270 Module 3 and 4

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement? "Which drills and safety checks do you think we could eliminate?" "I agree with you. We need to focus more on the positive things we do instead of what could go wrong." "Highly reliable organizations think about the possibility of failure and what to do to avoid it." "I am afraid that there may be an issue when our next accreditation visit occurs."

"Highly reliable organizations think about the possibility of failure and what to do to avoid it."

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Nutrition Health promotion Self-perception Activity and rest

Activity and rest (A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.)

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk?

Albumin, 1.5 g/dL

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? Intelligence Preparation Previous knowledge Anxiety

Anxiety (Too much anxiety can paralyze high-order thinking skills. The other answers would tend to increase the client's ability to learn.)

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role? Providing client education related to colostomy care Identifying individuals who are at risk of developing diabetes mellitus Verifying that all documentation is updated prior to surgery Collaborating with all agencies to provide for the client's home health needs

Collaborating with all agencies to provide for the client's home health needs

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? Precision Relevance Accuracy Clarity

Clarity (The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue.)

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect? Educator Counselor Coordinator of care Care provider

Coordinator of care

In collecting assessment data on the school-aged population, which factor could be the most significant predictor of childhood obesity?

Having parents who are obese

A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate? Extended Respite Hospice Palliative

Hospice

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way? Part A of Medicare is voluntary and is paid for by a monthly premium. Benefits and reimbursement cannot be changed annually. Part B of Medicare covers most inpatient and outpatient costs. Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

Which statement best captures the current understanding of the etiology of mental illness?

Mental illness exists from the interplay of biologic factors and psychosocial influences.

Which statement provides accurate information related to chronic illness?

Most people with chronic conditions do not consider themselves sick or ill.

A nurse receives a report that a client has had an overdose of heparin. Which action by the nurse is most important in managing the overdose?

Obtain an order to give protamine sulfate.

Which students study the best in a group setting? Auditory learners Sensory learners People-oriented learners Kinesthetic learners

People-oriented learners (People-oriented learners are social; they prefer to study in groups rather than alone, and they enjoy the process more than focusing on the task at hand.)

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. (There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.)

A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate? Respite care Parish nursing services Palliative care Hospice care

Respite care

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain? Voluntary services Respite care Hospice care Palliative care

Respite care

The nurse is discussing deinstitutionalization of mentally ill persons at a community forum. What is a consequence of the trend towards deinstitutionalization?

The number of persons with mental illness in prison has increased.

Which registered nurse should be assigned to the client who had a chest tube inserted yesterday?

a registered nurse who use to work on the cardiovascular unit

Put the phases of the nursing process in the correct order. Use all options. diagnosis planning implementation evaluation assessment

assessment diagnosis planning implementation evaluation

An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will: exercise every day for at least 30 minutes. only eat three meals per day. create an exercise plan that is realistic and valued. stop eating meat and walk every day after dinner.

create an exercise plan that is realistic and valued. (Outcomes should be realistic and valued by the client and family. If this client creates an exercise plan that the client values and is realistic, then the client will be more likely to meet the outcome. Exercising every day, only eating three meals per day, or excluding meat from the diet may not be realistic or valued by the client who openly acknowledges liking to eat and does not like to exercise.)

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as: life-sized mannequins with a sophisticated computer interface. small, doll-like devices used for measuring vital signs. health care equipment that has practice modes. life-saving equipment that resuscitates clients in cardiac arrest.

life-sized mannequins with a sophisticated computer interface. (The human client simulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. The other equipment and devices described are tools used to learn and practice skills, rather than build on critical thinking skills.)

The nurse is explaining metastatic rhabdomyosarcoma to a group of parents with children diagnosed with the disease. The most common site of metastasis in clients diagnosed with rhabdomyosarcoma is the

lung.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis.

What is one of the most significant trends in health care today? narrowing of the areas for nursing practice increased length of hospital stays emphasis on disease management shift from hospitals to community-based care

shift from hospitals to community-based care

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply.

"The client will be involved in the verification process prior to surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." "The client can be involved in marking the knee, the site for the surgery."

The nurse understands that the dosage recommended by drug manufacturers is based on an individual weighing:

150 lb (68 kg).

Which client would a nurse correctly refer to Medicare services? A client with a disability A 66-year-old client with diabetes A low-income family with infants needing immunizations A client with cancer

A 66-year-old client with diabetes

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?

Treatment with antimicrobial prophylaxis as soon as possible

Which scenario is using a prospective payment plan to reimburse for services? An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. A client is hospitalized for an emergency appendectomy. Since the hospital is a preferred provider the fee for service was discounted. A client with chronic heart failure is offered health care teaching and preventative services for free. A child is hospitalized and treated for a fractured femur. The hospital receives a preset fee for each member regardless of whether the member required services.

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price.

A 12-year-old client comes to the clinic for an annual checkup. The nurse needs to take a health history and perform a physical exam. Which method would be the most appropriate when obtaining the client's health history?

Ask the client if it's OK for the parent to be in the room.

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? Establish a nursing diagnosis of Altered Skin Integrity. Assess the client's back visually. Report it to the health care provider. Document the rash in the client's chart.

Assess the client's back visually. (Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing diagnosis.)

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:

Battle sign.

A nurse is assessing a patient's nails and observes Beau's lines. Which of the following depicts this condition?

Beau's lines, (option C) are transverse depressions in the nail that may reflect retarded growth of the nail matrix because of severe illness or more commonly local trauma. (horizontal lines across nailbeds)

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? Clinical reasoning Reflection Assessment Caring

Clinical reasoning (Clinical reasoning is the process of making a nursing judgment that will provide safe and quality care. Caring is holistically meeting the needs of the client. Reflection is looking back on events that have occurred and learning from them how to improve one's practice. Assessment is careful observation and evaluation of a client's health status.)

A nurse is caring for a client who has a PPO health care plan. What is the greatest advantage of this type of plan? Care coordination Ease of referrals Cost effectiveness Improved health outcomes

Cost effectiveness (Cost effectiveness is the greatest advantage of the PPO health care plan. PPOs are not known for the ease of referrals, care coordination, or improved health outcomes.)

An ambulatory care center that facilitates socialization and provides health-related services to seniors who are unable to fully care for themselves is best known by what name? Extended care center Hospital at Home Day care center Ambulatory care center

Day care center (Day care centers provide these services to senior citizens. Ambulatory care is an overarching category of care centers and clinics that can include psychosocial, physical, and mental health care. Hospital at home care and extended care centers are for patients who require more complex care than can be provided in a day care center.)

Which action exemplifies the purpose of evaluation in the nursing process? Decide whether to continue, modify, or terminate client care. Develop an individualized plan of client care. Develop a prioritized list of nursing diagnoses. Determine the client's health status, self-care ability, and need for nursing.

Decide whether to continue, modify, or terminate client care. (Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care.)

The goals of health care reform include which? Decreasing health care services to provide all citizens with some access to care but control escalating costs Improving quality of care while limiting access for the uninsured to control rising costs Controlling health care costs by providing limited services for more consumers of health care Focusing on cost containment with improved access and quality of services for everyone

Focusing on cost containment with improved access and quality of services for everyone

Which medication is categorized as a loop diuretic?

Furosemide

Nurses provide care for clients in a program called "Hospital at Home." What are the characteristics of this program? Select all that apply. Higher satisfaction with care Higher use of sedatives and restraints Better client outcomes Lower chance of developing delirium Higher average client length of stay Lower overall costs

Higher satisfaction with care Better client outcomes Lower chance of developing delirium Lower overall costs

Nurses who assist clients to deal holistically with their health care needs at the end of their lives work primarily in which health care delivery system? Rehabilitation Primary care Acute care Hospice

Hospice (The opportunity to help people maintain their ability to remain at home and deal holistically with their health and family needs at the end of their lives is home health hospice care.)

