Nursing Concepts Beginning Test

a nurse is caring for a client who has cancer. The client has decided to stop treatment and request a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles?

autonomy Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustrating by making the referral as requested.

A nurse is reinforcing teaching to a client who has aphasia. Which of the following action by the nurse is appropriate when communicating with the client?

having the client use eye blinks to indicate yes or nor Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.

a nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly license nurse while documenting requires the nurse preceptor to intervene?

including in a client's nurses' note that an incident report was completed after a medication error This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record.

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include?

initial HIV symptoms are often similar to the flu Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include. HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client become symptomatic and has a severely compromised immune system.

A nurse is caring for an adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following?

Celecoxib is contraindicated in clients with an allergy to sulfonamide.

A nurse in a local clinic is caring for a female client who is 35 yrs old. Which of the following screenings should the nurse recommend to the client?

Dermatologist evaluation every 3 years to detect skin cancer A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. which of the following should be the nurse's first action?

Determine the client's condition The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care.

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention?

Potassium 2.5mEq/l A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time.

a nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective?

The patch should be effective within an hour of being applied Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. which of the following could result in a violation of client confidentiality?

ability of staff to access electronic health records of clients throughout the facility

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. which of the following is acceptable for the nurse to include in discussion with the client?

acupuncture has been proven to reduce pain and increase function The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

a nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective?

demonstrating independent performance

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention?

difficulty breathing This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate?

let's talk for a minute about your concerns

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teach to place the client in which of the following positions?

lithotomy

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isonizid (INH) and ethambutol (Myambutol). Which of the following manifestation reported by the client necessitate the discontinuation of ethambutol?

loss of color discrimination The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops.

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should the nurse priority goals?

protect the client from further abuse The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.

A nurse is caring for a client who has nausea and a prescription for promethazine (Pheergan) 25mgIM. Which of the following is appropriate when preparing a medication for administration from an ampule?

set the ampule on a flat surface to withdraw the promethazine To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle.

a nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication?

speech pathologist

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching

states that pain is an 8 on scale of 0 to 10 Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education.