312- Foundations of Nursing Exam 3

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response" NOT- "I will call your doctor because you may have loosened sutures when walking."

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week." NOT- "Client will list positive coping strategies and use them."

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

The nurse is performing a preoperative assessment for a client prior to surgery in the morning. What statement made by the client alerts the nurse that there is a potential for latex allergy? Select all that apply.

"I am allergic to banana's" "I had a rash after using a condom." "I broke out in hives after eating sliced avocado"

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality." NOT- "Do you have any identification proving that you are related to the client?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body." NOT- "Wearing the TENS unit should not interfere with my daily activities."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense." not- "The pump is programmed to limit the chance of overmedicating."

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

"I will put a layer of cloth between my skin and the ice pack." NOT- "I can let this stay on my ankle an hour at a time."

The nurse has been educating a young adult client about living with type 1 diabetes and the importance of adhering to a strict dietary regimen. The client is repeatedly admitted and is not following the prescribed plan. What statement made by the nurse may facilitate values clarification for the client?

"Rank the three most important things in your life." NOT- "How can I help you stay on your diet and take your insulin?"

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

"Reinforced adhesive skin closures will hold my wound together until it heals." NOT- "I may have staples in place for a number of days."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States." NOT- "As long as your family knows your medical wishes, you will not need it."

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished?

"The provider will perform this laser surgery in an ambulatory care setting."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form." NOT- "The surgeon will leave your wound open intentionally for a period of time."

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." NOT- "Your wound will be purposely left open for a time."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

Licensed Practice Nurse (LPN) or Licensed Vocational Nurse (LVN)

-- education more related to bedside nurse, **able to give medication** if pharmacology course taken, cannot assess patient

Defamation of Character

-publication of false statements that result on damage to a person's reputation.

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

3

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso NOT- A client who is undergoing diagnostic testing for appendicitis

A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique?

A nurse applies intermittent heat and cold to a client's leg.

A nurse demonstrates the professional value known as altruism when caring for clients in a long-term care facility. What nursing action demonstrates this behavior?

A nurse researches the culture of a Muslim client when planning care. NOT- A nurse consults a client when planning care to determine priorities.

Which scenario is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special testing

Which process evaluates and recognizes educational programs as having met certain standards?

Accreditation

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply.

Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining

Which example best describes feminist ethics?

An approach critiquing existing patterns of oppression and domination in society

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

avulsion

An injury in which soft tissue is torn completely loose or is hanging as a flap. **Tearing of a structure from its normal position**

Which action constitutes battery?

An older adult client refuses an intramuscular injection, but the nurse administers it. **Battery is the intentional act of causing physical harm to someone. Unlike assault, you don't have to warn the victim or make him fearful before you hurt them for it to count as battery. If a nursing home attendant surprises the patient and pushes the patient from behind, that would qualify as battery** NOT- The nurse threatens to restrain a client if the client does not take a medication.

A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply.

Apply a bath blanket over the aquathermia pad. Assess skin and pain level at baseline and ongoing. Check the water level in the aquathermia unit periodically.

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate?

Ask the client whether the heart rate is normal for the client.

An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?

Asking the LPN/LVN to teach a new diabetic client how to administer insulin

Which are torts rather than crimes? Select all that apply.

Assault Defamation of character Negligence

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.

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

Battery

Six teenagers were killed in an accident following a night of drinking. The older brother of one of the victims bought beer for the group because none of them was old enough to purchase alcohol. Which statement(s) regarding the brother's action reflect customs rather than communal or personal ethical standards? Select all that apply.

Big brothers often introduce their younger siblings to alcohol. Drinking alcohol is a rite of passage.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale NOT- FLACC scale

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty NOT- duty

The nurse is performing assessments for an assigned client. Which methods are appropriate ways for the nurse to gather objective data related to a client's pain? Select all that apply.

By checking the vital signs By observing facial expressions By diagnostic tests and procedures NOT- By eliciting factual information By using pain assessment questionnaires

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?

Certification NOT- Licensure

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside. NOT- Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

Which is not considered a skin appendage?

Connective tissue

When examining values, a nurse notes that one country allows physician-assisted suicide and another outlaws it, making it punishable by imprisonment. Which factors best explain the differences in values between these two countries?

Cultural Not- Ethical

Debridement

Debridement- the removal of damaged tissue or foreign objects from a wound. *think you have to bride something out of someone*

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

The nurse enters a client's room and finds the client curled up in bed and crying. The client states, "My life is so good, and now I have cancer. Why me? I have tried to be a good person." The nurse recognizes the client as exhibiting signs of which stage of Engel's model of grief?

Developing awareness NOT- Shock and disbelief

A nurse is named as a defendant in a malpractice lawsuit. Which action would be recommended for this nurse?

Do not volunteer any information on the witness stand. NOT- Discuss the case with the plaintiff to ensure understanding of each other's positions.

The nurse is preparing to irrigate a client's wound. Arrange the following steps in the correct order.

Don a mask, gown, and eye protection. **Carefully remove the soiled dressing. ***Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. NOT- Chart tunneling by using a quadrant approach to describe the location.

Which of the following is considered to be the most potent neuromodulators?

Endorphins

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when reflecting on the decision-making process and the role it will play in making future decisions?

Evaluating

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

Fidelity

Which nursing action demonstrates the principle of fidelity?

