Fundamentals exam 2

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have:

personal values.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?

boxs away from body

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

demonstrating a common gait for the older

The nursing student is describing moral values to another student. Which statement is correct?

"Moral values give individuals some sense of what is right and wrong."

Which statement by the nurse is an example of deception?

"This injection of procaine will feel like a little pinch."

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

Which word is best described as protection and support of another's rights?

Advocacy

Which ethical principle refers to the obligation to do good?

Beneficence

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability?

Filling out an occurrence report and notifying the healthcare provider

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal

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

Parents giving money to a child for receiving an exemplary report from school is an example of which type of value transmission?

Rewarding

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?

lying flat

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?

move the client to edge of the bed opposite the side that client will be turning

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client is aware of spatial relationships to avoid the table.

Which is the best definition of ethics?

The formal, systematic study of moral beliefs

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Which action would cause a charge nurse to have concerns about a nurse's moral agency?

The nurse was seen at a grocery store after calling in sick.

Which traits are examples of virtues that can exemplify character and conduct as a professional nurse? Select all that apply.

Trustworthiness Humility Compassion

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

transfer belt

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

A client is to do quadriceps drills as an isometric exercise after surgery. The nurse provides which information about this exercise? Select all that apply.

"Do not hold your breath while tightening the muscle." "The muscle you are tightening is the one on the front of the thigh."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else."

A charge nurse has implemented staff education on nursing values. The nurse would determine that further education is required when which statement(s) are overheard? Select all that apply.

"If that was my mother, I sure wouldn't agree to a no-code. "I can't believe the client is giving that precious baby up for adoption." "The gonorrhea test was positive. That's what the client gets for sleeping around."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?

"To preserve the client's functional ability to grasp and pick up objects."

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward."

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

A nurse's friend states, "I admire you so much. I would love to be a nurse, but I don't think I have the courage." Which response will the nurse make?

"You can work on being more courageous as you learn to be a nurse."

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"near the client's hip, with legs shoulder width apart and one foot near the head of the bed

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A nurse has completed 4 hours of an 8-hour shift on a medical-surgical unit when the nursing supervisor calls. The nursing supervisor directs the nurse to give a report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with client assignments and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources

Which example best describes feminist ethics?

An approach critiquing existing patterns of oppression and domination in society

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?

Assist in decision making based on the client's best interests.

A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?

Autonomy

A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle?

Autonomy

Which ethical principle is related to the idea of self-determination?

Autonomy

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Quality improvement (QI) Teamwork and collaboration

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

Which example most accurately depicts the ethical principle of autonomy?

Describing a surgery to a client before the consent is signed

A nurse pulls the curtains closed before changing the dressing of the surgical wound on the abdomen of a postsurgical client. What value is served?

Dignity

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

A nurse is promoting exercise and activities for an older adult client. Which teaching point would be appropriate for this client?

Encourage the client to warm up before beginning exercises and to cool down after exercising.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away.

A hospice nurse is caring for a client with terminal cancer. The family would like the client to continue aggressive therapy to treat the cancer, but the client has voiced to the nurse that no further pursuit of treatment is desired. The nurse speaks to the family about the client's wishes, condition, and terminal state. This action is most likely derived from which nursing obligation?

Ethical principles

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

Florence Nightingale

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating?

Integrity

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

Integrity

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources

A nurse is caring for a hospitalized client. Which nursing actions demonstrate a caring and compassionate attitude? Select all that apply.

Notifying the client before leaving for lunch Offering snacks and beverages to visiting family Listening to the client tell stories about past experiences Explaining all nursing procedures clearly

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

Paternalism

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient portal

What is likely to have the greatest influence on an adolescent's formation of values during this developmental stage?

Peers

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for Poisoning related to poor eyesight and the inability to read medication labels

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Safety equipment for playing sports

A nurse is providing care to an older adult client who was just diagnosed with cancer. The client together with the immediate family discuss their preferences with the health care providers involved. The health care providers offer their clinical recommendations about possible treatments. Ultimately, the group arrives at a decision. The nurse interprets this decision-making process as reflecting which type?

Shared

A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing the nurse's own judgments based on the nurse's expertise. Which type of healthcare decision making does this represent?

Shared decision making

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth from the legs to the back muscles.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk gently to her.

A client continues to complain of pain despite receiving medication. The family states, "In our culture it is acceptable to complain out loud." What would be the best response by the nurse?

Tell me more about your cultural beliefs.

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

Which nursing action(s) best demonstrate the ethical principle of autonomy? Select all that apply.

The nurse documents that a client refused a new medication. The nurse checks to ensure an informed consent document is signed prior to transferring the client for a surgical procedure.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

Which is a characteristic of the care-based approach to bioethics?

The promotion of the dignity and respect of clients as people

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.

Nurses who value client advocacy follow what guideline?

They give priority to the good of the individual client rather than to the good of society in general.

n informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

Use of strong passwords

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment.

What is the term for the beliefs held by the individual about what matters?

Values

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Vomiting Drowsiness Headache

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.

We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive." "This system fits nicely into how we work."

A parent teaches a child not to drink and drive; however, the parent does drink and drive. This action results in:

a failure to model one's own values.

A nurse is caring for an 18-month-old client after a tracheostomy. The client is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A client tells the nurse that the client does not want to have a painful procedure. By respecting and supporting the client's right to make decisions, the nurse is demonstrating

advocacy.

To practice ethically, the nurse should avoid:

allowing the nurse's own judgment to guide practice.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

An informatics nurse specialist is describing the role of informatics in health care to a group of staff at a facility. The nurse specialist determines that the teaching was successful when the group identifies which as a core practice area?

electronic health record

When moving a client up in bed with the assistance of another caregiver, the nurse should:

have the client fold the arms across the chest.

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

Which scenario is an example of the laissez-faire approach to value transmission?

let a kid decide for an iv

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

near the client's hip, with legs shoulder width apart and one foot near the head of the bed

A nurse shows client advocacy by

offering a hospice consultation to a client who is terminally ill.

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?

orthostatic hypotension

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

prone

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

restrain the baby in car seat

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

simplicity

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding?

spasticity.

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

supine

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

tremor

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls