Nursing I-test 4

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."

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

A nurse should recognize which of the following are non-verbal indications of stress in an adolescent client?

Easily angered Withdrawing from peers Disheveled appearance

Which of the following strategies should a nurse use to establish a helping relationship with a client?

Encourage the client to communicate his thoughts and feel

The nurse manager is concerned about the large number of teenage mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?

Enlist volunteers to help develop a community outreach project that will educate teenagers on methods to prevent pregnancy.

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.)

Family members should provide a code prior to receiving client health information Communication of client information can occur at the nurses' station A client can request a copy of their medical record A nurse can photocopy a client's medical record for transfer to another facility

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.)

Right supervision and evaluation right direction and communication right circumstances

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?

SOAP charting

A nurse manager best demonstrates effective leadership characteristic by which action?

Sharing a vision for the unit and enlisting support

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)

Showing a client how to use progressive muscle relaxation Repositioning a client every 2 hr to reduce pressure injury risk

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged?

Slander Explanation: The nurse can be charged with slander, which is a verbal attack on a person's character. Libel pertains to damaging written statements read by others. Both libel and slander are considered defamation of character—an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation. Negligence and malpractice pertain to actions which are committed or omitted, thereby causing physical harm to a client.

Which of these statements reflects the expected functioning at a hospital that has achieved Magnet status?

Staff nurses are developing innovative solutions to problems.

A nurse is using the teaching-learning process to teach new parents how to care for their infants. Which nursing actions reflect recommended steps of this process? Select all that apply.

The nurse assesses the learning needs and readiness of the parents. The nurse formulates a verbal or written contract with clients. The nurse relates new learning material to clients' past life experiences to help them to assimilate new knowledge.

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.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access."

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences."

The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client?

"It sounds as though you are most concerned about how your children will feel."

A client who has metastatic ovarian cancer states "I do not want and more treatment". How should the nurse respond?

"Tell me about your decision to discontinue chemotherapy" "Would you like to speak with a hospice representative?"

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following staternents should the nurse make? (Select all that apply.)

"Your daily routines will be different when you get home" "Tell me about the support system you'll have after you leave the hospital"

SBAR communication

(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition.

Which is the proper way to document midnight in a client's record?

0000

Which statement describes the person who is likely the most motivated to learn?

A 70-year-old female who is the client's spouse and is learning the care so the client can come home

ADLs

Activities of Daily Living such as eating, dressing, bathing.

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first?

Administer a dose of digoxin that is two hours behind schedule.

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

Which action is an example of cognitive learning?

A patient describes how to portion food to maintain within a prescribed calorie range

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A.Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

A,C, D

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

A. "I will determine the most important client problems that we should address."

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer."

A. A client who has terminal cancer requests hospice care in the home B. A client asks about community resources available for older adults D. A client requests an electric wheelchair for use after discharge

UAP scope of practice

ADL's, routine vitals, weight, I&O, safety

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

A nurse has completed 4 hours of an 8 hour shift on a medical-surgical unit when the nursing supervisor calls. The nursing supervisor directs the nurse to give a report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with client assignments and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources

Telephone orders (TO) or verbal orders (VO)

Always documented Taken by RN only protocol to write it down, then read it back to the person who gave the order for confirmation of accuracy.

A nurse cares for a client with terminal lung cancer. Which action should be delegated to the assistive personnel?

Assist the client to ambulate to the bedside chair twice a day.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate?

Ask the client if information can be given to the parent.

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UP). Which task is appropriate for the UAP to complete?

Bathing a combative client

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will eno on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of following client activities should the nurse include? (Select all that apply.)

Bathing, ambulating

An RN enters a client's room and observes the unlicensed assistive personnel (UP) forcefully pushing a client down on the bed. The client starts crying and informs the UP of the need to En Sube Distroom. What action is the RN witnessing that should be immediately reported to the supervisor

Battery

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?

Blocking 30 minutes of time for skill teaching

A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report?

Bone scan scheduled for today

A nurse cares for a group of clients on a medical surgical unit. Which client should be delegated to the PN?

Bronchitis receiving bronchodilator treatments Advanced regular diet two days postoperative cholecystectomy

The nurse manager for the psychiatric unit sees that there are major conflicts between and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which conflict resolution style does the nurse manager display?

