NU222 Exam 1
You are care manage,r how long are you in charge of patient?
Admission to dischaarge
What is nonverbal communication?
Body language, facial expressions
When giving immunization, what are you are doing?
Health promotion and preventing illness
Who would give patient medical services when going home?
Home health
What kind of communication is nurse touching patient hand?
Nonverbal kinesthetic
Patient is not paying attention while nurse is education, what will happen?
Patient will not understand what to do later
What are you documenting when PIE charting?
Problem, intervention, evaluation
When transferring patient to new setting, what will you use to relay information?
SBAR
What are some effective therapeutic communications?
Silence, empathy, understanding, observations
What are needs addressed for patient?
Social, emotional, developmental, physical
What are some breaches of confidentiality?
Staying logged in, wrong fax number, social media posts
How do you avoid errors when documenting?
Timeliness, check twice
A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? a. "New mothers need support." b. "The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation."
a. "New mothers need support."
A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply) a. A client who has terminal cancer requests hospice care in the home b. A client asks about community resources available for older adults c. A client states, "I would like to have my child baptized before surgery." d. A client requests an electric wheelchair for use after discharge e. A client states, "I do not understand how to use a nebulizer."
a. A client who has terminal cancer requests hospice care in the home b. A client asks about community resources available for older adults d. A client requests an electric wheelchair for use after discharge
A nurse working in a rehabilitation facility focuses on the goal of restoring health for patients. Which examples of nursing interventions reflect this goal? (Select all that apply) a. A nurse counsels adolescents in a drug rehabilitation program b. A nurse performs range-of-motion exercises for a patient on bedrest c. A nurse shows a diabetic patient how to inject insulin d. A nurse recommends a yoga class for a busy executive d. A nurse recommends a yoga class for a busy executive e. A nurse provides hospice care for a patient with end-stage cancer f. A nurse teaches a nutrition class at a local high school
a. A nurse counsels adolescents in a drug rehabilitation program b. A nurse performs range-of-motion exercises for a patient on bedrest c. A nurse shows a diabetic patient how to inject insulin
A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan or referrals to another facility. Which patients would most likely be a candidate for these services? (Select all that apply) a. An older adult who is diagnosed with dementia in the hospital b. A 45-year-old man who is diagnosed with Parkinson's disease c. A 35-year-old woman who is receiving chemotherapy for breast cancer d. A 16-year-old boy who is being discharged with a cast on his leg e. A new mother who delivered a healthy infant via a cesarean birth f. A 59-year-old man who is diagnosed with end-stage bladder cancer
a. An older adult who is diagnosed with dementia in the hospital b. A 45-year-old man who is diagnosed with Parkinson's disease f. A 59-year-old man who is diagnosed with end-stage bladder cancer
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? a. Assault b. Battery c. False imprisonment d. Invasion of privacy
a. Assault
A nurse is caring for a client who si 24 hour postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? a. Basic b. Commitment c. Complex d. Integrity
a. Basic
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply) a. Bathing b. Ambulating c. Toileting d. Determining pain level e. Measuring vital signs
a. Bathing b. Ambulating c. Toileting e. Measuring vital signs
When interacting with a patient, the nurse answers, "I am sure everything will be fine, you have nothing worry about." This is an example of what type of inappropriate communication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject
a. Cliché
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity c. Providing specialized intraoperative training in surgical treatments for obesity d. Educating acute care nurses about postoperative complications related to obesity
a. Collaborating with providers to perform obesity screenings during routine office visits
Nursing in the United States is regulated by the state nurse practice act. What is a common element of each state's nurse practice act? a. Defining the legal scope of nursing practice b. Providing continuing education programs c. Determining the content covered in the NCLEX examination d. Creating institutional policies for health care practices
a. Defining the legal scope of nursing practice
A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? a. Determining the progress made in achieving established goals b. Clarifying when the patient should take medications c. Reporting the progress made in teaching to the staff d. Including all family members in the teaching session
a. Determining the progress made in achieving established goals
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse of the transferring facility? (Select all that apply) a. Ensure that the client has possession of their valuables b. Confirm that the rehabilitation center has a room available at the time of transfer c. Assess how the client tolerates the transfer d. Give a verbal transfer report via telephone e. Complete a transfer form for the receiving facility
a. Ensure that the client has possession of their valuables b. Confirm that the rehabilitation center has a room available at the time of transfer d. Give a verbal transfer report via telephone e. Complete a transfer form for the receiving facility
