Unit 2 Foundations
A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice? - "Health care should be a right for everyone" - "All clients should have a private room in a health care facility" - "I plan to volunteer at the local homeless shelter on my days off" - "I will respect a client's right to refuse a procedure"
"Health care should be a right for everyone"
A nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching? - "I need to choose a family member as my health care surrogate" - "Once I sign my advance directives, I cannot change my decisions" - "My health care surrogate will make health care decisions for me if I am unable" - "I need to have an attorney present to complete my advance directives"
"My health care surrogate will make health care decisions for me if I am unable"
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? - "I'd rather have my brother make decisions for me, but I know it has to be my wife." - "I know they won't go ahead with the surgery unless I prepare these forms." - "I plan to write that I don't want them to keep me on a breathing machine." - "I will get my regular doctor to approve my plan before I hand it in at the hospital."
- "I plan to write that I don't want them to keep me on a breathing machine."
A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? - "I should consume a diet high in carbohydrates" - "I should increase my protein intake" - "I should include fruit and vegetables with every meal" - "I should avoid meat products"
- "I should increase my protein intake" Foods high in protein are essential to wound healing and tissue strengthening. Also, Omega3, omega6, vitamins A, and C.
A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information? - "I should expect a small separation along the incision line" - "If I feel like something popped, I should sit up in bed" - "I should report pain at my wound site" - "Recurrent vomiting is expected after surgery"
- "I should report pain at my wound site"
A nurse manager is reviewing with nurses on the unit in the care of a silent who has had a seizure. Which of the following statements by a nurse requires further instruction? - "I will place the client on their side" - "I will go to the nurses' station for assistance - "I will note the time that the seizure begins" - "I will prepare to insert an airway"
- "I will go to the nurses' station for assistance
A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? - "I will have the steps to my house painted a dark color" - "I will put a night-light in the hallway" - "I will put on socks when I get out of bed" - "I will secure any wires in my home under rugs"
- "I will put a night-light in the hallway"
A nurse is assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include? - "Preoperative teaching can reduce the length of the client's hospital stay" - "Preoperative teaching results in an increase in client anxiety" - "Preoperative teaching results in a decrease in client's' participation in their health care plan - "Preoperative teaching can cause an increase in the cost of healthcare"
- "Preoperative teaching can reduce the length of the client's hospital stay"
A wound, ostomy, and continence nurse ((WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? - "Pressure injury documentation includes location, stage, measurements, and condition of the wound bed and any drainage present" - "Drainage from a pressure injury only needs to be documented if a foul odor is present" - "If the pressure injury is healing as expected, documentation can be completed with very other dressing change" - "Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries"
- "Pressure injury documentation includes location, stage, measurements, and condition of the wound bed and any drainage present"
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? - "You can wear artificial fingernails if they are kept short" - "Leave rings on your fingers when performing surgical hand asepsis" - "Keep your fingernails less than half an inch in length - "Remove nail polish on your fingernails if it is chipped"
- "Remove nail polish on your fingernails if it is chipped"
A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury? - "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue" - "Stage 3 pressure injury to the coccyx observed with a non-blanchable area of erythema" - "Stage 3 pressure injury to the coccyx observed with partial-thickness skin loss, wound bed pink and moist" - "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bones visible"
- "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue"
A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - "The skin is strongest during early childhood" - "The epidermis pads internal organs and structures" - "The sub-Q later of the skin contains cells that contribute to skin and hair color" - "The skin assists in the regulation of body temperature"
- "The skin assists in the regulation of body temperature" The main functions of the skin are to provide a barrier from injury, infection, and UV radiation, as well as control fluctuations in body temp
A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? - "Skin changes cause the synthesis of vitamin B to decrease with age." - "The layers of the skin become detached with age." - "Older adult clients have more moisture in the skin, placing them at risk for maceration." - "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."
- "The skin of older adults is thinner and has less subcutaneous padding over bony prominences." As an individual ages, expected changes occur in the skin, including a decrease in elasticity and subcutaneous tissue.
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - Frequent bowel sounds with flatus - Absent bowel sounds with distention - Hyperactive bowel sounds with diarrhea - Normal bowel sounds with increased peristalsis
- Absent bowel sounds with distention
A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing? - "The dressing will need to be changed every 24 hours" - "This type of dressing is used in small wounds with small amounts of drainage" - "This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped" - "This type of dressing will need a secondary dressing for reinforcement"
- "This type of dressing will need a secondary dressing for reinforcement" An alginate dressing is not self-adhesive and needs a secondary dressing for reinforcement
A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention? - "This type of healing carries a lower risk of infection than others" - "This type of healing begins in the wound bed with the generation of granulation tissue" - "These wounds heal faster than those that heal by other processes" - "These wounds require a dry wound bed in order for healing to occur"
- "This type of healing begins in the wound bed with the generation of granulation tissue" Secondary healing/intention is when the wound is left open to heal and granulation tissue forms from the bottom up in the wound bed. It is prolonged and the wound bed needs to be kept moist. Risk of infection is high.
