Select all that apply

The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately?

. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan

Nursing students are researching how cultural practices affect the dying process of terminal cancer clients. For their research, which theory will the students most likely explore?

. Critical theory

The nurse has two older parents who were recently hospitalized at the same time and are being discharged home on the same day. What should the nurse do to ensure these family members receive the highest quality of care in the home?

. Determine if custodial support is needed for the parents. 5. Find out when the home care nurse is scheduled to arrive.

A client asks what is done to keep computerized personal health information confidential. How should the nurse respond?

. Information in our system requires a password to retrieve.

The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code?

. It serves as a standard for professional actions.

The nurse has accepted a position as a case manager. What should the nurse expect to perform when functioning in this role?

. Managing a clients hospital stay

The nurse is reviewing the Healthy People 2020 primary goals. Which plan should the nurse realize is in alignment with one of the goals?

. Opening a wellness clinic

While caring for a client of a different culture, the nurse becomes disturbed when the clients spouse makes all the decisions about care and treatments. What behavior is this nurse demonstrating?

. Opinion

The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next?

. Plan

During a home visit, the client with terminal cancer undergoes respiratory arrest. The client has agreed to a DNR (do not resuscitate) order; however, the spouse tells the nurse to call 911. What action should the nurse take?

. Remind the spouse of the clients desires.

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention?

1. 60 to 90 degrees during feeding times

The nurse is taking a tour of a home care agency as part of the interview process. Which services should the nurse recognize as being provided through this health agency?

1. A case manager arranging services to meet the clients need for physical therapy after a fall 3. A durable supply company delivering a wheelchair to a client with spina bifida 4. A nurse assessing the feet of a homebound diabetic client

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence?

1. A root cause analysis 2. Paperwork about a sentinel event

The nurse is explaining the definition of being a nurse to a new nursing assistant. Which themes should the nurse include when talking with the assistant?

1. Adaptive 2. Client-centered 5. An art 6. A science

A multi-organization medical system is designing a community-based facility to support the health care needs of members who live in an urban area. What should the medical system keep in mind when designing the new facility?

1. Affordable 2. Easy to travel to the facility 4. Many services available to meet community members needs 5. Communication of care needs to the community members other health care providers

A nurse educator believes computers can enhance student learning. Which actions should the instructor take to demonstrate this belief?

1. Allow students to research a nursing topic either by going to the library or via an online literature search. 2. Require a student to remediate after a failed test by completing appropriate computer-assisted instruction modules. 3. Use PowerPoint slides to reinforce complex concepts during classroom lectures. 4. Assign a collaborative group project to students enrolled in an online course.

The nurse is providing care to an assigned client. Which action indicates that the nurse supports the clients respect for dignity?

1. Allowing the client to complete hygienic care when possible

The ANAs proposal for entry level for professional practice initiated debate among nurses. Which nurse would be at greatest risk if the ANA proposal were implemented?

1. An RN with an associate degree who has a head nurse position

The nurse is planning to apply to graduate school to earn a masters degree in nursing. On what should the nurse expect the programs curriculum to focus?

1. An advanced leadership role

Several nurses at the county health department are involved in planning community health. In order to create a plan that will be acceptable to members of the community, who else should be involved in this venture?

1. As many people from the community as possible

A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. What should the nurse do to relate the intervention to the outcome?

1. Ask how many times per day the client practiced the coughing and deep breathing exercises.

The nurse using evidence-based practice to guide care has identified a study in which the findings would be appropriate to address a clients health care need. What actions should the nurse take before implementing these findings?

1. Ask the client if the findings can be used. 3. Examine how the findings fit with the clients health needs. 4. Determine if resources are available to implement the findings. 5. Identify organization policies to support or address the findings.

On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take?

1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

1. Assessment

The nurse educator is considering ways to impact the learning of students through the use of computer technology. Which actions should the educator take to achieve this goal?

1. Assign distance learners to conduct a research study of current evidence-based articles on caring for the diabetic client. 3. Require a clinical group to make daily reflective entries in an online journal. 5. Encourage the learners to access online NCLEX review questions as a way to assess their classroom learning.

The nurse wants to search for articles having to do with a client care problem. Which database should the nurse use to find this information?

1. CINAHL

The home health nurse has scheduled a visit to a client who lives in a neighborhood that is known to be unsafe because of gang activity. Before going to the clients home, what should the nurse do?

1. Call for an escort.

The nurse ensures that a patient is covered during a bath. In which nursing role is the nurse functioning?

1. Caregiver

When providing client care the nurse demonstrates practices that are designed to provide legal protections from liability. Which actions is the nurse demonstrating?

1. Checking the clients name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 5. Reviewing the five rights of medication administration when the client states, This doesnt look like my usual pill

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

1. Client will ambulate without a walker by 6 weeks.

The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. Which individual should the nurse include in this clients plan?

1. Clients spouse

Several nurses are working with other health care providers to provide care for a group of community members who have complications of diabetes mellitus and require extensive dressing changes and comprehensive education. In what capacity are the nurses and care providers working?

1. Collaboration

The nurse is explaining the difference between community and population to a group of community members. What should the nurse use as an example for population?

1. Commuters on the subway

The nurse needs to complete mandatory continuing education on client safety as part of a regulatory requirement for the hospital. Which computerized approach should the nurse consider to complete this required education?

1. Complete a computerized tutorial on client safety

The nurse is participating in the development of a research study. What elements of the computer should the nurse ensure are in place before the study begins?

1. Computer speed adequate 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs

The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client?

1. Congruent with the clients values, beliefs, and culture 2. Are within established standards of care 4. Achievable with the resources available 5. Must be safe and appropriate for the clients age

The admitting nurse explains the process of signing forms to allow for the clients insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. Which type of law did the nurse explain to the client?

1. Contract law

A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise?

1. Deductive reasoning

The nurse is reviewing the nursing process with a firstyear nursing student. What should the nurse explain as being the purpose of the diagnosis phase?

1. Develop a list of problems. 2. Identify client strengths. 5. Identify problems that can be prevented.

The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment?

