NU-205 Exam 3

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

Which is not an example of a problem statement?

"Is it better to tell clients that a medical error has occurred with their care and do an internal investigation, or tell them about the error and do an internal investigation?"

Sign every entry Document in chronological order Identify the day and time for each entry Acknowledge the client's response to the medication

Add the correct information, making a notation of why the error occurred with the date of correction.

A nurse is conducting a research study involving a group of individuals diagnosed with inflammatory bowel disease. The nurse researcher protects the subjects' privacy by ensuring which? Select all that apply.

Anonymity Confidentiality

Which ethical principle refers to the obligation to do good?

Beneficence

What is the primary purpose of the client record?

Communication

A nurse researcher is planning to conduct a research study and applies to the appropriate Institutional Review Board (IRB) for approval. When applying to the IRB, which information would the nurse researcher be required to include? Select all that apply.

Detailed plans for data security A proposed consent form

A nurse researcher is involved in an experimental research study. Which component would the nurse researcher manipulate?

Independent variable

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 is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered?

Nursing care now uses EBP as a means of ensuring quality care.

Which is an example of nonmaleficence?

Protecting clients from a chemically impaired practitioner

Which skill is foundational for a nurse's participation in the evidence-based practice process?

Read and understand a research article.

Which events in the history of nursing research occurred in the 1970s and 1980s? Select all that apply.

Research was focused on clinical practice, including clinical interventions. Primary client care led to research investigating outcomes and quality of care. The nursing process was studied. Concerns of nursing education involved student-learning experiences and clinical evaluation.

Which is the best definition of ethics?

The formal, systematic study of moral beliefs

A nurse has accessed a website while conducting a literature review. The nurse determines that the coverage is reliable based on which findings? Select all that apply.

The intended audience is clear. Extra features not available in other formats are provided

A nurse is using the quantitative research process to study the cause of healthcare-associated infections (HAI) and how to prevent them. Which actions are examples of the components of this process? Select all that apply.

The nurse collects data from subjects in the study. The nurse formulates a hypothesis and variables in the study.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

A nurse seeks to incorporate the principle of bioethics known as nonmaleficence when caring for clients in a long-term care facility. Which nursing actions best exemplify this principle? Select all that apply.

The nurse performs regular client assessments for pressure injuries. The nurse follows "medication rights" when administering medicine to clients.

A nurse exits the room of a confused client without raising the side rails on the bed. The failure to raise the side rails would constitute which element of liability related to malpractice?

breach of duty

A nurse is developing a plan for a qualitative research study. Which elements would be most important for the nurse to incorporate into the plan? Select all that apply.

holistic viewpoint of the problem use of subjective interactions application of intuition for analysis

Ethical distress is:

knowing the correct action but being unable to perform it due to constraints.

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.

"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." "If that was my mother, I sure wouldn't agree to a no-code."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

An illegal immigrant with no health insurance sustained life-threatening injuries in an automobile accident. Which action in this case demonstrates the ethical principle of justice?

Airlifting the client to a local trauma center for emergency surgery

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

Breach of duty

Which statement best reflects translational research?

Bridge from theory to practice

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?

Certification

Which example most accurately depicts the ethical principle of autonomy?

Describing a surgery to a client before the consent is signed

Which aspect of nursing would most likely be defined by legislation at the state level?

Differences in scope of practice between registered nurses and licensed practical nurses

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

The nurse is reading about nursing theorists for a class. The theory reveals the following, "Individuals who use self-care to sustain life and health, to recover from disease or injury, or to cope with its effects." Which individual developed this theory?

Dorothea Orem

Which is a focus of medical research rather than nursing research?

Drug metabolism

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated?

Duty

A nurse is being sued for malpractice in a court of law. What elements must be established to prove that malpractice or negligence has occurred? Select all that apply.

Duty Breach of duty Causation

A nurse is providing care to a client and is preparing the client for breakfast. The nurse assists the client out of bed to the chair and then helps the client open the items on the breakfast tray. The client begins to eat breakfast. The nurse tells the client, "I'll be back in about 10 minutes to check on you. In the meantime, here is your call light in case you need me." About 10 minutes later, the nurse returns to check on the client. The nurse is demonstrating which ethical principle?

Fidelity

A nurse is reviewing nursing theory for usefulness in a home healthcare setting. Which is the appropriate application of Dorothea Orem's Self-Care Model in a home healthcare setting?

Match the client's self-care needs with appropriate supportive interventions.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider?

SBAR

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply.

The client exhibits agitation and shouts at the nurse. The client's blood pressure is 135/82 mm Hg. The client's skin turgor is normal. The client has redness around the ankles bilaterally. The client participates in range-of-motion exercises.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report?

The client was found lying on the floor.

Which are areas of potential liability for the nurse? Select all that apply.

The nurse fails to document refusal by the client to ambulate following surgery. The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour.

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

A nursing student is formulating a problem statement for a research project. What will ensure that the study is a logical extension of the problem cited?

The population being studied is specified in the problem statement.

The nurse is preparing to submit a research project to the institutional review board (IRB). The nurse understands that if the IRB were to reject the research project, it would most likely be for which reason?

The project lacks sufficient safeguards to protect human subjects.

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

The promotion of the dignity and respect of clients as people

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.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

flow sheet

A nurse uses the process of quantitative research to study the incidence and causes of hospital-acquired pneumonia in the nurse's hospital. The statement of what the researcher expects to find in these studies is called the:

hypothesis.

