Nursing AE 1

Although all of the following are nursing responsibilities, which one would be expected of a nurse with a baccalaureate degree?

using research findings to improve practice

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the teaching session, the nurse should:

turn off the television in the room.

The nurse-client relationship is dependent on communication. Effective communication between the nurse and the patient includes. Select all that apply.

• Spoken words • Sight • touch

Which qualities in a nurse help the nurse to become effective in providing for a client's needs while remaining compassionately detached?

Empathy

The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing process

Which of the following factors is most important in the development of rapport between nurse and patient?

Trust

Nursing Diagnosis

as the logical conclusion of the assessment phase, These and other studies led to the development of the five-step nursing process commonly used today: assessment, diagnosis, outcome identification and planning, implementation, and evaluation.

Which action by the nurse best represents the evaluative portion of the nursing process?

assessing a client's blood pressure after teaching stress reduction techniques

The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?

"Keep all medications in a locked cabinet."

When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is what?

"The thought of having surgery is keeping you awake."

After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that

ANA aims at fostering high standards of nursing in the United States.

There are various levels of preparation for nursing practice. Which degree program will best prepare a nurse to work as a nurse researcher?

Doctoral

Bias

Error: Placing excess emphasis on the first data receivedAvoiding information contrary to one's opinion Selecting alternatives to maintain status quo Being predisposed to a single solution Stating the problem in a way to support one's choices Making decisions to support past choices

nurse is discussing the history of the profession with a client and describes that a shift in societal focus from religion to warfare had a negative impact on nursing due to which of the following?

Female criminals recruited as nurses

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease? -It persists for a long time. -It has a gradual onset and lasts for a long time. -It takes a long time to cure. -It is a sequela of acute illness.

It has a gradual onset and lasts for a long time.-Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population.

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? Termination phase Orientation phase Evaluation phase Working phase

Orientation phase

During the Christian era, nursing care excluded which area?

Psychiatric services

A nurse is caring for a client in a semi-private room. The nurse is preparing to discuss the medical treatment plan with the client. To best ensure privacy the nurse should do what?

Pull the curtain dividing the two beds, maintain eye contact, and speak in a low, audible voice.

Florence Nightingale was a nursing pioneer who challenged prejudices against women and elevated the status of all nurses. Which statement accurately describes one of her accomplishments?

She promoted the publication of books about nursing and health care.

A nurse and an older adult patient with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

The nurse will be sensitive to the patient's emotional barriers.

The nursing process includes step(s)? Select all that apply. Assess Plan Prescribe Implement Evaluate

Think ADPIE Assess, Diagnosis, Plan, Implement, Evaluate

Establishing the criteria for the education and licensure of nurses is a component of:

a state's nurse practice act.

A nurse must possess several characteristics in order to be successful in this profession. Secondary to critical thinking skills, which of the following is of great value?

advocating for the client at all times

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: an ophthalmologist. a clinical psychologist. an optometrist. an audiologist.

an audiologist.

A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to: ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel. approach and tell the night shift nurse that the night shift nurse is "out of line." call hospital security and ask them to take a report. ignore the comment and begin the shift.

ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel.

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work.

A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as?

message

A nurse is caring for a client who presents with a skin infection. While obtaining the patient's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should:

remain honest, open, and frank.

A nurse enters a client's room to complete an admission history. The nurse will convey interest in the client's story if the nurse:

sits at the client's bedside and faces the patient.

When planning the care of a client, which nurse-prescribed interventions would be appropriate to implement? Select all that apply.

turning clients every 2 hours to prevent skin breakdown monitoring IV site access every 2 hours for clients with IV fluid infusion monitoring the day's Input and Output to determine fluid retention initiating contact precaution for a client with Methicillin-resistant Staphylococcus aureus

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Can you tell me why your physician sent you here to be admitted?"

A nurse is calling a physician to communicate a change in the client's condition. According to the I-SBAR-R format for hand-off communication among healthcare personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital."

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation? "I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!" "My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." "Good morning, I am calling about Mrs. Jones, who is a client of yours." "My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital."

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."

A client asks asks an RN to prescribe a medication for pain. Which of the following is the best answer by the nurse?

"Only advanced practice registered nurses have prescriptive authority."

A client with a cardiac dysrhythmia was recently prescribed metoprolol (Lopressor) and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?"

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask: "Do you check your blood pressure and pulse before you take your medication?" "Have you tried exercising at all in the last week or two?" "Tell me about the foods you are eating." "Were you tired and depressed before starting the new medication?"

"Were you tired and depressed before starting the new medication?"

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation? "Are you in a hospital?" "What is your name?" "Is your name Evelyn?" "Is today the first day of the month?"

"What is your name?"

A long-term care facility is seeking the consultation from an advanced practice nurse to educate the staff regarding palliative care for the residents. The facility will benefit most by hiring which advanced practice nurse?