1. Discuss codes of ethics with the students. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences.

Nursing students have been studying the stability model of nurse theorists. What phrases or terms should the students use to describe this model?

1. Dominant 2. Systems framework 3. Stress/adaptation framework 6. Callista Roys theory

The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process?

1. Effectively assessing the clients needs 2. Selecting the appropriate nursing diagnosis related to the clients needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes

A registered nurse is supervising several LPNs who provide patient care. Which responsibility should the registered nurse expect to complete?

1. Evaluating the care provided to the client

A client woke in the middle of the night, confused and unaware of the surroundings. Although the call light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell. Which element of malpractice should the clients attorney realize is missing in this case?

1. Foreseeability

The nurse is hired to provide care in a hospital that offers services in all specialty areas. How should the nurse categorize this type of health care facility?

1. General hospital

A client in the hospital is concerned about the cost of receiving hospitalized care. What should the nurse realize is causing the increase in the clients medical expenses?

1. Health care of the older adult 2. Number of uninsured population 4. Cost of prescription drugs 5. State of inflation 6. Amount of diagnosed chronic illnesses

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client?

1. Hello, Im your nurse and Ill be taking care of you today.

The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client?

1. Help the client look for available community resources that may be of assistance.

The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use?

1. How would you describe your sleep pattern?

The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective?

1. I can look up interventions according to the nursing diagnosis that Ive selected. 3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions. 5. I find NIC interventions a really good place to start when Im working on client interventions.

The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent?

1. I wont lie to you. It may be easier for you if you step out until we get the line in.

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase?

1. Im going to set up your physical assessment now. Do you have any questions?

Parents ask why invasive diagnostic tests were prescribed for their ill child. The nurse has just gotten out of report and has not had a chance to review additional information. What should the nurse respond to the parents?

1. Im not sure I can answer your question just now.

The nurse is using the central concepts of nursing when providing client care. What actions is this nurse performing?

1. Including a clients family in discussions regarding the clients discharge health needs 2. Assessing a physically dependent clients spouse for indications of caregiver stress 3. Asking clients to define what healthy and well means to them 5. Advocating for a client who is not responding to current pain control treatment

The nurse implements a quicker way to set up and initiate an intravenous infusion while still following safe practice. Which attitude of critical thinking is this nurse practicing?

1. Independence

The nurse desires to improve critical thinking skills when providing client care. On which attributes should the nurse focus when developing these skills?

1. Independence 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance

The nurse is reviewing the principles of the Affordable Care Act with a client. What information should the nurse include when discussing the act with the client?

1. Individuals will be fined if they do not have health insurance. 2. Employers must offer health insurance if they meet identified requirements. 3. Insurance can be purchased through exchanges. 4. Individuals with preexisting health conditions cannot be denied health insurance coverage.

The nurse is reviewing a clients plan of care. Which statements indicate that this care plan has been completed accurately and appropriately?

1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms.

A nurse educator has always believed that lectures with focused outlines are the best way to present theory content in class. A colleague, who teaches the same group of students, but a different subject, utilizes group work and in-class activities to teach difficult content and finds that students perform as well, or better, on their tests. The first educator in this situation is starting to rethink her position. What behavior is the first educator demonstrating?

1. Integrity

The nurse researcher is determining the best way to formulate a research problem. What should the nurse identify if implementing the PICO format?

1. Intervention to use 2. Problem of interest 3. Comparison of treatments 4. Outcome of the treatments

Grounding nursing research in theories from other disciplines is argued to be undesirable by some scholars. What should the nurse identify as reasons why grounding theory is not desired?

1. It detracts from developing nursing as a separate discipline. 2. It makes nursing less relevant. 5. Other disciplines get the benefit of nursings research.

The nurse is interested in specializing in forensics. What should the nurse expect to learn prior to assuming the role of a forensics nurse?

1. Knowledge about the legal system 2. Approaches to collecting evidence 4. Information necessary when providing testimony in court 5. Training in identification, evaluation, and documentation of injuries

After completing an initial assessment, the nurse identifies teaching that the client will need. Why did the nurse identify learning needs for this client?

1. Lack of knowledge related to health conditions and self-care

During a home visit, the nurse is concerned that a client recovering from hip replacement surgery is at risk for falling in the home. What information from the home assessment did the nurse use to come to this conclusion?

1. Laminated floors highly polished 2. Scatter rugs in the kitchen and bathroom

When completing a community assessment, the community health nurse will take several aspects into account. What is the first stage of this assessment that the nurse will complete?

1. Learn about the people in the community.

The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical thinker. What did the manager observe the nurse perform?

1. Listening with empathy to a client who recently has been diagnosed. 3. Questioning a medication order that does not appear to meet the clients needs for pain management. 4. Exhibiting a willingness to try alternate methods of addressing a clients care needs. 5. Practicing nursing in a culturally competent fashion.

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines?

1. Looking directly at the client to ensure good eye contact 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position

A nurse is working in a clinic that emphasizes cost control, customer satisfaction, health promotion, and preventive services. In which type of health system is this nurse providing care?

1. Managed care

The staff nurse is considering membership in the National League for Nurses. What should the nurse expect as a member of this organization?

1. Members that are non-nurses

The nurse is scheduled to attend a continuing education program to learn about the latest urinary catheterization care. Which type of credential should the nurse expect to earn after attending this program?

1. None because this program is designed to enhance a skill

The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses?

1. Nonjudgmental statements 3. Must be legally advisable 4. Cause/effect correctly stated 6. Diagnosis worded specifically and precisely

A nursing units records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records?

1. Nursing audit

The nursing instructor is explaining the present economic challenges in health care to students in a community health course. What should the instructor emphasize as being important for the students to be aware of?

1. Passage of the Affordable Care Act

During a clinical conference, a staff nurse states that critical thinking is essential when providing client care. What additional statements should this nurse make to support the use of critical thinking?

1. Patient acuity is so much greater than it was even 10 years ago. 2. Care delivery systems are only as good as the nurses delivering care. 4. With health care being so expensive, nursing has to take on responsibility to keep the costs controlled. 5. My practice involves caring for clients who require care that didnt even exist when I went to school.

