nursing fundamentals - week 1 & 2
A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?
Critical thinking is the foundation for clinical decision making
A nurse manager is planning an in-service about culturally competent care. Which of the following cultural competencies should the manager describe as enabling a nurse to interact with clients from other cultures?
Cultural encounters
A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request?
Cultural factor Death-related rituals might be very closely tied to cultural factors such as religion. The nurse should recognize that this client is expressing a death ritual of the last rites, which is associated with Catholicism.
A nurse is completing a medication reconciliation on a newly admitted client. Which of the following information should the nurse include? (Select all that apply.)
Current prescribed medications is correct. Nutritional supplements the client takes is correct. Over-the-counter medications the client uses is correct.
A nurse is teaching a newly licensed nurse about professional competence. Which of the following examples should the nurse include in the teaching?
present a summary of evidence-based journal (A component of maintaining professional competence is to seek out and implement improved evidence-based practices. This ensures the nurse's practice remains current, evidence-based, and promotes safe and competent care.)
A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Associations Code of Ethics for nurses w/ interpretive statements? - take the clients vital signs now & document them as being completed 8 hr earlier - document vital signs that are the same as those obtained - make reminder note to be more diligent next day - report this omission to charge nurse and the nurse on the next shift
report this omission to charge nurse and the nurse on the next shift
A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media? - posting a comment on social media about facility staffing shortage - reviewing the use of a fitness application w/ a client - accepting a social media friend request from a client - sharing client information w/ a coworker in a private social media message
reviewing the use of a fitness application w/ a client
A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications?
Have the client confirm their name and date of birth.
A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?
Have the client perform a return demonstration of the procedure.
A nurse is teaching a client about the benefits of a healthy diet and regular exercise to achieve weight loss. Which of the following topics is the nurse teaching to the client?
Health Promotion
A nurse is reviewing the use of electronic documentation with a newly licensed nurse. Which of the following statements should the nurse make?
"Electronic documentation provides evidence of care provided."
A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make?
"Finish the entire course of the prescription."
A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice?
"Health care should be a right for everyone." Social justice is the recognition of and fighting for equality of every individual for equal access to health care, food, housing, educational opportunity, and fair and equal treatment in all aspects of life. This statement demonstrates an understanding of the professional value of social justice.
A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make?
"I am unable to send your discharge instructions via email due to the HIPAA Privacy Act." The HIPPA Privacy Act consists of rules that govern the protection of the client's protected health information (PHI). The use of emails, texting, and faxing must occur with equipment and communication lines that are secure and encrypted. All electronic communication of PHI must have these safeguards in place. Sending the discharge instructions to a personal email outside the facility would breach this law.
A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?
"I should try to escape or put a barrier between myself and the client." The nurse should always try to escape a dangerous situation. If escape is not possible, creating a barrier where the client cannot reach them until help arrives is the next acceptable action.
A nurse is teaching about hospice care to a client. What statement shows that the client understands?
"I understand that services provided will include just what is needed to keep me comfortable."
A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct the use of the IDEAL method?
"I will include the client and caregivers in the discharge discussion." "I" stands for "include" in this model. The nurse should include the client and caregivers to review the discharge instructions. Research shows including caregivers in the discharge instructions with the client leads to a safer transition.
A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?
"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level." This response indicates the client understands and is using the SMART goal method: creating goals that are specific (S), measurable (M), attainable (A), realistic (R), and timely (T).
A nurse is caring for a client who has a prescription for opioid analgesia. The client tells the nurse, "I don't want to take that medication because it makes me sleepy." Which of the following responses should the nurse make?
"I will speak to your provider to see if there is a different medication to treat your pain."
A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations?
"I'm glad you decided to continue your fitness routine." This statement by the nurse builds the client's confidence and acknowledges the client's efforts to make positive changes. It is an example of the use of affirmations to acknowledge the client's efforts to make healthy behavior changes.
A nurse is caring for a client who has suction equipment in their room. The client asks the nurse, "Why do you check my suction equipment every day even though I am not using it?" Which of the following statements should the nurse make?
"It is part of the quality assurance plan of the unit."
A nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
"My health care surrogate will make health care decisions for me if I am unable." The client chooses a health care surrogate who maintains the client's durable power of attorney for health care. This document allows the health care surrogate to make health care decisions on the client's behalf if they are unable to do so.
A nurse is teaching a newly licensed nurse about an OSHA standard that is engineer controlled to minimize needlestick injuries. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Needleless IV tubing for IV infusions is an example of an OSHA standard that is engineer controlled."
A nurse is participating in a high school career day and is teaching about accreditation of nursing programs. Which of the following statements should the nurse make?
"Nurses who graduate from accredited nursing programs will have more employment opportunities." According to the Accreditation Commission, employers are more likely to hire nurses that graduate from accredited nursing programs. Accreditation ensures that the nursing program is meeting standards and is providing quality education for their students
A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Nurses will pair together to care for an assigned group of clients." Team nursing is the concept of nursing that pairs two or more nurses together to provide care for a group of clients. Team nursing provides support for novice nurses and others that are not as skilled in performing more complex tasks. A positive outcome of team nursing is the team works together. No one is expected to perform tasks that they are uncomfortable with or not competent to perform.
A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.)
"Respect the client during the conversation" is correct. The nurse should respect the client during the conversation to enhance communication. "Allow time for reflection during the conversation with the client" is correct. The nurse should allow time for reflection. This would enhance communication with the client. "Show empathy during the conversation with the client" is correct. Showing empathy during the conversation enhances communication with the client.
A nurse in a provider's office is completing an admission history for a client. The client tells the nurse that they have not had their annual mammogram screening because their insurance plan does not include that test. Which of the following statements should the nurse make?
"The Affordable Care Act requires all insurance plans to offer preventive services such as mammogram screenings." This statement helps to inform the client regarding their insurance and the essential benefits that should be included in all insurance plans by law under the Affordable Care Act (ACA). It also helps inform the client that mammogram screening is a preventive measure.
A nurse is discussing chain of command with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion?
"The chain of command clarifies the steps I need to take when I have a concern about a client's care." (The chain of command is the process of making an immediate supervisor aware of a client concern or situation. The nurse should report concerns to the charge nurse on the unit initially and move up the chain of command only if the charge nurse does not address the concern.)
A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?
"This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being."
A nurse is caring for a client whose religious belief prohibits them from receiving blood products. The client states, "My adult children don't agree with my beliefs and want me to receive a transfusion." Which of the following responses should the nurse make?
"You have the right to choose what treatments are best for you."
A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing?
"You said that you're sad. What is making you feel sad?" Motivational interviewing uses OARS (open-ended questions, affirmations, reflective listening, summarizing), which includes open-ended questions. This is an example of an open-ended question because it requires more than a yes or no answer.
A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make?
"Your income will determine if you are eligible for Medicaid."
A nurse is discussing culturally competent care w/ another nurse. Which of the following statements should the nurse include? -"use a medical interpreter for a client who does not speak the same language" - "provide the client w/ information in print only so they can have it as a resource" - "provide standard educational materials to all clients for continuity" - "limit communication with the client if there is a language barrier"
"use a medical interpreter for a client who does not speak the same language"
A nurse is caring for a client who is postoperative and requests spiritual support. Which of the following statements should the nurse make?
'Tell me what I can do to help fulfill your need for support."
A nurse is teaching about the Affordable Care Act. What should she include?
A focus of the ACA is disease prevention.
A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements from a staff member indicates understanding of a CPOE system? - "CPOE systems are associated with a slightly higher error rate." - "CPOE use does not include medication prescriptions." - "CPOE systems can increase the speed of care delivery." - "CPOE use is mandated by HIPAA under the Privacy Rule."
- "CPOE systems can increase the speed of care delivery."
A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? - "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." - "I can take a telephone prescription if a provider is directing a code for an unresponsive client." - "If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription." - "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."
- "I can take a telephone prescription if a provider is directing a code for an unresponsive client."
