FINAL EXAM NUR102

Pharacodynamics

-alters cell physiology -indications -adverse effects

Cognitive Domain

The domain involved in the learning and storage of basic knowledge. It is the thinking portion of the learning process and incorporates an individual's previous experiences and perceptions; the learning/thinking domain.

psychomotor domain

The domain involved in the learning of a new procedure or skill; often called the doing domain.

The nurse is assessing the bowel sounds of a client who has Crohn disease. What assessment technique does the nurse use?

auscultation

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

oriented to person, place, and time

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen.

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

Which nursing action demonstrates safe injection practice?

use sterile single-use disposable syringes for each injection

When documenting subjective data, the nurse should:

use the client's own words placed in quotation marks.

Which group of terms best describes the nursing process?

Client-centered, systematic, outcome-oriented

SBAR

Situation Background Assessment Recommendation

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it."

A client scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response by the nurse?

"What questions do you have about the surgery?"

Which activities take place during the working phase of the nurse-client relationship? Select all that apply.

-The client participates actively in the relationship. -The client genuinely expresses concerns to the nurse.

Which nursing actions help improve listening skills when conversing with clients? Select all that apply.

-Using facial expressions and body gestures to indicate attention to what the client is saying -Thinking before responding to the client, even if this creates a lull in the conversation -Listening for themes in the client's comments

Which is a characteristic of a person-centered or helping relationship?

An unequal sharing of information

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

Which action should the nurse first consider when attempting to become culturally competent?

Assess own personal cultural beliefs and prejudices.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration.

A nurse is experiencing difficulty obtaining the client's cooperation in performing exercises after surgery. Which would be the best method for the nurse to obtain the client's cooperation?

Explain the purpose and benefit of the postsurgical exercises.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

A health care provider approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" Which response by the nurse is most appropriate?

Inform the health care provider that client permission is needed to release any information.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

A nurse is educating a home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction?

The message will likely be misunderstood.

Affective Domain

The most intangible domain of the learning process. It involves affective behavior, which is conduct that expresses feelings, needs, beliefs, values, and opinions; the feeling domain.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement.

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. Which expectation should the nurse have when developing the relationship?

The nurse is accountable for the outcome.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse is providing education to a client who sometimes has difficulty remembering information. Which form of communication will be most helpful for this client?

Written communication

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

The nurse recognizes that identifying outcomes/goals must include

involvement of the client and family.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

Which nursing assessment guideline is most accurate?

"Collect assessment data about the client continuously."

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

A nurse caring for client who is unconscious knows that communication is important even if the client does not respond. Which nonverbal action by the nurse would communicate caring?

Holding the client's hand while talking

The nurse is using an assessment guide that includes a hierarchy of five life requirements universal to all persons. Which model for organizing assessment data is the nurse using?

Human Needs (Maslow) model

The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement?

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

The client is being seen for chest congestion, coughing up thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a two-pack-per-day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client?

Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice.

After the nursing plan of care has been developed, the nurse knows that:

each encounter with the client is an opportunity to reassess and revise the plan of care, if necessary.

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick.

RACE

rescue, alarm, contain, extinguish

Giving medication occurs in which step of the nursing process?

Implementation

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?

In a bag marked "biohazards"

Which flow sheet provides the health care provider with information on an ongoing record of fluid loss?

Intake and output graphic sheet

What is the priority goal of interventions for a risk diagnosis?

Prevent an actual problem

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

Stop lifting the client and reassure him.

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur.

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement?

"If I give this medication, the client probably will be sleepy."

Alcohol does not kill C. difficile spores.

!

The client is an older adult with osteoporosis. The client fractured a hip following a fall and had surgery. The nurse identified interventions based on the client's needs and outcomes. Which actions are nurse-initiated interventions? Select all that apply.

-Assess vital signs and oxygen saturation every 4 hours. -Instruct the client about foods high in calcium. -Assess surgical wound daily for redness, inflammation, and drainage.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

-Establishing priorities -Identifying expected client outcome -Selecting evidence-based nursing interventions -Communicating the plan of nursing care

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

The nurse is conducting a health assessment on a client. Which subjective data would the nurse gather about the client's sleep habits?

Client reports only sleeping 2 hours per night

A client comes to the health care provider's office reporting abdominal pain, for which the client has previously sought care. Which type of assessment would the nurse perform?

Focused

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)?

Nurses do carry out interventions in response to a health care provider's order.

What generalization can be made about safety in client care?

Safety is a paramount concern underlying all nursing care.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies client's full name and date of birth

nursing health history

identify the client's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

ptosis.

What organ is the primary site of heat loss in the body?

skin

SOAP

subjective, objective, assessment, plan

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

A nurse is assessing a client's nutritional intake prior to admission the client has lost 10 lb (4.5 kg) over the last 2 months. Which example best represents therapeutic communication technique?

"Tell me about the type of foods you like to eat."

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

"What brings you here today?"

The nurse must use appropriate interviewing techniques to elicit accurate and complete health information. Which statement is an example of an open-ended question or comment?

"What brought you to the hospital this morning?"

What is a violation(s) of the nurse's responsibility when using electronic communication? Select all that apply.

