FUND EXAM 1 NCLEX EAQ

during an assessment, which finding prompts the nurse to don a protective gown?

excessive wound drainage

which nursing action is most appropriate to help reduce the likelihood of an older adult pt falling during the night?

instructing the pt to call nurse before going to bathroom

the registered nurse is evaluating the statements of a new nurse about wound dressings. which statement made by the new nurse is incorrect?

"I should use the cotton swab placed on the table"

an older client asks "how do i know that the medications that i take are safe?" how would you respond?

-ask your health care provider how and when you should be taking your medications -check name, dose, and instructions about administration of medications each time before leaving pharmacy -inform your health care provider of the over the counter mediations, recreational drugs, and amount of alcohol you ingest

which information must be clearly described in the medication administration record before administering a medication?

-dosage and route -clients full name -time to be administered -frequency of administration -full name of prescribed medication

which physiologic symptom would the nurse associate with a pt sleep deprivation?

-ptosis and blurred vision -decreased auditory alertness ---ptosis may result from loss of elasticity of eyelids

the nurse notes that a client has mild hypothermia based on which body temperature?

35 C=95 C hypothermia occurs when the body is below 36.2 C

when preparing to assess a client with active tuberculosis, which piece of personal protective equipment would the nurse put on before entering the clients room?

N95 respiratory mask

which clients need would be considered priority?

a client with dysphagia who is choking while eating

which information would the registered nurse provide tp a student nurse about the importance of nursing documentation for risk management?

a nurses documentation is the evidence of care that a client receives the nurse would note assessments and significant changes in the pt health nurses would always document the primary health care providers responses whenever they are contacted

Accountablity

ability to answer for one's own actions

which principle refers to the professional obligation of the nurse to assume responsibility for actions?

accountability

the most important part of nursing practice regarding medication is administering the medication

administering medications safely requires an understanding of legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics

which is the most important nursing action involved in caring for a client receiving medications?

administering the medications

fidelity

agreement to keep promises

which scenario is an example of primary prevention?

an infant receives the rotavirus vaccination in hospital setting primary- health promotion efforts and wellness education activity

a client reports sleeping until noon every day and taking frequent naps during the rest of the day. initially, which action would the nurse take?

arrange a referral for a thorough medical evaluation

a pt request information about primary health care providers prescribed medications. which is the correct response by the nurse?

asking the client to state what the client already knows about the medications

the nurse is changing the dressing of a postoperative client. another client has fallen near the nursing station and is unconscious. which is the priority nursing action in this situation?

attend to the client who lost consciousness

nonmaleficence

avoidance of harm or hurt

how would the nurse respond to an alcohol recovery program sponsor requesting to read the clients progress record?

by not allowing the sponsor to review the record HIPPA- pt records are confidential and may be see by only those who are associated with direct care of pt

the nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. which personal protective equipment would the nurse wear?

clean gloves

which nursing interventions require the nurse to wear gloves?

cleaning a newborn immediately after delivery emptying a portable wound drainage system NOT: giving a back rub interviewing a client in emergency room obtaining the blood pressure of a client who is positive for human immunodeficiency

which category of isolation would the nurse implement for a client who is positive for Clostridium difficile?

contact precautions contact precautions- should be used for direct client or environmental contact with blood or body fluids from an infected pt

which quality and safety education for nurses competency does integrating current research with clinical experience and client preference comply with?

evidence based practice

the nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to pt. which nursing function does this represent?

delegation delegation- assignment of a nursing task to someone else who is able or qualified to perform task

according to the nursing process, which action would the nurse take after administering pain a=medication to a postoperative to?

determine whether the pain medicine received the clients pain

which step should the nurse take to alert the risk management system after notifying the primary health care provider of a pt fall?

document the incident in the occurrence report tool

to assess the status of circulation to the foot, which site would the nurse monitor for a pulse?

dorsalis pedis artery posterior tibial artery

the nurse working in a cardiac center is preparing to enter client data using health information technology. the nurse needs to refer to these data during subsequent follow-up client visits. which type of record would the nurse use to enter the clients data?

electronic medical record

which standard of practice would the nurse perform when evaluating a clients pain after performing a back massage?

evaluation -when a nurse evaluates progress toward attainment of outcomes, it is referred as evaluation -when nurse monitor pt on an hourly basis to check if pt is comfortable after giving back massage; considered evaluation

which statement by the student nurse indicates the need for further education about medication administration?

