3515 Fundamentals of Nursing

A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?

"I hold the boxes away from my body so I don't drop them on my feet"

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8mg/dL (28.0 g/L)

An informatics nurse specialist is presenting an in-service program for a group of staff nurses on using the electronic health record. As part of the presentation, the nurse specialist is emphasizing the need for maintaining security and privacy of the record. During a break in the program, the nurse specialist overhears a conversation among several of the staff nurses. Which statement would the nurse specialist identify as a cause for concern?

"I've always put a sticky note on the computer terminal with my password on it in case i forget it"

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"do you experience incontinence?"

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"it combines nursing science with information management and analytical sciences"

A nurse asks an informatics nurse, "How can I make sure that the passwords I create are strong enough to prevent a security problem?" Which action would be appropriate for the informatics nurse to suggest to the nurse? Select all that apply.

"make sure that your password is at least eight characters long" "try using a mnemonic that works only for you"

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound"

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary?

"the hand rolls help me develop strength in my grip"

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"to best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator"

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"to prevent your legs from rotating outward"

an informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. which response by the group would indicate to the nurse that the systems usability is effective? select all that apply

"we've noticed that this system really helps to save us valuable time" "using the system is highly intuitive" "this system fits nicely into how we work"

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

"you are free to move onto the stretcher without assistance, but I will supervise for your safety"

the nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. which statement by the student requires intervention from the nursing instructor

"you can make extra money with overtime pay with end-of-shift charting"

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"your elbows will be slightly bent when you are using your crutches"

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"your wound will heal slowly as granulation tissue forms and fills the wound"

place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process

Establishing the database Interpreting and analyzing client data Establishing priorities Carrying out the plan of care Measuring how well the client has achieved desired outcomes Modifying the plan of care (if indicated)

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

Florence Nightingale

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

Modify the plan of care and interventions to meet the client's needs

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims'

The nursing process is based upon the process of problem solving. The nurse attempts to obtain blood pressure on the client's right. arm, then on the left arm, then on the left leg, and finally one the right left, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

activity and rest

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

adduction

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

analyze and plan

the nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. the client laboratory test results reveal an increased HgbA1C level, which could indicate blood glucose levels. What is the next step for the nurse to take based on the nursing process?

analyze the data and create an individualized nursing diagnosis

a nurse is educating a pregnant client in preterm labor on the use of the clients home monitoring equipment and medications. Which factor could impede the clients ability to learn

anxiety

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?

assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider

a nurse technician is assigned to take clients' vital signs. when making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. what is most appropriate for the nurse to do about these findings?

assess the client's vital signs again

put the phases of the nursing process in the correct order. use all options

assessment diagnosis planning implementation evaluation

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

Which activity is the clearest example of the evaluation step in the nursing process?

checking the client's blood pressure 30 minutes after administering captopril

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

clean the wound from the top to the bottom and from the center to outside

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

client is in supine position with arms in functional position and pillow support under the knees

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment

which is not considered a skin appendage?

connective tissue

An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will:

create an exercise plan that is realistic and valued

A nurse is documenting a client's vital signs, height, and weight in the electronic health record. Applying the framework for informatics practice, the nurse would identify these values as which component of the framework?

data

An informatics nurse specialist is collecting data from the clinical information system about the demographics of individuals diagnosed with heart failure admitted to the facility over the past five years. The nurse specialist is preparing a presentation to the facility's executive board. To promote understanding of this complex information, the nurse specialist prepares the data results using a pie chart and a bar graph. The nurse specialist is using which area of analytics?

data visualization

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

dehiscence of the wound

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

desiccation

An informatics nurse specialist is working on a team that is considering a new technological system for the facility. Which aspect would be most important for the team to do as the first step?

determine the need or problem to be solved

the nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. what interpersonal skill is the nurse displaing

developing accountability

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

diffuse dermatitis accompanied by pruritus

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

discontinue the therapy and assess the client

An informatics nurse specialist attends a three-day seminar on current trends in health information technology. Experts are presenting sessions involving the current state of informatics, issues associated with this field, and new and innovative methods being developed based on current research. The informatics nurse specialist plans to share this information with the facility's health information technology team to see if they can incorporate it into the facility's current clinical information system. The informatics nurse specialist is demonstrating which ANA informatics competency? Select all that apply.