A nurse is talking with a client about their electronic health record (EHR) at the facility. Which fo the following client statements indicate understanding of EHRs? - "I will be able to track my health information." - "My personal information will be entered into a national database." - "I will have one EHR that will encompass the health care I've received over my lifetime." - "The goal of EHRs is to improve insurance coding."
- "I will be able to track my health information."
A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? - "Accessing the medical record of clients on units other than where you are assigned is allowed." - "There are large financial penalties for charting vital signs you obtain for another nurse's client." - "Personnel can be terminated for breaching a client's confidentiality." - "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."
- "Personnel can be terminated for breaching a client's confidentiality."
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? - "The client is now asleep, and they ate most of their breakfast a few hours ago." - "The client vomited 240 mL of clear emesis but denies pain or nausea." - "The client reports not feeling good, but they look fine." - "The client has 8 to 10 sores on their body."
- "The client vomited 240 mL of clear emesis but denies pain or nausea."
A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include? - Providers designate to other staff which abbreviations cannot be used. - A nurse who delegates a task to an AP will review the charting for that task. - Providers read and cosign nursing documentation for accuracy. - Licensed personnel should document out-of-range vital signs for AP.
- A nurse who delegates a task to an AP will review the charting for that task.
A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? - A problem-oriented medical record is created using the PIE model for documentation entries. - A problem-oriented medical record contains separate sections for laboratory and diagnostic information. - A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. - A problem-oriented medical record is rarely used in acute care settings.
- A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.
A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? - By mouth - Intramuscularly - Per rectum - Intravenously
- By mouth
A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? - Charting by exception - Subjective, objective, assessment, plan format - Problem, intervention, evaluation model - Data, action, response charting
- Charting by exception
A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? - American Nurse Association (ANA) standards prevent client records from being used for legal proceedings. - HIPAA regulations vary from one state to another. - Privacy regulations apply to electronic data transfer rather than verbal communication. - Facilities can establish their own rules for documentation methods.
- Facilities can establish their own rules for documentation methods.
A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? - Immunization data - Record of client health care payments - Complete medical information for household members - Facility policies
- Immunization data
A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? SATA - MSO4 - IU - PO - qhs - NKA
- MSO4 - IU - qhs
A nurse in a clinic is reviewing a client's prescription prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? - PRN - NPO - AC -Ad lib
- PRN
A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? - The client states, "I've had abdominal pain for the past 3 days." - The client reports consuming about 1,500 mL of water per day. - Rebound tenderness noted in RLQ of the abdomen. - Recommend client referral to a registered dietitian.
- Rebound tenderness noted in RLQ of the abdomen.
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? SATA - Reduces medical errors - Improves listening skills among interdisciplinary team members - Less convenient than paper-based charting - Makes client medical history more easily available - Increases accuracy of coding procedures
- Reduces medical errors - Makes client medical history more easily available - Increases accuracy of coding procedures
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? - Synthroid 100 mg PO every morning ac - Enoxaparin 75 mg SQ bid - Digoxin 0.25 mg PO qd - Metformin 500.0 mg PO with evening meal
- Synthroid 100 mg PO every morning ac
A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? - The "I" in PIE - The "S" in SOAP - The "R" in DAR - The "E" in PIE
- The "S" in SOAP
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs? - The Institute of Medicine - Department of Veteran Affairs - American Hospital Association - The Joint Commission
- The Institute of Medicine
A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? SATA - The admitting provider - The charge nurse on the unit - The client's sibling - The client - The client's spiritual advisor
- The admitting provider - The charge nurse on the unit - The client
A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which if the following information should the nurse include as a benefit of electronic documentation? - The system alerts providers of possible actions that could cause client harm. - An electronic system prevents breaches of confidentiality of client data. - Providers can document client information in the electronic record during system downtime. - System encryption eliminates the need for security firewalls.
- The system alerts providers of possible actions that could cause client harm.
A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smoking cessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply) - advocate - collaborator - change manager - health promotor - nurse educator
- health promotor - nurse educator
A nurse is explaining to a newly licensed nurse that caring for clients involves lifelong learning by the nurse. The nurse should include which of the following as examples of learning opportunities for nurses? (select all that apply). - nursing blogs or opinions - online continuing education journal articles - nursing skill refresher opportunities - continuing education presentations - participating in healthcare research
- online continuing education journal articles - nursing skill refresher opportunities - continuing education presentations - participating in healthcare research
A nurse is reviewing the contributions made by various nursing organizations that have impacted the nursing profession. The nurse should identify that which of the following are contributions made by the American Nurses Association (ANA)? (select all that apply). - providing a definition of nursing - lobbying for whistle blower protection - providing objective data to improve the health of society - providing all RN's w/ competency expectations - providing the nursing magazine imprint
- providing a definition of nursing - lobbying for whistle blower protection - providing all RN's w/ competency expectations
A nurse is advocating for a client who is seeking treatment for an eating disorder. In which order should the nurse take the following steps?
1. Determine the client's level of understanding regarding their eating disorder. The nurse should collect data regarding the client's level of understanding, interests, personal values, mental function, and awareness of rights in order to advocate for the client. 2. Assist the client in establishing goals for treatment. The nurse should assist the client in identifying the goals for treatment, which are based on the client's needs and beliefs, in order to advocate for the client. 3. Encourage the client to communicate their preferences during the team meeting to establish the steps of treatment. The nurse should next assist the client in communicating their preferences to the rest of the health care team to implement the advocacy plan. 4. Review the client's weight prior to each treatment session. The nurse should monitor the outcomes of the plan and make adjustments as needed to advocate for the client.
A nurse is discussing shared governance with a newly licensed nurse. Which of the following components should the nurse include in the discussion? (Select all)
1. Guides decisions toward accountability is correct. Guiding decisions toward accountability is a function of shared governance. 2. Improves client outcomes is correct. Improving client outcomes is a function of shared governance. 3. Promotes professional development is correct. Promoting professional development is a function of shared governance.
A nurse is preparing a poster about professional accountability for an in-service. Which of the following examples should the nurse include? (Select all)
1. Lowers a client's bed to the lowest position after assisting the client to lie down is correct. A nurse is accountable to the client as well as the facility to take actions to ensure a client's safety. This includes lowering the client's bed to reduce the risk of falls if the client tries to get out of bed. 2. Administers pain medication to a client 30 min before the client is scheduled for physical therapy is correct. Planning actions, such as providing pain medication to a client prior to physical therapy, demonstrates planning and accountability for ensuring the client receives quality care. This action allows the medication time to take effect prior to the client having to perform physical activities, allowing for a more effective physical therapy session and decreasing the risk of client injury and discomfort. 3. Provides instructions to assistive personnel (AP) on how to provide culturally competent care to a client is correct. Professional accountability involves not only ensuring the safety and quality of nursing care, but also delivering it in a culturally competent manner.
A nurse is preparing a presentation on the regulation of nursing practice. Place the hierarchy of the regulation of practice in the correct order, beginning with the highest level.
1. Nursing regulatory board (each state has a BON) 2. nurse practice act (Each BON determines laws of practice) 3. organization policies and procedures 4. individual self regulation
A nurse is preparing to administer acetaminophen 320 mg oral solution to a school-age child. The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10
A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle?
10° angle
A nurse is preparing to administer phenytoin suspension 300 mg PO, twice per day. The amount available is phenytoin suspension 125 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
12
A nurse is preparing to administer clindamycin 0.3 g IM to a client. Available is clindamycin 150 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2
A nurse is preparing to administer amikacin 7 mg/kg/day IM to a client who weighs 165 pounds. Available is amikacin 250 mg/mL solution for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2.1
A nurse is planning a presentation about shared governance. Which of the following examples should the nurse plan to include?
A group of staff nurses in a clinic work together to recommend new equipment purchases for the unit. (Shared governance is a leadership structure that encourages group collaboration to make shared decisions. Being a contributing partner in decisions promotes interprofessional collaboration, professional development and accountability, and improves client outcomes.)
A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first?
A client who has an abdominal wound that is actively bleeding
A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who has audible wheezing during respirations
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?
A client who has impaired kidney function
A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?