Clinical nurse specialist

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? Sympathy Empathy Indifference Pity

Empathy

Failure to consider the total situation

Error: Using inaccurate data Not clearly identifying the problem Failing to prioritize or rank the problems in order of importance Using unrealistic goals

Impatience

Error: Failing to identify multiple solutions Incorrectly implementing the decision Failing to use appropriate resources

Which of following are approved as nursing diagnoses? Select all that apply.

Impaired Skin Integrity Caregiver Role Strain Compromised Family Coping

The nurse going back to school for nurse midwifery can trace education for nurse midwifery to which of the following nursing leaders?

Mary Breckinridge

Which theory describes, explains, predicts, and controls outcomes in nursing practice?

Nursing theory

A nurse is developing a foreground question for nursing research using the PICO model. Which component would be represented by the statement, "a 45-year-old male with coronary heart disease and atrial fibrillation"? C P I O

P- population

The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to? Environmental Physical

Physical dimension

A nurse is attempting to communicate with a patient who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process?

Speaking slowly and distinctly, but not loudly

The nurse is using nonverbal communication when caring for a group of clients. Which situation(s) reflects nonverbal communication? Select all that apply. The nurse documents on the SBAR form and sends it to the transferring unit. The nurse assess a client is in pain from a grimace. The nurse has a smile when being thanked for caring for a family member. The nurse gives a brochure to a client upon discharge. The nurse is maintaining eye contact when changing a client's dressing.

The nurse has a smile when being thanked for caring for a family member. The nurse assess a client is in pain from a grimace. The nurse is maintaining eye contact when changing a client's dressing.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted in the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. What phase of the working relationship is best described in this scenario?

The working phase

A nurse who "unblocks" and "clears" congested areas of energy in a patient's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch

Social media use is a form of communication that, if used incorrectly, can result in Health Insurance Portability and Accountability Act (HIPAA) violations and be both ethically and legally problematic for nurses. Which of the following is an appropriate use of social media for professional nurses?

To connect with other nursing professionals and gain insight into new educational information and share ideas

A nurse working in a long-established hospital learned a specific approach to administering intravenous injections from the previous generation of nurses at the hospital. This is an example of which type of knowledge? Scientific knowledge Traditional knowledge Authoritative knowledge Philosophy knowledge

Traditional knowledge

Which of the following practices by the nurse indicate that the nurse is a professional?

Using evidence-based practice interventions

The nurse is caring for a postoperative client who refuses a blood transfusion due to religious beliefs. The nurse is demonstrating trustworthiness when taking which action in response to the client's treatment wishes? -asking the client's family to discuss the importance of the prescribed treatment with the client -recommending assessment of the client's cognitive capacity to make health care decisions -explaining the health consequences of refusing to undergo the prescribed treatment -contacting the interprofessional care team to discuss alternative treatment options

contacting the interprofessional care team to discuss alternative treatment options

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: have group members issue a written warning to the dominant member. have group members confront the dominant member to promote the needed team work. plan a meeting where the dominant person cannot attend. pick a team leader who is not the dominant member.

have group members confront the dominant member to promote the needed team work.

A community health nurse arranges for a dentist to teach local children in the school district how to properly brush their teeth. Which goal will the nurse set for this event?

health promotion

A nurse is performing a wet to dry dressing change on a client's abdomen. During this intervention the nurse is communicating with the client in the:

intimate zone.

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

involve the child's stuffed animal in the educational session.

Decision making

is about choosing from options as "purposeful, goal-directed effort applied in a systematic way to make a choice among alternatives," and they explain that even choosing not to act in a certain situation is a decision.

Due to the rising cost of health care services, many procedures and treatments are being delivered in what type of setting?

outpatient facility

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a client's room to empty his or her urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the patient to explain the statement.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by

swaddling the child and gently stroking its head.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell herself to "remain calm" and remember that she was trained to perform this skill.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should: tell oneself to "remain calm" and remember that the nurse was trained to perform this skill. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. inform the client that several nurses will be needed to care for this wound. ask the charge nurse to change the assignment.

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

A nurse is communicating the plan of care to a patient who is cognitively impaired. Which nursing actions facilitate this process? (Select all that apply.)

• The nurse maintains eye contact with the patient. • The nurse keeps communication simple and concrete. • The nurse is patient and gives the patient time to respond

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client? "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position." "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120." "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically." "I will be by your side throughout the procedure; the procedure will be painless if you don't move."

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask in order to assess the client's orientation?

"What day of the week is it?"

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: "Are you allergic to any medications?" "What did your health care provider tell you about your need to be admitted?" "Can you tell me the medications you take on a daily basis?" "Do you have an advanced directive or a living will?"

"What did your health care provider tell you about your need to be admitted?"

A nurse is examining a child age 3 years with conjunctivitis. During the examination, the child starts crying and refuses to sit still. What statement by the nurse is most appropriate?

"Would you like to see my flashlight?"

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening? "I understand you are not sure about having the surgery. Why do you think you really do not need the surgery?" "You seem unsure, please let me know if you decide to postpone the surgery until you are no longer unsure." "I understand your confused, what do you think you should do?" "You seem unsure. Tell me your concerns about your surgery."

