Fundamentals Unit 2 (Professional Standards in Nursing)

8. An antihypertensive medication has been prescribed nurse that she would like to take an herbal substance for a client with hypertension . The client tells the to help lower her blood pressure . Which statement by the nurse is most important to provide to the client ?

" You will need to talk to your primary health care provider ( HCP ) before using an herbal substance . "

26. The nurse is educating a new nurse about mass casualty events ( disasters ) . Which statement by the new nurse indicates a need for further teaching ? Select all that apply .

2. " Mass casualty events do not require an increase in the number of staff that are needed . " 3. " A mass casualty event occurs only within the heath care facility and could endanger staff " 5. " A mass casualty event occurs if a fight between visitors occurs in the emergency department . "

3. The nurse is caring for a group of clients who are taking herbal medications at home . Which client should be given instructions with regard to avoiding the use of herbal medications ?

A 10 - year - old female client with a urinary tract infection

30. The nurse is assigned to care for four clients . When planning client rounds , which client should the nurse collect data from first ?

A client receiving oxygen who is having difficulty breathing

24. The nurse is assigned to care for four clients . When planning client rounds , which client should the nurse check first ?

A client who is dependent on a ventilator

23. The nurse employed in a long - term care facility is planning the client assignments for the shift . Which client should the nurse assign to the unlicensed assistive personnel ( UAP ) ?

A client who requires a 24 hour urine collection

22. The nurse is planning the client assignments for the day . Which is the most appropriate assignment for the unlicensed assistive personnel ( UAP ) ?

A client who requires frequent ambulation

25. The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department . The nurse should assign priority to which client ?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

16. The nurse finds the client lying on the floor . The nurse calls the registered nurse , who checks the cli ent and then calls the nursing supervisor and the pri mary health care provider to inform them of the occurrence . The nurse completes the incident report for which purpose ?

A method of promoting quality care and risk management

2. The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch . A kosher meal is delivered to the client . Which nursing action is appropriate when assisting the client with the meal ?

Allowing the client to unwrap the utensils and prepare his own meal for eating

21. The nurse is recording a nursing hands - off ( end - of shift ) report for a client . Which information needs to be included ?

As - needed medications given that shift

28. A client experiences cardiac arrest . The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group . In this situation the nurse is implementing which leadership style ?

Autocratic

15. The nurse enters a client's room and notes that the client's lawyer is present and that the client is prepar ing a living will . The living will requires that the cli ent's signature be witnessed , and the client asks the nurse to witness the signature . Which is the appropriate nursing action ?

Decline to sign the will .

12. The licensed practical nurse ( LPN ) enters a client's room and finds the client lying on the bathroom floor . The LPN calls the registered nurse , who checks the client thoroughly and then assists the cli ent back into bed . The LPN completes an incident report , and the nursing supervisor and primary health care provider ( PHCP ) are notified of the incident . Which is the next nursing action regard ing the incident ?

Document a complete entry in the client's record concerning the incident .

6. The nurse is planning to reinforce nutrition instructions to an African American client . When reviewing the plan , the nurse is aware that which food may be a common dietary practice of clients with African American heritage ?

Fried foods

27. The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility . The nurse is told that the nursing model is a team nursing approach . The nurse determines that which describes the team - based model of nursing practice ?

Nursing staff are led by the nurse when providing care to a group of clients .

29. The nurse has delegated several nursing tasks to staff members . Which is the nurse's primary responsibility after the delegation of tasks ?

Perform follow-up with each staff member regarding the performance and outcome of the task .

5. The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair . Which information about the client is of lowest priority during the data collection ?

Psychosocial

17. The nurse observes that a client received pain med ication 1 hour ago from another nurse , but the client still has severe pain . The nurse has previously observed this same occurrence several times . Based on the nurse practice act , the observing nurse should plan to take which action ?

Report the information to a nursing supervisor .

The nurse arrives at work and is told to report ( float ) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients . The nurse has never worked in the pediatric unit Which is the appropriate nursing action ?

Report to the pediatric unit and identify tasks that can be safely performed .

7. The nurse consults with a dietitian regarding the dietary preferences food should the nurse suggest to include in the diet of an Asian American client . Which plan ?

Rice

19. A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights . The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent

9. A Hispanic American mother brings her child to the clinic for an examination . Which is most important when gathering data about the child ?

Touching the child during the examination

13. An unconscious client , bleeding profusely is brought to the emergency department after a serious accident . Surgery is required immediately to save the client's life . With regard to informed consent for the surgical procedure , which is the best action ?

Transport the client to the operating department immediately without obtaining an informed consent

4. The client asks the nurse about various herbal ther apies available for the treatment of insomnia The nurse should encourage the client to discuss the use of which product with the primary health care provider ?

Valerian

20. An older woman is brought to the emergency department . When caring for the client , the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks . The nurse asks the client how the bruises were sustained . The client , although reluctant , tells the nurse in confidence that her daughter frequently hits her if she gets in the way . Which is the appropriate nursing response ?

" I have a legal obligation to report this type of abuse . "

1. A client is diagnosed with cancer and is told that sur gery followed by chemotherapy will be necessary . The client states to the nurse , " I have read a lot about complementary therapies . Do you think I should try any ? " The nurse should respond by making which appropriate statement ?

" Tell me what you know about complementary therapies . "

10. A nursing student is asked to identify the practices and beliefs of the Amish society . Which should the student identify ? Select all that apply .

1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 5. They use both traditional and alternative health care , such as healers , herbs , and massage . 6. Funerals are conducted in the home without a eulogy , flower decorations , or any other dis play. Caskets are plain and simple, without adornment

11. Which identifies accurate nursing documentation notations ? Select all that apply .

1. The client slept through the night . 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness , drainage , or edema .

18. A client has died , and the nurse asks a family member about the funeral arrangements . The family member refuses to discuss the issue . Which is the appropriate nursing action ?

Remain with the family member without discuss ing funeral arrangements .