A nurse is admitting a client who has cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply) a. Explain the roles of other care delivery staff b. Begin discharge planning c. Inform the client that advance directives are required for hospital admission d. Document the client's wishes about organ donation e. Introduce the client to their roommate
a. Explain the roles of other care delivery staff b. Begin discharge planning d. Document the client's wishes about organ donation e. Introduce the client to their roommate
During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? (Select all that apply) a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness
a. Group decision making d. group identity e. Group patterns of interaction f. Group cohesiveness
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities E. Oncology centers
a. Home health care b. Rehabilitation facilities d. Skilled nursing facilities
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply) a. Intensive care unit b. Oncology treatment center c. Burn center d. Cardiac rehabilitation e. Home health care
a. Intensive care unit b. Oncology treatment center c. Burn center
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? a. Knowledge b. Experience c. Intuition d. Competence
a. Knowledge
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply) a. Make sure the surgeon obtained the client's consent b. Witness the client's signature on the consent form c. Explain the risks and benefits of the procedure d. Describe the consequences of choosing not to have surgery e. Tell the client about alternatives to having the surgery
a. Make sure the surgeon obtained the client's consent b. Witness the client's signature on the consent form
A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? (Select all that apply) a. Making accurate assessments b. Researching new treatments for chronic diseases c. Communicating effectively d. Delegating tasks appropriately e. Performing clinical skills effectively f. Making independent decisions
a. Making accurate assessments c. Communicating effectively e. Performing clinical skills effectively f. Making independent decisions
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply) a. Medication error b. Needlesticks c. Conflict with provider and nursing staff d. Omission of prescription e. Missed specimen collection of a prescribed laboratory test
a. Medication error b. Needlesticks d. Omission of prescription
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? a. Orient the client to their room b. Conduct a client care conference c. Review medical prescriptions d. Develop a plan of care
a. Orient the client to their room
A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? a. Pain b. Anxiety c. Depression d. Fluid volume deficit
a. Pain
A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? a. Provide a verbal report to the nurse on the new unit b. Provide a detailed written report to the unit secretary c. Delegate the responsibility for providing information d. Make a copy of the patient's medical record
a. Provide a verbal report to the nurse on the new unit
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply) a. Provider b. Certified nursing assistant c. Pharmacist d. Registered nurse e. Respiratory therapist
a. Provider c. Pharmacist d. Registered nurse
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all the apply) a. Repeat the details of the prescription back to the provider b. Have another nurse listen to the telephone prescription c. Obtain the provider's signature on the prescription with 24 hours d. Decline the verbal prescription because it is not an emergency situation e. Tell the charge nurse that the provider has prescribed morphine by telephone
a. Repeat the details of the prescription back to the provider b. Have another nurse listen to the telephone prescription c. Obtain the provider's signature on the prescription within 24 hours
Which of the following action should the nurse take when demonstrating an empathic presence to a client? (Select all that apply) a. Use an open posture b. Write down what the client says to avoid forgetting details c. Establish and maintain eye contact d. Nod in agreement with the client throughout the conversation e. Sit facing the client
a. Use an open posture c. Establish and maintain eye contact e. Sit facing the client
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply) a. Find a mentor b. Use a journal to write about the outcomes of clinical judgments c. Review articles about evidence-based practice d. Limit consultations with other professionals involved in a client's care e. Make quick decisions when unsure about a client's needs
b Use a journal to write about the outcomes of clinical judgments c. Review articles about evidence-based practice e. Make quick decisions when unsure about a client's needs
A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of exchange, what communication by the nurse would been more effective? a. "I placed a request to have 8th of August off, but I'm woking and I have a doctor's appointment." b. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" c. "I will need to call in on the 8th of August because I have a doctor's appointment." d. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"
b. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?"
A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"
b. "May I help you with a bed bath now or later this morning?"
Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had major abdominal surgery? a. "I"ll bet you will be so glad to be home in your own bed." b. "What are your expectations for recovery from your surgery?" c. "Be sure to take your pain medications and change your dressing." d. "You will be just fine! Please stop worrying."
b. "What are your expectations for recovery from your surgery?"