A client who is receiving a blood transfusion and reports urticaria
A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care?
A client who received digoxin and has a heart rate of 48/min
A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment?
A client who reports new chest pain
A nurse is teaching a newly licensed nurse about health literacy. Which of the following information should the nurse include?
A client's comprehension of education can be affected by low health literacy.
A nurse is assisting with teaching a class about incident reports. The nurse should include that which of the following situations requires an incident report?
A nurse administers the wrong medication to a client.
A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care?
A nurse did not read back a verbal medication prescription to a provider. Standards of care guide nursing practice to perform safe and effective care. Failing to verify a medication prescription can result in harm to a client and is therefore a breach of the standard of care.
A nurse is assisting with teaching a class about sentinel events. The nurse should include that which of the following situations is a sentinel event?
A nurse infused an incompatible blood product to a client.
A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity?
A nurse keeps a promise to a client not to tell their family about their diagnosis. The ethical principle of fidelity refers to the nurse's obligation to keep a promise. Keeping a promise to a client promotes trust between the client and the nurse.
A nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy?
A nurse respects a client's wish to discontinue a treatment. The professional value of autonomy refers to respecting the client's right to make their own decisions regarding their health care, including the right to refuse care.
A nurse is teaching a newly licensed nurse about using credible databases for research studies. Which of the following sources should the nurse include?
A peer-reviewed journal
A nurse is assisting with teaching a class about types of research studies. The nurse should include that which of the following is an example of a randomized controlled trial (RCT)?
A study arbitrarily assigning people who smoke into either an experimental group or a control group to determine the effects of a new therapy to reduce smoking
A nurse is providing an in-service about research methods for a group of nurses. Which of the following methods provides the most credible evidence to support practice changes?
A systemic review summarizing findings of studies.
A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting?
A young adult client who is positive for tuberculosis Diseases and illnesses that are considered a threat to public health, such as tuberculosis, HIV, and influenza, require mandatory reporting to the health department to track and develop prevention and protection protocols.
A nurse is teaching a group of nurses and asks which of the NLN integrating competencies is defined as having respect for diversity, holistic care, client-centered approach, and client advocacy. Which of the following competencies does this describe? A) Human flourishing B) Nursing judgment C) Patient-centered care D) Spirit of inquiry
A) Human flourishing
A nurse holds a single state nursing license and is preparing to move to another state. For the nurse to apply for reciprocity, which of the following actions should the nurse take? (Select all that apply.) A) Present a current and valid nursing license. B) Submit an application. C) Pay the fees for new license. D) Retake the NCLEX exam. E) Reapply for specialty nursing certifications held in their previous home state.
A) Present a current and valid nursing license. B) Submit an application. C) Pay the fees for new license.
A newly licensed nurse is reviewing information about the National Council of State Board of Nursing (NCSBN) Transition to Practice (TTP) program. Which of the following factors should the nurse expect? A) TP programs increase job retention. B) TP programs decrease the ability to provide safe client care. C) TP programs increase stress in the workplace. D) TP programs decrease competency.
A) TP programs increase job retention.
A nurse is educating a group of nurses about the Nurse Practice Act (NPA). Which of the following statements should the nurse include? (Select all that apply.) A) The PA contains current laws and regulations for nursing practice. B) The PA is the same for all states. C) The PA contains standards and scope of practice. D) The federal government enforces the PA for each state. E) The nurse is responsible to know current roles and responsibilities as defined by the NPA.
A) The PA contains current laws and regulations for nursing practice. C) The PA contains standards and scope of practice. E) The nurse is responsible to know current roles and responsibilities as defined by the NPA.
A newly licensed nurse is reviewing electronic information about the NCLEX® exam from the National Council of State Board of Nursing (NCSBN) website. Which of the following information should the nurse identify as passing criteria for the NCLEX computerized adaptive test (CAT)? A) The computer will stop giving items using the 95% confidence interval rule. B) The board of nursing for each state determines the passing grade for the NCLEX exam. C) The candidate receives the maximum number of items available. D) The candidate runs out of time before answering the minimum number of items.
A) The computer will stop giving items using the 95% confidence interval rule. The NCLEX is graded as pass or fail. The candidate will pass the NCLEX once it is determined by the 95% confidence interval that the candidate's ability is above passing standards. This is the pass or fail criteria for the 95% confidence interval rule.
A graduate nurse is offered a position in the emergency department upon the granting of initial licensure. Which of the following information should the graduate nurse identify as a requirement during the initial licensure process? (Select all that apply.) A) Verification of graduation B) Criminal background check in certain states C) Passing score on NCLEX examination D) Submitting continuing education hours with the application E) Self-disclosure of any substance use in the past 5 years
A) Verification of graduation B) Criminal background check in certain states C) Passing score on NCLEX examination E) Self-disclosure of any substance use in the past 5 years
A nurse is talking with a group of clients in a community setting. Which of the following statements by the nurse describes how culture affects a client's definition of health and illness? A.) "Health and illness can be defined differently by individual clients." B.) "Health and illness are similarly defined for all clients." C.) "Health is similarly defined for all clients, but illness can be viewed differently." D.) "Health and illness only need to be defined if a client has a chronic health condition."
A.) Health and illness can be defined differently by individual clients.
A nurse is conducting a cultural assessment. Which of the following factors are incorporated in Leininger's Sunrise Enabler? (Select all that apply.) A.) Kinship and social factors B.) Biological factors C.) Health disparity factors D.) Economic factors E.) Political and legal factors
A.) Kinship and social factors B.) Biological factors D.) Economic factors E.) Political and legal factors (Leiniger's Sunrise enabler consists of the following basic elements that work together to influence the client as a whole person: technological, religious, spiritual, philosophical, kinship/social, cultural valus, beliefs, and lifeways, biological factors, politicfal/legal, economic, education)
A nurse is planning care for a client who is a veteran. Which of the following information should the nurse consider? A.) The client is at an increased risk for poor health outcomes B.) The client will require a social services consult. C.) The client is guaranteed veterans health benefits. D.) The client will not be affected by socioeconomic factors.
A.) The client is at an increased risk for poor health outcomes
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A.) Use a certified medical interpreter B.) Use a family member as an interpreter C.) Repeat important words so the client recognizes their importance D.)Talk slowly so that each word is heard clearly
A.) Use a certified medical interpreter
a nurse is teaching a newly licensed nurse about receiving and transcribing verbal prescriptions. which of the following instructions should the nurse include? A: read back the prescription to the provider after transcribing. B: use symbols when transcribing a verbal prescription. C: include abbreviations when transcribing a verbal prescription. D: place a zero after a decimal when transcribing a dosage.
A: read back the prescription to the provider after transcribing.
a nurse is caring for a client who has diabetes mellitus and does not adhere to the prescribed diet. which of the following interventions by the nurse demonstrates collaborative health care? A: requesting a referral to a dietitian to work with the client. B: instructing the client's family no to bring in snacks for the client. C: asking the client why they are not adhering to the prescribed diet D: informing the client that they will get used to eating the prescribed diet.
A: requesting a referral to a dietitian to work with the client.
a nurse is using the introduction, situation, background, assessment, recommendation, and readback communication tool when contacting a provider about a client who has Parkinson's disease. which of the following statements by the nurse should be included in the situation component? A: the client is coughing while eating. B: should I obtain a chest X-ray? C: i will request a referral with a speech therapist D: the client has a history of Parkinson's disease.
A: the client is coughing while eating
A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment?
ABCDE
A home health nurse is visiting a client who lives in an older home and is concerned about their child's exposure to lead paint in the house. The nurse should identify that which of the following is a potential health risk from exposure to lead paint?
Learning disabilities
A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category?
Access to foods that support healthy eating patterns. Crime and violence. Environment conditions.
A nurse is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Where is this client going to be admitted to?
Acute care hospital
A nurse is discussing leadership styles with a newly licensed nurse. The nurse should include that which of the following is a characteristic of situational leadership.