A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? - "You should shift your weight off your buttocks at intervals throughout the day." - "You should be sure your legs are placed on the floor prior to transferring." - "Position yourself in the back of the wheelchair after transferring." - "Lock your brakes when you are sitting in the wheelchair."
- "You should shift your weight off your buttocks at intervals throughout the day." This action will increase circulation to the tissues and prevent skin breakdown.
A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? - "Your staples will dissolve in about 4 weeks" - "You will need to be placed under general anesthesia for the staples to be removed" - "Staples are unlikely to become embedded in the skin, making removal simple" - "Your staples will be removed in about 2 weeks"
- "Your staples will be removed in about 2 weeks" In general, wounds closed with staples heal faster than wounds that are sutured. They're removed 7-14 days
A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect? - A red incision site with small amount of exudate - A bright pink incision site that is absent of exudate - A pale pink incision site with moderate amounts of exudate - A white to silver incision site absent of exudate
- A bright pink incision site that is absent of exudate By the 7th day, the incision should be bright pink and drainage should have subsided
A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? - A client who has Braden score of 9 - A client who has Braden score of 23 - A client who has Braden score of 12 - A client who has Braden score of 15
- A client who has Braden score of 9 The lowest overall score a client can receive is 6 with 23 being maximum. The lower the score, the greater the risk for alterations in skin and tissue integrity.
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? - A client who is incontinent and is taking a prescribed diuretic - A client who has a lower extremity fracture and uses the overhead bed trapeze to move - A client who is NPO for surgery and is receiving IV fluids - A client who has lung cancer and will be receiving their first radiation treatment
- A client who is incontinent and is taking a prescribed diuretic Clients who are incontinent have an increased risk for developing alterations in tissue integrity, such as mace ration, due to prolonged exposure to moisture
A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (SATA) - A client's visitor falls in the hallway - A nurse forgets their computer password - A client develops an unexpected reaction to a medication - A client's dentures are lost - An antibiotic was administered to a client 30min after the scheduled time
- A client's visitor falls in the hallway - A client develops an unexpected reaction to a medication - A client's dentures are lost
A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity? - A nurse involves a client in making decisions about their care - A nurse implements fall precautions for a client who is at risk for falling - A nurse tells the truth about forgetting to perform a procedure for a client - A nurse keeps a promise to a client not to tell their family about their diagnosis
- A nurse keeps a promise to a client not to tell their family about their diagnosis
A nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy? - A nurse provides the same quality care for every client - A nurse maintains client confidentiality - A nurse admits they forgot to change a client's dressing - A nurse respects a client's wish to discontinue a treatment
- A nurse respects a client's wish to discontinue a treatment The professional value of autonomy refers to respecting the client's right to make their own decisions regarding their health care, including the right to refuse care
A nurse is caring for a client who is postoperative following a femur fracture repair. The client suddenly reports chest pain and is experiencing shortness of breath. Which of the following conditions should the nurse suspect? - Deep vein thrombosis - Thrombotic stroke - Hypovolemic shock - A pulmonary embolism
- A pulmonary embolism
A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use? - A hydrogel dressing - A wet gauze dressing - A transparent film - A alginate dressing
- A transparent film Due to their reduced ability absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? - Extinguish the fire - Close the windows in the client's room - Close the client's door - Activate the fire alarm
- Activate the fire alarm
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? - After donning a gown and before collecting vital signs on the client - After removing food items off the client's tray and before removing soiled linens from the client's bed - After helping the client stand up and before helping them brush their teeth - After changing a dressing on the client and before documenting findings on a computer
- After changing a dressing on the client and before documenting findings on a computer
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that TB is transmitted by which of the following modes of transmission? - Airborne - Droplet - Direct ocntact - Indirect contact
- Airborne
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? - Protective isolation - Contact - Droplet - Airborne
- Airborne
