ADN Exam 1 Dalta co

A registered nurse assigns the task of tracheostomy suctioning of a client to the LPN. The LPN informs the nurse that she has never done the procedure practically on a client. What should be the most appropriate response from the registered nurse?

"I will help you" -Although the registered nurse has assigned the task to the LPN, the overall responsibility lies with the registered nurse. The registered nurse is answerable for the client's care, not the LPN. Telling the LPN that she should know the procedure because it is taught in class is inappropriate; putting theory into application would require supervision. Asking the LPN to refer to the manual and perform the procedure is incorrect because the LPN may commit mistakes. The LPN is not confident about the procedure and therefore should not be asked to do the task alone or with another nurse who knows the procedure.

Organize these events in chronological order, beginning with the earliest (1) and ending with the most recent (5). 1) During the Crusades, religious orders provided nursing care to the sick. 2) Florence Nightingale administered care to British soldiers during the Crimean War. 3) Clara Barton organized the American Red Cross. 4) Mary Elizabeth Mahoney graduated from the New England Hospital for Women and Children in 1879 as America's first African American nurse. 5) Margaret Sanger advocated for contraception and family planning in the United States.

1, 2, 3, 4, 5

What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled for effective hand hygiene?

20 seconds

What is the position of the State Board of Registered Nursing or the professional regulatory body of the state regarding services provided by student nurses?

A student may provide care (service) to clients when the service is part of a course of study and the student is enrolled in a board-approved prelicensure nursing program/school.

A charting format that monitors client problems by applying the process of Assessment, Problem identification, Intervention, and Evaluation for entries.

ADPIE

The Scope of Practice is.....

Actions and procedures permitted by law for a specific profession. Includes nursing assessment and treatment of human responses to actual or potential health problems and the ongoing assessment thereof. The definition is found in the Nurse Practice Act (review Boards of Registered Nursing or Professional Boards' specific website).

The NANDA-I nursing diagnoses are classified and formulated to address the client's health problems or needs, which can be:

Actual, risk for, syndrome

Cassie is working with an experienced staff RN. The staff RN instructs Cassie to raise all four bedside rails on Mr. W because she is concerned that he will fall and injure himself.

An order is not needed due to pt condition, and four bedrails up could be considered restraints

A nurse is assigned the care of a client who has been admitted to the health care facility with high fever. Which nursing skill should be put into practice at the first contact with the client?

Assessment

During the clinical rotation, a nurse documents the vital signs of a client on the bedside chart. What role is the nurse playing in such a situation?

Communication

Medicare reimburses in-hospital costs based on a set payment for a diagnostic related group (DRG). This means the hospital is reimbursed for a fixed amount based on the diagnosis and projected cost for care. As a result of this system the hospital can make a profit or a loss. Select the responses that describe when a profit for care of the client can be achieved.

Discharged prior to recommended date, all of hospital costs are less than projected

Which of following is a function of the Boards of Registered Nursing or other Professional Regulatory Bodies? PLEASE SELECT ALL THAT APPLY

Enforcement of disciplinary action Regulation of nursing education Creating the definition of the scope of nursing practice Developing the Nurse Practice Act of the state

Mark is a graduate nurse and started working as soon as he received his RN license. He administered medications through the patient's nasogastric tube. During the administration of the medication, the patient began coughing forcefully and gasping for air, Mark noticed that the nasogastric tube had been significantly out of the patient's nose.

Fill out incident report, notify physician, do not reinsert the tube, do not readminister meds

Who is considered to be the founder of professional nursing?

Florence Nightingale

The nurse working in the hospital understands the changes that have resulted in shorter hospital stays, with a focus on acute care needs of the client. Which of the following factors influence shorter hospital stays? Select all that apply.

Improvement in treatment of illness, increased emphasis preventative care, federal regulation

The Public Health Service (PHS) is a federal agency of the U.S. Department of Health and Human Services. The professional nurse is aware that the services provided by the PHS include which of the following? Select all that apply.

Indian health, care to migrant workers, care in federal prison, NOT VA hospitals

The client goes weekly to the outpatient clinic to have his blood pressure checked. He smokes one pack of cigarettes per day. His blood pressure is 146/88. His father died from heart disease at age 49 years, and his brother is recovering from aheart attack. The nurse should write which of the following nursing diagnosis:

Ineffective health maintenance, r/t smoking one pack of cigarettes daily

North American Nursing Diagnosis Association International

NANDA-I

What guidelines do nurses follow to identify the patient's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes?

