review when they identify which of the following as an advanced practice nurse? A) Certified nurse midwife B) Nurse practitioner C) Clinical nurse specialist D) Nurse manager

D) Nurse manager