A client being discharged needs physical therapy for progressive ambulation, wound care to treat a postoperative wound, and assistance with the payment of hospital bills. Before the nurse contacts a home care agency, who should write the order for the client to receive home care?

1. Physician

A client is experiencing metabolic acidosis, a condition that involves the bodys pH level, carbon dioxide level, and bicarbonate balance. According to Roys model, to which mode should the nurse realize that this client is responding?

1. Physiologic

In order to comply with the U.S. Department of Health and Human Services most current health care goals as stated in Healthy People 2020, what should the nurse do?

1. Plan a depression screening for senior citizens who regularly have lunch at the senior center. 3. Advocate for psychiatric health care for those with no private insurance coverage. 4. Organize a park cleanup day to assure that the communitys children have a safe place to play. 5. Counsel older clients regarding programs available to assist them to live in their homes independently.

The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans?

1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment.

The clinical nursing instructor determines that a nursing student understands the legal responsibilities to clients when providing care. What did the instructor observe to come to this conclusion?

1. Prepared to discuss the clients medical diagnosis in pre-conference 2. Overheard stating, My care is held to the same standards as that of the unit nurses 5. Asks for help with a dressing change involving techniques he or she has not yet performed alone

A seasoned RN is especially competent in knowledge of the computerized charting system in a facility and is able to assume the team leader role on a regular basis. In which type of care delivery system is this nurse most likely providing care?

1. Primary nursing

The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble?

1. Promote health. 2. Restore health. 5. Prevent illness. 6. Alleviate suffering.

After implementing interventions and reassessing the clients response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process?

1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments

A seasoned nurse uses past experiences and knowledge gained from previous care situations to care for a client with complex health issues. Which attribute of critical thinking is this nurse practicing?

1. Reflection

The nurse manager is concerned that a staff nurses care demonstrates gross negligence. What actions did the manager use to make this determination?

1. Removed a clients central line 2. Reconnected contaminated intravenous tubing to a client 4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom 5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel

A nurse on the unit notices that a co-worker exhibits a pattern of behavior suggestive of drug abuse. What should the nurse do?

1. Report the situation to the unit charge nurse.

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database?

1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 4. A list of current medications 5. Information about the clients cultural preferences

Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?

1. Retake the vital signs.

The nurse is preparing to complete a spiritual assessment with a client. Which theorist should the nurse review before completing this assessment?

1. Roy

The nurse is evaluating the results of a study prior to implementing its findings into practice. Which action should the nurse take when scientifically validating the research results?

1. Scrutinizing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its findings

While working a scheduled shift the nurse focuses on actions to protect the privacy of a client with local notoriety. What actions should the nurse take at this time?

1. Secure the clients medical record. 3. Remove the clients name from the door. 5. Fax the clients lab values with a cover sheet.

A nurse researcher is considering the use of various nonpharmacological distraction techniques that have shown success for behavior control in troubled adolescents. Which criteria is this researcher considering to use?

1. Significance

A nurse researcher is exploring and formulating research problems. Which criteria should the nurse researcher consider in this process?

1. Significance 3. Researchability 5. Feasibility 6. Interest to the researcher

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do?

1. Sit next to the client, a few feet apart.

The community health nurse is identifying approaches to support a communitys health care needs. Which programs should the nurse select to support community-based health care?

1. Smoking cessation classes 2. Personal safety classes for women 3. Blood pressure measurement clinic

The spouse of a client referred to hospice care asks why the client needs the change in services. How should the nurse respond to this question?

1. So we can see if theres any way to improve your spouses life.

The high school graduate desiring to attend nursing school reviews the schools for accreditation. Which regulatory bodys actions is the student analyzing?

1. State board of nursing

After the data have been analyzed, the nurse realizes that the probability has a value of less than .05. What should this finding indicate to the nurse?

1. Statistically significant

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information?

1. Strengths can be an aid to mobilizing health and the healing process.

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client?

1. Syndrome diagnosis

A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated?

1. Technical

A 20-year-old client with Down syndrome is diagnosed with an illness. Even though the client is able to live in an assisted environment and work part-time for a local bookstore, the parents of the client are adamant about not initiating a course of treatment whose side effects are unknown with Down syndrome clients. According to the nursing code of ethics, to whom is the nurses first loyalty?

1. The client

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis?

1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 5. The clients clothes are soiled. 6. The client has obvious body odor.

A client wishes to discontinue cancer treatment. If acting as the client advocate, which statement should the nurse make to the clients physician?

1. The client is making his own decision.

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis?

1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses?

1. The ones that the nurse is licensed to treat

While a nurse is conducting a health assessment, the individual asks why the term patient is being used. What should the nurse explain about the implication of the term patient?

1. The person is seeking assistance because of illness.

An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent?

1. The physician should have the clients wife sign the consent form.

A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning?

1. This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make.

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis?

1. Unfamiliarity of disease process

The staff nurse is helping a new graduate understand the relationship between care concepts and planned interventions. What value would it be for the staff nurse to encourage the new graduate to use a concept map?

1. Used to highlight key areas 2. Provides a visual representation 3. Can be quicker than taking notes 5. Aids in developing critical thinking

The nurse is beginning a physical assessment of a client who is freelance computer information technologist. On which areas should the nurse place particular emphasis during this assessment?

1. Vision 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms

The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique?

1. What makes you think cramming for a test is an ineffective way to study?

The nurse is reviewing sources of federal funding for health care services provided to clients. For which clients should the nurse recognize as most likely having health care paid through a federal funding source?

2. 72-year-old retired schoolteacher 4. 29-year-old mentally challenged sheltered workshop employee

A nurse has agreed to delay a clients treatment until the matriarch of the family can be present. Understanding that this is an important consideration for this clients cultural practices, which of Leiningers intervention modes is the nurse implementing?

2. Accommodation, negotiation

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client?

2. Administer pain medication.

The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement and enforce the nurse practice act regulations?