-The nurse posted on a social media site, "Psychotic mean client in Room 502 hit me," and, within 5 minutes, deleted the post. -The nurse accidentally texted a message about a new prescription for HIV medication to the wrong phone number.

After providing care to a client, the nurse is disposing of waste materials. Which waste would the nurse identify as injurious waste? Select all that apply.

-Used fingerstick lancet -Used syringe with attached needle

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

Assess the client for dehydration.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Assess the client's ability to stand or sit.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

third check

read the medication package label when at the bedside with v the patient

Which question or statement would be an appropriate termination of the health history interview?

"Can you think of anything else you would like to tell me?"

How should the nurse best explain the care team's use of personal protective equipment (PPE) in the health care facility?

"PPE protects clients from infections that may be carried by the care team and also protects the care team from infections carried by clients."

A client reports to a primary care health care provider with aggravated chest pain. The health care provider orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it."

Which are considered vital signs? Select all that apply.

-blood pressure -respiratory rate -pulse -temperature

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a health care provider to report a client's new onset of chest pain.

A nurse develops the nursing diagnoses "Appendicitis" and "Acute Pain" for a client. Which of the diagnoses is a medical diagnosis?

Appendicitis

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome?

Ask the client to demonstrate self-injection of insulin.

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

A 66-year-old female client is reporting that it has been several days since the last bowel movement. The nurse begins an assessment of the client's abdomen by first inspecting the abdomen. What should the nurse do next?

Auscultate the client's abdomen.

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. What action best reduces the nurses' risk of needlestick injuries?

Avoid recapping needles except when absolutely necessary.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home

The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met?

Client no longer requires supplemental oxygen.

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client?

Complete a systematic nursing history and nursing examination.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What is the best action by the nurse?

Discard the supplies and field and prepare a new sterile field.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Document normal breath sounds.

A 78-year-old client is taking his own heart rate, as directed by his care provider and following the instructions provided by the nurse. The client's pulse is 56 beats per minute. What should he do next?

Document the finding

How should the nurse ensure that care is not legally negligent?

Documenting the nursing actions in the client's record

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect.

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

Gown and gloves

Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?

Implementing

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

Which priority action should be implemented by the charge nurse when observing a new graduate nurse perform the procedure displayed in the image?

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

A 56-year-old client has a medium skin tone and a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32 breaths/min. The nurse notices that the client is restless and their skin has an ashen appearance. Which nursing action is the priority intervention?

Measure the pulse oximetry.

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes

Which are subjective client data gathered during assessment?

Nausea, abdominal pain

A charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which of the following assessments is appropriate?

Occlusion of one of the client's nostrils while the client breathes through the nose

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?

Orienting clients to the surroundings decreases the potential for injury.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching?

Put a small nightlight in the hall and stairway.

Which pulse site should the nurse recommend the client use for home monitoring?

Radial

After completing an assessment of a client, which finding should the nurse determine is the priority for care?

Severe bleeding from a wound

SMART

Specific, Measurable, Attainable, Realistic, Timely

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field?

Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends.

What situation would permit the nurse to disclose information without the client's approval?

The nurse suspecting that a client is being abused or neglected

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How should the nurse best perform chest auscultation?

Use a stethoscope that remains in the client's room

Which action should the nurse perform first after an exposure to a client's body fluids?

Wash the exposed area with soap and water.

A client who is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60 to 100 bpm for adults. Today her pulse is 58 bpm. The client asks the nurse at her annual screening if she should be concerned. What is the most appropriate response by the nurse?

Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise.

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client?

You may have orthostatic hypotension and should be seen by your health care provider as soon as you can.

The client demonstrates stair climbing using a quad cane. This is an example of:

a psychomotor outcome.

After a client falls out of bed, the nurse completes:

a safety event report (incident report).

Clients demonstrating apnea have what?

a temporary cessation of breathing

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

charting by exception (CBE)

A new mother is having difficulty breastfeeding a newborn. A goal was established stating that the infant would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding 4 days ago. The nurse evaluates the original goal as:

completely unmet.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

immediately deposit uncapped needles into a puncture-proof plastic container.

The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding?

jaundice

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

A nurse needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment?

penlight

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords.

second check

read medication package label when comparing it to the eMAR

first check

read the medication package label from medication drawer

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

wash the area with soap and water

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

wheezes

Which statement about client records and documentation is correct?

Communication is the primary purpose of client records.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

asks the client what promotes sleep.

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

auscultation of high-pitched continuous sounds during inspiration

What is the leading cause of injury-related deaths in adults 65 and older?

falls

Which is a correctly written client outcome?

The client will ambulate 10 ft (3 m) with a walker by October 12.

In the eyes of the law, if it is not documented, it was not done.

The nurse transfers responsibility but is accountable for the outcome.

Which statements describe the qualities of a helping relationship? Select all that apply.

-The helping relationship is built on the client's needs, not on those of the helping person. -A helping relationship is dynamic. -A helping relationship is purposeful and time limited.

A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. What statement by the nurse communicates concern and caring about the client?

"I can imagine you have many concerns about your health. Tell me what is on your mind."

