NUR02: Clinical Decision ➺ Final Review Questions

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?

"Do you mostly participate in the religious traditions of your family?

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the *background* portion of the report

"He is four days postoperative and his incision is open to air."

A nurse plans to initiate rapport and build trust with their client. Which of the following statements by the nurse displays an appropriate communication technique?

"Tell me more about how you are feeling.

The client indicates verbally to the nurse that she does not want to "be bothered" and that "it doesn't matter anyway". Which of the following is an appropriate response from the nurse trying to develop patient trust in her?

"Tell me more about why you feel this way"

When evaluating an article for levels of evidence, which has a higher (more valid) level of evidence

*Filtered information* 1. systematic reviews 2. critically-appraised topics (evidence syntheses) 3. critically-appraised individual articles (article synopses) *Unfiltered information* 1. Randomized Controlled Trials (RCTs) 2. Cohort Studies 3. Case-Controlled Studies Case Series/Reports 4. Background Information/Expert Opinion

Which of the following is an example of closed-ended questioning? SATA

- "Are you going to group therapy tomorrow?" - "How long have you been depressed?" - "Do you not want to take your medication?" - "Do you have a family history of depression?" is correct

Which of the following is an example of the nurse using clarification on facilitate communications?

- "What would you say is the main point of what you are saying?" - "I am not sure I am following you"

A nurse is using communication techniques to resolve a conflict. Which of the following examples by the nurse displays effective communication? SATA

- Actively listening. - Embracing the concerns of others. - Communicating openly. - Using a give and take approach

A charge nurse is preparing informational material for the nursing staff on cultural competence. Which of the following would she include when discussing components of cultural congruent behavior?

- Assess the client's belief system - Determine the client's familial involvement - Evaluate the client's preferences - Understand client's decision making role

A nurse is caring for a client who is postoperative and whose airway is patent and respirations are 20 breaths per minutes. The nurse would conduct what assessments in relation to the client's circulatory status: SATA

- BP - Urinary output - Skin turgor - Pulse

Which of the following are examples of a nurse using nontherapeutic communication techniques?

- Changing the subject - Focusing on the nurse rather than the client - Giving advice - Making value judgments

Which of the following can be used to help to determine the priority risk of a client who has multiple risks? SATA.

- Maslow's - Determining the complication that poses the highest risk - Assessment of airway breathing and circulation needs

A nurse is preparing an educational program on cultural perspectives in nursing. The nurse should include that which of the following factors are influenced by an individual's culture? SATA

- Nutritional practices - Family structure - Health care interactions - Views about illness

Which of the following statements is true of factors that influence communication?

- The rate of language development is directly correlated with the patient's neurologic competence and cognitive development - Culture influences a person's worldview and relationships with the surrounding environment, religion, time an others - Communication is influenced by the way ppl value themselves, one another, and the purpose of any human interaction

Which of the following is an example of nonverbal communication?

- clearing your throat to catch someone's attention - smiling at a new resident - positive: leaning forward to listen as a resident talks about her day

Which of the following should be included in an interpersonal or interdisciplinary team? SATA

- respiratory - therapist - provider - nurse - dietitian

The rights of delegation include:

- task - circumstance - person - direction/communication - supervision/evaluation

Levels of evidence

1) Systematic reviews of RCTs 2) Individual RCT 3) Systematic reviews non-RCT (correlational) 4) Individual correlational studies 5) Systematic reviews of descriptive studies 6) Individual descriptive studies 7) Exert opinion of respected authorities or expert panels *Highest level of evidence is systematic review of findings from MULTIPLE RCTs.*

Which of the following factors are most likely to be influenced by culture as opposed to personal characteristics? Select all that apply. 1. Value of older people in society 2. Gender roles 3. Nonverbal gestures 4. Skill with technology 5. Intelligence 6. Diet

1,2,3,6

The nurse has administered a pain medication to a patient by an IV infusion. The nurse should reassess the patient's response to the pain medication within ______ minutes?

