L/M Final Exam

42. The nurse uses which part of the SBAR acronym when stating, "I think the client is dry." a. Background b. Assessment c. Situation d. Recommendation

b. Assessment

58. When administering blood, the nurse must check the name on the label of the blood with the name on the client's: a. Wristband with a family member present b. Medical chart with the unit clerk c. Medication administration record with the pharmacist. d. Wristband in the presence of another nurse.

d. Wristband in the presence of another nurse.

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? (Select all that apply) 1. A 38-year old with moderate persistent asthma awaiting discharge 2. A 63-year old with a tracheostomy needing tracheostomy care every shift. 3. A 56-year old with lung cancer who has just undergone left lower lobectomy 4. A 49-year old just admitted with a new diagnosis of esophageal cancer.

1, 2 1. A 38-year old with moderate persistent asthma awaiting discharge 2. A 63-year old with a tracheostomy needing tracheostomy care every shift.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? (Select all that apply) 1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day 3. use a soft-bristled toothbrush or tooth sponge for oral care 4. Use a rectal thermometer to obtain a more accurate body temperature 5. Be sure the patient's footwear has a firm sole when the patient ambulates

1, 2, 3, 5 1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day 3. use a soft-bristled toothbrush or tooth sponge for oral care 5. Be sure the patient's footwear has a firm sole when the patient ambulates

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply) 1. Auscultate breath sounds 2. Administer medications via metered-dose inhaler (MDI) 3. Complete in-depth admission assessment 4. Initiate the nursing care plan 5. Evaluate the patient's technique for using MDI's

1, 2, 4, 1. Auscultate breath sounds 2. Administer medications via metered-dose inhaler (MDI) 4. Initiate the nursing care plan

The patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (UNP)? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? 1. Observe how well the patient performs pursed-lip breathing 2. Plan a nursing care regiment that gradually increases activity intolerance 3. Assist the patient with basic activities of daily living 4. Consult with the physical therapy department about reconditioning exercises

1. Observe how well the patient performs pursed-lip breathing

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water seal chamber 3. Complaints of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water seal chamber

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? 1. A 58-year old on airborne precautions for tuberculosis (TB) 2. A 68-year old just returned from bronchoscopy and biopsy 3. A 72-year old who needs teaching about the use of incentive spirometry a 69-year old with COPD who is ventilator dependent

3. A 72-year old who needs teaching about the use of incentive spirometry

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? 1. A 68-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab 2. A 57-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year old with pneumonia who needs to be started on intravenous (IV) antibiotics 4. A 52-year old with asthma who complains of shortness of breath after using a bronchodilator

4. A 52-year old with asthma who complains of shortness of breath after using a bronchodilator

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? 1. Discuss weight-loss strategies such as diet and exercise with the patient 2. Teach the patient how to set up the BiPAP machine before sleeping 3. Remind the patient to sleep on his side instead of his back. 4. Administer modafinil (Provigil) to promote daytime wakefulness

3. Remind the patient to sleep on his side instead of his back.

You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using universal precautions 4. Replacing the inner cannula and cleaning the stoma site. 5. Changing the soiled tracheostomy ties and securing the tube in place

3. Removing the inner cannula and cleaning using universal precautions

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? 1. Evaluating the patient's complaint of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2 F (38.4C)

4. Oral temperature of 101.2 F (38.4C)

65. A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse her concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best? a. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so." b. "I promise I won't tell anyone." c. "I can't lie to them if they ask me." d. "I'll avoid any questions."

a. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so."

77. A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? a. 1 Unit of glucose. b. 1 bottle of glucose. c. 1U of glucose. d. One U of glucose.

a. 1 Unit of glucose.

16. What percentage of patients admitted to acute care hospitals and long term care facilities have a hospital acquired or nosocomial infection. a. 5 - 10 percent b. 2 - 4 percent c. 15 - 20 percent d. Less than 1 percent

a. 5 - 10 percent

73. Factors contributing to malpractice claims include all of the following except a. Actuarially value of a person's life b. Seriousness of the error c. Social factors d. Characteristics of suit-prone patients

a. Actuarially value of a person's life

38. One of the most frequently reported occurrences by nurses that leads to medication errors is interruptions while administering medications. a. True b. False

a. True

55. Statutory law includes all written laws and governmental codes a. True b. False

a. True

7. Centers for Medicare and Medicaid Services (CMS) is the agency that processes and pays claims for the Medicare and Medicaid programs T/F