Nursing Process-The nursing process is one of the major guidelines for nursing practice. Nurses implement their roles through the nursing process. The nursing process is used by the nurse to identify the patient's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes.

Throughout the morning, the client has become progressively more confused. He is restless and attempted to get out of bed. He says it is "1982." His laboratory diagnostic studies indicate that he has a decreased serum sodium level.

Nursing diagnosis- Acute confusion r/t decreased serum Na+ level as evidenced by altered mental status

A charting format that organizes and lists the client problems. All health care providers make charting entries with the same problem list. Problem Oriented Medical Record.

POMR

A charting format that focuses on a specific client problem and includes Subjective data, Objective data, Assessment, and Plan to document the progress/ lack of progress for the specific problem.

SOAP

Which of the following is a primary documentation (charting) format used in the clinical settings?

SOAP (SOAPIE) Electronic Charting ADPIE Narrative Charting

After a stroke, a client is having difficulty swallowing. The nurse may make a referral to what member of the health care team?

Speech therapist

What is the position of the State Board of Registered Nursing or the professional regulatory body of the state regarding delegation of tasks?

Tasks may be delegated provided that the delegate is clinically competent to perform the task for the specific client and within the specific time frame. Before assigning the task, the RN is responsible for assessing the client situation, determining the ability of the person who will be performing the task, and ensuring the task is within the person's scope of practice.

Cindi, a second-year nursing student, has been under a lot of personal stress. She tells another student that she gave her patient the wrong amount of sedative in the morning but that the patient was fine because she carefully monitored his vital signs all day. Cindi is an excellent student and will not allow this to happen again.

Tell the instructor, charge nurse, physician, and fill out an incident report

Who provides physicians with the authority to admit and provide care to clients requiring hospitalization?

The healthcare institution itself

Four aims of nursing

To promote health, to prevent illness, to restore health, to facilitate coping with disability or death

The first step of the nursing process, which includes the purposeful collection, verification, organization, and communication of data.

assessment

Which of the following is one of the five steps of the nursing process?

assessment, nursing diagnosis

A charting format that primarily documents significant client data or abnormal assessment findings.

charting by exception

Preprinted care plan that outlines routine interventions for patients with similar needs. May be changed to meet the individual needs of the client. Also called critical pathways or care maps.

clinical pathway

Which of the following clients is the most appropriate candidate for receiving outpatient care?

colonoscopy

Documentation of assessment findings and care by using a computer-based program.

electronic charting

Which one of the following is an INDEPENDENT function of a nurse?

feeding

Documentation of assessment data and care by using a checklist format.

flow sheets

A charting format that uses three columns to document client data (problem), action (interventions), and evaluation or client response.

focus charting

An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed?

hand hygiene must be performed after touching inanimate objects near the patient

Incubation

interval between invasion by pathogen and appearance of symptoms

Which of the following is NOT a part of the basis of Nursing Practice?

intervention

Which of the following is NOT a part of a three part nursing diagnosis?

medical diagnosis

Which of the following is an DEPENDENT function of a nurse?

medication admin

Documentation using statements to describe the assessment findings and care in a chronological format.

narrative charting

A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?

nosocomial

The second step of the nursing process involves making a clinical judgment based on data collected and formulation of the diagnostic statement (nursing diagnosis).

nursing diagnosis

A systematic method of problem solving employing critical thinking that includes assessment, nursing diagnosis, planning, implementation, and evaluation.

nursing process

Which one of the following is NOT one of the four elements that constitute professional negligence?

personal bankruptcy

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process?

prodromal

convalescent period

recovery stage of the infection

Which of the following is an INTERDEPENDENT function of a nurse?

resp therapist breathing treatment

full stage of illness

specific signs and symptoms of illness are present

A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure?

sterile gloves to touch the drape

prodromal stage

time of most infectious, early stages of symptom appearance and they are often vague

Intentional and Uniintentional are the two types of torts.

true

A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted?

vectors

A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend?

written infection prevention protocols

A man is scheduled for hospital outpatient surgery. He tells the nurse, "I don't know what that word, outpatient, means." How would the nurse respond?

you will have surgery and go home that same day