"You seem unsure. Tell me your concerns about your surgery."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse? "There are many good medications to decrease the pain; it will not be so bad." "You're worried about how you will tolerate the pain associated with labor." "Don't worry about labor, I have been through it and it is not so bad." "I would recommend keeping a positive attitude."

"You're worried about how you will tolerate the pain associated with labor."

The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment?

Asking the client, "How are you today? I am really worried about you."

A nurse is planning to continue her education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which of the following expanded career roles is the nurse preparing?

Clinical nurse specialist

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? Sympathy Empathy Commiseration Kindness

Empathy

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique? Reflection Clarification Restating Encouraging elaboration

Encouraging elaboration

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor? Environmental risk factor Lifestyle risk factor Physiologic risk factor Health habits risk factor

Environmental risk factor -Working and living environments may contribute to disease. Working with cancer-causing chemicals is an example of an environmental risk factor for illness. Physiologic risk factors are those relating to an individual's body or biology. Lifestyle risk factors are habits or behaviors people choose to engage in. A health habit risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon? Morbidity Infection Exacerbation Risk factor

Exacerbation

Which theory emphasizes the relationships between the whole and the parts, and describes how parts function and behave? Developmental theory Nursing theory General systems theory Adaptation theory

General systems theory

A registered nurse plans to return to the nursing profession after a long hiatus. Which statement about the trend in health care services would be most important for the nurse to keep in mind?

Health care delivery systems are less controversial now.

A nurse is reviewing nursing theory for usefulness in a home healthcare setting. Which is the appropriate application of Dorothea Orem's Self-Care Model in a home healthcare setting? Monitor therapeutic interventions in the client's home. Counsel client on methods to adapt to current state to reduce stress. Assist the client to conserve and maintain principles of personal and social integrity. Match the client's self-care needs with appropriate supportive interventions.

Match the client's self-care needs with appropriate supportive interventions.

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? Working phase Intimate phase Orientation phase Termination phase

Orientation phase aka Interview Phase

A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment? Direct the client in the other bed to walk in the hallway. Bring the client into the hallway to discuss the treatment plan. Ask all visitors to leave the room. Pull the curtain dividing the two beds.

Pull the curtain dividing the two beds.

Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding? Ask the mother to come to the emergency room. Suggest that the mother bottle feed her infant. Email the mother a link for breastfeeding. Refer the mother for a home care visit.

Refer the mother for a home care visit.

The client does not speak the dominant language. The nurse plans on providing preoperative teaching and uses an interpreter to communicate with the client. What intervention(s) will the nurse employ to aid in interpretation? Select all that apply. Allow the interpreter to elaborate extensively in the client's language. Position the interpreter to sit between the nurse and the client. Inform the interpreter of the expected outcome of the communication exchange. Look at the client while speaking. Speak slowly, using nontechnical terms.

Speak slowly, using nontechnical terms. Look at the client while speaking.Inform the interpreter of the expected outcome of the communication exchange.

A nurse has been caring for a client who suffered a myocardial infarction two days ago. During the morning assessment, the nurse asks the client how he or she feels. Which of the following scenarios warrants further investigation?

The client stares at the floor and states, "I feel fine."

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities?

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe.

The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event?

The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order.

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive.

The primary aim of the Healthy People 2020 initiative is: coping with disability. health promotion. illness prevention. health restoration.

health promotion

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: staring into the neonate's eyes and smiling. offering the neonate infant formula. softly humming a song near the neonate. swaddling the child and gently stroking its head.

swaddling the child and gently stroking its head.

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but removal will be painless and the IV location needs to be changed."

A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy? "Don't worry, I have seen lots of people with cancer do fine." "I see you are upset. Would you like to talk?" "I see you have been crying. Do you want me to call someone for you?" "I am sorry to hear you have cancer. I would be upset too, is there anything I can do?"

"I see you are upset. Would you like to talk?"

A pregnant client at 10 weeks' gestation is receiving education by the nurse about the importance of abstaining from alcohol while pregnant. What statement made by the client demonstrates an understanding of the education provided? -"I should abstain from alcohol to prevent the development of a fetal alcohol spectrum disorder." -"Abstaining from alcohol will prevent any type of congenital disorder." -"Alcohol use while pregnant will predispose my child to idiopathic illness." -"If I drink alcohol while pregnant, my child will have a hereditary disorder."

"I should abstain from alcohol to prevent the development of a fetal alcohol spectrum disorder."

A nurse is asking a colleague about a situation. Which of the following statements demonstrates assertive communication?

"I think there is a better way to handle this."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids, how many times have you actually been pregnant?"

The nurse is discussing entry level for professional nursing practices. Which is the most accurate statement by the nurse?

"BSN is the recommended entry level by national nursing organization."

A nurse is discussing cataract treatment with a client. Which of the following statements by the nurse would be most therapeutic?

"Have you ever thought of laser surgery?"