Adjusts quickly to different circumstances. (A situational leader looks at each situation quickly and adjusts strategies based on the circumstances. The situational leader aligns their style to assist in the development and growth of others and the overall effectiveness of the organization. This leader communicates, problem-solves, organizes, and prepares with their employees to accomplish tasks and improve overall efficiencies.)
A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take?
Administer the medication to the client in a liquid form.
A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take?
Administer the medication within 30 min of the health care provider prescribing the medication.
A nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. The nurse should include that barcode technology is used to reduce errors during which of the following phases of the medication process?
Administering
A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors? (Select all that apply.)
Administering medication outside of prescribed time intervals Failing to administer a medication Incorrect dose of the prescribed medication administered to the client
A school nurse who works in a low-income school district is assisting with planning a community program to improve healthy eating habits of school-age students in the district. Which of the following organizations should the school nurse contact to provide funding?
Administration for Children and Families (ACF) The school nurse should contact the ACF. The ACF's mission is to provide resources to promote economic and social well-being of children through funding, strategic partnerships, and technical resources.
A nurse in a provider's office is speaking with a client who needs a refill for a prescription that has expired. The nurse should identify that which of the following team members can assist the client with the refill?
Advanced practice registered nurse (APRN) Physician Assistant (PA) Physician
A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.)
Age of the client Lipid solubility of a medication Route of administration
A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values?
Altruism The professional value of altruism is the selfless desire to help someone else without any benefit.
A nurse is reviewing the contributions of various nursing organizations that provide support in caring for clients. The nurse should identify that which of the following agencies provides The Nursing Scope and Standards of Practice? - American Nurses Association (ANA) - American Academy of Nursing - National StudentNurses Association (NSNA) - National Academy of Medicine
American Nurses Association (ANA)
A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include? - American Nurses Associations The code of ethics -National Academy of Medicine - American Academy of Nursing - National Student Nurses Association
American Nurses Associations The code of ethics
A nurse is caring for a client who asks about naturopathy. The nurse should include that which of the following is a component of naturopathy? (Select all that apply.) Dietary supplements Exercise Establishing harmony between fire, water, air, earth, and sky Traditional Chinese medicine Homeopathy
Dietary supplements Exercise Traditional Chinese medicine Homeopathy
A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?
Ask the client to explain the information using their own words.
A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply)
Ask the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level.
A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take?
Ask the provider to discuss the procedure with the client. If the client states that they are unclear about a procedure, the nurse should contact the provider to return to answer the client's questions. The nurse should verify that the client has adequate knowledge to make the treatment decision before the client signs the informed consent form.
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates professionalism?
Asks a client for their name, DOB, scans their medical ID bracelet before med administration
A nurse and urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?
Assessment
In what order should an RN perform the steps of the nursing process?
Assessment, analysis, planning, implementation, evaluation
A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles?
Autonomy Autonomy refers to the nurse's obligation to respect the client's right to make their own decisions regarding their health care, including the right to refuse care. A client who has chosen to sign a blood product refusal form is demonstrating autonomy or the right to make their own health care decisions.
A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?
Available resources, awareness of client status, support from other staff
A nurse is responsible for their actions with whom they interact professionally, including clients, colleagues, and society as a whole. Which of the following components of the practice of nursing addresses this expected behavior? A) Standard to plan nursing care B) Standards of professional performance C) Standards of care D) Clinical practice guidelines
B) Standards of professional performance
A nurse receives a license renewal notification from the board of nursing. The nurse should identify that a license renewal requires the disclosure of which of the following? A) Medical history B) Substance use within the past 5 years C) Certifications received D) Current salary
B) Substance use within the past 5 years
A nurse resides in a state that recently enacted the Nurse Licensure Compact (NLC). Which of the following information should the nurse identify as a part of the NLC? A) The NLC requires a nurse to obtain a license for each state in which they wish to practice. B) The NLC allows a nurse to practice across state lines with one license. C) The NLC allows a nurse to have a suspended license when practicing under a multistate license. D) The NLC is not a good option for telehealth nursing.
B) The NLC allows a nurse to practice across state lines with one license.
A nurse in a community clinic sees clients experiencing health disparities within vulnerable populations. The nurse should consider which of the following clients as belonging to a vulnerable population? (Select all that apply.) A.) A white male who has no chronic illness. B.) An African American adolescent who is pregnant. C.) A low-income family D.) A female who is Latina and has type 2 diabetes mellitus. E.) A middle class male who lives in a large city
B.) An African American adolescent who is pregnant. C.) A low-income family. D.) A female who is Latina and has type 2 diabetes mellitus.
A nurse is reviewing the medial record of an adolescent who is a lesbian. The nurse should identify that which of the following findings are likely caused by the client being marginalized by others? (Select all that apply.) A.) Having a large group of close friends B.) Being bullied at school C.) Depression D.) Using illicit drugs E.) Working an after-school job
B.) Being bullied at school. C.) Depression D.) Using illicit drugs.
A nurse is planning care for a client who uses culturally based folk- care for medical treatments. Which of the following actions should the nurse take? A.) Encourage the client to stop the use of folk care treatments. B.) Coordinate folk care treatments with modern medical treatments. C.) Educate the client that folk care treatments cannot be used within the facility. D.) Avoid the use of modern medial treatments administered by the provider.
B.) Coordinate folk care treatments with modern medical treatments.
A nurse helping to develop an in-service about cultural competence is reviewing a list of health beliefs provided by members of a local cultural group. The nurse should recognize that this list provides which of the following types of information? A.) Health disparity data B.) Emic knowledge C.) Etic Knowledge D.) Objective data
B.) Emic knowledge (emic knowledge provides info from the viewpoint of an individual within a cultural group)
A nurse is reviewing a client's medical record for factors that could impact accessibility to health care services. For which of the following factors should the nurse monitor? A.) Cultural diversity B.) Health disparities C.) Health equity D.) Cultural competence
B.) Health disparities
A nurse is reviewing information to enhance their own cultural awareness. The nurse should identify the need to examine which of the following? A.) The nursing process B.) Self-bias C.) Health disparities D.) Cultural diversity
B.) Self-bias
a newly licensed nurses is talking about their day with another nurse. which statement by the newly licensed nurse demonstrates incivility? A: i hate when i have to ask my preceptor for help with tasks i am unsure about. B: the charge nurse called me stupid in front of the team. C: my preceptor laughs when I tell a joke. D: the charge nurse give me a difficult assignment
B: the charge nurse called me stupid in front of the team.
a nurse is using the introduction, situation, background, assessment, recommendation, and readback communication tool when contacting a provider about a client who has COPD. which of the following statements by the nurse should be include in the assessment component? A: the client has a history of COPD B: the client has a respiratory rate of 38/min C: i will obtain a sputum culture D: should i increase the client's supplemental oxygen?
B: the client has a respiratory rate of 38/min
a nurse is teaching a class about barriers to inter-professional collaboration between health care professionals. the nurse should include that which of the following is a barrier? A: trust in the ability of a team member B: unresolved conflicts between team members. C: effective communication between team members D: cultural competency within team members
B: unresolved conflicts between team members.
a nurse is teaching about change-of-shift report with a newly licensed nurse. which of the following statements should d the nurse make? A: change-of-shift report performed at the client's bedside results in increased overtime by nurses. B: using ISBARR during change-of-shift report decreases the risk of missing information. C: change-of-shift report performed at the client's beside decreases client satisfaction about their care D: taking notes during change-of-shift report increase the risk for error
B: using ISBARR during change-of-shift report decreases the risk of missing information.
A nurse enters a client's room and finds the client crying. The nurse sits beside the bed in silence. Which of Swanson's five categories of caring behaviors is the nurse demonstrating?
Being with
A nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles?
Beneficence The ethical principle of beneficence refers to the nurse's obligation to implement actions that minimize harm and benefit clients. Beneficence includes meeting a client's physical, social, or emotional needs. The nurse is demonstrating beneficence by providing comfort and praying with the client who is alone
A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next?
Blood pressure
A nurse is caring for a client who is emotionally distraught. Which of the following uses of touch should the nurse implement to convey caring?
Briefly holding the clients hand.
A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors?
