Exam 1

which member of the health care team is responsible for consulting other health care professionals in planning and delivering client care?

primary nurse

which physiological factor increases the risk of falls for a toddler?

poorly developed depth perception

which blood pressure is optimal for an adolescent?

110/66 mm Hg

which available staff member would be the best for the nursing manager to assign to take frequent vital signs for a client with suspected shock?

registered nurse

one day ago, a client underwent extraction of a tooth because of an underlying tumor. which health care professional is appropriately involved in caring for the postoperative oral hygiene needs of this client?

registered nurse (RN)

in the case of a client with which condition would it be most safe for the nurse to delegate the task of vital sign obtainment to an unlicensed assistive personnel (UAP)?

ankle sprain

which nursing professional has the maximum span of control?

nurse manager

the nurse plans to help a client get out of bed for the first time after surgery. which assessment would the nurse complete before having the client sit on the side of the bed? select all that apply

presence of safe footwear, status of comfort and pain. appearance of wound and skin, patency of urinary catheter

which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress?

sharing humor

which action would be included in an organization's policy for hand hygiene? select all that apply

wash hands before applying sterile gloves, wash with either soap and water or alcohol-based hand rub before client contact, wash with soap and water when hands are visibly soiled with blood, and wash with ABHR if hands are not visibly soiled

which best response would the nurse make to a client with antisocial personality disorder who asks, "can I have your phone number so I can call you for a date?"

"our relationship is professional; therefore, I will not see you socially"

according to Maslow's hierarchy of needs, in which order would the nurse prioritize actions? 1. assisting the client in getting out of bed to join family members for meals 2. providing a warm bath to the client to promote a good night's sleep 3. praising the client for administering insulin correctly 4. encouraging the client to talk about fears and feelings

2, 4, 1, 3

which action would the nurse take when using a mechanical lift device to transfer a client?

fold the client's arms across the chest

which play activity would the nurse provide for a 4-year-old child on bed rest?

finger painting on blank sheets of paper

according to Quality and Safety Education for Nurses (QSEN), which phrase defines patient-centered care?

understanding that the client is the source of control when providing care

which example mentioned by the nurse belongs to the fifth level of Maslow's hierarchy of needs? select all that apply

"a client wished to become the best swimmer in the whole world" and "a client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia"

which data would the nurse use to determine a client's score on the Braden Scale to predict a client's risk for developing pressure injuries? select all that apply

anorexia, hemiplegia, history of diabetes, and urinary incontinence

which intervention would the nurse manage include in a fall prevention program to decrease the number of falls on the unit? select all that apply

apply fall wristband, install bed safety alarms, and establish a toileting schedule

for which physical assessment situation would the nurse use an alcohol-based hand sanitizer for hand hygiene?

before and after palpating a pulse

the nurse is teaching members of a health care team how to help dibbled clients stand and transfer from the bed to a chair. which step would the nurse do next after placing the nurse's arms under the client's axillae?

bending and then straightening their knees

the vital sign assessment of a client who gave birth reveal temperature 99.3 F; pulse 80 beats per minute, regular and strong; respirations 16 breaths per minute, slow and even; and blood pressure 148/92 mmHg. which vital sign would the nurse check more frequently?

blood pressure

which strategies will promote safety and quality of client care on the unit? select all that apply

communicate with clarity and precision when designing multidisciplinary plans of care, create a safety huddle so all health care professionals are aware of the clinical objectives, and conduct communication simulations to increase knowledge about expertise of other health care disciplines

when learning about the rules of leaders, which action of the nurse indicates effective implementation of the rules? select all that apply

communicating in a simple language with followers, giving an opportunity tot he followers to express their views, and ensuring proper eye contact while communicating with followers

while assessing the nails of a client with diabetes, the nurse finds the skin on the client's hands and feet are dry due to infection. which rationale would the nurse associate with this dryness?

cutting nails after soaking them for 10 minutes in warm water

which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls?

decreased bone density

which strategy would improve safety when the nurse manager institutes strategies to decrease the omission of important information during communication between staff nurses and care providers?

