NURS 320: Exam 2- Prep U Practices Qs

Which is the proper way to document midnight in a client's record?

0000

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

An informatics nurse specialist is meeting with a primary care provider's staff members. The office has agreed to implement a patient portal. When describing this tool, the nurse specialist would identify which aspects as being possible for clients? Select all that apply.

Access their medical history Schedule office appointments Communicate with the health care provider

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse is caring for a client newly diagnosed with diabetes mellitus and developing a holistic plan of care. For this plan of care to be successful, it must what?

Address the disease but also incorporate the mind, body, and spirit.

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

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

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access."

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?

"Leaning forward may help you to breathe better."

A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family?

"Our 16-year-old just seems to butt heads with us at every turn."

The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care?

"What can we do to help you meet any religious needs you may have?"

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important?

Emphasizing the clients strengths

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

A nurse is working with a single-parent family. When planning the care for this family, which need should the nurse anticipate as being a priority concern?

Financial concerns

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

Health teaching and health promotion

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection

When providing care to a client, the nurse prioritizes the client's needs. Which intervention would the nurse employ to meet the client's physiologic needs? Select all that apply.

Weighing the client Assessing the client's skin color Promoting a high-fiber diet

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

progress notes

The primary purpose of developing expected client outcomes is to:

provide individualized care.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

sit with the client and ask them about their feelings

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable?

Omitting documentation of blood pressure at the end of the shift

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing

A client is admitted to the emergency department following a tornado in which multiple people were killed or injured. The nurse applies direct pressure to an open wound on the client's thigh while assuring the client that the weather has cleared. Which of Maslow's basic human needs is the nurse addressing with the actions? Select all that apply.

Physiologic Safety and security

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? You Selected:

Remind the UAP about the client's right to privacy.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?

Self-esteem needs

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?

Setting up parenting classes

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

Sociocultural dimension

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

A client who was admitted to the acute care unit with angina pectoris is no longer having chest pain. Based on this assessment, what does the nurse decide to do with the plan of care for chest pain?

Terminate the plan of care related to the nursing diagnosis of chest pain.

A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory?

Erikson's theory of psychosocial development

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis?

Ineffective Airway Clearance

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

Which statements about the family unit are accurate? Select all that apply.

The family is a buffer between the needs of individual members and society. Duvall (1977) identified critical family developmental tasks and stages in the family life cycle. The nuclear family is composed of two parents and their children.

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?

Adjustment to retirement

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?

Create an addendum with a correction

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

Which nursing diagnoses are stated correctly? Select all that apply.

Deficient Fluid Volume related to abnormal fluid loss Nutrition Deficit related to inability to eat a balanced diet

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time

A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept?

Effective interactions

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

What is the focus of community-based nursing?

Promoting and maintaining the health of individuals and families

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?

Safety and security

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

Simplicity

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing.

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

An informatics nurse specialist is assisting with the implementation of a new clinical information system at the facility. Before beginning this phase, the specialist would ensure that which action has been completed? Select all that apply .

Testing End-user education Support services availability

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Which organization audits charts regularly?

The Joint Commission

What is an example of a community risk factor?

Children are kept inside on a sunny day due to a lack of recreational opportunities.

Which are examples of subjective data? Select all that apply.

A client reports being cold and requests an extra blanket. A client feels nauseated after eating breakfast. A client describes pain as an 8 on the pain assessment scale.

Which client requires priority intervention by a nurse providing care on a medical-surgical unit?

A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action?

Assess the client and re-evaluate the vital signs.

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

being able to prioritize

A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function?

affective and coping functions

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences."

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply.

"My leg hurts when I move." "I am always anxious." "I am so afraid of what my diagnosis is."

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?

Assess the client's blood pressure to determine if the medication is indicated.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client?

Introduce oneself to the client.

Which is the primary benefit of outcome identification?

It promotes the client being an active participant in care.

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

Usability

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity

The nurse is assessing a client in an outpatient setting. The client states, "I do not want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client?

suicide attempt risk

A client's record can be more accurate if the nurse:

uses point-of-care documentation