15

Place the following in order of occurrence of the steps of evidence-based practice: 1. Assess barriers to knowledge use 2. Identify a problem 3. Evaluate knowledge use 4. Identify and review knowledge to address the problem 5. Select and tailor interventions

2,4,1,5,3

A nurse is advocating for local leaders to place a newly approved community health clinic in an area of the city that has fewer resources than other areas. The nurse is advocating for the leaders to uphold which of the following ethical principles? A. Distributive justice B. Fidelity C. Respect for autonomy D. Veracity

A

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?

A client who has a fever of 38.4°C (101.2°F) with tenderness in right lower quadrant

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion

An unstable client may be defined as one who fits which of the following descriptions?

A client whose newly placed tracheostomy is producing a large amount of secretions

In which situation would the nurse be most likely to perform a focused or problem-centered history?

A patient in an outpatient clinic has cold and flu like symptoms

The nurse is providing care for a client who has a diagnosis of pneumonia due to Streptococcus pneumonia infection. What aspect of nursing care would constitute part of the planning phase of the nursing process?

Achieve SaO2 92% at all times

A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs and interdependent nursing intervention when performing which of the following actions?

Administering an IV bolus of normal saline to a patient with hypotension

The nurse is following the care plan that was created for a client newly admitted to the hospital unit. What aspect of the care plan should the nurse consider to be a nursing implementation?

Ambulate the client twice per day with partial assistance.

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

Ask the patient about the item and its significance.

The nursing process is a sequential method of problem solving that nurses use and includes which steps?

Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?

Assimilation

The nurse has just taken report on a newly admitted client who is a 15 y/o girl who is a recent immigrant. When planning interventions for this client, the nurse knows the interventions must be which of the following? SATA A. Appropriate to the nurse's preferences B. Appropriate to the patient's age C. Ethical D. Appropriate to the patient's culture E. Applicable to others with the same diagnosis

B,C,D

Expectant (Class IV)

Black tag- expected and allowed to die Ex: Massive head trauma, extensive full-thickness body burns, & high cervical SCI requiring mechanical ventilation

At the beginning of rounds when entering the room, what should the nurse do first? a. Check the intravenous (IV) infusion site for swelling or redness. b. Check the infusion pump settings for accuracy. c. Make eye contact with the patient, and introduce him or herself as the patient's nurse. d. Offer the patient something to drink.

C

The designed purpose of a clinical pathway to

CPWs are used to reduce variation, improve quality of care, and maximize the outcomes for specific groups of patients.

Which of the following statements explain why the needs of a client with a chronic illness are usually of lower priority than clients with an acute need?

Chronically ill clients have had the opportunity to physically adjust to their illness

Staff nurses in an ICU setting have noticed that their clients required lower and fewer doses of analgesia when noise levels on the unit were consciously reduced. They informed an advanced practice RN of this and the APRN to quantify the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the role of the APRN?

Contributing to the scientific basis of nursing practice

Agency policies are important to achieve culturally competent care. When reviewing a hospital's current policy framework, what action has the *most* potential to improve the overall level of culture competence?

Creating greater flexibility in visiting hours

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D

The major factor contributing to the increased emphasis on the need for proficiency in cultural nursing practice in the US is which of the following?

Demographic changes

Which of these would be formulated by a nurse using a diagnostic reasoning?

Diagnostic hypothesis

When assessing a patient's general appearance, the nurse should include which question?

Does the patient respond appropriately to questions?

The nurse is reviewing information about evidence-based practice. Which statement best reflects evidence-based practice (EBP)?

EBP emphasizes the use of best evidence with the clinician's experience.

The nurse is reviewing information about evidence-based practice. Which statements best reflects EBP?

EBP emphasizes the use of best evidence with the clinician's experience.

A nurse has integrated the principles of evidence based practice into care. EBP has the potential to help the nurse achieve what goal?

Ensuring high quality patient care

The client has their back towards the door when you enter the room. Which statement by the nurse would hinder the development of a trusting relationship?

Everyone can feel bad from time to time

A nurse is reviewing information on Hispanic culture before caring for a client who speaks only Spanish. Which of the following should bridge the cultural gap?