Collaborating

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

D. Occupational therapist

The nurse returns to the client as promised 30 minutes after giving an analgesic. What ethical principle was observed?

Fidelity

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have the client rate pain level, and reschedule the teaching session.

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

Health teaching and health promotion

Which word is best described as protection and support of another's rights?

advocacy

ISBAR

Introduction Situation Background Assessment Recommendation

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply).

Medication Error Needlesticks Omission of prescription

A nurse working in a critical care unit has experienced personal tragedy, extreme shortage of staff in the work environment, and health issues. The nurse has overcome much of these hardships and is now mentoring other nurses in similar situations. What behavior is this nurse demonstrating?

Moral resilience

A family member states, "I am going to watch you enter the information in the computer system." Which of the following actions should the nurse take?

Move to a computer in a private location

A nurse knows that the expression "Do not cause harm" refers to which ethical principle?

Nonmaleficence

Which statement about laws governing the distribution of controlled substances is true?

Nurses are responsible for adhering to specific documentation about controlled substances.

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN?

Providing nasopharyngeal suctioning for a client who has pneumonia

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.)

Put the date and time on all entries Document objective data, leaving out opinions

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 (AP)?

Reapplying a condom catheter for a client who has urinary incontinence

A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

Reflecting

A nurse manager is assigning care of a client who is being admitted from the PAC following thoracic surgery. The nurse manager should assign the client to which of the following staff members?

Registered nurse (RN)

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)

Repeat the details of the prescription back to the provider Have another nurse listen to the telephone prescription obtain the provider's signature on the prescription within 24 hr.

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

Injuries related to lifting or transferring clients occur in the health care setting and may be considered work related. Which law was intended to reduce work related injuries and illnesses?

The Occupational Safety and Health Act of 1970

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve a other staff nurse who is less experienced. Which of these would best describe

The charge nurse is providing support for the staff nurse in new responsibilities.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.)

The client ambulates wearing slippers over antiembolic stockings. The client uses a front-wheeled walker when ambulating. The client had pain medication 30 min ago.

Infomatics

The collection, classification, storage, retrieval, and dissemination of recorded information

I&O

intake and output

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have Been very vocal about being unhappy if they do not receive their choice of preceptor. Which I'll strates the nurses using a compromise approach to conflict resolution?

The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate the quality of care provided and assess the potential risks for injury to the client

A nurse cares for a group of clients. Which of the following information can be disclosed about a client

Uncontrolled seizure disorder of a school bus driver

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

Usability

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.)

Use an open posture Establish and maintain eye contact Sit facing the client

An informatics nurse specialist is looking to evaluate the optimization of a clinical information system being used in the facility. On which area would the nurse focus? Select all that apply.

Ways to reduce errors Measures to eliminate inefficiencies in workflow Ways to improve clinical decision support Plans to improve basic processes

A nurse assigns four clients to the PN. Which finding should the PN immediately report to the nurse? A client...

With a baseline regular apical pulse of 88 who has an irregular apical pulse of 120 today

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

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?

assessment

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 ethical principle is related to the idea of self-determination?

autonomy

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and physicians is exhibiting what style of leadership?

democratic

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?

experience

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

fidelity

The nurse manager calls a staff into a unit meeting to discuss patient satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying?

laissez-faire

A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit?

malpractice

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

paternalism

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

patient portal

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

patient portal

A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief?

personal morality

An older adult was just diagnosed with stage 4 pancreatic cancer. The client states, "I am so overwhelmed and I feel like everyone has already decided that I need to be put in hospice care." › Complete the following sentence by choosing from the lists of options. The nurse upholds the principle of autonomy by

providing the client with the information needed to obtain a second opinion obtaining routine vital signs Offering to answer questions the client may have about care and treatment options

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

referral

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

role playing

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

simplicity

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

sit at eye level with a child

A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?

speech language pathologist

Healthcare Analytics

the process of analyzing current and historical industry data to predict trends, improve outreach, and even better manage the spread of diseases. The field covers a broad range of businesses and offers insights on both the macro and micro level.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

Which statements indicate a correct understanding of the tenets of the Code of Ethics for Nurses? Select all that apply.

• The nurse maintains standards of personal conduct. • The nurse is active in developing a core of research based principles. • The nurse holds personal information as confidential.