Exam #1 Test Review
RACE stands for.
Alerting Rescue Activating the Alarm Containing Extinguishing
The nurse on an orthopedic unit is instituting a falls prevention program. Which of the following personnel should be involved in the program? Select all that apply. a) Family members. b) Client. c) Registered nurses. d) Housekeeping services. e) Unlicensed personnel. f) Physicians.
All of them
A nurse implements a health care facility's disaster plan. Which action should she perform first? a) Identify a command center at which activities are coordinated. b) Turn off all cellular phones and pagers. c) Provide treatment for incoming clients according to time of admission. d) Instruct all essential off-duty personnel to report to the facility within 24 hours.
a)
A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Report this finding to the Adult Protective Services (APS). b) Report this finding to the physician. c) Document the bruising and continue to assess the area over the next 72 hours. d) Report this finding to the nurse who is taking care of the client.
a)
When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first? a) Gloves b) Gown c) Mask d) Cap
a)
Which of the following is a cultural norm of the healthcare system? a) There is the use of a systematic approach and problem-solving methodology. b) The omnipotence of technology is yet to be recognized. c) There is high flexibility in certain procedures attending birth and death. d) There is a tolerance of tardiness, disorderliness, and disorganization.
a)
Which option is an example of a primary preventive measure? a) Avoiding overexposure to the sun b) Having an annual physical examination c) Practicing monthly breast self-examination d) Participating in a cardiac rehabilitation program
a)
Which type of nursing intervention does the nurse perform when she administers oral care to a client? a) Maintenance b) Psychomotor c) Supervisory d) Educational
a)
A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM? a) Team nursing b) Functional nursing c) Primary nursing d) Case management
a) Case management would require more nurses. Primary and Functional nursing are for more cost effective reasons.
A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? a) Fidelity. b) Nonmaleficence. c) Autonomy. d) Justice.
a) Fidelity is keeping a promise.
A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed: a) on contact isolation. b) in a negative-pressure room. c) on protective isolation. d) on neutropenic precautions.
a) on contact isolation Negative-pressure isolation is for air-borne contact. Protective isolation is for immunocompromised patients. Neutropenic Precautions are for patients with a neutrophil count of 1,000 or less.
The nurse has just received change-of-shift report on four clients. Based on the following, the nurse should assess which of the following clients first? a) 35-year-old admitted after a motor vehicle accident whose urine output has totaled 30 mls over the last 2 hours. b) 84-year-old with resolving left-side weakness who is slightly confused and has been awake most of the night. c) 52-year-old with pneumonia and chronic back pain who is requesting pain medication. d) 38-year-old who is 2 days post-mastectomy due to breast cancer, having difficulty coping with the diagnosis.
a) physiological needs come first, normal is 20 ml/hr (500 ml/a day)
Values are known to affect a person's functional health. Which of the following values may be related to the perception of health? Select all that apply. a) Cooperation. b) Responsibility. c) Language. d) Discipline. e) Intuition.
a, b, and d. Values.
A 75-year-old male client has a history of macular degeneration. While in the hospital, the priority nursing goal will be to: a) Provide health care related to monitoring his eye condition. b) Promote a safe, effective care environment. c) Improve vision. d) Provide education regarding community services for clients with adult macular degeneration (AMD).
b)
A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which of the following is the nurse attempting to enact? a) Nonmaleficence. b) Justice. c) Fidelity. d) Beneficence.
b)
Although living will laws vary from state to state, these statutes generally include which provisions? a) How long the living will remains in effect b) Instructions on when and how to implement the living will c) What will happen to the client's valuables after his death d) Who may uphold a living will declaration
b)
In addressing health promotion for a patient who is a member of another culture, the nurse should be guided by which of the following principles? a) A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development. b) The patient may have a very different understanding of health promotion. c) The nurse should avoid performing health promotion education if this is not a priority in the patient's culture. d) Health promotion is a concept that is largely exclusive to American culture.
b)
A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle? a) The right to die b) Autonomy of the client c) Advance directive d) Substituted judgment
b) Autonomy of the client is the right to refuse treatment. Substituted judgement is the nurse making a decision for the client.
A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation? a) Tell the charge nurse she feels hurt by her statement. b) Ask for a private meeting to explore the charge nurse's concerns in detail. c) Discuss her feelings with a coworker in order to vent. d) Tell the charge nurse she needs to be more specific about what she means.
b) Read the question.
After completing initial assessment rounds, which of the following clients should the nurse discuss with the physician first? a) A client who had a right total knee replacement 2 days ago and now reports constipation and abdominal discomfort. b) A client admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place. c) A client who returned from abdominal surgery last evening and now has a dime-sized bright red spot on the dressing. d) A client admitted for lower extremity vasculitis and wound care who is requesting more pain medication before the next dressing change in 2 hours.
b) The nurse should mark the wound and assess for growth, but a dime-sized wound is not an immediate priority.
The nurse is taking care of a client with Clostridium difficile. The nurse should do which of the following to prevent the spread of infection? Select all that apply. a) Cleanse hands with alcohol-based hand sanitizer. b) Wear a protective gown when in the client's room. c) Wash hands with soap and water. d) Wear a particulate respirator. e) Wear sterile gloves when providing care.
b) c)
The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These measures are designed to: a) Protect the privacy of clients. b) Provide for an aseptic environment to prevent infection. c) Separate the family from the surgical team while they are working on the client. d) Prevent electrical sparks that could ignite the anesthetic gases.
b) Operating room. Read the question.
