NurseLogic 2.0 Nursing Concepts Beginning Test
A nurse is working with the information technology department of the the facility to establish protocol regarding security mechanisms that will protect the electronic health records of clients period which of the following could result in a violation
Ability of staff to access electronic health records of clients throughout the facility The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?
Acupuncture has been proven to reduce pain and increase function Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client.
A nurse is caring for a client who has cancer. The client has decided to stop treatment and request a referral to hospice. They making the referral as requested the nurses illustrating which type of ethical principles?
Autonomy Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustration by making the referral as requested The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. - Justice is the use of fairness, which is not the ethical principle the nurse is illustrating by making the referral as requested. Examples of justice in nursing practice includes advocating for fair distribution of resources or providing all clients with the same level of care regardless of his or her level of health benefits. - Veracity is the act of truth-telling. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of veracity in nursing practice includes telling a client of his terminal diagnosis when he asks, even if it goes against the wishes of the family. - Fidelity is the act of keeping promises. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of fidelity includes following through on a promise to return with pain medication in a specified period of time
A nurse is caring for an older adult who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states that keep seeing commercials on TV for Celebrex and want to try it period upon review of scientific evidence the nurse should inform the client which of the following?
Celecoxib is contraindicated in clients with allergy to sulfonamides Celecoxib (Celebrex) is a non-steroidal anti-inflammatory, cyxlooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors of the client indicates that teaching has been effective?
Demonstrating independent performance of the procedure Return demonstration is the best evaluation tool for psycho-motor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.
A nurse in a local Clinic is caring for a female client who is 35 years old. Which of the following screening should the nurse recommend to the client?
Dermatologist evaluation every three years to detect skin cancer Men and women between the ages of 20 and 40 should have skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. - A mammogram every year is not an appropriate screening to recommend to a 35-year-old client. Women ages 40 or older should have annual mammograms. - A colonoscopy every 10 years is not an appropriate screening to recommend to a 35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10 years. - A complete eye examination every year is not an appropriate screening to recommend to a 35-year-old client. Clients ages 40 or below should have a complete eye examination every 3 to 5 years. Clients between the ages of 40 and 64 should have a complete eye examination every 2 years, and clients older than 65 should have a complete eye examination annually.
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action?
Determine the client's condition The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. ~Other answers (not most correct answer): - Complete an Incident Report: This is not the first action the nurse should take when discovering a medication error. While creating an incident report is important and should typically occur within 24 hr of the incident, there is another action that better ensures the safety of the client. - Inform the Nurse Manager & Notify the Provider
A nurse is caring for a client following a Bronchoscopy . Which of the following findings requires immediate intervention?
Difficulty breathing This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. ~ other answer (wrong/not most right) rationales: - This finding may require intervention if it doesn't resolve within a specified time frame; however, it does not require immediate intervention. Blood-tinged mucous and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted - This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea. - This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure. When the reflex returns, the client may experience some discomfort and difficulty when swallowing.
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?
Having the client use eye blinks to indicate yes or no This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires a nurse preceptor to intervene?
Including in a client notes that an incident report was completed after a medication error When an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record. - The nurse should draw a horizontal line through blank spaces in the nurses' notes to prevent incorrect information being added by another individual. - The nurse should not chart vital signs taken by another nurse. The vital signs might not be accurate and the nurse is accountable for the information she documents - The nurse should document when a provider is contacted to clarify a questionable prescription because the nurse is legally responsible, and liable, for carrying out the prescription.
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include
Initial HIV symptoms are often similar to the flu HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client becomes symptomatic and has a severely compromised immune system The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include.
A nurse on the coronary care unit is caring for a client who was transferred from the medical for from experience of myocardial infraction. After the client is stabilized she asked why she had been transferred where her family is unable to visit. What is the appropriate response?
Lets talk for a minute about your concerns Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication
A nurse in a provider's office is orientating a newly licensed nurse on how to position a client in a vaginal examination. The nurse include in the teaching to place a client in which following position?
Lithotomy The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is the appropriate position for the nurse to place the client. ~ other answer (wrong/not most right) rationales: - The dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck, lungs, breasts, axillae, heart, and abdomen. - The prone position is used to assess hip joint extension, skin, and buttocks. - The lateral recumbent position is used to detect heart murmurs when assessing the heart.
Hunter's is caring for a client who is diagnosed with active pulmonary tuberculosis is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client acetate the discontinuation of ethambutol?
Loss of color discrimination The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. ~ other answer (wrong/not most right) rationales: - Ethambutol is well absorbed from the GI tract in either the presence or absence of food. Adverse GI effects are not common. -
A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration which of the following findings requires immediate intervention
Potassium 2.5 mEq/L A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmia's or cardiac arrest. Because this level is life threatening, it is the priority at this time. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention. ~Other answers (not most correct answer): - Blood Glucose 150 mg/dL: This finding does not require immediate intervention. While this blood glucose level is above the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. - Total Protein 5.2 g/dL: This finding does not require immediate intervention. While this total protein level is below the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. - Urine Specific Gravity 1.040: While this urine specific gravity is above the expected reference range, it will not cause life-threatening complications. A natural mechanism of the body is to conserve urine when fluids are being lost in other places. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregiver. Which of the following should be the nurse's priority goal?
Protect the client from further abuse The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.
A nurse is caring for a client who has nausea and prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule?
Set ampule on a flat surface to withdraw the promethazine To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is appropriate. ~ other answer (wrong/not most right) rationales: - The ampule should be broken away from the body to prevent injury from the shattering glass. - Expelling air bubbles back into the ampule creates pressure in the ampule, which forces the medication out, wasting it. Air bubbles should be expelled by removing the needle from the ampule and tapping the side of the syringe, then pulling back on the plunger, and finally pushing the plunger up gently to remove the air. - A filter needle should be used to withdraw the medication from the ampule, but should be replaced with a regular needle before administering the medication to the client.
A nurse is caring for a client who has a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professional should attend the clients next interdisciplinary team meeting to address this complication?
Speech pathologist A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting address difficulty swallowing in a client who has had a CVA
A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. Which of the following responses by the client should the nurse postpone the teaching?
States that pain is an 8 on a scale of 0 to 10 Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. ~ other answer (wrong/not most right) rationales: - states that partner should be given the information: - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client believes that learning how to deep breathe and cough is the responsibility of her partner should indicate to the nurse that additional teaching is needed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications and can be uncomfortable. The fact that the client is expressing concern about the exercises causing pain when performed after surgery should indicate to the nurse the need for additional explanation, such as mechanisms that will be used to control the pain. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client is expressing uncertainty about the benefits of the exercises should indicate to the nurse that reinforcing the importance of the exercises, and a description of possible negative outcomes, should be discussed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching
A nurse is reinforcing teaching about trans dermal nitroglycerin (Nitro-Dur) to a client who is stable angina. Which of the following indicates teaching has been effective?
The patch should be effective within one hour of being applied Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.