a. True

71. Boundary violations are a situation in which the nurse moves beyond a professional relationship and becomes involved with patients and their families. a. True b. False

a. True

25. Twelve hours after cardiac surgery, the nurse is assessing a 3 year old who weights 15 kg. The nurse should notify the surgeon about which of the following clinical findings? a. Alterations in levels of consciousness b. Fluctuations of fluid in the collection chamber of the chest drainage system c. A urine output of 120ml in four hours d. Short attention span

a. Alterations in levels of consciousness

4. The best definition of sentinel event is a. An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. b. A common occurrence involving death or serious physical or psychological injury, or the risk thereof. c. An unexpected occurrence involving death or serious physical or psychological injury. d. An unexpected occurrence involving death, or the risk thereof.

a. An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

52. The payment system where a fee is paid to a provider organization for each person who is enrolled in the plan whether that person uses any healthcare or not is referred to as a. Capitation b. Fee-for-service c. Diagnosis related group d. Cost based reimbursement

a. Capitation

21. A 56 year old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy? a. Cough and shortness of breath b. Spasms of the diaphragm c. Drowsiness d. Decrease in appetitive

a. Cough and shortness of breath

9.The culture of an organization is a product of its history, its mission and values, its policy and customs, the structure of the organization, and the manner in which providers of healthcare carry out their roles. A culture in which trust and mutual respect encourage healthcare providers to report errors, near misses, and other adverse events without fear of retribution is known as a? a. Culture of safety b. Culture of acceptance c. Culture of culture d. Culture forgiveness

a. Culture of safety

60. A nurse pulls the curtains before changing the dressing of the surgical wound on the abdomen of a post-surgical client. What value is served? a. Dignity b. Altruism. c. Freedom d. Accountability

a. Dignity

85. Following abdominal surgery, a client refuses to deep breath and cough every 2 hours as ordered. The nurse should do which of the following first? a. Explain the risks of not expanding the lungs and why the exercise is important. b. Respect the client's wishes and turn the client from side-to-side more frequently. c. Ask the client's wife to insist that the client take the deep breaths every 2 hours. d. Suggest that the client increase the daily fluid intake to at least 2500 ml.

a. Explain the risks of not expanding the lungs and why the exercise is important.

51. The fixed reimbursement amount for all the care required for a particular surgical procedure, an illness, or an acuity category if referred to as a. Fee-for-service payment b. Prospective payment c. Retrospective payment d. Cost-based reimbursement

a. Fee-for-service payment

45. A woman diagnosed with acquired immunodeficiency syndrome is admitted to the emergency department with a closed head injury after being found unconscious on the kitchen floor by her neighbor. Based on information from the client's neighbor, the staff suspects domestic abuse. The client has a restraining order against the husband. The husband repeatedly attempts to visit the client. Which nursing action ensurers client's safety? a. Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client. b. Admit the client to the pediatric unit under an assumed name so the husband cannot find her. c. Place the client in a reverse isolation room and post an isolation sign on the door restricting visitors. d. Instruct the client that she should put on her call light if her husband enters the room.

a. Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.

48. A 22-year-old woman with an ovarian cyst and who recently immigrated from Laos has been admitted to the hospital. The client and her husband both speak Lao exclusively, which has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take to communicate with the client? a. Organized professional interpretation, either in person or by telephone b. Encourage the client to write out her concerns on paper c. Communicate with the client and her husband nonverbally d. Arrange for a trusted family member member to come in to translate

a. Organized professional interpretation, either in person or by telephone

74. Quality is evaluated through all of the following except a. Peer review b. Evidence based research c. Use of outcome measures d. Individual patient outcome standards

a. Peer review

40. The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!." Which of the following responses by the nurse is most appropriate. a. She still has her long-term memory, but her short-term memory will not return. b. I'm glad she can sing even if she can't talk to you c. I am so happy to hear that. Maybe she is getting better d. Do not get your hopes up. This is only a temporary improvement

a. She still has her long-term memory, but her short-term memory will not return.

80. A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what happens next? a. The incident report will provide a basis for promoting quality care and risk management. b. The facility will report the incident to the state board of nursing for disciplinary action. c. The incident will be documented in the nurse's personnel file. d. The nurse will be suspended and, possibly, terminated from employment at the facility

a. The incident report will provide a basis for promoting quality care and risk management.