Which nursing action is important in preventing cross-contamination? a) Speak minimally when in the room. b) Change gloves immediately after use. c) Stand 2 feet (61 cm) from the client. d) Wear long-sleeved shirts.
b) Change gloves immediately after use.
What is the most common cause of medication errors among noninstitutionalized elderly clients? a) Dementia b) Deficient knowledge c) Confusion d) Poor vision
b) Deficient Knowledge
A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff? a) A nursing assistant administers medications to a client in ICU. b) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. c) A nursing assistant attempts to initiate I.V. therapy. d) A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy.
b) Read the question.
The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should: a) Change taking all vital signs to every 8 hours. b) Initiate paper charting back-up. c) Review the census for clients that are candidates for early discharge. d) Ask parents to leave to free up the parent sleep areas for incoming victims.
c)
Which of the following clients is the most appropriate candidate for outpatient care? a) A client with a history of depression who is currently expressing suicidal ideation. b) A man who is receiving treatment for sepsis after his blood culture came back positive. c) A client whose reports of irregular bowel movements have necessitated a colonoscopy. d) A woman who has previously borne two children and is entering the second stage of labor.
c)
The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed? a) High Fowler's position. b) Lowest position. c) Highest position. d) Middle position.
c) Highest position for stretcher. Lowest position for ambulatory clients.
A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error? a) Late entry b) Omission c) Unauthorized entry d) Improper correction
c) Omission is leaving out information. Late entry is the original nurse writing the information at a later time. An improper correction is crossing out, erasing, etc.
A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? a) Ask the assistant manager to develop a plan for the review and revision of client-education materials. b) Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. c) Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. d) Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change.
c) Must be specific.
An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? a) Comparative negligence b) Collective liability c) Negligence d) Battery
c) Negligence Comparative negligence holds the patient accountable. Collective liability is failing as a group. Battery is harmful contact with the patient.
What should a nurse expect to find while assessing the vital signs of a client who has abruptly stopped taking his beta-adrenergic blocker? a) Abnormally low blood pressure b) Increased respiratory rate c) Irregular pulse d) Decreased respiratory rate
c) Used to treat hypertension.
A client has received numerous different antibiotics and now is experiencing diarrhea. The physician has ordered the following of transmission-based precautions. Which of the following types of precautions would be most appropriate for all personnel to use? a) Needlestick precautions b) Airborne precautions c) Contact precautions d) Droplet precautions
c. Airborne precautions are required for clients with presumed or proven pulmonary tuberculosis (TB), chickenpox, or other airborne pathogens. Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms, such as influenza or meningococcus, that can be transmitted by close respiratory or mucous membrane contact with respiratory secretions. The most important aspect of reducing the risk of bloodborne infection is avoidance of percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp objects are handled.
A client's rights to information, informed consent, and treatment refusal are addressed in the: a) code for nurses. b) nurse practice act. c) standards of nursing practice. d) Patient Care Partnership.
d)
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing? a) With two people, one at each side using a drawsheet, and one person at the head. b) With two people using a roller and a drawsheet. c) With two people at each side using a drawsheet. d) With two people, one at each side using a drawsheet, one person at the head, and one person at the feet.
d)
Communicating with parents and children about health care has become increasingly significant because: a) Consumers of health care cannot keep up with rapid advances in science. b) Nurse educators have recognized the value of communication. c) Clients are more demanding that their rights be respected. d) The influence of the media and specialization have increased the complexity of managing health.
d)
The nurse is planning a staff development program on how to care for clients with hepatitis A. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A? a) Assigning the client to a private room. b) Wearing a mask when providing care. c) Gowning when entering a client's room. d) Wearing gloves when giving direct care.
d) Contact precaution is advised for patients with hepatitis A. A gown isn't necessary unless planning to deal with fluids. A mask isn't necessary. A private room isn't necessary unless incontinent stool is observed.
A client's attorney may file a lawsuit within which time frame? a) Discovery rule b) Alternative dispute resolution c) Grace period d) Statute of limitations
d) Statute of Limitations is when the client can file a lawsuit. Discovery rule is when the patient discovers the problem. Grace period is when payment is permitted. Alternative dispute resolution is when the problem can be settled outside of court.
A nurse-manager appropriately behaves as an autocrat in which situation? a) Planning vacation time for staff b) Evaluating a new medication-administration process c) Identifying the strengths and weaknesses of a client-education video d) Directing staff activities if a client experiences a cardiac arrest
d) Autocrat means boss lady
During a meal, a client with hepatitis B dislodges her I.V. line and bleeds onto the surface of the overbed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with: a) alcohol. b) acetone. c) ammonia. d) bleach.
d) Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective in destroying the hepatitis B virus.
The nurse is obtaining a health history from a client of Puerto Rican descent. Which of the following is most likely to be a health problem with a cultural connection for this client? a) Suicide. b) Sickle-cell anemia. c) Tuberculosis. d) Lactose enzyme deficiency.
d) Lactosa enzyme deficiency is for Puerto Ricans, Sickle-cell anemia is for African Americans, Tuberculosis is common in Native Americans, and Suicide is common in Native Americans and white people.
The children of a 78-year-old female client with a recent diagnosis of early-stage Alzheimer's disease are attempting to convince their mother to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and her children have expressed to the nurse how they are entrenched in their position. Which of the following statements expresses a utilitarian approach to this dilemma? a) The client's autonomy and independence are the priority considerations. b) The client has a right to self-determination that is the ultimate priority. c) Benefits and burdens should be evenly distributed between the children and the client. d) The decision should be made in light of consequences.
d) Utilitarian decision.