The nurse is caring for the following clients. Which client requires a negative air flow room?

81-year-old client with active tuberculosis and a productive cough

Which components must be included in an outcome? Select all that apply.

-The action the client will perform -The particular circumstances in which the outcome is to be achieved -The client or some part of the client -A target time by which the client is expected to be able to achieve the outcome

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done.

The nurse, orienting a new client to the facility, explains that the staff will ask for and honor the client's preferences and choices while providing care. This represents which expectation of the health care environment?

Individualization

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

-0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?

Evaluating

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

-Acknowledge the client's response to the medication -Identify the day and time for each entry -Document in chronological order -Sign every entry

Which characteristics would indicate a professional relationship? Select all that apply.

-An emphasis on addressing the client's needs in the current situation -The relationship ending with goal achievement

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.

-"I will draw a straight line through any blank space." -"I will use only agency-approved abbreviations." -"I will write, print, or type information legibly."

The client is being discharged, and the nurse observes the client crying. What is the nurse's most appropriate response?

-"Would you like to talk about anything before you go home?"

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

-Approach the client from the front. -Use the client's name. -Smile and maintain eye contact.

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.

-Faxing the results of blood chemistry levels to the provider's office -Informing the provider of the client's present heart rate of 116 beats/min -Showing the provider the trends from baseline to present in blood pressure

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse?

-Inform the provider, to ensure safety for the client, it must be read back

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply.

-S: The nurse handling the transfer describes the client situation to the new nurse. -B: The nurse gives the background of the client by explaining the client history. -A: The nurse presents an assessment of the client to the new nurse. -R: The nurse gives recommendations for future care to the new nurse in charge.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.

-The client's oxygen saturation level increases. -The client states, "I can breathe easier now." -The client's respiratory rate decreases.

A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply.

-ensuring that individuals log off a computer terminal when documentation is completed -placing computer screens in locations that face away from any public areas such as hallways -having each person responsible for documenting in the electronic health record not share his or her password

Pharamokinetics

-movement of drug molecules -onset -duration of effects -peak effects

The nurse is caring for a hospitalized client. The nurse explains to the client that a care plan will be used for which reason(s)? Select all that apply.

-to ensure that the client is involved in decision making about care -to revise the care provided when planned interventions are not effective -to improve the communication between nurses about the client's care needs

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed.

Which provides the nurse with the most reliable basis on which to formulate a nursing diagnosis?

A cluster of several significant cues of data that suggest a particular health problem

The nurse has discovered a fire in the care facility and is implementing the "RACE" acronym when responding to it. When implementingt he "A" in this acronym, what should the nurse do?

Activate the fire alarm and notify the appropriate person

Which is a health care provider-initiated intervention?

Administer oxygen at 4 L/min per nasal cannula.

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

Assessing

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the client's room

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the health care providers to coordinate their orders.

The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

Compare the client's pulse rate to the standard range.

The nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse do first?

Complete a comprehensive assessment.

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

A nurse recently attended a conference that focused on management of acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information from the conference. Which resource is the nurse using to enhance practice?

Evidence-based practice

Which statement regarding the difference between data collected for assessment and data collected for evaluation is correct?

Data collected for assessment identify client health issues, whereas data collected for evaluation determine whether client outcomes are being achieved.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting?

Ensure that the client's name appears on all pages.

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?

Ensure that the scale is correctly calibrated and repeat the assessment.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

The nurse is caring for a hospital client who was admitted for an exacerbation of congestive heart failure but who has just been diagnosed with Clostridium difficile-related diarrhea. How will the nurse categorize this development?

Health care-associated infection (HAI)

What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?

Inspection

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record?

Place one line through the entry and initial it.

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

Promote and monitor hand hygiene

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for Enhanced Knowledge: Childhood Immunizations

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls.

Which technique would a nurse employ when using listening skills appropriately when interviewing a client?

The nurse would listen to the themes in the client's comments.

Adherence to defined principles is recommended when delegating care tasks to assistive personnel. According to these principles, who is responsible and accountable for nursing practice?

The registered nurse

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Time-lapse

During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique?

To assess capillary refill and oxygenation

To assess subjective data related to a client's elimination pattern, the nurse:

asks the client about changes in elimination patterns.

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym?

client reports of pain

The nurse is assessing a newly admitted client. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. How does the nurse document this finding?

crackles

The primary purpose of nursing diagnoses is to:

guide selection of nursing interventions to meet expected outcomes.

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition

hepatitis

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation?

immediately report the suspected abuse of the client.

The nurse is preparing to perform an examination of the abdomen of a 23-year-old client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client?

inspection, auscultation, percussion, palpation

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

objective data.

A risk nursing diagnosis indicates that:

the client is more vulnerable to a certain problem than other individuals are.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature?

the dorsum

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission

What is the purpose of obtaining a nursing history?

to identify actual and potential health problems

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

tuning fork

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning?

unlicensed assistive personnel who is in nursing school

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

unlicensed licensed personnel

The nurse is preparing to assess the client's vital signs. The client just had morning coffee. What explanation and action does the nurse take in this situation?

wait 30 minutes, then assess the oral temperature because the client had a beverage