A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record? (SATA) - Allergies - Discontinued medications - Alcohol use - Spiritual beliefs - Financial status
- Allergies - Alcohol use - Spiritual beliefs
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and reports discomfort and nausea. The nurse notes minimal bowel sounds on auscultation. The nurse should anticipate that the client may have which of the following conditions? - An ileus - Dehiscence - Irritable bowel syndrome - Hemorrhoids
- An ileus
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? - Use a brush to scrub the surface of the hands - Rinse antiseptic solution from the hands before it dries - Apply chlorhexidine and ethanol to the hands - Leave jewelry on the hands when cleansing them
- Apply chlorhexidine and ethanol to the hands
A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan? (SATA) - Ask the client what interventions they prefer - Limit medications to one type of analgesic - Determine how the client has responded to analgesics in the past - Include the use of a placebo for pain management - Include nonpharmacological methods to reduce pain
- Ask the client what interventions they prefer - Determine how the client has responded to analgesics in the past - Include nonpharmacological methods to reduce pain
A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia? - Diarrhea - Aspiration - Pain - Pruritis
- Aspiration
A nurse is assisting a postsurgical client who has had previous trouble swallowing prepare for a meal. Which of the following actions should the nurse take? - Instruct the client to quickly eat their food - Assist the client to sit upright to eat - Cut the food into medium-sized pieces - Encourage the client to talk during the meal
- Assist the client to sit upright to eat
A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? - Burn - Frostbite - Bacteria - Radiation
- Bacteria
A nurse is caring for a client who is preoperative and reports a history of regular tobacco use. The nurse should identity that the client is at the greatest risk for which of the following postoperative complications? - Urinary retention - Constipation - Nausea - Blood clots
- Blood clots
A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding? - Oxygen saturation 97% on room air - Respiratory rate 14/min - Heart rate 72/min - Blood pressure 88/60 mm Hg
- Blood pressure 88/60 mm Hg A blood pressure less than 90 mm Hg systolic is considered hypotension and is a manifestation of bleeding. (Other manifestations of bleeding are tachycardia and tachypnea)
A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is hospital-acquired injury? (SATA) - Blood transfusion incompatibility - Wrong site surgery - Ineffective insulin usage - Dysphagia following a stroke - Dehydration due to diarrhea
- Blood transfusion incompatibility - Wrong site surgery - Ineffective insulin usage
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests? - C-reactive protein - Troponin - Creatine kinase - Lactic acid
- C-reactive protein C-reactive proteins is a nonspecific marker that can increase when inflammation is present
Surgical attire for the surgical suite consists of which of the following items? (SATA) - Belt - Cap - Shoe covers - Gown - Mask - Gloves
- Cap - Shoe covers - Gown - Mask - Gloves
A nurse is assisting with teaching a class about evidenced-based protocols established by the CDC to prevent healthcare-associated infections. Which of the following infections should the nurse include? (SATA) - Influenza infection - Catheter-associated urinary tract infection - Myocobacterium tuberculosis infection - Central line-associated bloodstream infection - Surgical site infection
- Catheter-associated urinary tract infection - Central line-associated bloodstream infection - Surgical site infection
Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use? - Circulating nurse - Anesthesiologist - Certified surgical technologist - Surgeon
- Certified surgical technologist
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (SATA) - Extremes in age - Chronic illness - Low hemoglobin - Malnutrition - Poor wound care
- Chronic illness - Low hemoglobin - Malnutrition
A nurse is preparing to obtain a wound culture from a client who has suspected wound infection. Which of the following actions should the nurse take? - Obtain the culture using a clean cotton applicator - Clean the wound with 0.9% sodium chloride - Collect drainage from the area surrounding the wound - Place the applicator in a dry vial until cultures are complete
- Clean the wound with 0.9% sodium chloride To collect a wound using a sterile cotton applicator, the nurse should first clean the wound with 9.0% sodium chloride to rinse away any resident bacteria that may be present
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? - Complete a fall-risk assessment - Educate the client and family about fall risks - Eliminate safety hazards from the client's environment - Make sure the client uses assistive aids in their possession
- Complete a fall-risk assessment
A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? - Protective - Contact - Droplet - Airborne
- Contact
A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement? - Protective - Contact - Standard - Airborne
- Contact
A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection? - Incubation - Convalescence - Acute infection - Prodromal