education evidence-based practice and research

A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept?

efficient interactions

The nurse is providing discharge teaching to a family member of a client who has recently developed right sided weakness post-stroke. Which information will the nurse provide when educating the family member on how to assist the client to mobilize? Select all that apply.

encourage the client to slowly take small steps have the client stand for 1 minute before trying to take steps have the client dangle legs on the side of the bed before standing rock the client to standing position based on an agreed signal

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

ensuring the client's privacy during dressing changes and providing an explanation during the procedure

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

evidence-based practice

a nurse is demonstrating critical thinking when applying the nursing process to client care. Plan the behaviors in the order in which they would occur from first to last based on the nursing process. use all options

explore ideas interpret evidence detect bias predict consequences identify client's perception of results

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse?

firmly grasp the gait belt and gently lower the client into bed

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

fish

On a particular 12-hour day shift, the nurse-client ratio on a busy floor is lower than usual because a member of the health care team called in sick for the day. Which example shows this nurse practicing with a good sense of legal competence in response to this challenge

following the chain of command, the nurse requests help completing the tasks essential to client care that day

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.

greater client engagement improvement in health care quality reduction in privacy breaches of client information

When moving a client up in bed with the assistance of another caregiver, the nurse should:

have the client fold the arms across the chest

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

health teaching and health promotion

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

identify clients at risk for infection

Which statement best conveys the role of intuition in nurses' problem solving

intuition can be a clinically useful adjunct to logical problem solving

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?

move the client to edge of the bed opposite the side that client will be turning

An informatics nurse specialist is involved with implementing strategies to improve the performance of the clinical information system being used. As part of this process, the nurse specialist is working on updating the plans of care in the system to reflect changes to a procedure based on new evidence. The nurse is also working to streamline the display screens to reduce the need to document the same information in three different areas. The nurse specialist is addressing which aspect of the system?

optimization

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?

orthostatic hypotension

Which is the most appropriate example of the assessment phase of the nursing process

palpating a mass in the right lower quadrant of the abdomen

an informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. part of the presentation will focus on technological advances to promote greater client participation in managing health. which component would the nurse likely describe as playing a major role

patient portal

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

placing nightlights in the bathroom and hallways removing clutter from the floor moving the bedroom to the ground floor

An informatics nurse specialist is extracting data from the facility's electronic health record in an attempt to identify clients at risk for developing catheter-related bloodstream infections. When gathering this data, the nurse specialist is using which technique?

predictive analytics

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

a nurse has developed a plan of care for an adult client. what nursing function is important when using nursing diagnoses to guide the care of this client

prioritize the nursing diagnosis

which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

reflection

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

rotate the swab several times over the wound surface to obtain an adequate specimen

which are characteristics of one who has developed critical thinking skills

self-aware, honest, persistent, and authentic

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

simplicity

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

stage 2

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage 2

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce the risk of client handling injuries. Which action(s) would the nurse include as contributing to this risk? Select all that apply.

standing for long periods using uncoordinated lifts lifting when tired engaging in repetitive movements

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking

A client receiving a sitz bath starts complaining of light-headedness to the nurse. What is the nurse's most appropriate action?

stop the sitz bath and call for help

the type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

supervisory

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

supports the area around the wound

a nurse has a two-way video communication with the specialist involved in the care of a client long-term care facility. this is an example of what nursing informatics technology

telemedicine and mobile technology

which strategy could be implemented by the nurse in ensuring the protection of electronic data and health care agencies

the nurse locks out client information, except to those who have been authorized through appropriate security measures

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

to splint the area when engaging in activity

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

tremor

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

usability

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

use a drawsheet or friction-reducing sheet to facilitate smooth movement

An informatics nurse specialist is working with a group of nurses who are tasked to test a new electronic health record system. Which phase would the group be involved with as the last phase of testing?

user acceptance

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client

an informatics nurse specialist is looking to evaluate the optimization of a clinical information system being used in the facility. on which area would the nurse focus? select all that apply

ways to improve clinical decision support measures to eliminate inefficiencies in workflow ways to reduce errors plans to improve basic processes

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

when i lift and carry a heavy box of supplies i will keep it at arm's length from my body