Complex clinical situations, ongoing client and family concerns
A nurse is reviewing the licensing laws in their state of residence. Which of the following statements should the nurse use to define licensure? A) "Licensure increases state revenue." B) "Licensure limits the number of practicing nurses. C) "Licensure protects the health and welfare of the public." D) "Licensure protects a nurse from a malpractice lawsuit.'
C) "Licensure protects the health and welfare of the public."
A nurse is providing client care using the nursing process. The nurse should identify that which of the following standards or guidelines includes this criterion? A) Standards of care B) Clinical practice guidelines C) Standards of practice D) Standard to plan nursing care
C) Standards of practice Standards of practice are explanatory statements that describe a competent level of care for all nurses using the critical thinking model known as the nursing process. Nursing has general standards of practice to which every nurse is held accountable
A nurse is caring for a client who is from a different culture. To provide the best possible client care, which of the following actions should the nurse take first? A.) Obtain a cultural health assessment. B.) Develop a cultural competence. C.) Conduct a self-assessment. D.) Create an individualized plan of care.
C.) Conduct a self-assessment.
A nurse is caring for a newly admitted client. Which of the following actions should the nurse take first? A.) Implement nursing interventions B.) Plan nursing interventions C.) Perform a cultural health assessment D.) Evaluate the care plan
C.) Perform a cultural health assessment (assessment is the 1st step)
a nurse is teaching a newly licensed nurse about what to include in a medication reconciliation form for a client who is being transferred to a new facility. which of the following instructions should the nurse include? A: include a list of medications that the client no longer needs. B: do not include OTC medications the client takes C: include medications the client took at home. D: do not include nutritional supplements the client takes.
C: include medications the client took at home.
a nurse and an assistive personal disagree about how to move a client from the bed to a stretcher. which of the following statements should the nurse make to promote conflict resolution? A: i'm the nurse, you are the AP, so do what i say. B: you always need to get your own way. C: let's discuss how we can work together. D: if you do not help me. i will report you to the charge nurse
C: let's discuss how we can work together.
a charge nurse is proving teaching to a group of nurses about the collaborative teamwork skill of situation monitoring. which of the following statements by a nurse indicates an understanding of the teaching? A: situation monitoring identifies who should be included on the team B: situation monitoring identifies strategies to lead teams effectively. C: situation monitoring focuses on the awareness of the team's performance on client outcomes. D:situation monitoring supports the team by providing feedback to assist the team to function better
C: situation monitoring focuses on the awareness of the team's performance on client outcomes.
a nurse is teaching a client who has end-stage kidney disease and a new sacral pressure injury. the client's provider has requested a plastic surgery consultation. which of the following statements by the client indicates an understanding of the consultation? A: the plastic surgeon might adjust my renal diet B:the plastic surgeon will assist me with financial counseling. C: the plastic surgeon might change my wound care treatment D: the plastic surgeon will coordinate my health care team.
C: the plastic surgeon might change my wound care treatment
a nurse is caring for a client who asks. "why do i have to talk to so many people before i can go home? don't these people communicate?" which of the following statements should the nurse make? A: they are very busy and do not have time to communicate about your health. B: why are you concerned about talking to your health care team? C: your health care team works together so you can safely go home D: the sooner you talk with them, the sooner you can leave.
C: your health care team works together so you can safely go home
A nurse is a member of the facility's quality improvement committee. The committee is concerned with the increase in the number of catheter-associated urinary tract infections (CAUTI) at the facility. Which of the following agencies should the nurse use to find best-practice guidelines for the care of clients with indwelling urinary catheters?
CDC
A nurse is discussing nursing roles with a newly licensed nurse. which are roles of the nurse?
Caregiver, Advocate, Change agent
A charge nurse uses transformational leadership style when working with other staff on the unit. Which of the following actions by the charge nurse demonstrates transformational leadership?
Challenges a nurse to investigates evidence-based approaches to reduce the client fall rate on the unit
A nurse is collaborating with an interdisciplinary team to develop a plan of care for a client. Which of the following tools should the nurse use to guide the delivery of care?
Critical pathway
A school nurse notifies the guardian of a school-age child who has failed the vision screening and recommends the child see an optometrist. The guardian reports that they cannot afford private health insurance. Which of the following programs should the nurse recommend the guardian contact?
Children's Health Insurance Program (CHIP) CHIP is comprehensive and covers routine physical examinations, visits to the health care provider for health, vision, dental, immunizations, hospitalizations, prescriptions, and laboratory services. CHIP is for children under 19 years of age whose families may earn too much to qualify for Medicaid but cannot afford private insurance.
A nurse is discussing the Model of Professionalism with another nurse. Which of the following concepts should the nurse include as an outer process?
Clear communication (Clear communication is an outer process because it is a behavior or action that the nurse performs.)
A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?
Clinical judgment
A nurse is discussing clinical pathways with a newly licensed nurse. Which of the following information should the nurse include?
Clinical pathways use evidence-based practice guidelines for health care delivery.
A nurse is using evidence-based research to care for a client who has diabetes mellitus. Which of the following resources should the nurse use to manage the delivery of care?
Clinical practice guidelines
A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take?
Come back in a few minutes to administer the medication.
A nurse is assisting on a quality improvement committee to decrease the number of client falls occurring at night. After identifying the problem, which of the following is the next step the nurse should take?
Complete a literature review.
nurse who has a multistate nursing license receives a request from a facility in a neighboring state about providing care in their facility during an emergency disaster. Which of the following actions should the nurse take prior to responding to the request?
Contact the state board of nursing in the neighboring state. The nurse needs to confirm that the neighboring state participates in the Nurse Licensure Compact (NLC). The state's board of nursing regulates licensure and would be the best resource for the nurse to contact to verify permission to practice nursing.
A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?
Continuity of care The nurse should understand that continuity of care can cause a safety risk of a client when there are numerous hand-off reports completed during a transfer to another unit. The nurse should wait until the other nurse is available for report.
A nurse is reviewing a report by the Institute of Medicine. Which of the following competencies should the nurse identify health care professionals need in order to reduce errors?
Cooperation Communication Coordination
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first?
Cover the IV site with an elastic bandage.
A nurse is reviewing the scope of nursing practice. Which of the following is the purpose of the nursing scope of practice? A) Provides recommendations for nursing practice B) Provides competencies for the nurse to achieve before receiving initial licensure C) Serves as a contractual document between the nurse and their employer D) Specifies the actions a nurse can perform
D) Specifies the actions a nurse can perform
A nurse is delivering client care in partnership with multidisciplinary members of the health care team. This is an example of which of the following QSEN competencies? A) Safety B)Patient-centered care C) Quality improvement D) Teamwork and collaboration
D) Teamwork and collaboration
A newly licensed nurse is reviewing the standards of care when performing client care. Which of the following describes a standard of care? A) Explanatory statements that describe the competent level of care for all nurses to follow in practice B) A component of the nursing scope of practice that specifies the competent level of behavior expected in the professional role C) Part of the nursing scope of practice that specifies the nurse's role in alleviating client suffering and promoting client healing D) The level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
D) The level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
A nurse is reviewing information about culture with a group of newly hired nurses. Which of the following statements by a newly hired nurse should the nurse identify as an understanding of culture? A.) "Inclusion means each client is treated in the same manner, regardless of their culture." B.) "Cultural preferences do not include beliefs about health promotion and disease treatment." C.) "Not every individual has cultural preferences." D.) "Culture can include language and communication practices."
D.) "Culture can include language and communication practices."
A nurse is caring for a client who was born in India but has lived in the U.S. for 30 years. The client speaks English and has family members at the bedside. Which of the following actions should the nurse take? A.) Assume that the client has special cultural practices that will need accommodation. B.) Obtain use of a certified medical interpreter at the beginning of providing care. C.) Ask the family to leave the room while the nurse is present. D.) Inquire about any special cultural beliefs or practices.
D.) Inquire about any special cultural beliefs or practices.