12. Patients undergoing certain high risk procedures have lower than expected mortality rates in hospitals that perform large numbers of those procedures. a. True b. False

a. True

20. Ideally the patient is involved in the time out process. a. True b. False

a. True

31. Brenner's five levels of function are novice, advanced beginner, competent, proficient and expert. a. True b. False

a. True

32. Sexual harassment in the workplace is always illegal. a. True b. False

a. True

30. The five step process by which alternative and complementary therapies can be evaluated include. (Check all that apply.) a. Safety and effectiveness of the therapy b. Credentials of the provider c. Service delivery d. Cost of services e. Consultation with the regular healthcare provider

abcde a. Safety and effectiveness of the therapy b. Credentials of the provider c. Service delivery d. Cost of services e. Consultation with the regular healthcare provider

8.CMS will not reimburse hospitals for the cost associated with which of the following serious hospital acquired complications. (Check all that apply) a. Air embolism b. Catheter associated urinary tract infection c. MRSA d. Pressure ulcers e. Blood incompatibility f. Foreign object left behind in a surgical patient

abcdef a. Air embolism b. Catheter associated urinary tract infection c. MRSA d. Pressure ulcers e. Blood incompatibility f. Foreign object left behind in a surgical patient

28. Community-based nursing emphasizes the following. Choose all that apply a. Patient rehabilitation b. Advocating for patients c. Disease prevention d. Disease diagnosis e. Health promotion

abce a. Patient rehabilitation b. Advocating for patients c. Disease prevention e. Health promotion

5. All of the following would be considered Sentinel events except a. Surgery on the wrong body part b. Discharge of an infant to the wrong family c. Perforation of the uterus during a D & C d. A hip fracture resulting from a patient fall e. Death resulting from a treatment related or medication error f. Overdosing with commonly used anticoagulants

abef a. Surgery on the wrong body part b. Discharge of an infant to the wrong family e. Death resulting from a treatment related or medication error f. Overdosing with commonly used anticoagulants

35. All of the following would be considered a(n) ambiguous or error-prone abbreviation except a. OU b. 0.5 c. 5.0 d. HS

b. 0.5

23. A ten year old child has the following blood glucose reading during a 24-hour period. Which reading requires the most immediate intervention? a. 100 mg/dl b. 50 mg/dl c. 200 mg/dl d. 150 mg/dl

b. 50 mg/dl

57. An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the unit, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? a. Collective liability b. Comparative negligence c. Battery d. Negligence

b. Comparative negligence

15. The time out involves only licensed members of the team regardless of their place in the hierarchy a. True b. False

b. False

18. Evidence based research has shown when registered nurse hours spent on direct patient care were greater, there was an increased risk of hospital related death and longer length of stays. a. True b. False

b. False

27. Alternative care therapies are considered integrative therapies when used along with traditional medical care. a. True b. False

b. False

39. Health promotion and prevention of illness and disease are a part of nursing practice in community health nursing only. a. True b. False

b. False

6. IOM is the initials of the International Office of Medicine. T/F

b. False

72. Nursing homes provide supportive services to those who can manage most of their own ADLs. a. True b. False

b. False

56. The nurse and a nursing assistant are caring for a group of adolescents. Which task could the nurse safely delegate to the nursing assistant? a. Administering acetaminophen (Tylenol) for a fever b. Helping a girl into a wheelchair c. Assisting a physician during the first postoperative dressing change d. Reviewing discharge instructions for an adolescent recently e. diagnosed with diabetes

b. Helping a girl into a wheelchair

64. A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussing the treatment with the staff, the client requests that a family member come in to help him decide whether to undergo this treatment. Which document must the client sign before undergoing ECT? a. Health care power of attorney b. Informed consent c. Outpatient commitment form d. Voluntary commitment form

b. Informed consent

2.Serious reportable events are also referred to as a. Near misses b. Never events c. Close call d. Safe practices

b. Never events

68. A client who took an overdose of acetaminophen in a suicide attempt is transferred overnight to the psychiatric inpatient unit from the intensive care unit. The night shift nurse called the primary health care provider on call to obtain initial prescriptions. The primary health care provider prescribes the typical routine medications for clients on this unit: Milk of Magnesia, Maalox and acetaminophen as needed. Prior to implementing the prescriptions, the nurse should? a. Ask the primary health care provider about holding all the client's PM prescriptions. b. Question the primary health care provider about the acetaminophen prescription. c. Suggest the primary health care provider write a prescription for intravenous fluids. d. Request a prescription for a medication to relieve agitation.

b. Question the primary health care provider about the acetaminophen prescription.