Expanding knowledge of the client's values

Non-urgent (Class III)

Green tag - Minor injuries that do not require immediate treatmentEx: Fractures, sprains, strains, abrasions, and contusions

When planning a cultural assessment, the nurse should include which component?

Health-related beliefs

A nurse on a postsurgical unit is providing care based on a clinical pathway. When performing assessments and interventions with the aid of a pathway, the nurse should prioritize what goal?

Helping the patient to achieve specific outcomes

Which of these is a necessary tool for building cultural competency?

Heritage Assessment Tool

A nurse is caring for a client who states, "I would like to go out on a date with you." Which of the following is an appropriate response by the nurs?

Inform the client that this is an inappropriate statement.

In a small, rural hospital the nurse is caring for a client who speaks a language other than English. The nurse needs to use an interpreter to communicate but the hospital does not have access to an interpreter who speaks the client's language. When choosing another individual to interpret for this client, what characteristic should the nurse prioritize?

Interpreter should ideally be fluent in several dialects of the client's language.

A nurse is caring for a client who has depression. THe client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems." Which of the following is an appropriate response by the nurse?

It seems as though you're expressing feelings of hopelessness

The nurse wants to use appropriate therapeutic communication when interacting with her client. Which of the following is an appropriate nursing statement?

It sounds like you are afraid

In the United States, access to health care usually depends on a client's ability to pay for health care, either through insurance or by paying cash. The client the nurse is caring for needs a liver transplant to survive. This client has been out of work for several months and does not have insurance or enough cash. A discussion about the ethics of this situation would involve predominantly the principle of:

Justice, because the first and greatest question in this situation is how to determine the just distribution of resources

The nurse is reviewing the development of culture. Which statement is correct regarding the development of one's culture? Culture is

Learned through language acquisition and socialization

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program?

Living wills detail treatment wishes of the client in the event of terminal illness

A nurse has begun creating a client's plan of care shortly after the client's admission. The nurse knows that it is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis?

NANDA

In most ethical dilemmas, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?

Nurses develop a relationship to the patient that is unique among all professional health care providers

Symptoms, such as pain, are often influenced by a person's cultural heritage. Which of the following is a true statement regarding pain?

Nurses need to recognize that many cultures practice silent suffering as a response to pain

Barriers to incorporating EBP include:

Nurses' lack of research skills in evaluating the quality of research studies.

Nursing knowledge is based on which of the following? SATA

Nursing Research and Discipline-specific research

Which of the following outcomes/goals is correctly written?

On discharge, client will be able to list five symptoms of infection.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

Perform fingersticks for glucose levels on clients who have diabetes mellitus

The ability to predict client needs and anticipate changes in the health status of a client stems from knowledge of which of the following topics?

Physiology and Pathophysiology

What activity is carried out during the implementing step of the nursing process?

Planned nursing actions (interventions) are carried out

What should the nurse assess before entering the patient's room on morning rounds?

Posted conditions, such as isolation precautions

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information his health assessment is important to:

Provide culturally sensitive and appropriate care

The horizontal bars of patient-centered care, interdisciplinary collaboration, evidence-based practice, quality improvement, informatics and safety are components of which organization?

QSEN

Which of the following should a nurse include in the verbal SBAR report to a provider? SATA

SBAR

Clinical reasoning requires the nurse to be able to do which of the following?

Separate relevant from irrelevant data

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to the LPN?

Set up oxygen and suction equipment

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?

Speaking to me like that makes me uncomfortable. Then talk to nurse supervisor and report it.

The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

Taking vital signs is within the education and scope of practice for a nursing assistant

Which of the following statements is an example of a therapeutic communication technique?

Tell me about your relationship with your wife

The nursing assistant is delegated the task of taking morning vital signs for all six clients. What would you instruct the nursing assistant to report immediately?

Temperature greater than 102 orally

A nurse on a medical-surgical 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?

The application of a condom catheter is a noninvasive, routine procedure that thenurse may delegate to an AP.