- Convalescence
A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (SATA) - Carbon dioxide - Nitrogen - Cooking oil - Oxygen - Heat
- Cooking oil - Oxygen - Heat
A client who had abdominal surgery 24 hr ag suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (SATA) - Cover the area with saline-soaked sterile dressings - Apply an abdominal binder snugly around the abdomen -Use sterile gauze to apply gentle pressure to the exposed tissues - Position the client supine with the hips and knees bent - Offer the client a warm beverage, such as herbal tea
- Cover the area with saline-soaked sterile dressings - Position the client supine with the hips and knees bent
A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take? - Ask the client to bear down and cough - Ask another nurse to bring ice packs to apply to the wound - Cover the client's wound with a sterile saline dressing - Place the client in high-Fowler's position
- Cover the client's wound with a sterile saline dressing The nurse should place a sterile normal saline soaked dressing over the wound and protect the organs (do not push back in) surgical emergency
A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? - Dehiscence - Evisceration - Hematoma - Fistula
- Dehiscence is a separation of part of all of the wound edges. This is common after abdominal surgery, where the client experiences a ripping sensation at the wound site
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? - Direct contact - Droplet - Airborne - Indirect contact
- Droplet
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? - Droplet - Indirect contact - Airborne - Direct contact
- Droplet
A nurse is caring for a client who has a portable wound bulb section device and notes that the drainage bulb is 3/4 full. Which of the following actions should the nurse take? - Decrease the drainage suction force - Place the bulb on a flat surface and measure the amount of drainage - Empty and measure the drainage - Kink the tubing to prevent further drainage
- Empty and measure the drainage The bulb of the portable wound bulb suction device should be emptied at least every 8 hr or when is more than half full
A new resident provider asks the nurse for an access code to review a clients online record. The resident is not scheduled to attend the Facility's orientation computer class until next week. Which of the following actions should the nurse take? - Explain that it is against policy to share access codes and refer the resident to his supervisor - Access the clients' online data and monitor the resident as he reads them - Access the online system and allow the resident to locate clients' data - Ask each client to give permission for the resident to access medical records
- Explain that it is against policy to share access codes and refer the resident to his supervisor
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (SATA) - Fall history - Medical diagnosis - Use of assistive devices - Mental status -DNR status
- Fall history - Medical diagnosis - Use of assistive devices - Mental status
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (SATA) - Fever - Malaise - Edema - Pain or tenderness - Increase in pulse and respiratory rate
- Fever - Malaise - Increase in pulse and respiratory rate
A nurse is providing discharge teaching to the caregiver for a client who has stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? - Be sure to keep the skin moist - Do not use pillows to support extremities - Flex the client's knees while in bed - Provide a firm mattress for the client
- Flex the client's knees while in bed This takes the pressure off the sacral area and prevents the client from sliding down in bed, which can cause shearing and further injury to the skin
A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? -Legitimate absenteeism - Strict adherence to facility policies - Consistent adequate work performance - Frequent reports of not being treated fairly
- Frequent reports of not being treated fairly
A nurse is assisting with teaching a newly licensed nurse about removing PPE. Which of the following items should the nurse instruct to remove first? - Mask - Gloves - Goggles - Face shield
- Gloves
A nurse is assisting with teaching about PPE with a newly licensed nurse. Which of the following instructions should the nurse include? - Gowns can be reused on the same client - Masks should be removed after leaving the client's room - Gloves should be removed from the inside out - Eyeglasses can be used in place of goggles
- Gloves should be removed from the inside out
A nurse stops at the side of the road to provide care to a person involved in a motor-vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident? - Whistle blower protection - Good Samaritan laws - Torts - Emergency Medical Treatment and Labor Act (EMTALA)
- Good Samaritan laws Good Samaritan laws protect people who provide aid in the event of an emergency from being held liable for their well-intentioned actions.
A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? - Hydrofiber - Alginate - Hydrogel - Transparent film
- Hydrogel Hydrogel can be successfully used for debridement of wounds with necrotized tissue and eschars, and causes minimal trauma to the healing wound bed. They draw moisture away from the wound bed.