Filing an incident report after making a medication error

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

Guarding of the chest area not- Increased respiratory rate

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply.

Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago Cyanotic nail beds in hands and feet bilaterally

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

Health care institution not- State legislation

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Heat Massage Cold

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating?

Integrity NOT- Autonomy

The nurse beginning practice would like to access the standards for ethical practice. Which organization should the nurse research for these standards?

International Council of Nurses

A parent of a 17-year-old high school student is allowing the child to decide which college the child will attend. When the child requests direction from the parent in making this decision, the parent responds by stating, "You will need to make this decision on your own." What type of value transmission is the parent displaying?

Laissez-faire NOT- Responsible choice

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?

Naloxone **It can treat narcotic overdose in an emergency situation.**

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics

A client has been diagnosed with a recent myocardial infarction. What **collaborative** problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage NOT- PC: Disturbed Body Image related to decreased activity tolerance

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

Paternalism **restricting the freedom and responsibilities of those subordinate to them in the subordinates' supposed best interest.** NOT-Deception

The International Council of Nurses (ICN) Code of Ethics for Nurses (2012) has which elements? Select all that apply.

People Practice Profession Coworkers

The nurse is caring for a client that is at the end of life. After the client is pronounced dead, what actions by the nurse are essential components of care? Select all that apply.

Removing all tubes according to agency policy, unless an autopsy is to be performed Placing identification tags on the client's dentures or other prostheses Arranging for family members to view the body before it is discharged to the mortician NOT- Washing the client's body

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Respiratory NOT- Cardiovascular

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?

Respiratory status, oxygen saturation, pain, and sedation level NOT- Heart rate, capillary refill, bowel sounds and pedal pulses

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

Nursing students are discussing the requirement that they carry personal professional liability insurance as students. The nurse instructor should offer additional information when which statements are made? Select all that apply.

Since I am a student, my instructor is the one liable if I make a mistake." "I will be protected both as a student and at my CNA job." "I think this is an unnecessary expense." "I thought we would be covered by the hospital's malpractice insurance."

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

Slander

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

When analyzing an ethical dilemma according to the ethical framework, what is most important for the nurse to take into consideration?

Standards of conduct NOT- The relationship between law and values

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case?

The agency's risk manager

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. NOT- Pharmacologic interventions should not be initiated.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. NOT- The client will ambulate 100 feet without supplementary oxygen or mobility aids.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

The client's breathing becomes noisy. ..so death rattle NOT - The frequency of urination decreases.

Which is the best definition of ethics?

The formal, systematic study of moral beliefs

A nurse becomes concerned that a coworker may have a substance use disorder. Which behaviors by the coworker would increase this concern? Select all that apply.

The last two times the nurse has needed help turning a client, the coworker could not be found. The coworker has needed to leave early "to pick up my kids" several times in the last 2 months. The coworker has stopped eating lunch in the breakroom with other nurses.

Which situation violates an element of informed consent?

The nurse says, "You have to sign this before we can do the surgery."

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it.

A nurse caring for a client who has a surgical wound after a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound. NOT- There is an accumulation of fluid in the interstitial tissue.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?

They bind to opioid receptor sites throughout the CNS.

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public NOT- To ensure that practicing nurses are of good moral standing

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability?

Tort NOT- Defamation

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

What are standards for decision-making that endure for a significant time in one's life?

Values

What is the term for the beliefs held by the individual about what matters?

Values NOT- morals

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?

When obtaining patient vital signs NOT- The first question you ask the patient

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform?

Wound irrigation

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down NOT- a client who must remain on his back for long periods of time

A parent teaches a child not to drink and drive; however, the parent does drink and drive. This action results in:

a failure to model one's own values. NOT- a disruption in consistency.

A pediatric nurse recognizes that preschoolers think of death as:

a long sleep.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

To practice ethically, the nurse should avoid:

allowing the nurse's own judgment to guide practice.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes NOT- a man with a sedentary lifestyle and a long history of cigarette smoking

Battery

any intentional touching w/o consent i.e. actually give injection.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

What is Kübler-Ross's third stage of grief?

bargaining

A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed:

battery.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

biosurgical debridement

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

contusion

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies NOT- pain management

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

decubitus ulcer

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar

Granulation tissue

forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

A fistula

is an abnormal passage connecting two body cavities or a cavity and the skin.

Necrotic tissue

is dead or devitalized tissue

Maceration

is defined as the softening and breaking down of skin resulting from prolonged exposure to moisture.

evisceration

is the protrusion of internal organs through the rupture

Dehiscence

is the rupture of a suture line

The **experience** of parting with an object, person, belief, or relationship that one values is defined as:

loss NOT- greif

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have:

personal values. NOT- moral agency.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?

serosanguineous

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

shock

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound?

suspected deep tissue injury

desiccation

the removal of moisture from something. *think vacation - sunburn - no moisture in skin*

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering NOT- to bridge between curative care and hospice care

purpose for a T-tube drain

to provide drainage for bile.

A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

transduction

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

A nurse is preparing a client for discharge from the cardiac unit and observes cigarettes in the client's belongings. The nurse asks the client to consider the client's health and that of the client's spouse. This is an example of:

values clarification. not- social justice.

Assault

verbal or offensive contact i.e. **threaten** to give injection w/o consent.