Foundations Exam 2

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

"My wife's been gone for about 7 months now."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records"

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

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.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

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 normal tensive.

Nurses are involved in many types of evaluation. All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Clients and their care

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plan

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

Coordinate with the case manager to make a safe discharge plan.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

A client has just given birth to a stillborn infant. The client is sobbing and states she feels God is punishing her for some bad choices in her past. She states she has always believed in God as a loving and caring presence in her life but now feels her faith is destroyed. Which nursing diagnoses would be included in the patient's care plan? Select all that apply

Grieving Spiritual Distress

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 nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery.

The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

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

Nurses do carry out interventions in response to a physician's order.

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

Nursing assistant who is a nursing student

A group of nurses of the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. The nurses know that this program is termed:

Peer review

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in his care

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance

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 hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which example is a nurse-initiated intervention?

Teach client how to splint abdominal incision when coughing and deep breathing.

Which client outcome is an example of a psychomotor outcome?

The client demonstrates stair climbing using a quad cane.

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 client outcome is a psychomotor outcome? Select all that apply.

The client measures capillary blood sugar level. The client catheterizes himself using clean technique

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

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

a psychomotor outcome.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of:

a referral

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

a standardized care plan

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

assess the clients response to the ambulation

Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?

client will demonstrate improved motion in left arm

When the nurse prepares to discharge a client, and subsequently evaluate the effectiveness of the patient care, the nurse should determine whether the:

client's goals have been achieved.

A client is about to leave the hospital after having surgery for a fractured left femur. It is now in a plaster cast. The client asks how long before the cast will be dry. The nurse notes on the client's plan of care a learning outcome stating "Client will verbalize appropriate cast care upon discharge." This represents what type of outcome?

cognitive

Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs?

cutting up food and opening drink containers for the client

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

documentation

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

Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called:

evaluative statement

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change

The nurse is orienting a new client to the facility. The client is told that her preferences and choices would be sought and honored. This represents which expectation of the health care environment?

individualization

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family

As the nurse bathes a client, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

it enables the nurse to revise the care plan appropriately

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

ongoing planning

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

ongoing planning

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

psychomotor

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

revise or modify the patient care plan

A client has just been admitted to the clinical unit. The nurse is providing her with the expectations she may have of the health care she will receive. She is told that she will not be harmed by any errors that might be made and she can expect to be safe in the facility. This assurance represents which expectation of the health care environment?

safety

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

standardized

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed:

standing orders.

The nursing student is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?

tell the student that the RN will assist with the clients ambulation

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

the client has a 12-year-old sister who has been treated for a seizure disorder for 3 years

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

the nurse should inform the charge nurse that she does not have the experience to properly care for this client

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

upon her admission to the hospital