A nurse is caring for a client who reports a severe throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? - Prodromal - Incubation - Convalescence - Illness
- Illness
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA) - Increase in incisional pain - Fever and chills - Reddened wound edges - Increase in serosanguineous drainage - Decrease in thirst
- Increase in incisional pain - Fever and chills - Reddened wound edges
A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis? - Hypertension - Increased blood glucose - Decreased WBC count - Increased BUN
- Increased blood glucose
A nurse is planning care for a client who has distended bladder and has not voided 8 hr after surgery. Which of the following interventions should the nurse plan to take? - Instruct the client to perform pelvic muscle exercises - Restrict the client's fluid intake - Insert a straight urinary catheter into the client - Administer an anticholinergic medication to the client
- Insert a straight urinary catheter into the client
A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values? - Integrity - Human dignity - Altruism - Social justice
- Integrity The professional value of integrity involves showing honesty and choosing to do what is right and fair, even when the situation is difficult
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? - Lock the wheels on the bed and stretcher - Instruct the client to raise his arms above his head - Elevate the stretcher 2.5 cm (1in) above the height of the bed - Log-roll the client
- Lock the wheels on the bed and stretcher
A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicate to the nurse that the AP understands how to perform this task? - Locking the brakes on the bed and the wheelchair before moving the client - Lowering the footplates of the wheelchair before the transfer - Placing the wheelchair perpendicular to the bed - Placing the wheelchair on the client's weaker side prior to the transfer
- Locking the brakes on the bed and the wheelchair before moving the client
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (SATA) - Locks the brakes on the client's bed - Checks the maximum weight of the lift before using it - Places the client on the edge of the sling - Uses the lift without assistance from another team member - Performs a safety check before lifting the client
- Locks the brakes on the client's bed - Checks the maximum weight of the lift before using it - Performs a safety check before lifting the client
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (SATA) - Place a belt restraint on the client when they are sitting on the bedside commode - Keep the bed in its lowest position with all side rails up - Make sure that the client's call light is within reach -Provide the client with nonskid foot wear - Complete a fall-risk assessment
- Make sure that the client's call light is within reach -Provide the client with nonskid foot wear - Complete a fall-risk assessment
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (SATA) - Make sure the surgeon obtained the client's consent - Witness the client's signature on the consent form - Explain the risks and benefits of the procedure - Describe the consequences of choosing not to have the surgery - Tell the client about alternatives to having the surgery
- Make sure the surgeon obtained the client's consent - Witness the client's signature on the consent form The rest of the responsibilities fall under the provider role
A nurse is caring for a client who had a stroke and is at risk for falls. Which of the following actions should the nurse take? - Assign the client to a private room - Keep 4 side rails up while the client is in bed - Monitor the client at least once every hour - Request a PRN prescription for restraints
- Monitor the client at least once every hour
A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority? - Monitor the client's oxygen saturation - Check the client's bowel sounds - Administer analgesics to the client - Measure the client's intake and output
- Monitor the client's oxygen saturation ABCDE priority
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? - Extinguish the fire - Activate the fire alarm - Move clients who are nearby - Close all open doors on the unit
- Move clients who are nearby
A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? - Near-miss event - Client safety event - Adverse event - Sentinel event
- Near-miss event
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? - Incontinence - Mental State - Nutrition - General physical condition
- Nutrition Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers
During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? - Wipe the catheter with povidone-iodine and continue the catheter insertion - Soak the catheter in chlorexidine for 15 min and then reattempt insertion - Continue with the catheter insertion - Obtain a new catheter and reattempt insertion
- Obtain a new catheter and reattempt insertion
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? - Open the first flap on the sterile package away from their body - Place objects on the sterile field at lest 1.3cm (0.5 in) from the edge - Unwrap both sides of the sterile package at the same time - Set up the sterile field next to a wall in the client's room
- Open the first flap on the sterile package away from their body
A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk? - History of foot surgery - Parkinson's disease - Leukemia - History of a total abdominal hysterectomy
- Parkinson's disease
A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? - Wear an N95 respirator when caring for the client - Place the client in a private room - Place a mask on the client when they leave their room - Place the client in a negative airflow room
- Place the client in a private room
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (SATA) - Place the client on round-the-clock surveillance - Remove objects from the room that the client could use to harm themselves - Search items brought into the client's room by visitors - Refrain from asking the client if they intend to harm themselves - Screen the client for suicidal ideation
- Place the client on round-the-clock surveillance - Remove objects from the room that the client could use to harm themselves - Search items brought into the client's room by visitors - Screen the client for suicidal ideation
A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? - Open the windows in the client's room to allow smoke to escape - Obtain a class C fire extinguisher to extinguish the fire - Remove all electrical equipment from the client's room - Place wet towels along the base of the door to the client's room
- Place wet towels along the base of the door to the client's room
A nurse is caring for a client who has severe acute respiratory syndrome (SAR S). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting (SATA) - Planning and evaluating control and prevention strategies - Determining public health priorities - Ensuring proper medical treatment - Identifying endemic disease - Monitoring for common-source outbreaks