Which of the following statements describe what clinical judgment is?

The decision made regarding the course of action a nurse will taken to solve a client problem.

The nurse is preparing discharge planning for a hospitalized patient. When should the nurse start discharge teaching?

The nurse should start discharge teaching upon admission.

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse?

The nurse transfers responsibility but is accountable for the outcome.

What must the nurse assess first when providing culturally competent health care to an Asian American patient?

The nurse's heritage-based cultural values, beliefs, attitudes, and practices

The nurse is caring for a client with a newly diagnosed allergy to peanuts. What immediate goal should the nurse apply to a nursing diagnosis of "deficient knowledge r/t appropriate use of an EpiPen"?

The patient will demonstrate correct injection technique with today's teaching session.

When assessing the neurologic system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?

The patient's ability to communicate

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life". Which of the following responses is appropriate?

This must be a difficult time for you

A nurse is caring for an older client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate?

This must be a difficult time for you

The quality improvement team at a large, urban hospital has recognized the need to better integrate the principles of transcultural nursing into client care. When explaining the concept of transcultural nursing to uninitiated nurses, how should the team members describe it?

Transcultural nursing refers to research-focused practice that focuses on patient-centered, culturally, competent nursing.

The nurse is preparing a discharge teaching session with an Asian client to evaluate the client's ability to change a dressing. The client speaks and understands minimal English. What would be the best way to promote understanding during the teaching session?

Use an interpreter during the teaching session

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to

Validate the data by asking a coworker to listen to the breath sounds.

When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient?

What cultural or spiritual beliefs are important to you?

A client presents at a community shelter after surviving the destruction of her home by a fire. WHich of the following questions should the nurse ask to determine the client's ability to cope?

Who do you talk to when you have the feeling of being overwhelmed

Urgent (Class II)

Yellow tag - Major injuries tha require treatment, patients who can wait a short time for careEx: Open fractures w/ distal pulse, large wounds that need tx w/in 30 min to 2 hrs

The nurse educator is conducting a class for new graduate nurses. During the teaching session, the nurse educator should keep in mind that novice nurses without a background of skills and experience from which to draw are more likely to make their decisions using?

a set of rules

The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses without a background of skills and experiences from which to draw, are more likely to make their decision using

a set of rules

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these?

abnormal laboratory values

A nurse is caring for a client who is 48 hour postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?

absent dorsalis pedis pulse

What should the nurse *not delegate* to the CNA?

any activity involving critical decision making or nursing judgment

A nurse is reviewing professional communication skills with a newly licensed nurse. Which of the following is a form of effective communication?

assertive

When using the nursing process priority setting framework, the nurse should always remember to do which of the following first?

assess the client

What step of the nursing process includes data collection by health history, physical examination, and interview?

assessment

The client has COPD. Which intervention for airway management should you delegate to the nursing assistant?

assist client to sit up on side of bed

Not everyone learns in the same manner. A student who is finding the online environment especially beneficial because lectures are recorded is likely what type of learner?

audio

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries, The nurse understands that this client's choice is an example of which of the following ethical principles?

autonomy

The nurse is developing a nursing care plan for a client who is being treated for hypertension. What is a measurable client outcome/goal that the nurse should include?

client will reduce Na+ intake to no more than 2.4 g daily

The nurse is caring for a client who is a recent immigrant. Which of the following variables should the nurse prioritize when performing an assessment of the client's cultural beliefs?

client's communication style

Which critical thinking skill helps the nurse to see relationships among the data?

clustering

Which critical thinking skills help the nurse see relationship among the data?

clustering related cues

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/in, BP 132/76 mmHg, and temperature 98.2 F. Which of the following actions should the nurse perform?

complete a neurological check

A nurse is caring for a child with a diagnosis of hemophilia. The child is in need of a blood transfusion, which her family's religious beliefs forbid. What term would best describe this religion's beliefs and their impact on health care for this child?

cultural taboo

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor?