i should advise the certified medical assistant to administer intravenous medication

the registered nurse is teaching a nursing student about how to safely use a urinary catheter. which statement made by the nursing student indicates ineffective learning?

i will avoid draining urine from the tubing before ambulation

the nurse has provided instructions about back safety to a client. which statement by the client indicates understanding of these instructions?

i will carry objects close to my body this can lessen a back strain

the registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a health care sitting. which statement made by the nursing student indicates the need to further teaching?

i would avoid asking about the clients over the counter medications

the nurse is preparing to change a clients dressing. for which reason would the nurse use surgical asepsis?

keeps the area free of microorganisms

which rationale is correct for the nurse to empty a hemovac wound suction device when it is half full?

negative pressure in the unit lessens as fluid accumulates, interfering with further drainage

the nurse is caring for a surgical client who develops a wound infection during hospitalization. which classification would this infection belong to?

nosocomial -infection acquired in a health care setting

which information would then nurse provide the clients regarding benefits of electronic health records?

obtains medicare and medicaid payments shares personal health info with selected family members provides more accurate diagnoses and treatment in emergency conditions

which action would the nurse take first when caring for a postoperative client who reports pain?

perform a focused assessment of a client

the nurse would recommend that the clients pharmacist relabel the medication in large letter so that the client can easily read the name of the medicine and can take the medication properly

pill organizers may help the client sort the medications by time of day for a 7 day period but will not help in reading pill bottle labels

the nurse changed a dressing on a clients wound with vancomycin resistant enterococci. which step would the nurse take to ensure proper disposal of soiled dressing?

place the dressing in the red bag/ hazardous materials bag

urine should be drained from the tubing into the drainage container before ambulation or exercise

polling of urine should be avoided because this action may increase the risk for infection prolonged clamping of tubing should be avoided because intermittent clamping helps maintain the bladders capacity and tone

which explanation regarding the term "just culture" is accurate?

promoting open discussion whenever error occurs without fear of recrimination

the nurse finds that a visually impaired client is having difficulty in determining which medications to take after being discharged from the hospital. which intervention would be the best in this situation?

recommending that the clients pharmacy relabel the medication in large letters - so that the client can easily read the name of medicine and can tale medication appropriately

which action is the professional nurses legal responsibility regarding child abuse?

report any suspected abuse to local law enforcement authorities

to ensure safe medication administration, the nurse must ensure that all required documentation is present in the MAR before administering medication

required information includes medication dosage and route, clients full name, time the medication is to be administered, frequency of administration, full name of prescribed medication

primary infection- synonymous with initial infection secondary- made possible by a primary infection that lowers the host resistance and causes an infection by another kind of organism

superinfection- new infection cause by organism different from at which caused the initial infection

the nurse finds the orders from the primary health care provider inappropriate. clarification from the health care provider does not resolve the nurses doubts. whom would the nurse contact and inform next?

supervising nurse

which description does beneficence in health ethics refer to?

taking positive action to help others

loss of consciousness may pose a threat to the clients safety and survival and is a high priority need

the nurse would attend to the unconscious client -risk of infection is not a threat to survival and is considered an intermediate need

during medication reconciliation, the nurse would ask about all over the counter medications the client may be taking

the nurse would compare the new medication prescription with current list to ensure accuracy

according to Avers Donabedian, which finding is the most important validator of quality and effectiveness of health care in a Hospital?

the pt outcomes achieved by the care provided

the nurse is providing restraint education to a group of nursing students. which reason to use restraints is incorrect to teach?

to prevent an adult client from getting up at night when three is insufficient staffing on the unit -restraints are not used for staff inconvenience

after neck surgery, the client asks the nurse why the head of the bed is up so high. which reason would the nurse give?

to reduce edema at the operative site

which information is appropriate to include in education about sentinel events?

undesirable and largely avoidable

which action would the nurse take to minimize ambiguity and confusion when entering a pt data in electronic health record?

use consistent, codified terminology

which intervention by health care professionals helps prevent client medication errors according to Leapfrog group?

using computer prescription order entry

when preparing to administer medications to a client, which action made by the new nurse requires an intervention?

using one client identifier -the nurse should always use 2 pt identifiers before administering any medication

coordination of care

when nurse coordinates care delivery with other team members

outcomes identification

when nurse identifies expected outcomes for a plan individualized to the client or situation

consultation of a pt

when nurse provides consultation to influence the identified plan, enhance abilities of others, and effect change

the nurse is caring fir a client who had head and neck surgery which complication will the nurse try to prevent by positioning the clients head in functional alignment after surgery?

wound dehiscence