- Planning and evaluating control and prevention strategies - Determining public health priorities - Ensuring proper medical treatment - Monitoring for common-source outbreaks
A nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication? - Use of probiotics - Prescribed antibiotics - Prescribed anticholinergics - Use of antiseptic skin cleanser
- Prescribed anticholinergics Anticholinergics are given to decrease secretions int he upper airway, but they can cause delirium, which poses a risk for a client who has dementia
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing? - Incubation - Convalescence - Acute illness - Prodromal
- Prodromal
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? - Record the time and length of the seizure - Restrain the client's extremities - Place the client in the prone position - Monitor the client's hemoglobin level
- Record the time and length of the seizure
A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing? - General - Local - Regional - Epidural
- Regional
A nurse is caring for a client who has prescription for wrist restraints. Which of the following actions should the nurse take? - Tie the restraints to the side rails on the client's bed - Remove the restraints with each vital sign check - Use a square knot to secure the restraints - Make sure one finger can fit under the restraints
- Remove the restraints with each vital sign check
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? - Remind the nurse that safe client care is a priority on the unit - Ask others on the team whether they have observed the same behavior - Report observations to the nurse manager on the unit - Conclude that her coworker's fatigue is not her problem to solve
- Report observations to the nurse manager on the unit
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? - Empty sharps containers when they become full - Report the needlestick injuries to the nursing supervisor - Engage the safety device on a needle after documenting the medication administration - Recap needles after medication administration
- Report the needlestick injuries to the nursing supervisor
A nurse is assisting in planning postoperative care for a client who is scheduled for surgery. Which of the following interventions should the nurse include in the plan? - Reposition the client every hour - Have the client cough and deep breathe every 4 hr - Instruct the client to perform ankle pump exercises once a day - Reinforce with the client that they should use an incentive spirometer every 2 hr
- Reposition the client every hour
A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent? - Reservoir - Susceptible host - Portal of entry - Portal of exit
- Reservoir
A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take? - Rinse the client's skin with water - Remove the client's clothing by pulling it over their head - Dispose of the client's clothing in a single biohazard bag - Prepare to administer potassium iodide to the client
- Rinse the client's skin with water
A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? - Sanguineous - Purulent - Serous - Hyperemia
- Sanguineous
A nurse is caring for a client who is scheduled for surgery and is at risk for postoperative venous thromboembolism (VTE). Which of the following prescriptions should the nurse anticipate to reduce the risk of VTE? - Incentive spirometer - Antibiotic therapy - Antihypertensive medication - Sequential compression devices
- Sequential compression devices
A nurse is discussing the time-out procedure with newly licensed nurse. The nurse should include that a time-out is performed at which of the following times? - Once at the beginning of the procedure - Several times throughout the procedure - Once at the end of the procedure - After the anesthesia has been administered
- Several times throughout the procedure
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? - Alcohol-based sanitizer - Soap and water - Iodine solution - Chlorhexidine solution
- Soap and water The nurse should wash their hands with soap and water after caring for a client who has an infection caused by spores
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (SATA) - Stage 3 pressure injury - Sutured surgical incision - Casted bone fracture - Laceration sealed with adhesion - Open burn area
- Stage 3 pressure injury - Open burn area
A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? - Suction equipment - Clean gloves - Blankets - Oxygen
- Suction equipment The greatest risk to a client who is having a seizure is an injury from aspirating or emesis, therefore, the nurse must have suction equipment available for clearing the mouth
A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? - Allows minimal treatment - Benefits the client's family - Offers hope for a cute - Supports self-determination
- Supports self-determination A nurse must honor a client's autonomy and ability to make health care decisions.
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? - Reservoir - Susceptible host - Portal of entry - Portal of exit
- Susceptible host
List the 6 pressure injury stages with a brief description
- Suspected deep tissue injury- depth unknown & discoloration but intact skin from damaged underlying tissue - Stage 1, Nonblanchable erythema: Intact skin with an area of persistent nonblanchable redness/swollen/discomfort -Stage 2, Partial-thickness: Involves epidermis and dermis. The ulcer is visible with red/pink wound bed. Appears as abrasion or blister -Stage 3, Full-thickness skin loss: Damage to or necrosis of the sub-Q tissue. No undermining or tunneling. -Stage 4, Full-thickness tissue loss: Destruction, tissue necrosis, or damage to muscle or bone. Sinus tracks, deep pockets of infection, tunneling, undermining etc -Unstageable: No determination of stage as slough or eschar obscures the wound bed. Depth of injury unknown
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? - Swab the back of the client's pharyngeal wall - Place the swab in a clean container after obtaining the culture - Insert the swab in the culture medium within 1 hr of obtaining the sample - Don sterile gloves to obtain the culture from the client
- Swab the back of the client's pharyngeal wall
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? - Allergic reaction - Ringworm - Systemic lupus erythematosus - TB
- TB
A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? - The AP places the client in high-Fowler's position - The AP places pillows under the client's lower extremities - The AP feeds the client 80% of each meal - The AP cleans and dries the client's perineum after each episode of incontinence
- The AP places the client in high-Fowler's position This increases the risk for shearing and alterations in skin integrity.
A nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating? - The Emergency Medical Treatment and Labor Act (EMTALA) - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Tort law - Good Samaritan laws
- The Emergency Medical Treatment and Labor Act (EMTALA) EMTALA was enacted to allow clients to access the ER departments of hospitals for equal care regardless of their ability to pay. Refusing to accept clients who do not have health insurance is a violation of the EMTALA
A nurse is assessing the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound? (SATA) - The client states the wound is painful - The client's blood pressure is 115/72 mmHg - The edges of the wound are red - The client is ambulating frequently - The client has a fever
- The client states the wound is painful - The edges of the wound are red - The client has a fever
A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should be the nurse's priority concern? - The client lives alone - The client cares for a pet - The client takes medications that cause dizziness - The client takes medications that cause heartburn
- The client takes medications that cause dizziness
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (SATA) - The client's full name - The client's date of birth - The client's telephone number - The client's diagnosis -The client's room number
- The client's full name - The client's date of birth - The client's telephone number
A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? - The client's admitting diagnosis - The client's medical history - The client's laboratory results - The client's response to treatment
- The client's laboratory results
A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (SATA) - The date the medication was mixed - The client's age - The client's room number - The dose of the mixed medication - The time of the medication was mixed
- The date the medication was mixed - The dose of the mixed medication - The time of the medication was mixed
A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster? - The epidermis contains cells that assist in systemic immune responses - Collagen and elastin fibers increase with age - The skin consists of four distinct layers - The dermis contains blood vessels that help nourish the epidermis
- The dermis contains blood vessels that help nourish the epidermis The dermis is composed of connective tissues with capillaries, blood vessels, and lymph vessels, which sustains and supports strength, flexibility, and noursishment
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AAIR). Which of the following information should the nurse include? - The door to the AIIR should remain closed - Clients who are on contact precautions require AIIR - An AIIR has at least 4 exchanges each hr - A mask is not needed to care for client who are in an AIIR
- The door to the AIIR should remain closed
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? - An extension cord is secured under a rug - The edges of stairs are marked with brightly colored tape - A toaster is plugged in when not in use - The water heater is set to 55C/ 131F
- The edges of stairs are marked with brightly colored tape
A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? - The nurse plugs in a sequential compression device with wet hands - The nurse holds onto the plug to unplug a client's electronic blood pressure machine - The nurse rolls the client's bed over an electrical cord - The nurse uses an extension cord to plug in a client's smart infusion pump
- The nurse holds onto the plug to unplug a client's electronic blood pressure machine
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? - Fasten the ties on the restraint to the side rails of the bed - Tie the restraint with a quick-release knot - Allow a fingerbreadth between the restraint and the client's chest - Place the restraint under the client's clothing
- Tie the restraint with a quick-release knot
A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown? - Firmly massage lotion into the client's skin - Tilt the client on their side at 30 degrees - Slide the client to the edge of the bed to transfer - Keep the head of the bed at 45 degrees when in the supine position
- Tilt the client on their side at 30 degrees This should be included in the care plan, tilt the client 20-30 degrees to prevent the client from sliding down in the bed (which can cause shearing of the skin and relieves pressure on hips)
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? - Washes their hands for 10 sec - Turns off the faucet with a towel - Uses hot water to wash their hands - Holds their hands above their elbows while rinsing off the soap
- Turns off the faucet with a towel
A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing? (SATA) - Type 2 diabetes - BMI 28 - Married - Current smoker - Corticosteroid use - 68 years old
- Type 2 diabetes - Current smoker - Corticosteroid use - 68 years old
A nurse is planning to implement the Transforming Care at the Bedside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? - Require nurses to spend 50% of their time at the bedside of clients - Perform change-of-shift report at the nurses' station - Complete client rounds every 4 hr - Use a standardized communication tool
- Use a standardized communication tool (ISBARR)
A nurse is reinforcing teaching with a newly licensed nurse about informed consent. The nurse should include that which of the following is the nurse's responsibility when obtaining informed consent from a client? (SATA) - Verify the client has signed the consent - Describe the procedure to the client - Check that the client is of legal age to provide consent - Explain alternatives to the procedure to the client - Confirm the client is competent
- Verify the client has signed the consent - Check that the client is of legal age to provide consent - Confirm the client is competent
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (SATA) - Place the client in a room that has negative air pressure - Wear a mask when providing care within 3 ft of the client - Place a surgical mask on the client if transportation to another department is unavoidable - Use sterile gloves when handling soiled linens - Wear a gown when performing care that might result in contamination from secretions
- Wear a mask when providing care within 3 ft of the client - Place a surgical mask on the client if transportation to another department is unavoidable - Wear a gown when performing care that might result in contamination from secretions
A nurse observes an assistance personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? -Assault -Battery -False Imprisonment -Invasion of Privacy
-Assault By threatening the client the AP is committing assault
A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? -Assault -False Imprisonment -Negligence -Breach of Confidentiality
