Foundations Exam #2

A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?

" I should try to escape or put a barrier between myself and the client"

A nurse is speaking with a client who is noncompliant in performing a daily blood glucose testing regiment. Which of the following responses should the nurse make?

" What is preventing your consistency with your daily blood glucose checks? (is an open ended question that encourages the client to talk)

A nurse is providing postoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"Can you tell me about how long the surgery will take?"

A nurse is orienting a newly licensed nurse to the unit. Which of the following statements by the newly licensed nurse indicates an understanding of the importance of documentation of client education?

"Client documentation can increase staffing and services"

A nurse has received change of shift report for a group of clients. Which of the following clients should the nurse plan to see first?

A client who is receiving a blood transfusion and reports urticaria

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first?

Perform a physical assessment

A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing?

"You said that you're sad. What is making you feel sad?"

A nurse is assessing a postoperative client prior to a teaching session. The nurse notes that the client is grimacing and restless. Which of the following barriers to learning is the client exhibiting?

Physical discomfort

A nurse is using a question and answer session to teach a client about a diabetic diet. Which of the following outcomes is an example of cognitive learning?

The client understands a diabetic meal plan

A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge information. Which of the following responses should the nurse make?

"I am unable to send your discharge instructions via email due to the HIPAA Privacy Act."

A nurse is admitting a client for surgery. Which of the following questions should the nurse ask to determine the client's health literacy level and learning needs?

"How comfortable are you with filling out medical forms by yourself?"

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) - "You will do great! You just have to get used to it" - "Why are you worried about going home?" - "Your daily routines will be different when you get home." - "Tell me about the support system you'll have after you leave the hospital." - "it sounds like you are not sure how having a colostomy will affect swimming."

- "Your daily routines will be different when you get home." - "Tell me about the support system you'll have after you leave the hospital." - "it sounds like you are not sure how having a colostomy will affect swimming."

A nurse is planning a teaching session for a client. Place the steps of the teaching process in the correct order.

- Assessment - Analysis - Planning - Implementation - Evaluation

A nurse is reviewing the goals of client education with a newly licensed nurse. Which of the following information should the nurse include? (Select all that apply) - improvement of health - provide knowledge about an illness or injury - relevance - health promotion - motivation

- improvement of health - provide knowledge about an illness or injury - health promotion

A nurse is assessing a client who came into the ER reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with the. Which of the following actions should the nurse take to improve communication with the client (select all that apply).

- move the client to a quiet area or private room - speak at a slower pace - stand next to the client when talking - avoid using medical terminology

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (select all that apply) - observe the client's lower extremities for indications of DVT - obtain a respiratory rate for one full min - measure the client's temp - check the client for bruising - obtain a blood pressure measurement

- observe the client's lower extremities for indications of DVT - measure the client's temp - check the client for bruising

A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first?

A client who has an abdominal wound that is actively bleeding.

A nurse is reviewing the medical records for four clients. Which of the following clients should the nurse identify as the priority for care? - A client who received digoxin and has a HR of 48/min - A client who received pain meds and has a respiratory rate of 14/min - a client who has a UTI and temp of 37.9 (100.2 F) - A client who has anemia and a BP of 118/78 mmHg

A client who received digoxin and has a HR of 48/min

A nurse is providing teaching about performing blood glucose checks to a client who has a new diagnosis of diabetes mellitus. Which of the following actions indicated the nurse is using the affective domain of learning?

Ask the client how they feel about checking their blood glucose levels

A nurse is participating in a question-and-answer session with a client. Which of the following domains of learning uses this type of client education?

Cognitive domain

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client?

Determine what the client knows about stress incontinence

A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Which of the following actions should the nurse take during client education?

Direct the education to the caregivers as well as the client.

A nurse is reviewing information about client education with a newly licensed nurse. Which of the following information should the nurse include as the focus of client education?

Empowering clients to be accountable for self-care

Which of the following strategies should a nurse use to establish a helping relationship with a client?