29. The major emphasis in maintaining continuity of care focuses on. a. Transporting paper copies of a patient's record to the receiving facility b. Reconciling medication records from one setting to another c. Posting the patient's medical record information online where it is available to everyone d. Stopping CPR when an ambulance crosses a state line

b. Reconciling medication records from one setting to another

84. The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the participants identify which of the following activities to be high risk for acquiring hepatitis B? a. Ingestion of large amounts of acetaminophen (Tylenol). b. Sharing needles for drug use. c. Ingestion of contaminated seafood. d. Frequent use of marijuana.

b. Sharing needles for drug use.

19. Methods to increase safe medication administration include all of the following except a. Eliminating ambiguous abbreviations b. Taking the chart to the patient's room to aid in identification c. Computerized physician/provider order entry system d. Barcode point of care

b. Taking the chart to the patient's room to aid in identification

59. A nurse says she's forgotten her computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage? a. Telling the nurse that she may use the password b. Telling the nurse that she may not use the password c. Telling the nurse to ask someone else for her password d. Writing down the password so the nurse won't forget it

b. Telling the nurse that she may not use the password

78. A physician's order for a client states the administration of a medication "b.i.d." How many times should the nurse administer the medication to the client? a. Every other day b. Twice a day c. Every day d. Four times a day

b. Twice a day

14. A pre-procedure verification process, marking the surgical site, and performing a time-out before each surgery are all part of a process known as a(the) a. Root Cause Analysis b. Universal Protocol c. Joint Commission d. Utilitarianism protocol

b. Universal Protocol

86. You are caring for a patient with an acute MI. You want to assign a certified nursing assistant to the patient. Which of the following would be an appropriate job to give the CNA? a. teaching the patient about a low salt diet b. helping the patient to bathe c. assessing their pain d. nothing

b. helping the patient to bathe

49. I client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? a. It is too late to change your mind now b. We will have to ask your physician if this is possible c. It is not a problem to rescind your DNR order; I will tell your physician so he/she will know your wishes right away d. Why do you want to do this?

c. It is not a problem to rescind your DNR order; I will tell your physician so he/she will know your wishes right away

37. Seven properties within an organization have been identified as being important to the development and maintenance of a culture of safety. Identify the two of the seven properties that are critical to a culture of safety. a. Hospitals that learn from their mistakes b. Organization must view errors as opportunities to improve the delivery of care c. The organization must actively encourage and support people to report situations that threaten or could threaten the safety of patients, caregivers, and providers. d. An organization that actively, persistently, and relentlessly seeks to identify those that make errors and remove them for their institution by the most aggressive means possible

bc b. Organization must view errors as opportunities to improve the delivery of care c. The organization must actively encourage and support people to report situations that threaten or could threaten the safety of patients, caregivers, and providers.

3. What quality organization requires institutions to investigate all sentinel events? a. IOM b. AHRQ c. Joint Commission d. National Quality Forum

c. Joint Commission

11. CMS will not reimburse hospitals for all of the following hospital acquired complications except a. Blood Incompatibility b. Pressure Ulcers c. Maternal Death d. HAI - MRSA

c. Maternal Death

62. A 16-year-old adolescent is transferred to the medical-surgical floor from the intensive care unit (ICU) after sustaining a closed head injury that left him comatose. The adolescent's mother is identified as his only guardian. During the evening shift, a man identifying himself as the adolescent's father asks the nurse for information about the adolescent's condition. How should the nurse respond? a. Let's go to the conference room where we can discuss your child's condition privately." b. "What have you been told about your child's condition?" c. "I'm sorry. I can't give you any information. Privacy laws dictate that information is to be given to the legal guardian. You'll need to contact the client's mother for information." d. "Is it O.K if I talk with you"

c. "I'm sorry. I can't give you any information. Privacy laws dictate that information is to be given to the legal guardian. You'll need to contact the client's mother for information."

67. The client says he'd like to stay in contact with a nurse who's discharging him and asks if she'd meet him for coffee. The nurse's best response is a. "I'll have to see if your physician feels our meeting would be beneficial for you." b. "I'm really not interested in meeting with you outside the hospital." c. "Thank you, but it's important that we maintain a professional relationship." d. "I'm not allowed to fraternize with anyone who has been my client."

c. "Thank you, but it's important that we maintain a professional relationship."

61. A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best? a. "Would you like me to help you tell them?" b. "I must share this information with your family." c. "The information you confide in me is confidential." d. "I must share this information with your employer."

c. "The information you confide in me is confidential."