2. Administrative law

A client who has been the recipient of home health care has made the decision to discontinue hemodialysis. The client understands all the consequences of this decision and is not supported by his family. The nurse is meeting with the family to help them understand the significance of the clients decision and to help them support the client during this difficult time. In which role is the nurse functioning?

2. Advocate

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview?

2. After the client has settled in and been oriented to the room

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system?

2. Age 3. Time 4. Health status 6. Location

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention?

2. Ambulate with client, using a gait belt, twice daily for 15 minutes.

The nurse notes that assessment data indicate a change in a clients condition. What should the nurse ask before changing this clients plan of care?

2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan?

The nurse is implementing Watsons Assumptions of Caring philosophy. Which actions demonstrate that the nurse is using this philosophy?

2. Asking clients when they prefer to be given the opportunity to bathe 3. Feeling empathy toward the clients loss of mobility as a result of a fractured hip 5. Arranging to fulfill a clients request to stay with him during a painful diagnostic test

According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client?

2. Assist the client in finding an alternative plan for the achieving the therapys outcomes.

The nurse is planning interventions for a client based upon Hendersons fundamental needs. Which interventions should the nurse include in the plan of care?

2. Attend to spiritual needs as desired. 3. Wear clothing suitable for the weather. 4. Bathe and keep the body well-groomed.

A high school graduate is considering entering a nursing program that offers a baccalaureate degree. What organization accreditation should the nurse use to help select a nursing program?

2. CCNE (Commission on Collegiate Nursing Education)

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do?

2. Call the pharmacy and do further investigating before administering the medication.

A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered by the physician. Which action demonstrates the nurses respect for the clients autonomy?

2. Calling the physician for further orders

The nurse is consulting other professionals as well as educating, supporting, and managing a clients chemotherapy regimen. In which role is this nurse functioning?

2. Clinical nurse specialist

While listening to a client describe current symptoms, the nurse considers the clients entire situation. Which attribute of critical thinking is the nurse practicing?

2. Context

The nurse is teaching health and wellness principles to junior high students. According to Orems theory, which category of self-care requisite is the nurse using to guide this teaching?

2. Developmental

The nurse enrolled in graduate courses is able to continue studies while visiting abroad. What has this nurses nursing school implemented to make this possible?

2. Distance learning

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?

2. Document that the problem has been resolved and discontinue the care for the problem.

The nurse is providing care to a group of clients. For which situation would the nurses use of critical thinking be a priority?

2. Educating a home health client about treatment options

The student nurse is reviewing the code of ethics prior to beginning a clinical assignment. On what areas should the nurse focus when providing client care?

2. Ensure the safety of all clients. 3. Maintain client confidentiality. 4. Provide care in a professional manner.

The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff?

2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time

A nurse educator is explaining primary health care (PHC) and the extension of its boundaries beyond traditional health care services to a group of community members. What issues related to PHC should the nurse include in this discussion?

2. Environment, agriculture, and housing

The nurse researcher is testing the effects of a new dressing preparation on certain participants, while continuing to use older but more familiar products on others. Which type of research design is the nurse using?

2. Experimental

After completing a health history the nurse reviews the content to determine metaparadigms that contribute to the clients health. Which metaparadigm should the nurse categorize as being a part of the clients environment?

2. Family 3. Friends 5. Significant others

After completing a health history the nurse reviews the content to determine metaparadigms that contribute to the clients health. Which metaparadigm should the nurse categorize as being a part of the clients environment?

2. Family 3. Friends 5. Significant others

The nurse case managers office is in a cluster of offices that share a fax machine. Which action by the nurse ensures that HIPAA requirements are met?

2. Have sending agencies call ahead before any information is sent.

Nursing staff members from an acute psychiatric unit have been asked to establish a nurse theorist they can easily identify with in their practice. Understanding the importance of developing a therapeutic relationship between themselves and their clients, especially in this unit, to which theorist would they most likely be drawn?

2. Hildegard Peplau

A nurse educator incorporates stress, power, authority, and personal space along with other concepts and considers these concepts essential knowledge for use by nurses. From which theorist is the educator applying principles into the curriculum?

2. Imogene King

A client complaining of extreme low back pain is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse suspects that the blood pressure and heart rate will be elevated. What thought process did the nurse use to come to this conclusion?

2. Inference

The nurse who just moved from an urban area to a sparsely populated rural area understands that certain customs and practices the nurse follows may be quite foreign to the people in the new area. Which attitude of critical thinking is the nurse demonstrating?

2. Insight into egocentricity

A large community clinic provides health education, illness prevention, acute care, screening, and rehabilitation and health promotion services for the chronically ill. What should the community health nurse identify this approach to health care as being?

2. Integrated health care system

A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the clients scheduled procedure; and documented the situation in the clients medical record. What did this nurse demonstrate?

2. Integrity

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients?

2. Interpersonal

A clinical instructor senses that a student has been struggling with clinical skills learned in lab. To combat this, the educator pairs the student with a staff nurse who has clients with a variety of treatments and cares. Which type of problem solving is the instructor using?

2. Intuition

The nurse enters the room of a critically ill child after sensing that something isnt right. Once the nurse determines the child is stable, the nurse continues to perform a check of all the lines and equipment in the room and finds that the last IV solution hung by the previous nurse was not the correct solution. Which problemsolving method did this nurse use?

2. Intuition

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do?

2. Investigate whether the best nursing interventions were selected.

The nurse has been asked to participate on the hospitals Shared Governance Committee. To which nurse leader should the nurse attribute the ability for nurses to control the profession?

2. Lavinia Dock

A hospice nurse has been working closely with a client who, on several occasions, has asked about guidance and support in ending her life. What information should the nurse use when making an ethical and moral decision about this clients request?

2. Legal issues are not the same as moral or ethical ones.

Several nurses are looking for an agency to sponsor a program that would meet the needs of a community group lacking in health promotion education. Which agency should the nurse approach to fill this need?

2. Local health department

A nurse has implemented the use of noncontact therapeutic touch. Which theorist is the nurse using as a basis for this intervention?

2. Martha Rogers

The nurse is reviewing changes occurring within the health care industry. What should the nurse identify as factors that have an effect on health care delivery?