Encourage the client to communicate their thoughts and feelings

A nurse on a med sure unit has received change of shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Reapplying a condom catheter for a client who has a urinary incontinence

A nurse is caring for a client who states "I have to check with my partner and see if they think I am ready to go home." The nurse replies "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

Reflecting

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request assistance from the facility's interpreter.

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs?

Self- Esteem

A nurse I giving the change of shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?

The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues.

A nurse is reviewing a client's plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome?

Timed

A nurse is preparing for a teaching session with a client who has pernicious anemia. Which of the following should the nurse identify as part of the implementation step of the teaching process?

Use demonstration to teach the client about vitamin b12 injections.

A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?

continuity of care

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request?

cultural factor

A nurse is evaluating a client's plan of care. The desired outcome of having the client sit on the side of the bed by the end of the shift was not met. Which of the following actions should the nurse take?

determine if different nursing interventions are required

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client teaching?

ensure the room is well lit

A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take?

lower the volume on the television

A nurse is precepting a newly licensed nurse and suggests the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct use of the IDEAL method?

"I will include the client and caregivers in the discharge discussion"

A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding of the teaching?

"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level"

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use fo affirmations?

"Im glad you decided to continue your fitness routine"

A nurse is teaching a client how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach-back method of learning?

"Let me show you how I will take my blood pressure at home each day"

A nurse is discussing the nurse's role in client education with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of a nurse's role?

"Nurses make up the greatest percentage of members on a health care team."

A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching?

"Nurses will pair together to care for an assigned group of clients"

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply)

- "Respect the client during the conversation" - "Allow time for reflection during the conversation with the client"m - "Show empathy during the conversation with the client"

A nurse os assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next?

Blood Pressure

A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?

Right task

A nurse is delegating the ambulation of a client who had a knew arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (select all that apply) - the roommate ambulates independently - the client ambulates wearing slippers over anti embolic stockings - the client uses a front-wheeled walker when ambulating - the client had pain med 30 min ago - the client is allergic to codeine - the client ate 50% of breakfast this morning

- the client ambulates wearing slippers over anti embolic stockings - the client uses a front-wheeled walker when ambulating - the client had pain med 30 min ago

Which of the following actions should the nurse take when demonstrating an empathetic presence to a client? (Select all that apply) - use an open posture - write down what the client says to avoid forgetting details - establish and maintain eye contact - nod in agreement with the client throughout conversation - sit facing the client

- use an open posture - establish and maintain eye contact - sit facing the client

A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. (Move the levels into the box on the right, placing them in order of priority. use all the levels.)

1. Physiological needs (Level 1) 2. Safety needs (Level 2) 3. Love and belonging (Level 3) 4. Esteem (Level 4) 5. Self-actualization (Level 5)

A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment?

A client who reports new chest pain.

A nurse is caring for a client who is experiencing unexpected manifestation with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment?

ABCDE

A nurse in a provider's office is collecting data from the caregiver of a 12 month old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?

Affective (because the client's ideas about toilet training has changed)

A nurse is providing teaching to a client who has a new prescription for eye drops. Which of the following teaching strategies is an example of using the psychomotor domain of learning?

Ask the client to teach-back about how to use the medication

A nurse is planning a 30-min group education class. Which of the following actions should the nurse plan to take to address various learning styles related to the domains of learning?

Provide games, discussion, and question-and-answer

A nurse is planning a smoking cessation program for a client. Which of the following actions is a component of SMART outcome goals?

Providing a time frame to accomplish the outcome.

A charge nurse is assisting client care for 4 clients. Which of the following tasks should the nurse assign to a PN?

Providing nasopharyngeal suctioning for a client who has pneumonia

A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Its that correct?" Which of the following therapeutic communication techniques is the nurse using?

Restating

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

Sit at eye level with the child

A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client?

Speak to the client clearly and at a slow pace

A nurse is preparing to educate a client about the proper procedure for a dressing change. Which of the following indicates an understanding of Knowles's fundamental principles of client readiness?

The client is engages and alert.

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?

Use an alternate method for determining the client's pain level.