1. According to the IOM what number of hospitalized patients die from preventable medication errors each year? a. No reportable deaths in the last two years b. 4,400 to 9,800 c. 44,000 to 98,000 d. 440,000 to 980,000

c. 44,000 to 98,000

From the following list of patients which one can be assigned to a nursing assistant/CNA? a. A patient with sudden unexplained bleeding b. A patient with unresolved pain over the past 8 hour shift c. A patient scheduled to have a chest x-ray done d. A patient who has multiple allergies to medications?

c. A patient scheduled to have a chest x-ray done

63. In which circumstance may the nurse legally and ethically disclose confidential information about a client? a. The fact that a woman is 32 weeks pregnant with twins to the husband b. from whom she is legally separated c. A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency d. A single male client's human immunodeficiency virus (HIV) status to his family members e. A diagnosis of pancreatic cancer to a client's significant other

c. A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency

54. If a nurse is involved in criminal cases, which would most likely be the related charge? a. Fraud assault and battery false imprisonment b. Negligence, fault, tort c. Assault and battery, malpractice oir false imprisonment d. Negligence, malpractice, tort

c. Assault and battery, malpractice oir false imprisonment

22. The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 ml/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: a. Apply a warm soak to the site b. Stop the flow of the solution temporarily c. Discontinue the infusion d. Irrigate the needle with normal saline

c. Discontinue the infusion

75. Access to healthcare must be considered in all of the following terms except a. Geographic b. Sociocultural c. Economic d. Age

c. Economic

17. What is defined as "deaths per 1,000 patients having developed specified complications of care during hospitalization"? a. Error rate b. Sentinel event c. Failure to rescue d. Hospital death rate

c. Failure to rescue

79. A nurse-manager in a pediatric intensive care unit notices an increase in nosocomial infections. What should the nurse do next? a. Talk with the hospital administrator about her concerns. b. Notify infection control that staff members aren't wearing gloves. c. Gather data on possible reasons for this increase. d. Report the issue to the Centers for Disease Control and Prevention.

c. Gather data on possible reasons for this increase.

81. A nurse is planning care for a 25-year-old female client who has just been diagnosed with human immunodeficiency virus (HIV) infection. The client asks the nurse, "How could this have happened?" The nurse responds to the question based on the most frequent mode of HIV transmission, which is: a. Sharing food utensils with an HIV-positive person without proper cleaning of the utensils. b. Hugging an HIV-positive sexual partner without using barrier precautions. c. Having sexual intercourse with an HIV-positive person without using a condom. d. Inhaling cocaine.

c. Having sexual intercourse with an HIV-positive person without using a condom.

76. The nurse is developing a primary disease prevention program for older adults. Which of the following is the most appropriate topic? a. Blood glucose screening for diabetes. b. Range-of-motion exercises. c. Immunizations for influenza. d. Diet and exercise for people with heart disease.

c. Immunizations for influenza.

41. Which of the following statements about the initial care of a suspected abuse victim, when documented on the chart, would be most helpful for others when caring for the client? a. Refuses a follow up appointment, stating she does not have time. b. States that she is not employed outside the home. c. Seems fearful to discuss how bruises on her body had been caused. d. Ask that her husband not be called at work, stating that he is very busy.

c. Seems fearful to discuss how bruises on her body had been caused.

83. A nurse is to administer several oral medications to a client at the same time. Which nursing instruction or action is appropriate in this situation? a. Leave the medications at the bedside for the client to take when he wishes. b. Tell the client to take all the medications at once. c. Tell the client the name and action or use of each medication before administering it. d. Advise the client to take each medication with 8 oz (240 ml) of water.

c. Tell the client the name and action or use of each medication before administering it.

70. Which use of restraints in a school-age child should the nurse question? a. To facilitate examination b. To aid in carrying out procedures c. To ensure the child's comfort or safety d. To substitute for observation

c. To ensure the child's comfort or safety

46. In which of the following situations can a client's confidentially be breached legally? a. Answer a request by the client's spouse about the client's medication. b. When a client's employer request the client's diagnosis to initiate medical claims. c. When a client near discharge is threatening to harm an ex-partner. d. In a student nurse's clinical paper about client.

c. When a client near discharge is threatening to harm an ex-partner.

