Basic Practice Quiz

While teaching about advance care planning, which fact is important for the nurse to share with a client who has been diagnosed with a terminal illness?

A durable power of attorney for health care appoints an agent the person trusts to make decisions.

An acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in the acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

Administering medications to the client

Hourly neurovital signs have been ordered for a client who has been admitted after experiencing an ischemic stroke. The client's neurological status has declined over the past few hours. Which nursing action best prevents an adverse outcome in this client's care?

Assessing the client's neurological status more frequently than ordered

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

Battery

A client with a body mass index of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time?

Past interventions for weight loss

The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of the vehicle with a lap and shoulder belt in place?

The child's feet touch the floor of the car when belted in which the lap and shoulder belt.

A client, eager to go home from an acute care facility, calls out to have discharge education completed. The nurse is not able to get to the client's room until an hour later, and finds the client asleep. The client's significant other states, "She will be out for a couple hours after that pain medication." Which of the following best describes what must happen with the education session?

The client is not demonstrating readiness to learn due to the effects of medication.

A nurse is taking care of a 66-year-old client post knee surgery. The nurse follows a clinical pathway that guides the care of this client after this specific procedure. The client is 2 days post-op and the clinical pathway states that the nurse should advance the diet. The nurse enters the client's room to discuss this order and finds the client vomiting in the wastebasket. A change in client care that deviates from the clinical pathway is called:

variance

A nursing student administers an overdose of a narcotic to a client and the client arrests. When discussing the incident with nursing faculty, which statements, if made by the student, indicate the need for further teaching?

"I cannot be held liable because this is only my second time at this facility." "I am glad I am a student because nursing faculty will be blamed, not me."

A nurse is transfusing multiple units of packed RBCs. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

The parents of a client ask the nurse to review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request into writing."

A nurse educator understands that his teaching was effective regarding the Code of Ethics for nurses when students state what?

"The code is an expression of nursing's own understanding of its commitment to society."

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

1600: consumed 80 % of breakfast. Reports pain level on 3 on scale of 1-10

When performing fall risk assessments, the nurse understands that which of these clients is most at risk for falls?

A 70-year-old female that has postural hypotension and wears eyeglasses, but has no history of falls

A nurse is caring for an 18 month-old boy status post tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?

A rocking horse

The health care provider prescribes cold therapy every 4 hours for a client after foot surgery. The nurse places the ice pack directly on the client's skin and returns 60 minutes later. After removal of the ice pack, the skin is pale and cold to the touch. The client develops frostbite and begins a lawsuit for malpractice. When reviewing the case, the nurse attorney recognizes which most important statement about the malpractice suit?

All elements are in place to hold the nurse liable.

During a nursing shift, which events warrant completion of an incident report? (select all that apply.)

An IV antibiotic was administered 2 hours late because the IV site infiltrated. A visitor slipped and fell in the hallway, but was not injured. A client falls while being transferred from the bed to the chair.

The nurse is caring for a 70-year-old client with a fractured wrist. Which of the following is the best method to determine if the client has retained the information taught?

Ask the client to recall after approximately 15 minutes

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

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

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart

A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent, which element of informed consent would be violated?

Competence

When deciding what information the patient needs to meet the learner objectives successfully, the nurse is planning which part of the teaching plan?

Content

Nursing documentation is inclusive. Which is the best example of documentation of a teaching plan?

Cord care shown to mother, questions answered. Return demonstration observed.

A nurse fails to alert a physician after a client's condition worsens. This is an example of which aspect of malpractice?

Duty

A nurse is caring for a client 72 years of age with arthritis. Which action is the priority for the nurse when conducting the health education for the client?

Find out what the client wants to know.

An older adult patient has had a severe stroke and is unable to swallow. The patient has no cognitive deficits and is adamant that he does not receive a feeding tube or intravenous nutrition. Members of the care team have taught the patient that he will not survive without one of these two interventions. What is the most ethical response to this situation?

Honor the patient's wishes and advocate for the rejection of artificial feeding methods.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

In most age groups, motor vehicle accident are major causes of death.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments?

Libel

An emergency department nurse and health care team are caring for a semiconscious child age 2 years with numerous fractures and evidence of cigarette burns. They suspect child abuse. The nurse reports the family to the child abuse hotline. The nurse is following which ethical principle?

Nonmaleficence -to avoid doing harm, the remove harm, and to prevent harm

A school nurse is discussing bike and outdoor safety measures with a group of Boy Scouts. What type of health education and counseling is the nurse providing to this group of children?

Preventing illness

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group?

Providing drug, alcohol, and sexuality education

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?

Reduce the temp. on the water heater.

A client on a hospital unit has been infected with Hep. C virus because a nurse mistakenly connected an HCV- positive client's IV pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to the Joint Commission and to relevant state agencies.

The nurse is writing learner outcomes for a client admitted with heart failure. Which learner outcomes statement is correctly written?

The client will describe symptoms of hypokalemia associated with diuretic use.

When teaching an adult client how to control stress through relaxation techniques, the nurse should consider what assumption concerning adult learners?

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction

A complex medical patient is receiving care as an inpatient. What aspect of the patient's medical and health history would necessitate the use of a specialized flow sheet?

The patient has a diagnosis of Type 1 diabetes. (diabetes flow sheets are among the most commonly used specialized flow sheets)

Which party is responsible for obtaining informed consent from a client?

The person performing the procedure, study, or treatment

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 her health and the health of her husband. This is an example of

values clarification