A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of the which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence
b. Autonomy
Which of the following strategies should a nurse use to establish a helping relationship with a client? a. Make sure the communication is equally distributed between the nurse's and client's desires b. Encourages the client to communicate their thoughts and feelings c. Give the nurse-client communication no time limits d. Allow communication to occur spontaneously throughout the nurse-client relationship
b. Encourage the client to communicate their thoughts and feelings
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis b. Ensuring that health care providers comply with regulations c. Setting quality standards for accreditation of health care facilities d. Determining whether medications are safe for administration to clients
b. Ensuring that health care providers comply with regulations
A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? (Select all that apply) a. Performing an admission health assessment b. Evaluating the nursing plan for effectiveness of care c. Participating in the transfer of the patient to the postoperative care unit d. Making referrals to appropriate facilities e. Maintaining records of patient satisfaction with services f. Assessing the strengths and limitations of the patient and family
b. Evaluating the nursing plan for effectiveness of care d. Making referrals to appropriate facilities f. Assessing the strengths and limitations of the patient and family
A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? a. Assault b. False imprisonment c. Negligence d. Breach of confidentiality
b. False imprisonment
A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply) a. A single electronic records password is provided for nurses on the same unit b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of their medical record e. A nurse can photocopy a client's medical record for transfer to another facility
b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of their medical record e. A nurse can photocopy a client's medical record for transfer to another facility
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply) a. Advance directives status b. Follow-up care c. Instructions for diet and medications d. Most recent vital sign data e. Contact information for the home health care agency
b. Follow-up care c. Instructions for diet and medications e. Contact information for the home health care agency
A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of food should I avoid to prevent gas?" The patient's question allows for what type of communication of the nurse's part? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior
b. Information clarification
A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing is necessary to practice at this level? a. LPN b. ADN c. BSN d. MSN
b. MSN
A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply) a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid
b. Medicare e. Medicaid
According to the National Advisory Council on Nurse Education and Practice, what is a current health care trend contributing to 21st century challenges to nursing practice? a. Decreased numbers of hospitalized patients b. Older and more acutely ill patients c. Decreasing health care costs owing to managed care d. Slowed advances in medical knowledge and technology
b. Older and more acutely ill patients
A charge nurse is reviewing documentation with the group of newly licensed nurse. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply) a. Cover errors with correction fluid, and write in the correct information b. Put the date and time on all entries c. Document objective date, leaving out opinions d. Use as many abbreviations as possible e. Wait until the end of the shift to document
b. Put the date and time on all entries c. Document objective date, leaving out opinions
A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? a. Pacing b. Reflecting c. Paraphrasing d. Restating
b. Reflecting
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? a. Charge nurse b. Registered nurse (RN) c. Practical nurse (PN) d. Assistive personnel (AP)
b. Registered nurse (RN)
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? a. Fairness b. Responsibility c. Risk-taking d. Creativity
b. Responsibility
A nurse is preparing an in-service program about delegation. Which of the following are components of the 5 rights of delegation? (Select all that apply) a. Right place b. Right supervision and evaluation c. Right direction and communication d. Right documentation e. Right circumstances
b. Right supervision and evaluation c. Right direction and communication e. Right circumstances
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? a. Touch the child's arm b. Sit at eye level with the child c. Stand facing the child d. Stand with a relaxed posture
b. Sit at eye level with the child
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) a. The roommate ambulated independently b. The client ambulates wearing slippers over antiembolic stockings c. The client uses a front-wheeled walker when ambulating d. The client had pain medication 30 minutes ago e. The client is allergic to codeine f. The client ate 50% of breakfast this morning
b. The client ambulates wearing slippers over antiembolic stockings c. The client uses a front-wheeled walker when ambulating d. The client had pain medication 30 minutes ago
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a. "I'd rather have my brother make decisions for me, but I know it has to be my wife." b. "I know they won't go ahead with the surgery unless I prepare these forms." c. "I plan to write that I don't want them to keep me on a breathing machine." d. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
c. "I plan to write that I don't want them to keep me on a breathing machine."
A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) a. "You will do great! You just have to get used it." b. "Why are you worried about going home?" c. "Your daily routines will be different when you get home." d. "Tell me about the support system you'll have after you leave the hospital." e. "It sounds like you are not sure how having a colostomy will affect swimming."
c. "Your daily routines will be different when you get home." d. "Tell me about the support system you'll have after you leave the hospital." e. "It sounds like you are not sure how having a colostomy will affect swimming."