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

Which of the following illustrates the activity of acting in values clarification?

respecting the human dignity of all clients

As part of a class assignment, a beginning professional nursing student is to prepare a research paper. Which action would be most appropriate to take when identifying a problem area?

review scientific literature to develop a research idea

A client who is cognitively impaired is scheduled to undergo surgery. The nurse demonstrates understanding of the principle of autonomy and checks the client's health record to ensure that consent has been obtained from which person?

surrogate decision-maker

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

to improve quality of care

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

A nurse is caring for a client with a complete spinal cord injury that has caused paraplegia. The client is very distraught and asks the nurse, "Are they sure, even with therapy, I will never walk again?" Which statement made by the nurse demonstrates veracity?

"You have a complete injury, which results in a total loss of movement and sensation below the level of injury."

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

Which could be considered an example of a qualitative research project?

A PhD nursing student is collecting data on how Somali immigrants perceive the care they receive in one community clinic. The nursing student is taping and analyzing interviews with clients that have been in the country and community 2 years or less and who have sought care at least once at this clinic.

A nurse is planning to participate in a research project and is looking for information about what is already known about the topic. The nurse is involved in which step of the research process?

A nurse is planning to participate in a research project and is looking for information about what is already known about the topic. The nurse is involved in which step of the research process?

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Assault

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

A nurse who provides the information and support that clients and their families need to make the decision that is right for them is practicing what principle of bioethics?

Autonomy

A nurse develops the following foreground question using the PICOT format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention?

Chromium supplements

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

Which statement is most applicable to evidence-based practice?

Clinical expertise is integrated with external evidence.

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice?

Code of Ethics

A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However, the client asks the nurse not to put on vest restraints. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. Which element of liability does this description of the client's injuries represent in terms of proof of malpractice?

Damages

A nursing student learns how to give injections from the nurse manager, who dictates a list of steps to follow. This is an example of the acquisition of what type of knowledge?

Descriptive rule-based

A client is brought to the emergency department by an adult child, who states, "I am unable to care for my parent anymore. Although I would like to, financially and physically I can't do it anymore." What ethical problem is the adult child experiencing?

Distress

Which charting format permits documentation on any significant topic, not just client problems?

FOCUS

The nurse is gathering data from interviews of terminally ill clients and their families while conducting a research study on how family support impacts the quality of life in a terminally ill client. Which element would the nurse identify as the independent variable?

Family support

A nurse has applied soft wrist restraints to a client following endotracheal intubation. Documentation of which information is essential when using restraints on a client? Select all that apply.

Findings from patient assessment, performed every 2 hours Foley catheter draining clear yellow urine 0.9 normal saline infusing intravenously at 100 mL/hr

The nurse beginning practice would like to access the standards for ethical practice. Which organization should the nurse research for these standards?

International Council of Nurses

What is the primary ethical dilemma posed when using restraints on an older adult client in a long-term care setting who is confused?

It threatens autonomy

The nursing staff on a clinical unit is excited to learn a recent nursing graduate with a Master's degree is joining the team. As the team is working toward achieving a Magnet designation, which functions will the new nurse help to fulfill with this goal?

Provide expertise and knowledge related to nursing research

Which is the best example of evidence-based nursing practice?

Recommending ginger to alleviate nausea and vomiting in obstetric clients based on a literature review

Which action most clearly demonstrates a nurse's commitment to social justice?

Lobbying for an expansion of healthcare resources and benefits to those in poverty

Which actions by the nurse demonstrate the ethical principle of fidelity? Select all that apply.

Maintaining current nursing registration and meeting continuing education requirements Performing an intervention for a client at the time that was promised Taking an extra client assignment so that the client will be cared for

A home health nurse performs a careful safety assessment of the home of a frail older adult client to prevent harm to the client. The nurse is acting in accord with which principle of bioethics?

Nonmaleficence

During the first half of the 20th century, a change in the structure of society resulted in changed roles for women and, in turn, for nursing. What was one of these changes?

Nursing research was conducted and published.

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

Sign every entry Document in chronological order Identify the day and time for each entry Acknowledge the client's response to the medication

A group of nurses is planning to conduct a research study and is evaluating various online sources for information. The search reveals the following information on the various sites. The nurses determine that the site containing which information is valid and accurate? Select all that apply.

Site purpose clearly stated Selected list of resources provided University affiliation provided

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What is an example(s) of legal safeguards for the nurse? Select all that apply.

The nurse confirms informed consent was give by the client to perform a procedure. The nurse educates the client about what to expect during the hospital stay. The nurse documents all client care in a timely manner.

A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse confirms that the client's family has signed the consent form.

A client nearing the end of life requests that the client be given no food or fluids. The physician orders the insertion of a nasogastric tube to feed the client. What is the primary concern of the nurse providing care?

The nurse faces an ethical dilemma about inconsistent courses of action.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?

The nurse should call and inform the nursing supervisor of the situation.

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?

The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public

A nurse is reading a journal article about evidence-based practice. The nurse understands that this practice is an outcome of which type of research?

Translational

A nurse is preparing to document care provided to a client. What would be most appropriate for the nurse to do to ensure that the documentation is concise?

Use phrases in narratives.

A client with a diagnosis of colorectal cancer has been presented with the treatment options, but wishes to defer any decisions to an uncle, who acts in the role of a family patriarch within the client's culture. The client's right to self-determination is best protected by:

respecting the desire to have the uncle make choices on the client's behalf.

A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. The nurse helps the client to get up, makes him comfortable, and then informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

to evaluate quality care and potential risks for injury to the client

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation?

when communicating a client's change in condition to the client's physician

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply.

A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit.

The American Nurses Association's Commission on Nursing Education developed guidelines for the investigative function of nurses at different educational levels. Which guideline is for a nurse with an associate degree?

Assists in collection of data within an established, structured format

A nurse researcher is planning to disseminate research findings. Which method would be appropriate for the nurse researcher to use? Select all that apply.

Oral presentation Poster presentation Printed clinical journal

A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which element will the "O" in the team's PICO question refer to?

Preventing Skin Breakdown