-False Imprisonment Administering the medications is chemical restraint
A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? - From the middle of the thigh toward the wound - From the left lower abdominal quadrant toward the wound - From the left hip toward the wound - From the wound toward the surrounding skin
-From the wound toward the surrounding skin
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? - Wipe down the client's bedside table with an antiseptic wipe - Conduct informal audits of medical records to identify the number of HAI -Perform hand hygiene - Instruct the client on ways to reduce the risk for infection
-Perform hand hygiene
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs) Which of the following interventions should the nurse include in the bundle? -Try to use alternatives before inserting indwelling urinary catheters - Use clean technique for insertion of indwelling urinary catheters - Check clients every 2 days to evaluate the need for indwelling urinary catheters - Disconnect the system to obtain urine samples from indwelling urinary catheters
-Try to use alternatives before inserting indwelling urinary catheters
A nurse is preparing a client for surgery and needs to scrub the surgical site. Identify the sequence the nurse should follow. - Scrub the outer edge and discard the sponge - Drape the client - Scrub the surgical site in a circular fashion with an antiseptic - Repeat with a new sponge - Start at the center and move to the area away from the site
1. Scrub the surgical site in a circular fashion with an antiseptic 2. Start at the center and move to the area away from the site 3. Scrub the outer edge and discard the sponge 4. Repeat with a new sponge 5. Drape the client
A nurse is reviewing the standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care? - A nurse did not reach back a verbal medication prescription to a provider - A nurse idd not return to a client's room with a promised blanket - A nurse documents client care as soon as it is completed - A nurse forgot to call a client's family after performing a procedure
A nurse did not reach back a verbal medication prescription to a provider
A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? - A nurse on a medical-surgical unit demonstrates signs of chemical impairment - A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints - A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill - A client who is terminally ill hesitates to name their partner on their durable power of attorney form
A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting? - An adolescent who has a fractured tibia following a football game - A young client who is positive for TB - An older adult client who has dementia, a history of falls, and bruising on their knees - A preschooler who has frequent enuresis
A young client who is positive for TB
A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values? - Integrity - Human dignity - Altruism - Social Justice
Altruism The professional value of altruism is the selfless desire to help someone else without any benefit
A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take? - Explain the procedure in detail to the client - Ask the provider to discuss the procedure with the client - Encourage the client to reread the consent form before signing - Tell the client that the surgeon will explain it to them in the operating room
Ask the provider to discuss the procedure with the client
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? - Fidelity - Autonomy - Justice - Nonmaleficence
Autonomy
A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles? - Veracity - Beneficence - Autonomy - Fidelity
Autonomy
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following principles? - Fidelity - Autonomy - Justice - Beneficence
Beneficence
A nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles? -Autonomy - Beneficence - Nonmaleficence - Justice
Beneficence This refers to the nurse's obligation to implement actions that minimize harm and benefit clients. This includes meeting a client's physical, social or emotional needs.
A nurse who has been working 12-hr shifts on a busy unit is experiencing nurse fatigue. Which of the following effects can result from nurse fatigue? - Increase in communication skills - Increase in effective clinical judgment - Increase in medication errors - Increase in productivity
Increase in medication errors
A nurse is caring for a 6-month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? - Cellulitis - Skin tears - Premature wrinkling - Dermatitis
Dermatitis During infancy and early childhood when the skin is immature, dermatitis develops when the skin is exposed to urine and feces.
A nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care? - Document that the medication was not administered - Document that the client is not experiencing pain - Contact the provider to change the PRN prescription - Fill out an incident report about the situation
Document that the medication was not administered Standards of care guide nursing practice to perform safe and effective care.
A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action? - HIPAA violation - Falsification of records - Assault - Defamation
Falsification of records Falsification of health records can include not documenting care that occurred, documenting inaccurate data, or documenting care or events that did not occur.
A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values? - Human dignity - Altruism - Social justice - Autonomy
Human dignity The professional value of human dignity is recogning that all human life has value and should be treated equally with respect, regardless of race, religion, gender, sexual orientation, culture, ethnicity, or socioeconomic status.
A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? - Fidelity - Autonomy - Justice - Nonmaleficence
Justice
A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating? - Fidelity - Autonomy - Justice - Veracity
Justice
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? - Fidelity - Autonomy - Justice - Nonmaleficence
Nonmaleficence
A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take? - Counsel the coworker about substance use - Report the coworker to the ethics committee at the facility - Ask the coworker how long they have been using substances - Tell the charge nurse that the coworker might impaired
Tell the charge nurse that the coworker might impaired
A nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles? - Justice - Nonmalficence - Fidelity - Veracity
Veracity The ethical principle of veracity refers to the nurse's obligation to provide truthful information to the client, the provider, and the nursing supervisor. Truthfully answering a client's questions about their laboratory results is demonstrating the ethical principle of veracity