Fundamentals PrepU Questions Exam 2

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? A. Ongoing B. Initial C. Outcome D. Discharge

A

A novice nurse is engaging in reflection. The nurse would most likely be involved in which action? A. Describing the events B. Evaluating what assumptions were made C. Asking what thoughts had occurred D. Looking at the context of the situation

A

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? A. Assess the client's response to the ambulation. B. Discuss the client's feelings about the illness. C. Document the client's ambulation. D. Inform the client when ambulation is scheduled next.

A

The primary purpose of nursing implementation is to: A. help the client achieve optimal levels of health. B. implement the critical pathway for the client. C. improve the client's postoperative status. D. identify a need for collaborative consults.

A

When providing culturally competent care to clients, a nurse understands that cultural competence involves which characteristics? Select all that apply. A. Knowledge of influences on the clients' beliefs B. Guidance by the principles of fidelity C. Awareness of one's own influences on responses D. A commitment to promoting health equity E. A process that requires life-long learning

A, C, D, E

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? A. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. B. Prioritize the nursing diagnoses. C. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. D. Do not allow the client to review the client's own nursing diagnoses.

B

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? A. Set priorities using client care standards. B. Seek research about the disorder. C. Consult with another nurse. D. Follow institutional guidelines.

B

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: A. dependent nursing diagnoses. B. actual or potential nursing diagnoses. C. syndrome nursing diagnoses. D. collaborative nursing diagnoses.

B

A new resident in a long-term care facility who was having difficulty adapting to the routine has begun participating in activities on a daily basis. Which stage of culture shock is this resident displaying? A. Disenchantment B. Honeymoon C. Beginning resolution D. Effective functioning

C

A nurse is demonstrating ethnocentrism. Which statement would reflect this concept? A. "Asians are always the smartest in the class." B. "Anybody on welfare is just lazy." C. "My Russian heritage is superior to all others." D. "Irish people are all heavy drinkers."

C

What outcome does the nurse hope to achieve by evaluating the plan of care of a client who is being discharged? A. To formulate a database of nursing diagnoses B. To transfer medical prescriptions to the plan of care C. To direct future nurse-client interactions D. To allow the nurse to terminate the nurse-client relationship

C

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis? A. Composition B. Dysfunction C. Descriptors D. Qualifications

C

Which is a cultural norm of the health care system? A. The omnipotence of technology is yet to be recognized. B. There are rigid procedures attending birth and death. C. There is the use of a systematic approach and problem-solving methodology. D. There is a tolerance of tardiness, disorderliness, and disorganization.

C

Which is the most appropriate example of the assessment phase of the nursing process? A. Documenting the administration of a medication provided for pain B. Including a nursing diagnosis of Acute Pain in the client's plan of care C. Palpating a mass in the right lower quadrant of the abdomen D. Evaluating the temperature of a client given medication for a fever

C

Which outcome for a client with a new colostomy is written correctly? A. Explain to the client the proper care of the stoma by 3/29/20. B. The client will know how to care for the stoma by 3/29/20. C. The client will demonstrate proper care of the stoma by 3/29/20. D. The client will be able to care for stoma and cope with psychological loss by 3/29/20.

C

Which statement best conveys the relationship between race and ethnicity? A. Race is based on an individual's cultural history and is independent of ethnicity. B. Race and ethnicity are both culturally determined concepts. C. Race denotes physical characteristics, while ethnicity is rooted in a common heritage. D. Race and ethnicity can be considered to be synonymous in the context of health care.

C

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? A. Previous knowledge B. Intelligence C. Preparation D. Anxiety

D

A preconceived and untested belief about an individual or group of individuals is: A. racism. B. cultural relativity. C. culturally competent care. D. stereotyping.

D

In a helping relationship, the nurse would most likely perform what action? A. Set up a reciprocal relationship in which both the client and nurse are giving and receiving help. B. Establish goals for the client that are not set in a specific time frame. C. Encourage the client to independently explore goals that allow the client's human needs to be satisfied. D. Establish communication that is continuous and reciprocal.

D

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: A. employs communication to meet the client's needs. B. applies intuition and routine care for clients. C. uses scientific problem solving to meet client problems. D. uses critical thinking to direct care for the individual client.

D

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? A. Assessing; diagnosing B. Diagnosing; implementing C. Implementing; evaluation D. Planning; implementing

D

The nurse is aware that nursing diagnoses are: A. dictated by the medical diagnoses and change day by day. B. based on assessment data and the primary care provider's input. C. collaborative and depend on the medical diagnosis. D. within the nursing scope of practice to develop and client-focused.