2. More knowledgeable consumers 3. Increase in the number of elderly 5. Technological advances 6. Economics

The nurse notes that a client has the outcome goal Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which client statement should the nurse use to evaluate this goal?

2. My pain is a 4.

The nurse educator develops the research question Do students who study in groups score better on the NCLEX exam when compared to students who study independently? Which phrase should the educator identify as the dependent variable?

2. NCLEX scores of both groups

The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a clients health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse?

2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the health care provider to clarify a confusing prescription for a clients pain

A client has been receiving home care for several weeks. Which individual should the nurse realize is responsible for ensuring that the client is receiving care at the appropriate times and in the appropriate amounts?

2. Nurse

A home health client has a complicated case involving occupational therapy, respiratory therapy, a dietitian, the nurse, and a nurses aide who provides assistance with bathing, housekeeping, and grocery shopping. Which care provider should be prepared to coordinate this clients care?

2. Nurse

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client?

2. Pain related to unknown etiology

A home health nurse has a weekly visit to a client living in less than desirable cleanliness. The client has a central venous access device and requires weekly infusion therapy. What is the best way for the nurse to protect the client against infection?

2. Practice strict aseptic technique during the infusion process.

A group of nursing students is helping to set up an immunization clinic. In which level of prevention are these students functioning?

2. Primary

The nurse is caring for several acutely ill patients. What nursing action demonstrates professional autonomy?

2. Prioritizing client according to client needs

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions?

2. Protocol

The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client?

2. Provide assistive devices and educate client to use grab bar and large handled utensils.

The student nurse is examining the dispersion of data in a research study. Which measurements should this student expect to review?

2. Range, variance, and standard deviation

An adult client who cannot read needs surgery and is competent to make his own decisions. What is the best action that the nurse should take?

2. Read the consent form to the client and have the client state understanding.

The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process?

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing intervention

The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care?

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing interventions

A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the increased risk a poor physical environment creates for this client, on what should the nurse focus during the intake phase of the interview?

2. Recent history of chills and body aches

A home health client lives alone in a small apartment and has only one phone, which is a land line. What safety recommendation should the visiting home health nurse make for this particular client?

2. Recommend that the client be enrolled in an emergency response system.

A parish nurse is helping a group of new parents within the congregation find appropriate health care providers within the community who specialize in infant/child and family health care needs. In which role is the nurse functioning?

2. Referral source

The nurse researcher is using an instrument that provides similar results each time its implemented. Which term should the researcher use to describe the quality of this instrument

2. Reliability

A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the clients back and arms. When questioned, the client is distracted and ambiguous with her answers. Which action should the nurse take?

2. Report the situation to social services.

The nursing student completes a literature review on evidence-based practice (EBP). Which action indicates that the student understands EBP?

2. Repositioning a client at risk for skin breakdown every 2 hours

A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve?

2. Require that the nurse use sound judgment and knowledge of the client

The nurse researcher is considering whether the findings of a project may present uncertain results in the clinical area. Upon which criteria is the researcher reflecting?

2. Researchability

Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents decision?

2. Respecting the parents decision

A nursing instructor is researching the implementation of assigning study guides for homework points and the effect this has on the students test grades. The instructor reports group data for published research. Which research right did the instructor implement?

2. Right of privacy

A client with a postoperative infection is afebrile but still receiving IV antibiotics. The nurse should realize that this client is receiving which level of prevention?

2. Secondary

A client with unstable cardiac dysrhythmias has orders for medications, one of which is by oral route, the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned about the side effects that this drug may produce and the fact that the client has never taken the drug, so any adverse effect is unknown. Which part of the decision-making process is the nurse using?

2. Seek alternatives

The student nurse contacts a number of other students to create a study group. What behavior is the student nurse demonstrating?

2. Socialization

A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated?

2. Structure

The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program?

2. Structure 4. Process 5. Outcome

The nurse is planning client care while keeping in mind Orems self-care deficit theory. Which methods of helping should the nurse include when determining the best care for the client?

2. Teaching 3. Supporting 4. Guiding 5. Preventing hazards to life

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care?

2. The clients skin is pale and mottled.

During orientation with a home care agency, the nurse is learning the difference in care delivery between home health nursing and community nursing. What should the nurse understand as being the focus of home health care nursing?

2. The individual and his or her family

The nurse manager learns that vital signs delegated to unlicensed assistive personnel (UAP) were not recorded accurately. With which care provider should the manager discuss this finding?

2. The nurse

The nurse is caring for a nurse who provided care to soldiers during the Vietnam War. What information in this patients history should the nurse use to understand the patients nursing career?

2. The patients first patient care experiences were during a time of war.

The nurse educator is reviewing concerns about the use of research for evidence-based practice. What particular concerns should the nurse highlight when discussing the use of research with the students?

2. The research environment results in strictly constructed and controlled circumstances. 3. There is a best solution or practice for any specific research question. 4. Evidence-based practice is most applicable to physiological problems. 5. Research evidence can be flawed when applied to various cultures and ethnic groups.

The nurse is concerned that the spouse of a home care client with multiple sclerosis is experiencing caregiver role strain. What did the nurse observe to come to this conclusion?

2. The spouse expresses feelings of anger. 3. The spouse reports decreased energy.

The nurse learns that two new home care agencies are opening in a community. What should the nurse consider as reasons why home care agencies are increasing in numbers?

2. Third-party payers who support cost control measures 3. The increase in the older adult population

The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care?

2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurses time

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client?

2. Use the translation services supplied by the hospital.

A pregnant client says her main concern is that her baby will be born healthy, even though she admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling?

2. Values clarification

After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors?

2. Verifying

A nursing student is assigned to develop a research question using a quantitative approach. Which question should the student write that demonstrates this approach?

2. What dressing selections work best for a wound dehiscence?

During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client?

2. What kind of questions do you have about your surgery?

An older client being discharged from an acute care facility is prescribed home care. When should the home care nurse see the client to understand needs for safety and mobility?

2. While the client is still a patient in the acute care hospital

The nurse is attending a seminar that focuses on the changes within the home health care industry. Which statements that the nurse makes indicate an understanding of home care as a primary health service delivery system?