decreased respiratory effort

A client admitted with right leg thrombophlebitis is to be discharged from an acute care facility. Following treatment with a heparin infusion, the nurse notes that the client's leg is pain free, without redness or edema. Which step of the nursing process does this reflect?

evaluation

During what phase of the nursing process would the nurse be required to consider the efficacy of nursing interventions related to drug therapy?

evaluation

In response to a client's report of pain, the nurse has given a PRN dose of hydromorphone. In what phase should the nurse determine whether this medication has had the desired effect?

evaluation

A nurse is performing triage at a mass casualty even and is selecting a tag for a client who is severely injured and has no potential for survival. Which of the following tags should the nurse apply to the client?

expectant (class IV)

Which of the following types of communication is informal, becomes distorted, and typically involves three or more individuals?

grapevine

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern?

incomplete amputation of the foot

A nurse provides care on an orthopedic reconstruction unit and is admitting two new clients, both status postknee replacement. What would be the *best* explanation why their care plans may be different from each other?

individual patients are seen as unique and dynamic, with individual needs.

A nurse manager is reviewing concepts related to organizational communication with a group of charge nurses. Which of the following statements made by a charge nurse requires additional teaching?

information should be informally distributed

A nurse manager is discussing aggressive communication with a nurse who is having conflicts with peers due to her ineffective communication pattern. Which of the following should the nurse manager identify as a characteristic of aggressive communication?

infringes on the rights of others

A nurse is considering the delegating of administering medications to an unskilled assistant. What is the first question the nurse must ask herself before doing so?

is the delegation task permitted by law

The nurse is a community health nurse who provides care to a group of Hispanic people living in an area that is predominantly populated by Caucasian people. How would the nurse characterize the Hispanic people in this community?

minority

During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the:

mobility and turgor

A healthcare provider ensuring the treatments administered to a patient does not cause them any harm is an example of the following which ethical principle?

nonmaleficence

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the ? diagonsis.

nursing

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupenic and his pulse is 58 beats per minute. These types of data would be:

objective

The three concepts of EBP include all of the following except

organizational culture

Based upon Maslow's Hierarchy, which of the following would be the nurse's first priority in the provision of patient care?

physiological needs

When determining if the person to whom the nurse has delegated a task is competent to perform that act, the nurse is using which part of the nursing process?

planning

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the priority concern of the nurse?

preventing injury

The novice nurse understands that the purpose of using the SBAR is?

provide a structure for an interaction that helps both the giver of the information and the receiver of it. It helps the giver by ensuring they have formulated their thinking before trying to communicate it to someone else

What tasks can a nurse delegate to a CNA?

provide patients with basic care and assist them in their everyday activities: - bathing - feeding patients - ambulating - restock rooms with essential supplies - change bed sheets - sanitizing and clean patients' areas - examine patients for blood in urine, bruises or other wound/injuries - answer patient calls

Emergent (Class I)

red tag - immediate threat to life Ex: Airway obstruction or shock

A hospital has reaffirmed its commitment to meeting National Patient Safety Goals. The hospital is most likely to meet these goals by:

reducing the incidence of HAIs

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?

research findings

Nurses with varying levels of experience possess leadership skills. A graduate nurse walks out of the nurse manager's office after a meeting. The graduate nurse reflects on the positive and negative feedback that she received from the manager regarding her three months working on the unit. What nursing leadership skill is best illustrated by the graduate nurse in this scenario?

self-evaluation skills

A student nurse who is employed as a nursing assistant may, while in the role of the nursing assistant, perform any functions that:

she was taught in school

A patient tells the nurse that he is very nervous, is nauseated, and "Feels hot". These types of data would be

subjective

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate?

tell me more about your concerns

The American Nurses Association recommends adherence to defined principled when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice?

the registered nurse

Which of the following priority setting frameworks is being applied by a nurse who has decided to hang a client's intravenous antibiotic within 30 minutes of the time specified instead of giving another client their PRN pain medication?

urgent vs. nonurgent

During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next?

use a doppler device to assess the pulses

A nurse is implementing therapeutic communication techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider a topic, or think through a point?

use of silence