A nurse is interviewing a client who states that they are transgender, although they have a biological sex of male listed in their records. Which of the following information should the nurse plan to incorporate when assisting with the client's plan of care? A.) The client will prefer to have caregivers who are female. B.) The client has changed the way they view sexuality. C.) The client will not want to be addressed by the use of pronouns such as "him" or "her". D.) The client associates their identity to something different from their sex assigned at birth.
D.) The client associates their identity to somethings different from their sex assigned at birth
a nurse is teaching an in-service about zero-tolerance for bullying and incivility in the health care facility. which of the following information should the nurse include? A: bullying can result in an increase in productivity. B: incivility can result in improved communication in the workplace C: incivility can result in a reduction of medical errors. D: bullying can result in an increase in nursing turnover
D: bullying can result in an increase in nursing turnover
a nurse is preparing a discharge plan for a client following a bilateral below-the-knee amputation. which of the following interventions is the priority? A: check the availability of transportation to follow-up appointments. B: request a referral for a home health nurse C: provide the client with written material about their medications. D: determine whether the client's home is wheelchair accessible
D: determine whether the client's home is wheelchair accessible
a nurse is assigned to care for a client. the client's provider is known to become angry and yell at the nurse. which of the following actions by the nurse demonstrates the use of cognitive rehearsal? A: The nurse asks another nurse to be present as a witness when the provider arrives. B: the nurse confronts the provider outside the client's room C: the nurse notifies the charge nurse about the provider's actions. D: the nurse mentally practices in advance what to say to the provider.
D: the nurse mentally practices in advance what to say to the provider.
A nurse is discussing leadership styles with a newly licensed nurse. Which of the following characteristics should the nurse identify as describing a bureaucratic leader? (select all)
Decisions are controlled by policies, enforces the rules, inflexible to creative suggestions
A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?
Delegation of the wrong task
A nurse is teaching a class about citing references to use for evidence-based changes. Which of the following requires citing a reference to avoid plagiarism? (Select all that apply.)
Direct quotations from a journal article. A photograph depicting equipment. Ideas published in a theoretical paper. Paraphrased sentence from an article.
A nurse is preparing to administer an influenza vaccine to a client. The client states that they understand being immunized will help protect them against the influenza virus. Which of the following concepts is the nurse demonstrating by administering the vaccine?
Disease prevention
A nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care?
Document that the medication was not administered. Standards of care guide nursing practice to perform safe and effective care. Accurate documentation facilitates communication to members of the client's health care team and is a component of expected standards of care. Documenting client data, interventions, and client responses promotes continuity of care and decreases the risk for error. The nurse should return to check the client to determine if the client requires the PRN pain medication.
A nurse manager is observing a newly licensed nurse provide care for a client. Which of the following actions should the manager identify as unprofessional behavior?
Documents in advance to save time (falsified documentation), Stays logged into clients EHR while obtaining supplies (runs the risk of another person accessing clients EHR), Contacts clients on social media to be friends (overstep of professional boundary between nurse and client, inappropriate conduct)
A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should include that Ayurveda is based on establishing a balance between the body, mind, and spirit with which of the following elements? (Select all that apply.) Earth Sky Darkness Light Water
Earth Sky Water
A nurse is caring for a client who reports that they have lost their job and do not have insurance. Which of the following social determinants of health is challenging for this client?
Economic stability
Which of the following ways is the Press Ganey survey conducted?
A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include?
Encourage the client to ask questions.
A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take?
Ensure the client is wearing their glasses during teaching. The nurse should take steps to facilitate learning, such as ensuring the client's assistive devices, including eyeglasses or hearing aids, are being used.
A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning?
Ensure the room is well lit. The nurse should identify that a well-lit room can allow the participants to better see the presentation as well as the nurse during the teaching.
A nurse is speaking to a client who smokes tobacco and has a child living in the home. The nurse should identify that the child's exposure to second-hand smoke is an example of which of the following types of risk factors?
Environmental
A nurse is planning an in-service for a group of staff nurses about spiritual care. Which of the following situations should the nurse identify as appropriate for a consultation with pastoral staff? (Select all that apply.)
Ethical dilemma Terminal illness Death of a client Hardship
A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?
Evaluation
A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship?
Exploitation The nurse is actively coaching the client toward a healthier lifestyle.
A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expect to perform?
Facilitate transfer of clients to meet the required level of care.
A nurse is reviewing the role of health information technology in client care with a newly licensed nurse. Which of the following information should the nurse include? (Select all that apply.)
Facilitates care coordination is correct. Improves practice efficiencies is correct. Is capable of being overridden by a nurse is correct. Improves clinical outcomes is correct.
A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action?
Falsification of records The nurse is falsely documenting that a medication was administered to the client, which is an example of falsification of health records. Falsification of health records can include not documenting care that occurred, documenting inaccurate data, or documenting care or events that did not occur. This action can lead to client injury and is considered failure to adhere to the standards of nursing practice.
A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of following components of the model?
Feedback In the Schramm model, one of the three components is feedback. Feedback is demonstrated when the receiver is allowed to let the sender know that the message was properly received.
A charge nurse is overseeing an AP who has been assigned care for a group of clients. Which of the following actions by the charge nurse demonstrates accountability?
Files an incident report when the AP performs a task that is outside their scope of practice. (An incident report is a risk assessment tool that identifies an unusual occurrence. By filing the report, the charge nurse is demonstrating accountability and ensuring safety standards are met, thus protecting the client from potential harm.)
A nurse is reviewing historical nursing data & how it has impacted nursing care. The nurse should identify that which of the following nurse pioneers is credited w/ first using evidence based practice in caring for clients? - Clara Barton - Dorthea Dix - Eddie Bernice Johnson - Florence Nightingale
Florence Nightingale
A nurse stops at the side of the road to provide care to a person involved in a motor-vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident?
Good Samaritan laws Good Samaritan laws protect people who provide aid in the event of an emergency from being held liable for their well-intentioned actions. The actions the nurse takes should be within their scope of practice as a licensed nurse and should not be considered grossly negligent.
A nurse is teaching about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS). What should she include?
HCAHPS measures the client satisfaction with health care services.
A nurse is assisting with teaching a class about HIPAA. Which of the following information should the nurse include? (Select all that apply.)
HIPAA protects the unauthorized release of a client's protected health information is correct. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach is correct. A breach in HIPAA should be reported within 60 days after the breach is discovered is correct.
A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first?
Have a second nurse confirm the insulin dose.
A nurse has completed administering a controlled substance to a client. There is 1 mL of the medication left in the syringe. Which of the following actions should the nurse take to dispose of the unused medication?
Have a second nurse witness the disposal of the client's unused medication. Controlled substances should be disposed of properly. According to the Controlled Substance Act, one of the safety measures is to have a second nurse witness the proper disposal of the remaining unused portion of medication. Proper disposal consists of both nurses witnessing and documenting disposal of the unused medication down the sink or flushed in a toilet per the policy of the facility
A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values?
Human dignity The professional value of human dignity is recognizing that all human life has value and should be treated equally with respect, regardless of race, religion, gender, sexual orientation, culture, ethnicity, or socioeconomic status. Providing privacy to a client who has incontinence is demonstrating respect and preserving the client's human dignity.
A nurse is caring for a client who has a new diagnosis of cancer. The client states, "I don't understand what my treatment options are." Which of the following statements by the nurse demonstrates advocacy?
I will contact your provider to review your treatment options. (The nurse is demonstrating advocacy by contacting the provider to communicate the client's concerns so that the client can make an informed decision regarding their health care.)
A nurse is teaching a client about the International Self-Care Foundation's seven pillars of self-care. Which of the following client statements indicates an understanding of the teaching?
I will perform moderate exercise several times each week.
A nurse is using evidence-based practice (EBP) to address the incidence of catheter-associated infections on a surgical unit. According to EBP, which of the following actions should the nurse take first?
Identify a clinical problem.
A nurse is assisting a quality improvement team that is using the Plan-Do-Study-Act (PDSA) model to address an increase in pressure injuries on a medical unit. Which of the following actions should the nurse identify as an example of the "Do" step of the PDSA model?