empty SBAR (situation, background, assessment, and recommendation) communication

which purposes are accomplished by applying the four elements of safety, critical thinking, stability, and time in the delegation of tasks? select all that apply

encouraging effective delegation decisions, ensuring effectiveness in performing elements of care, and assessing the ability of unlicensed assertive personnel (UAP) to perform the task

which nursing action is MOST appropriate to help reduce the likelihood of an older adult client falling during the night?

instructing the client to call the nurse before going to the bathroom

which example is a one-on-one communication between the nurse and another person?

interpersonal communication

which need would the nurse address using Maslow's hierarchy of needs when caring for an emancipated minor reporting improper nutrition?

physiological

the nurse is teaching an adolescent with a sprained ankle how to use one crutch when walking. which statement indicates that no further teaching is necessary?

"I should use the crutch on the side of my good ankle"

the nurse provides home care instructions to a client who was treated for injuries due to a fall. which statement made by the client indicates a need for additional instruction?

"I should walk on soft scatter rugs at home"

while assessing a client's hair, the nurse notices the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which client statement indicates an understanding of the teaching? select all that apply

"I will clean my comb with annomnia water," "I should use a dilute vinegar solution to loosen the nits," and "I should use a shampoo treatment once every 24 hours"

which instructions would the nurse give to an older adult with decreased perception of touch? select all that apply

"hold on to handrails while ambulating," "look where your feet are placed while walking," wear shoes that give good support while walking," and "if you are unable to change your position frequently, ask for assistance"

the newly promoted registered nurse (RN) is about the start the process of delegation for the first time in their career. which experiences foster professional self-confidence in the early career stage for an RN?

experience in clinical delegation, application of theory to practice, development of clinical judgement, and engagement with a nursing mentor

which activity should the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy or needs?

positioning the bed in a low position and keeping the side rials up, monitoring vital signs, such a blood pressure to decrease the risk of falls, observing a client who has suicidal tendencies to prevent adverse incidents

while hospitalized, a client with diabetes is observed picking at calluses on the feet. which intervention would the nurse implement immediately?

teach the client the importance of effective foot care

which point regarding ethics and values requires further education?

the American Nurses Association (ANA) code of ethics ensures that the code remains constant

which principle would the nurse consider when assisting a client with crutches to learn the four-point gait?

the client must be able to bear weight on both legs

which quality is the most important tool the nurse brings tot he therapeutic nurse-client relationship?

the self and a desire to help

which statement(s) related to initial assessment of blood pressure by the nurse require(s) correction? select all that apply

"the stethoscope applied too firmly against the antecubital fossa will show a low systolic reading" and "having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure"

after presenting information about falls risk assessments to nursing staff, which participant's statement needs review for corrective action?

"we will use the admission fall assessment for the entire stay"

wrist restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. which nursing intervention is correct regarding restraints?

assess the client's condition per hospital protocol

the nurse is transferring a client from the bed to the chair. which action would the nurse the first during the transfer?

instruct the client to dance the legs

which intervention is beneficial to an older adult in acute care who is at risk of skin breakdown? select all that apply

providing thorough skin care, reducing shear forces and friction, and avoiding pressure with proper positioning

the nurse delegates the tasks of caring for a postpartum client. during assessment, the nurse observes an infection in the client caused by lack of hygiene. which member of the health care team is MOST likely responsible for the client's condition? select all that apply

registered nurse (RN) and unlicensed assistive personnel (UAP)

which action by the nurse increase safety in the clinical setting? select all that apply

remain current with evidence and best practices, use only quality resources, especially websites, and report faulty equipment as soon as discovered

which safety consideration is the nurse following when obtaining the client's family history and checking for a medical alert bracelet?

risk for errors and adverse events

which nursing action illustrates the Quality and Safety Education for Nurses (QSEN) competency called informatics?

use information and technology to communicate, manage knowledge, mitigate error, and support decision-making

the nurse teaches a client about wearing thigh-high antiembolism elastic stockings. which instruction would be correct to include?

you will need to apply them in the morning before you lower your legs from the bed to the floor