Which is the acute care setting for people who are too ill to care for themselves at home, are severely injured, or require surgery? Day care centers Primary care centers Hospitals Ambulatory care centers

Hospitals

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. Impaired mobility Pneumonia Imbalanced nutrition Ineffective coping Heart failure

Impaired mobility Imbalanced nutrition Ineffective coping

A nurse is concerned about the requirements needed to complete all of her courses successfully. Which of the following factors would assist her to be successful? Begin studying the night before the test Read the text following the class Implement time-management skills Refine writing skills

Implement time-management skills (Time management significantly affects how well a person accomplishes his or her goals.)

Which is a characteristic of person-centered care? It can be used in hospital settings. It is a framework for providing care. It is independent of other disciplines. It involves general care for all clients.

It is a framework for providing care. The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs.)

The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to?

Physical dimension

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? Modify the plan of care and interventions to meet the client's needs. Reassess the client for more symptoms of deficient fluid volume. Change the nursing diagnosis because the client's problem was falsely identified. Develop an additional nursing diagnosis to meet the client's health needs.

Modify the plan of care and interventions to meet the client's needs. (The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.)

Which is the most appropriate example of the assessment phase of the nursing process? Palpating a mass in the right lower quadrant of the abdomen Documenting the administration of a medication provided for pain Including a nursing diagnosis of Acute Pain in the client's plan of care Evaluating the temperature of a client given medication for a fever

Palpating a mass in the right lower quadrant of the abdomen (Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.)

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? Assessing; diagnosing Diagnosing; implementing Planning; implementing Implementing; evaluation

Planning; implementing (Determining the correct length of the NG tube to insert is an example of the planning that is necessary to conduct this nursing action. The actual insertion of the NG tube would constitute implementation. Assessment would be checking that after insertion, the NG tube is properly working. Diagnosing is gathering the evidence that the client needs an NG tube. Evaluation would be determining whether the outcome associated with inserting the NG tube has been accomplished.)

A nurse is a member of an interdisciplinary team providing home health care to a client who was discharged home after experiencing a stroke. The client has been receiving services to assist with swallowing. The nurse would collaborate with which member of the team to discuss the client's progress? Social worker Physical therapist Speech therapist Occupational therapist

Speech therapist (A speech therapist diagnoses and treats swallowing problems in clients who have had a head injury or a stroke. A physical therapist seeks to restore function or to prevent further disability in a client after an injury or illness. Occupational therapists evaluate the client's functional level and teach activities to promote self-care in activities of daily living. Social workers assist clients and families in dealing with the social, emotional, and environmental factors that affect their well-being.)

You are the nurse employed in an acute care hospital. The head nurse states that you will be caring for 12 clients with the help of two nurse assistants. This is considered to be what type of nursing care delivery? Tertiary care Team nursing Modular nursing Primary care

Team nursing (Team nursing is the provision of care with a nurse supervising the work of one or more aides.)

Which statement is true when comparing home care with acute care? The nurse is the guest in the client's home. The client directs the education of all caregivers. The nurse and the client work independently of each other. The nurse directs all aspects of the home.

The nurse is the guest in the client's home.

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: expect the client to be drowsy, and let the client rest. complete the postoperative assessment. evaluate the abdominal dressing for drainage. administer pain medication.

complete the postoperative assessment. (Assessment is the first priority, which would include breathing, level of consciousness, vital signs, dressings, intravenous sites, and pain level. After assessing, pain medication may be needed. The nurse may expect the client to be drowsy, but ongoing assessment is required nonetheless.)

A nurse is providing care to a client who has undergone a mastectomy. The nurse provides the woman with information about where to obtain a breast prosthesis. This is an example of which type of community-based nursing intervention?

health system referral

A nurse is caring for a client with diabetes mellitus. The client takes insulin 2 times per day. The nurse makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the nurse is:

integrated

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: uses critical thinking to direct care for the individual client. employs communication to meet the client's needs. applies intuition and routine care for clients. uses scientific problem solving to meet client problems.

uses critical thinking to direct care for the individual client. (The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.)