2. With people living well into their 70s and 80s, the healthcare system is being stressed immensely. 3. The cost of acute hospital-based health care has become an economic burden to most people. 4. A clients chronic cardiac problems can be monitored well with in-home health services. 5. It relieves so much stress when care can come to them instead of their going to the health provider.

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client?

2. Youre right. Let me know if theres anything you need right now.

While reviewing a health insurance plan, the nurse learns that a client has coverage for durable medical equipment (DME). What care need should the nurse identify as being covered by the clients health plan?

3. A hospital bed

The nurse is concerned that the hospital will not receive payment for care provided to a client. Which client health problems are causing the nurse this concern?

3. A stage II pressure ulcer developed on the clients heels. 4. A urinary tract infection occurred because of an indwelling urinary catheter.

A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

3. Acting

The nurse is applying Neumans systems model during client care. Which response should the nurse identify as an intrapersonal stressor to a client?

3. Adverse reaction to medication

The pediatric nurse implements Watsons assumption regarding a caring environment. Which action did the nurse take to implement this assumption?

3. Allowing the clients to have choices, as appropriate, in their care

A student is attending a school with a high first-time pass rate on the NCLEX. Which student statement articulates a belief that the nursing student has about faculty in the program?

3. Are most concerned with the successful licensure of each student

A client being discharged from an acute care hospital requires IV antibiotics, is not able to complete activities of daily living without assistance, and has no family available to assist in the recovery phase. Which type of recommendation should the nurse make for this client?

3. Be discharged to an extended care facility.

A faculty member is speaking to prospective students interested in enrolling in the BSN program at the university. What should the faculty member emphasize as a major incentive for students to select a BSN program over an ADN program?

3. Better opportunity for career advancement

A client tells the nurse about research information on the Internet to learn more about a new health problem. What should the nurse respond to this client?

3. Bring your information to the clinic so we can go through it together.

A small nursing program has limited access to clinical sites, especially those with specialty areas. What should the nurse educators consider as an option to allow students hands-on simulated clinical experience in these areas?

3. CAI

A seasoned nurse is a mentor for a new graduate. Which of the standards of professional performance is the seasoned nurse practicing?

3. Collegiality

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take?

3. Consult other professionals and colleagues.

While completing a community assessment, the nurse needs to learn the location of main health facilities and the number of who receive welfare. Where should the nurse access this information?

3. County health department

Before applying for re-licensure, the nurse attends continuing education programs. Which action is the nurse performing to adhere to the state board of nursing expectation?

3. Credentialing

A nurse practitioner feels it is important to participate in nursing research. Which activity is most appropriate for this nurses level of education and position?

3. Critically analyzing and interpreting research for application to practice

The nurse questions the practice of administering rectal suppositories to residents in a long-term care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and thats the routine that has been practiced for a long time, the nurse continues to research whether there would be a better time, especially in the best interest of the residents. Which critical thinking attitude is this nurse demonstrating?

3. Curiosity

A nurse educator has taught the same courses for the past 5 years and each year implements a few minor changes. Over this time, the educator has stored the grade data, including homework and assignment scores, in order to track trends following the implemented changes. What is the educator using to maintain this information?

3. Data warehousing

A new graduate nurse is looking for employment and is hoping to find a facility that utilizes nursing personnel based on their educational preparation and skill set. In which type of facility should the new graduate apply for a position?

3. Differentiated practice

A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity?

3. Discovery

The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next?

3. Document all care in the progress notes.

A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client?

3. Draw curtains around the client and nurse to provide as much privacy as possible.

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time?

3. Educator

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?

3. Emergency assessment

The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning?

3. Evaluation

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this clients care?

3. Everybody involved in this clients care

During a hospital stay, the client has taken control of her recovery and rehabilitation and is utilizing available resources for her needs. In which level of Peplaus model should the nurse determine that this patient is functioning?

3. Exploitation

A nurse is caring for a client with a severe head trauma. Each shift, the nurse pays attention to the lighting, atmosphere, and surroundings the client is exposed to. The nurse is functioning according to the assumptions of which nursing theorist?

3. Florence Nightingale

A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal?

3. Goal met, client able to state two positive aspects of therapy by weeks end.

The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy?

3. Goal statement of the traditional care plan

A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. Which action should the nurse take?

3. Have the hospital interpreter explain the procedure.

After implementing health promotion activities and plans to prioritize health problems, the community must evaluate the effectiveness of the interventions. Which groups should be involved in this process?

3. Health care providers, consumers, community leaders, and politicians

A client with terminal cancer is refusing food and fluids, and pushes the caregivers hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is starving to death. What should the nurse do?

3. Honor the clients refusal and help the family come to terms with the situation.

The nurse is assessing a clients level of pain. Which open-ended question should the nurse use for this situation?

3. How has the pain impacted your life?

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?

3. Identify client needs and deliver care to meet those needs.

When a client who had a stroke gives up all hope of any amount of recovery, the nurse solicits a visit from a former stroke client who has physical limitations but has since gone back to work and, through adaptation, can function independently at home. This nurse has fulfilled which role, according to Parse?

3. Illuminating meaning

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing?

3. Implementation

The client presents her hand when the nurse makes this statement: I need to start an IV so you can get your antibiotics. Which behavior did the client demonstrate?

3. Implied consent

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client?

3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion?

3. Inference

The nurse is considering a position with a home health agency. What type of care should the nurse realize will be provided when working for this type of agency?

3. Instructing about care of a surgical wound 4. Providing intravenous antibiotics once a day 5. Teaching about medications for self-management of diabetes

The nurse implements being authentically present to clients by supporting them in their beliefs and helping to instill hopefulness in their recovery. Which theorist is the nurse using when performing these actions?

3. Jean Watson

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale?

3. Keep client in low-Fowlers position to prevent reflux.

The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant?

3. Letting the parents bathe the baby with direction and guidance from the nurse

The nurse documents in a clients medical record: The client is a drug addict and is always asking for more medication than what is necessary. With what might the nurse be charged?