A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3-4 hours. Which examples of documentation of care for this patient follow recommended guidelines? (Select all that apply) a. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1-10. M. Patrick, RN d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3-4 hours. M. Patrick, RN f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN
c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1-10. M. Patrick, RN d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN
A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of chemical impairment b. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints c. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill d. A client who is terminally ill hesitates to name their partner on their durable power of attorney form
c. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record
c. Bone scan scheduled for today
A home health care nurse is scheduled to visit a 38-year-old woman who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? (Select all that apply) a. collect information about the patient's diagnosis, surgery, and treatments b. Call the patient to make initial contact and schedule a visit c. Develop rapport with the patient and her family d. Assess the patient to identify her needs e. Assess the physical environment of the home f. Evaluate safety issues including the neighborhood in which she lives
c. Develop rapport with the patient and her family d. Assess the patients to identify her needs e. Assess the physical environment of the home
During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? (Select all that apply) a. Fill the silence with lighter conversation directed at the patient b. Use the time to perform the care that is needed uninterrupted c. Discuss the silence with the patient to ascertain its meaning d. Allow the patient time to think and explore inner thoughts e. Determine if the patient's culture requires pauses between conversation f. Arrange for a counselor to help the patient cope with emotional issues
c. Discuss the silence with the patient to ascertain its meaning d. Allow the patient time to think and explore inner thoughts e. Determine if the patient's culture requires pauses between conversation
A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? a. Determining the established goals of the institution b. Ensuring that verbal and nonverbal communication is congruent c. Engaging in self-talk to plan the day and decrease fear d. Speaking with fellow colleagues about how they feel
c. Engaging in self-talk to plan the day and decrease fear
A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explain that all clients waiting for a kidney transplant have to meet the same qualification, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence
c. Justice
A nurse instructor outlines the criteria establishing nursing as a profession. What teaching point correctly descries this criteria? (Select all that apply) a. Nursing is composed of a well-defined body of general knowledge b. Nursing interventions are dependent upon medical practice c. Nursing is a recognized authority by a professional group d. Nursing is regulated by the medical industry e. Nursing has a code of ethics f. Nursing is influenced by ongoing research
c. Nursing is a recognized authority by a professional group e. Nursing has a code of ethics f. Nursing is influenced by ongoing research
The charge nurse is assigning client care for 4 clients. Which of the following tasks should the nurse assign to a PN? a. Creating a plan of care for a client who is recovering following a stroke b. Assessing a pressure injury on a client who is on bed rest c. Providing nasopharyngeal suctioning for a client who has pneumonia d. Teaching a client who has asthma to use a metered-dose inhaler
c. Providing nasopharyngeal suctioning for a client who has pneumonia
A nurse on a medical-surgical unit has received change-of-shift report and will care for 4 clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? a. Updating the plan of care for a client who is postoperative b. Reinforcing teaching with a client who is learning to walk using a quad cane c. Reapplying a condom catheter for a client who has urinary incontinence d. Applying a sterile dressing to a pressure injury
c. Reapplying a condom catheter for a client who has urinary incontinence
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? a. Alert the American Nurses Assocation b. Fill out an incident report c. Report the observations to the nurse manager on the unit d. Leave the nurse alone to sleep
c. Report the observations to the nurse manager on the unit
A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? a. To assist with screening tests b. To provide patient teaching c. To assess what has been done and what still needs to be done d. To assist with hernia repair
c. To assess what has been done and what still needs to be done
A nurse enters a patient's room and examines the patients IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."
d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."
A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? a. "Do you take 2 injections of insulin to decrease the complications?" b. "Most health care providers recommend diet and exercise to regulate blood sugar." c. "Most complications of diabetes are related to neuropathy." d. "What specific complications have you experienced?"
d. "What specific complications have you experienced?"
During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? a. "You need to speak to the patient quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, but sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."
d. "When your patient is safe and comfortable, meet me at the desk."
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? a. Body mass index b. Usual times for meals and snacks c. Favorite foods d. Any difficulty swallowing
d. Any difficulty swallowing
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
d. Beneficence
A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. Confidence b. Perseverance c. Integrity d. Discipline
d. Discipline
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence
d. Nonmaleficence
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Certified nursing assistant c. Registered dietitian d. Occupational therapist
d. Occupational therapist
A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activity could the nurse delegate to licensed assistive personnel? a. Collecting information for a health history b. Performing a physical assessment c. Contacting the health care provider for medical order d. Preparing the bed and collecting needed supplies
d. Preparing the bed and collecting needed supplies
A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? a. Social worker b. Certified nursing assistant c. Occupational therapist d. Speech-language pathologist
d. Speech-language pathologist
A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? a. The bed linens are folded back b. A hospital gown is on the bed c. Equipment for taking vital signs is in the room d. The bed is in the highest position
d. The bed is in the highest position
A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? a. The nurse stands at the patients bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here everyday." d. The nurse holds the patients hand and asks, "What makes you feel so alone?"
d. The nurse holds the patients hand and asks, "What makes you feel so alone?"
A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions
d. The use of clarifying questions
A nurse is counseling an older woman who has been hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? a. To inform the patient that only the primary health care provider can authorize discharge from a hospital b. To collect the patient's belongings and prepare the paperwork for the patient's discharge c. To request a psychiatric consult for the patient and inform the PCP of the results d. To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form
d. To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form
