204A Fundamentals quiz's exam 1

Problem-focused assessment

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

waterbone disease

A community health nurse is caring for a client who has noticed that their drinking water isn't clear and reports they haven't been feeling well. The nurse should identify the client is at risk for which of the following conditions?

Ask about the chief concerns or problems.

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Implementation

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Dark-colored urine

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Indirect contact

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Portal of entry

A nurse is caring for a client who acquired hepatitis A from consuming contaminated food. The client's mouth is an example of which of the following links in the chain of infection?

Remove harmful objects from the client's room.

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?

Maintain eye contact with client and summarize the client's feelings.

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Nurses are required to take breaks during a shift

A nurse is evaluating ergonomic practice in the workplace. Which of the following should the nurse identify as an example of safe ergonomic practice?

Perform a thorough nursing health history.

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

Inspects the sterile package for holes before opening

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Disease prevention

A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?

Ask the client to demonstrate walking with crutches

A nurse is preparing a teaching plan for a client who is learning to walk with crutches. The nurse should identify that which of the following actions is part of the implementation step?

Rub hands together for 20 seconds.

A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?

Bones

A nurse is providing teaching about calcium to a client who is at risk for osteoporosis. The nurse should inform the client that calcium is stored in which of the following locations?

Facilitates the absorption of vitamins

A nurse is teaching a class about nutrients. The nurse should include that which of the following is a function of fats?

Enamel

A nurse is teaching a class about oral hygiene. The nurse should include that which of the following substances coats the teeth to protect them from plaque?

Organizes client services following discharge

A nurse is teaching a class about the roles and responsibilities of a case manager. Which of the following responsibilities should the nurse include?

Incubation

A nurse is teaching a class about the stages of infection. The nurse should include that which of the following is the first stage of an infection?

Vitamin C and B

A nurse is teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?

"keep your back straight"

A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?

Code of ethics

A nurse looks up information in a client's medical record but is not involved in the care of the client. The nurse is violating which of the following standards of professional performance?

Close all the doors.

A nurse sees smoke coming from the central supply room. Which of the following actions should the nurse take first?

The patient is fearful of being discharged

A patient expresses fear of going home and being alone. Vital signs are stable, and the incision is nearly completely healed. What can the nurse infer from the subjective data?

Ask the patient what causes the facial grimacing with movement.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the NAP to record the patient's vital signs before administering medications.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Validation involves comparing data with other sources for accuracy."

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?