Implementing a new evidence-based practice protocol
A nurse is explaining National Patient Safety Goals (NPSGs) to a newly licensed nurse. The nurse should include that which of the following is a goal addressed in the NPSGs?
Improving staff communication
A nurse is a member of a committee that is using evidence-based practice (EBP) to decrease the incidence of central line infections. The nurse should identify that which of the following interventions is part of the implementation step of EBP?
Incorporating the new practice into client care
A nurse who has been working 12-hr shifts on a busy unit is experiencing nurse fatigue. Which of the following effects can result from nurse fatigue?
Increase in medication errors Nurse fatigue can result in an increase in risk for medication errors that can result in client injury.
A nurse is reviewing the impact low health literacy has for clients with a newly licensed nurse. Which of the following information should the nurse include?
Increase in mortality rate
A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?
Inference, creativity, inductive reasoning
A nurse is caring for a young adult client who is deceased and has a valid organ donation card. The client's parents have expressed a desire against having the client's organs donated. Which of the following actions should the nurse take?
Inform the parents about the law that prohibits their ability to revoke the client's wishes to donate. The nurse should inform the parents about their adult child's organ donation card. The Uniform Anatomical Gift Act prohibits another person from revoking consent of a donor after death. The client's wishes must be followed per this act.
A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should she include?
Initiatives to reduce health care disparities. Activities to improve social determinants of health. Improving access to health care.
A nurse is completing the Minimum Data Set assessment for a resident in a skilled nursing facility. Which of the following information should the nurse include in the assessment?
Input from members of the interdisciplinary team. Client's cognitive status. Each physical therapy visit. Clients need for assistance with ADLs.
A nurse is preparing to use a video-enabled device to communicate with a client who is at home. Which of the following actions should the nurse plan to take?
Instruct the client to use a computer for the video conference.
A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values?
Integrity The professional value of integrity involves showing honesty and choosing to do what is right and fair, even when the situation is difficult. The nurse who admits that they administered the wrong medication to a client is demonstrating the professional value of integrity.
A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating?
Justice The ethical principle of justice refers to an obligation of the nurse to treat all clients the same regardless of age, sex, race, sexual orientation, or economic status.
A nurse at a hospital is interviewing a newly admitted client. The client tells the nurse they would like to adhere to their cultural beliefs during their hospitalization. Which of the following actions should the nurse take to provide the client with culturally competent care? (Select all that apply.)
Listen to the client's request with respect and compassion. Reassure the client that they can practice their cultural beliefs if safe to self and others. Provide resources to meet the client's culture needs.
A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred for further treatment?
Long-term care hospital
A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take?
Lower the volume on the television. The nurse should minimize the noise in the environment by decreasing the volume on the television when communicating with the client. Auditory communication is what the receiver hears when the sender speaks a message. It can be affected by environmental noise. The loud television presents a barrier to communication and the nurse should reduce the environmental noise.
A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?
Make a list and prioritize a plan. Managing multiple clients can be difficult for a new nurse. Making a list of all tasks to accomplish and then prioritizing a plan can help the nurse stay organized and efficient.
A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.)
Mark the area around the automated medication dispensing system. Provide the nurse administering medications with a vest. Double check dosages of high-alert medications.
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.)
Move the client to a quiet area or private room is correct. The nurse should reduce environmental noise as much as possible to enhance communication with this client. Speak at a slower pace is correct. Speaking at a slower pace might help the client to be able to better understand and communicate with the nurse. Avoid using medical terminology is correct. The nurse should avoid using medical terminology. These words are unfamiliar and can impede communication with all clients.
A nurse is reviewing the Institute of Medicine (IOM) Future of Nursing report to better understand proposed educational requirements of nurses. Which of the following organizations is responsible for publishing this report? - American Nurses Association - National Academy of Medicine - State Board of Nursing - American Association of Colleges of Nursing
National Academy of Medicine
A nursing student expresses a desire to become more involved w/ the nursing profession on a national level. Which of the following organizations should the student join? - National League for Nursing - National Student Nurses' Association - National Academy of Medicine - International Council of Nurses
National Student Nurses' Association
A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication?
Nonverbal The nurse should recognize the client is exhibiting nonverbal communication through their physical gestures. Nonverbal communication, also known as body language, plays an important role in interactions among nurses, clients, and their families. For instance, not making eye contact, not being engaged in the conversation, or having closed posture (folded arms, slouching) can portray a negative message.
A nurse is caring for a client who asks about using aromatherapy for nausea. Which of the following scents should the nurse recommend? (Select all that apply.) Ginseng Evening primrose Peppermint Ginger Orange
Peppermint Ginger Orange
A nurse is teaching a class about using smart infusion pumps to administer intravenous medications. Which of the following information should the nurse include?
Nurses enter client information into the smart infusion pump.
A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.)
Observe the client's lower extremities for indications of deep vein thrombosis. Measure the client's temperature. Check the client for bruising.
A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?
Oral
A nurse is caring for a client who states the health care provider recommends treatment to provide comfort because a cure is not possible. To which of the following concepts is the provider referring?
Palliative care
A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating?
Passive-aggressive During the phone call while talking with the oncoming nurse, the charge nurse was pleasant and accepting that the nurse would be late. However, once the phone call ended, the charge nurse then complained about the nurse always being late to the other staff. The charge nurse exhibited a passive-aggressive style of communication.
A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first?
Perform a physical assessment
A nurse is caring for a Parkinson's patient and needs assistance for their ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe?
Physical therapist Occupation therapist Dietician
A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority. Use all the levels.)
Physiological Safety Love/Belonging Esteem Self-actualization
A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.)
Place the medication reconciliation form with the client's transfer documents. Reinforce teaching about the medications to the client upon discharge. Include over-the-counter medications in the medication reconciliation. Compare the client's home medications with prescribed discharge medications.
A nurse is assisting with using the Plan-Do-Study-Act (PDSA) model to decrease client falls in a long-term care facility. The nurse should identify that developing guidelines to decrease falls is included in which of the following steps of the PDSA model?
Plan
A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?
Planning
A community health nurse is teaching about social determinants of health. What should she identify as a physical determinant or health?
Poor air quality
A nurse in a provider's office is calling a client's insurance company to obtain permission prior to scheduling a magnetic resonance imaging (MRI) test. Which of the following is the nurse obtaining?
Precertification
A nurse is discussing quality measurement with a newly licensed nurse. The nurse should include that medication reconciliation is an aspect of which of the following parts of quality measurement?
Process
A nurse is preparing for a presentation on professional identity in nursing. Which of the following statements should the nurse use to describe professional identity?
Professional identity is how one describes themselves as a professional
A nurse is discussing hospice care. What is the goal of hospice care?
Provide care for a client who has less than 6 months to live
A nurse is reviewing discharge instructions with a client who has low health literacy. Which of the following actions should the nurse take?
Provide examples.
A nurse is using evidence-based practice to reduce pain during venipunctures for adolescent clients by asking a PICOT question: "Does providing music to adolescent clients during venipunctures decrease their discomfort compared to those clients who do not listen to music?" Which of the following is a component of the "I" in this PICOT question?
Providing music.
A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply.)
Psychosocial factors is correct. The nurse should recognize that psychosocial factors are influencing communication with the client. Psychosocial factors include the client's financial situation. The client is working two jobs and going to dialysis appointments twice a week, which might require them to miss work time and pay. Furthermore, the client is the only income for this household. Situational factors is correct. The nurse should recognize situational factors, such as the new prescription for dialysis, influencing the communication with the client. Situational factors that can affect communication cause emotions including fatigue, anxiety, grief, and fear. This client's verbal and nonverbal communication are indicators of worry, anxiety, sadness, and grief.
A nurse is collecting data from a group of clients regarding their feelings and experiences of living with congestive heart failure. In which of the following types of research studies is the nurse participating?
Qualitative
A nurse is assisting with teaching a class about quality core measures. Which of the following information should the nurse include?
Quality core measures are a standard of care for treatment.
A nurse is assisting with developing a quality improvement (QI) plan to reduce the incidence of medication errors in an acute care unit. The nurse should recognize that which of the following actions is included in the identifying step of the QI process?