3. Libel

A client in the ambulatory clinic asks if there are any community programs to help with health and wellness issues. What should the nurse access to locate these types of activities?

3. Local newspapers

A client complaining of shortness of breath has no pallor, cyanosis, or use of accessory muscles with respirations. The clients respiratory rate is 16 breaths per minute. The nurse is concerned that the clients report and the physical findings conflict. Which standard of critical thinking is the nurse using?

3. Logical reasoning

A 68yearold client is concerned about paying for extended hospitalization and expensive medications to treat his health problem. What should the nurse respond to this client?

3. Much of your care will be covered by Medicare.

The nurse is accessing information about standard classification of terms prior to documenting in a clients computerized clinical record. Which systems should the nurse consider using for this documentation?

3. NANDA 4. The Omaha system 5. HHCC 6. NOC

The nurse forgets to put the call light within the clients reach and then leaves the room. The client reaches for it and falls out of bed. With what should the nurse expect to be charged?

3. Negligence

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?

3. Nursing care focus

Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data?

3. Objective data

A young adult client recovering from an injury that resulted in partial paralysis plans to live independently as before the injury. Which referral should the nurse identify as being the best for this client?

3. Occupational therapist

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client?

3. Parents

The manager of a small clinic has cross-trained the nurses to provide basic nursing care, and perform ECG testing, phlebotomy, and some respiratory therapy interventions. Which type of care delivery model has the manager implemented?

3. Patient-focused care

A group of nurses is researching how care providers of Stage I/II Alzheimers clients use prior coping skills in dealing with their current situation. Which qualitative research tradition are these nurses using?

3. Phenomenology

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus?

3. Process

A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention?

3. Provide ongoing assessment for skin breakdown every shift.

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

3. Reports of fatigue

A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter placed, saying Thats not part of the surgery. What should the nurse do?

3. Respect the clients wishes and document accordingly.

A hospital receives notice of being sued for an action performed by a nurse. The nurse realizes that which doctrine is being implemented in this case?

3. Respondeat superior

The nurse is offering free occult blood screening at a community health fair. Which level of practice is the nurse providing?

3. Restoring health

A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching?

3. Return demonstration of dressing change

The nurse has defined a research problem. What action should the nurse take next?

3. Review the literature.

A clinic in a rural area depends primarily on the services of a nurse practitioner. Which legislation provided the opportunity for the nurse practitioner to have this position?

3. Rural Health Clinics Act

A nurse is helping to set up an elder social group at a local senior center where residents can come to play cards or participate in structured activities three times a week. In which community function is this nurse working?

3. Social interparticipation

nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. Which professional value is the nurse demonstrating?

3. Social justice

A staff nurse is serving as a preceptor for nursing students. In which level of Benners proficiency is this nurse practicing?

3. Stage IV

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this clients care?

3. Standardized care plan

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first?

3. Submitting the diagnosis to NANDAs Diagnostic Review Committee

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues?

3. Take assessment notes and utilize information from textbooks for comparison.

A public health nurse is working with a group of home health nurses in an isolated, mountainous region where access to smaller communities and individuals is quite difficult, especially in the winter and early springseasons when the health needs of these individuals are quite high. The public health nurse has set up video conferencing and video clinics for these home health nurses regarding various client teaching and health promotion activities. What activity did the public health nurse conduct?

3. Telenursing

nurses co-worker makes a practice of telling offensive jokes or stories with a sexual undertone during the shift. Which action should the nurse take first?

3. Tell the co-worker to stop the activity because the conduct is offensive.

The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse?

3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward.

The spouse of a client diagnosed with Stage I/II Alzheimers disease must continue to work full-time. The spouse tells the occupational health nurse that the client has started to wander outside the house, forgets to turn off the stove after preparing food, and tries to drive the car if the keys are available. What should the nurse recommend for this family?

3. The client should be placed in an adult day-care environment.

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?

3. The goal is unrealistic.

A nurse who has been a longtime employee of a hospital, providing bedside care to clients, was seriously injured and is paralyzed from the shoulders down, with limited use of the upper arms. Through rehabilitation, the nurse is able to mobilize with a wheelchair and has no cognitive or psychological deficits. The nurse wants to return to the same position held prior to the injury. Under the guidelines of the ADA, what should the hospital do?

3. The hospital should claim undue hardship to accommodate this nurse.

The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision?

3. Utilitarianism

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client?

3. Wellness diagnosis

During the first home care visit, the nurse determines that the client needs speech therapy, physical therapy, and custodial care several times a week. When should the nurse schedule the clients care to begin?

3. When the physician signs the plan of care the nurse develops

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse?

3. Whirring of ventilators

A client asks the nurse to explain the difference between an HMO and a PPO. What should the nurse include when responding to the client?

3. Your PPO offered you a choice in your health care provider as well as services. Now, you will choose a primary care provider who will evaluate your health and will coordinate all of your care.

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient?

4. 24 hours

A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation?

4. A standing order

A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check for call light placement before leaving a clients room. What behavior did the student demonstrate?

4. Accountability

The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent?

4. Administering medications for pain

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described?

4. Alteration in thought processes, related to complex factors

A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing?

4. Altruism

The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out?

4. Appropriately supervising care

The nurse practitioner is working with a staff nurse to change the plan of care for a client with a terminal illness. In which areas of nursing practice are these nurses functioning?

4. Caring for the dying

The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis?

4. Client will have intake of at least 1000 mL within 24 hours.

Nursing students have been assigned to develop their own theory of nursing. What should they include in their theory, often referred to as the metaparadigm for nursing?

4. Client, environment, health, and nursing

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation?

4. Cognitive

A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, what must the nurse do?

4. Communicate only necessary information.

An older client has no family in the same community, lives alone in a small house, and is having greater difficulty with mobility due to advanced osteoarthritis. Cognitively, this client is alert, is able to manage her own business matters, and does her own cooking, but does not enjoy cooking for one. The home health nurse who visits has noticed that the client is losing weight and does not have as much energy or interest in activities as on previous visits. What should the nurse recommend for this client?