D

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: A. subjective. B. process. C. outcome. D. structure. E. goal.

D

Which is the priority question for the nurse to consider before implementing a new intervention? A. Will I need someone to assist me? B. What equipment do I need? C. How much experience do I have with this treatment? D. Does this treatment make sense for this client?

D

Which organization audits charts regularly? A. Sigma Theta Tau International B. American Nurses Association C. National League for Nursing D. The Joint Commission

D

Which activity is the clearest example of the evaluation step in the nursing process? A. Checking the client's blood pressure 30 minutes after administering captopril B. Recognizing that the client's blood pressure of 172/101 is an abnormal finding C. Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading D. Taking a client's blood pressure on both arms at the beginning of a shift

A

Which guideline should the nurse follow when including interventions in a plan of care? A. Date the nursing interventions when written and when the plan of care is reviewed. B. Make sure the nursing interventions are unrelated to the original outcomes. C. Make sure each nursing intervention does not describe the action the nurse should perform. D. Make sure the attending physician approves of and signs the nursing interventions.

A

Which nursing action can be categorized as a surveillance or monitoring intervention? A. Auscultating of bilateral lung sounds B. Providing hygiene C. Administering a paracetamol tablet D. Use of therapeutic communication skills

A

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? A. Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing B. Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor C. Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing D. Inadequate Hygiene related to homelessness as evidenced by client's stink

B

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A. "The provider will need to give permission for you to review." B. "Only authorized persons are allowed to access client records." C. "Let me get that for you." D. "I am sorry I can't access that information."

B

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A. Surveillance B. Psychomotor C. Psychosocial D. Maintenance

B

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: A. identifies the unhealthy response preventing desired change. B. identifies factors causing undesirable response and preventing desired change. C. identifies client strengths. D. suggests client goals to promote desired change.

B

Which is a characteristic of person-centered care? A. It involves general care for all clients. B. It is a framework for providing care. C. It can be used in hospital settings. D. It is independent of other disciplines.

B

Which phase of the nursing process most involves establishing priorities? A. Assessment B. Outcome identification and planning C. Implementation D. Diagnosis

B

A nurse is attempting to gain insight into a client's cultural beliefs and attitudes. Which methods would the nurse likely use? Select all that apply. A. Short-term observation B. Key informants C. Ethnographic interviewing D. Open-ended interviewing E. Use of the client's language

B, C, D, E

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: A. expect the client to be drowsy, and let the client rest. B. evaluate the abdominal dressing for drainage. C. complete the postoperative assessment. D. administer pain medication.

C

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? A. Evaluation B. Diagnosis C. Planning D. Implementation

C

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? A. Experience B. Reflection C. Nursing process D. Clinical reasoning

C

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? A. Possible B. Risk C. Actual D. Health promotion

C

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? A. Ongoing B. Discharge C. Standardized D. Initial

C

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? A. It provides and refers to a client's problem by a number. B. It documents assessments on separate forms. C. It provides quick access to abnormal findings. D. It records progress under problems, intervention, and evaluation.

C

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? A. Continue the education and remind the client that it is essential to learn self-care. B. Medicate the client for anxiety and continue the education later. C. Discontinue the education and attempt at another time. D. Discontinue the education and ask the client for permission to teach a family member.

C

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? A. Change the nursing diagnosis because the client's problem was falsely identified. B. Reassess the client for more symptoms of deficient fluid volume. C. Modify the plan of care and interventions to meet the client's needs. D. Develop an additional nursing diagnosis to meet the client's health needs.

C

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? A. Licensed practical nurse B. A senior nursing student present for clinical C. Nursing assistant who is a nursing student D. Registered nurse

C

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response? A. Move closer to the client. B. Back away from the client. C. Ask the client about personal space preferences. D. Ask the client why he or she is backing away.

C

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? A. Initiate an intravenous line and administer 500mL of normal saline. B. Perform a full review of systems. C. Discuss the need to change positions slowly, especially when moving from sitting to standing. D. Perform vital signs and blood glucose level.

D

The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action? A. Honoring rituals B. Racism C. Transcultural nursing D. Stereotyping

D

What is the purpose of the diagnosis phase of the nursing process? A. To decide whether to continue, modify, or terminate client care B. To determine the client's health status C. To develop an individualized plan of client care D. To develop a prioritized list of client-centered problems

D

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? A. narrative charting B. FOCUS charting C. PIE charting D. SOAP charting

D

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? A. Evaluation B. Memorization C. Assessment D. Reflection

D

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? A. Educational B. Maintenance C. Psychomotor D. Surveillance

D

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? A. Relevance B. Precision c. Accuracy D. Clarity

D