A nurse is providing discharge instructions to a client during a follow up telephone call. Based o the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating?

sender

A nurse is providing teaching to a client who has a recent diagnosis of pancreatic cancer. The nurse is using strategies in the affective domain of learning. Which of the following client statements is part of the affective domain?

"I've been crying a lot since I learned about my diagnosis. I'm worried about everything."

A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching?

Client education can improve self care at home.

A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?

"This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being."

A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority? - the client reports dizziness when standing - the client has not had a bowel movement in 3 days - the client has non-pitting edema in the lower extremities - the client has several scratch marks on their abdomen

- the client reports dizziness when standing

A nurse is planning to teach new assistive personal how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30 min face to face lecture and a written copy of the step by step procedure. Which of the following

- verbal - written - nonverbal

A nurse manager is assigning care of a client who is being from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?

Registered Nurse (RN)

A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take?

Ensure the client is wearing their glasses during the teaching

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

The client is able to demonstrate the appropriate technique

A nurse calls the unit to say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe" After hanging up the phone, the charge nurse then says to the staff at the nurse's station, "I'm tired of that nurse being late. I wish someone would do something about their tardiness" With of the following communication styles is the charge nurse demonstrating?

passive-aggressive

A nurse is preparing an in service program about delegation. Which of the following are components of the five rights of delegation? (select all that apply) - right place - right supervision and evaluation - right direction and communication - right documentation - right circumstances

- right supervision and evaluation - right direction and communication - right circumstances

A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive /least invasive priority setting framework, which of the following actions should the nurse take first?

Cover the IV with an elastic bandage

A nurse is instructing a client regarding heart healthy activities. This action represents which of the following phases of the nurse-client relationship.

Exploitation

A nurse is providing teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request a medical interpreter to be present

A nurse is caring fro a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care?

Urgent

A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?

make a list and prioritize a plan

A nurse is teaching a client who is newly diagnosed with Diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes". Using the Schramm model of communication, the nurse should recognize the client's statement as an example which of the following components of the model?

Feedback

A nurse educator is planning an in-service for staff nurses about psychomotor client teaching strategies. Which of the following activities requires the use of gross motor skills? (select all that apply) - a client walking with crutches - a client using manual wheelchair - administering an intradermal injection to a client - opening a client's medication bottle - applying an adhesive bandage to a client's finger

- a client walking with crutches - a client using manual wheelchair

A nurse is assessing a client's health literacy prior to providing education. Which of the following actions should the nurse take? (Select all that apply) - ask questions regarding the client's health care needs and concerns - obtain a health history - assess the client's education level - perform a physical assessment - use medical terminology when education the client

- ask questions regarding the client's health care needs and concerns - obtain a health history - assess the client's education level

A nurse is preparing for a teaching session with a client. Which of the following actions should the nurse take to provide the client with unbiased care? (select all that apply) - avoid assumptions about the client - compare the client to a former client. - Ask coworkers to share their past experiences with similar clients - control personal thoughts about the client - collaborate with another nurse to develop teaching strategies

- avoid assumptions about the client - control personal thoughts about the client - collaborate with another nurse to develop teaching strategies

A nurse is caring for a. client who has a new prescription for dialysis 3x/week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children.The client also states, "I dont know how I am goin two have time for dialysis" Which of the following factors are influencing there client's communication? (select all that apply) - psychosocial factors - cognitive factors - situational factors - environmental factors - physiological factors

- psychosocial factors - situational factors

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use?

schedule a face to face unit staff meeting

A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication?

Nonverbal

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods.

A nurse is preparing a low-stimulus environment for an educational session on smoking cessation. Which of the following should the nurse implement?

Set the thermostat to a comfortable temperature

A nurse has received change of shift report on four clients. Which of the following clients should the nurse plan to see first? - A client who is scheduled for an abdominal ultrasound - a client who needs a urine specimens sent to the lab - A client who has audible wheezing during respirations - A client who requests their routine pain medication

A client who has audible wheezing during respirations

A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart healthy diet. Which of the following actions should the nurse take to evaluate the client's learning?

Ask the client to explain how to select or prepare meals