4. Consider moving to an assisted living facility.

The nurse accesses previous hospitalization information to learn more about the clients previous health history. In what way is the availability of the clients health information assisting with the planning to address new care needs?

4. Constant availability of client health information

The nurse struggling with a demanding client focuses on experiencing a sense of true empathy for the clients situation. Which assumption of Parses human becoming theory is the nurse using?

4. Cotranscendence

A nurse is working in collaboration with a group of health care providers in a community clinic setting. They have defined a problem and now are focusing on objectives and considering various viewpoints presented by the group. Which collaboration competency is this nurse demonstrating?

4. Decision making

A client with a PhD in epidemiology has been to numerous physicians and has had numerous laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain the etiology of his problem. The client also states that he has a rare form of a neurological disorder. Which statement should the nurse make that demonstrates critical thinking?

4. Describe what tests youve had and explain the symptoms of this disorder.

The staff nurse asks why unlicensed assistive personnel are responsible for stocking the unit refrigerator with refreshments when dietary personnel place the items on the shelf in the kitchen. What characteristic of critical thinking is this nurse demonstrating?

4. Developing rationales

After a community was hit by a tornado, the nurses of the local Red Cross Chapter helped to make sure people had adequate food and clothing. Which function of community were these nurses focused on restoring?

4. Distribution of goods and services

While assessing a clients environment for safety concerns, the nurse finds that most of the rooms in the house have only one outlet with various cords entering the outlet. When this concern is shared with the client and spouse, they state that this is the way weve lived for years. What should the nurse do?

4. Document the findings and the client and spouses response to the concern.

The nurse would like to admit a client to home health care, but is worried about insurance reimbursement. What client action is causing the nurse to question if home care can be prescribed for this client?

4. Drives a car for trips to the barber

Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing interventions. Which decision-making action is the nurse using?

4. Evaluate the outcome

A parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the congregation who are not able to come to regular prayer services. In which role is this nurse functioning?

4. Facilitator

The nurse is reviewing public health and health promotion roles for available for nurses. To which leader should the nurse attribute the development of these roles?

4. Florence Nightingale

A client recovering from a stroke does not want to perform prescribed shoulder exercises. What should the nurse say to the client that demonstrates critical thinking with creativity?

4. Heres a marker. See how many circles you can make on this board in 10 minutes.

The nurse is creating a community education program on health promotion and wellness. Which topic should the nurse use for this program?

4. Home accident prevention

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process?

4. Identify the clients problem, health risks, and strengths.

A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make?

4. Ill call your physician back in the room to answer your questions.

During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using?

4. Implement safe care.

To help a home health client with a difficult medication regime, the nurse contacts the pharmacist for ideas to facilitate the process. Which behavior did the nurse demonstrate when caring for this client?

4. Indirect care

A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client?

4. Individualized care plan

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?

4. Ineffective airway clearance, related to increased secretions

The nurse observes a client working to include the spouse in the treatment and recovery process of an illness. Which of Roys modes should the nurse recognize that this client is demonstrating?

4. Interdependence

A client tells the nurse about researching on the Internet for information about a newly prescribed medication. What should the nurse respond to the client?

4. Lets look at some of the sites youve been visiting.

A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling?

4. Nonmaleficence

The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action?

4. Nurse

The nurse has starting working in a state other than the one in which the nursing education program was located. Which of the following should the nurse consult in order to understand the implications of this change of venue?

4. Nurse State Practice Act

The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate?

4. Observing

The nurse is hired to provide home care through a community agency that is operated by the state health department and financed by taxes. In which type of agency is this nurse employed?

4. Official

A client is in the end stages of cancer. Which type of service should the nurse consider as being the best for this client?

4. Palliative care

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label?

4. Promotes a taxonomy of nursing

A client has agreed to participate in a research study. Which action would constitute risk of harm to this client?

4. Providing the clients name as a participant in the study

Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform?

4. Reassessing the client

The nurse reviews clients records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing?

4. Retrospective

A researcher is conducting a study with single-parent families within a school system. What sample is the researcher using?

4. Single-parent families

A nurse manager is responsible for scheduling the staff of all units in a critical care hospital. Which program should the manager use for computerized scheduling?

4. Spreadsheet

A client was given the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the nurses attorney explain is applied to this situation?

4. Stare decisis

The new community health nurse is compiling information about the community and wants to understand more about services to maintain and promote health. What entity should the nurse access to learn this information?

4. Teachers and school nurses

The nurse is considering leaving a position in an organization that utilized differentiated practice. Which type of delivery system should the nurse consider as being the most similar to differentiated practice?

4. Team nursing

A client is being seen in the clinic for the final follow-up appointment after an extensive course of rehabilitation. According to Neumans model, which level of intervention should the nurse realize this patient is experiencing?

4. Tertiary prevention

A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis?

4. The data are not sufficient enough to support this diagnosis.

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process?

4. The difference is in how the data are used.

The community health nurse is caring for teenage mothers and their children. For what should the nurse assess these patients when determining their degree of vulnerability?

4. The normal difficulties of adolescence

A nurse who is opposed to abortion works in a hospital where abortions are performed. According to the Supreme Courts conscience clause, which action should the nurse take?

4. The nurse should refuse to participate in abortions.

The nurse systematically tries a variety of products to help with healing of a clients wound. Which problemsolving method is the nurse using?

4. Trial and error

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment?

4. Value/belief pattern

A Department of Nursing within a medical center is adopting the theory that is founded on 14 fundamental needs of individuals. Which nurse theorist is this department using to guide client care?

4. Virginia Henderson

The nurse is caring for clients in Stage II/III Alzheimers disease. If Orems theory is applied, which type of nursing system should the nurse use when providing client care?

4. Wholly compensatory

The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize that these laws apply?

5. Helping deliver the baby of a neighbor during a snowstorm

A student nurse resists when encouraged to be creative when providing client care. What should the nurse educator say to encourage this student to be creative?

Creativity allows unique solutions to unique problems.

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document?

Leave me alone

Several nurses are working to open a clinic that focuses on health promotion. Which activity should the nurses expect to perform once this clinic opens?

Teaching biofeedback techniques for stress reduction