34. Eliminating steps in a process to create ways to manage outside of the system is known as a a. Breach of duty of care b. Failure to rescue c. Work around d. A waste of time

c. Work around

36. Failure to rescue has been tied to a. The prevailing theory of nursing in the institution b. The number of registered nurses in administrative positions c. Of time the registered nurse spends in chart review d. The amount of time the registered nurse spends at the bedside

d. The amount of time the registered nurse spends at the bedside

69. A nurse is caring for a client who also works in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). While on lunch break in the cafeteria, the nurse sees the client's coworkers, who voice concern over his condition. The nurse's best response would be: a. "He's really upset about his medical condition. I'll get you the chart so you can review his laboratory values." b. "The antibiotics are really helping with his UTI. He should be back to work in no time." c. "He must be upset that everyone knows he has herpes." d. "I'll be sure to tell him you're thinking of him."

d. "I'll be sure to tell him you're thinking of him."

82. A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include? a. "Most falls among the elderly occur outside the home. Clients should confine themselves to their homes as much as practical." b. "Most accidental injuries among the elderly are automobile-related. Elderly clients should have vision testing every 6 months if still driving." c. "Because of the increase in home burglaries involving the elderly, these clients should have burglar bars on every window in the home." d. "Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

d. "Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

50. An institution that typically has patients stay more than 24 hours but less than 30 days would be classified as a a. Short stay b. Long-term-care c. In and out care d. Acute-care

d. Acute-care

33. All of the following are workplace safety and health concerns for nurses except a. Nurse staffing levels b. Infection as an occupational hazard c. Hazardous chemical agents d. Cafeteria food

d. Cafeteria food

47. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After her lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence her husband represents. Suddenly the client's husband arrives, shouting that he wants to "Finish the job". What is the first priority of the nurse who witnesses this? a. Tell the husband he must leave at once b. Remain with the client and stay calm c. Determine why the husband feels so angry d. Call a security guard and another staff member for assistance

d. Call a security guard and another staff member for assistance

You are listening as one of your co-workers, an RN, giving out assignments to her team with includes 2 LPN/LVN's and 2 nursing assistants. You know that one of the tasks she is assigning to the CNA should only be done by a licensed nurse. What should you do? a. Tell the charge nurse who is in a meeting. b. Discuss it at the next staff meeting c. Openly ask her about it and tell her that she is wrong and report her. d. Discuss with her why the task is not appropriate for the CNA.

d. Discuss with her why the task is not appropriate for the CNA.

66. A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best benefit the staff nurse? a. Assigning the staff nurse fewer patients than her coworkers b. Allowing the staff nurse to select her own assignments c. Assigning the staff nurse several clients with multiple physical problems d. Discussing the staff nurse's performance and ways she can improve

d. Discussing the staff nurse's performance and ways she can improve

26. Secondary prevention is best defined as a. Preventing long-term disability and restoring functional capacity b. Preventing disease c. Focus on providing the best evidence-based care for an individual with a specific chronic illness d. Early identification of health problems through screening and the prevention of complications and adverse consequences of illness

d. Early identification of health problems through screening and the prevention of complications and adverse consequences of illness

53. Nurses called as witnesses in trials because of their expertise in a particular area are known as a. Legal consultant b. Witness to fact c. Manager of legal case review d. Expert witness

d. Expert witness

24. The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.80 F (33.80 C). What should the nurse do in response to this reported assessment data? a. Tell the assistant to change thermometers and retake the temperature b. Ask the assistant to bathe the client with tepid water. c. Plan to give the client acetaminophen (Tylenol) to lower the temperature d. Promptly assess the client for potential perforation

d. Promptly assess the client for potential perforation

10. The Joint Commission required process that is a comprehensive in-depth analysis that seeks to identify all the underlying factors that contribute to an error and to identify their role in causing the error is known as a? a. Route calls answers b. Recording Company of America c. Reasonable causation analysis d. Root cause analysis

d. Root cause analysis

44. When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing a plan of care for the client. Which of the following styles of documentation is the nurse implementing? a. PIE charting b. Focus charting c. Narrative charting d. SOAP Charting

d. SOAP Charting

43. The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I do not know what's wrong. I am worried." Which of the following responses by the nurse is most appropriate? a. Maybe she is just mad at you. Did you have an argument? b. Do not worry about this. It happens sometimes. c. Go over to her apartment and see what is going on. d. She may have stopped taking her medications. I will check on her.

d. She may have stopped taking her medications. I will check on her.

13. The briefing and communication technique known as SBAR stands for a. Situation, Assessment, Backdrop and Recording b. Satisfaction, Background, Analysis and Recommendation c. Satisfaction, Background, Analysis and Recording d. Situation, Background, Assessment and Recommendation

d. Situation, Background, Assessment and Recommendation