Recognizing a need for a change
A nurse is reviewing a health care facility's policy that states to use a gauze dressing over IV insertion sites. After completing a literature review, the nurse discovers that evidence-based practice (EBP) indicates to use a transparent dressing over IV sites. Which of the following actions should the nurse take next?
Recommend changing the procedure to the policy and procedure committee.
A nurse has created a table of evidence to organize findings from a literature search. Which of the following components of the table provides information for implementing a change in practice?
Recommendations
A nurse is teaching a newly licensed nurse about Medicare reimbursement. What should she include?
Reimbursement amounts will be adjusted for clients who contract HACs.
A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Request assistance from the facility's interpreter. The nurse should request a facility-approved interpreter to assist with the communication barrier. This would also ensure that the information is correct and gives both the nurse and client an opportunity to ask questions.
A home health nurse is caring for a client who is receiving hospice care. The clients partner reports feeling overwhelmed from care for the client. What facility should the nurse recommend?
Respite care
A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using?
Restating The nurse is summarizing, paraphrasing, or restating the client's thoughts to confirm the nurse understands what the client is attempting to communicate.
A newly licensed nurse is assigned to care for a client who has a newly inserted chest tube. The nurse has not previously cared for a client who has a chest tube. Which of the following actions should the nurse take?
Review the facility's policy and procedure (P&P) manual. The nurse should review the facility's P&P manual prior to caring for the client. This will provide the nurse with the standard of care that every nurse should follow prior to performing tasks to meet regulatory and accreditation requirements to promote safety. The P&P manual should include the rationale, indications, contraindications, and specific equipment needed for the procedure as well as procedural steps.
A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?
Right task The charge nurse should delegate an assignment or task that is safe for a health care worker to carry out. Safety includes right training, competency, or within the health care worker's scope of practice.
A nurse is assisting with teaching a newly licensed nurse about the use of electronic health records (EHRs). Which of the following is an outcome associated with the use of EHRs that the nurse should include?
Saves time
A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use?
Schedule a face-to-face unit staff meeting. In-person communication of this important policy would permit for both verbal and nonverbal modes of communication between the sender (the nurse manager) and the receiver (the unit staff).
A nurse at a clinic is providing free blood pressure screenings for clients. Which of the following levels of health prevention is the nurse demonstrating?
Secondary prevention
A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs?
Self-esteem
A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating?
Sender The nurse is initiating the message; therefore, the nurse is the sender.
A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client?
Speak to the client clearly and at a slow pace. The nurse should speak to the client who has cognitive or developmental delays clearly and at a slower pace. The nurse should also avoid the use of complicated terms or medical terminology.
A nurse is caring for a client who tells the nurse, "Something is wrong. I feel like God is so far away from me and I don't know what to do." Which of the following is the client experiencing?
Spiritual distress
A nurse is admitting a client who has heart failure. Which of the following tools should the nurse use to implement nursing interventions for the client?
Standard of care
A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first?
Stop the infusion of the vancomycin.
A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include?
TJC ensures organizations remain up-to-date with state guidelines.
A nurse is teaching a group of guardians about primary prevention techniques. Which of the following topics should the nurse include as an example of primary prevention?
Taking measures to decrease the risk of childhood injuries within the home.
A nurse is providing information to a client who is from the Baby Boomer generation about a newly prescribed medication. Using information about generational preferences, which of the following methods of teaching should the nurse use?
Talk w/ the client in person.
A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take?
Tell the charge nurse that the coworker might be impaired. The nurse should report their suspicion to the charge nurse or supervisor to protect the safety of the clients. If the charge nurse suspects the coworker is impaired, they should remove the impaired employee from the work environment.
A nurse is caring for a client whose neighbor works on another unit. The neighbor calls the unit and asks the client's nurse, "What happened to the client?" Which of the following actions should the nurse take?
Tell the neighbor they cannot give them that information. The client's nurse should inform the neighbor that according to Health Insurance Portability and Accountability Act (HIPAA), they are not allowed to disclose the client's information. According to HIPAA, it is unlawful to share any client information with health care personnel who are not directly involved in the care of the client.
A nurse is teaching a client who has a new prescription for an antihypertensive medication.
Tertiary prevention
A nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating?
The Emergency Medical Treatment and Labor Act (EMTALA) The EMTALA was enacted to allow clients to access the emergency departments of hospitals for equal care regardless of their ability to pay. Refusing to accept clients who do not have health insurance is a violation of the EMTALA.
A nurse is teaching a class about the Hospital-Acquired Condition Reduction Program (HACRP). Which of the following information should the nurse include?
The HACRP links Medicare payments to health care quality.
A nurse is assisting with teaching a newly licensed nurse about the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include?
The HCAHPS tool is issued to measure client satisfaction about health care service.
A nurse is reviewing the HIPAA regulatory rules. Which of the following rules is restricted to electronic protected health information (e-PHI)?
The Security Rule
A nurse is caring for a client who is postoperative and has sanguineous drainage on their dressing. The nurse is unable to reach the client's provider. Which of the following members of the chain of command should the nurse contact next?
The charge nurse (According to evidence-based practice, the first person in the chain of command that the nurse should contact is the charge nurse. The nurse should initiate the chain of command to make the charge nurse aware of the situation and to ensure the client receives safe and effective care.)
A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?
The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues. The nurse is providing relevant and needed information for SBAR reporting: situation, background, assessment, and recommendation.
A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority?
The client reports dizziness when standing
A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client?
The deltoid muscle can be used to administer intramuscular injections.
A nurse is using evidence-based practice to develop a PICOT question. Which of the following describes the "O" in PICOT?
The desired result of the intervention to the problem.
A graduate nurse notes that a hospital with Pathway to Excellence recognition is hiring staff. What should the nurse expect from this facility?
The facility has practices in place that lead to a health workplace environment. The facility emphasizes shared governance. The facility emphasizes practices that positively affect the nurse well being
A nurse is preparing to perform a procedure on a client. Which of the following resources should the nurse use to meet the standard of care? (Select all that apply.)
The health care organization policy and procedure manual. Info from a government website. Article published by a perr-reviewed journal.
A charge nurse is supervising a nurse providing care to several clients. For which of the following actions by the nurse should the charge nurse intervene?
The nurse alters the steps in a procedure established in the clinical practice guidelines.
A nurse is discussing professional commitment with their supervisor during an annual performance review. Which of the following actions by the nurse demonstrates professional commitment?
The nurse attends an educational course to learn about the treatment and prevention of pressure ulcers. (Professional commitment includes a motivation to improve oneself in the domain of their profession. Attending a course that expands current knowledge contributes to promoting one's professional commitment.)
A nurse follows the six rights of medication administration when caring for a client. Which of the following concepts is the nurse demonstrating?
accountability (The nurse is demonstrating accountability because they are administering medications in a way that reduces errors and harm to the client.)
A nurse is talking w/ a client who arrived at the clinic over an hour ago and states, "doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the needs of the client. In which of the following roles is the nurse performing? - educator - case manager - advocate - leader
advocate
A nurse is planning to use evidence-based practice (EBP) to determine the best practice for dressing changes for clients. According to EBP, in what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
The nurse notices another nurse changing a dressing and recognizes that they perform the same procedure differently is the first step. The nurse asks a clinical question about methods to perform a dressing change is the second step. The nurse conducts a literature search to determine the presence of nursing literature on how to perform dressing changes is the third step. The nurse reads, organizes, and compares the results of the scientific literature search is the fourth step. The nurse develops recommendations about dressing changes to present to an interdisciplinary team in order to update the policy and procedure is the fifth step. The nurse implements changes for performing dressing changes and collects data to determine client outcomes is the sixth step.
A nurse is discussing the Healthy People initiative with a newly licensed nurse. Which of the following information should nurse include?
The program focuses on providing goals and data for improved public health.
A nurse is exploring leadership styles of nurse managers as a part of a quality improvement project. Which of the following statements by a nurse manager should the nurse identify as an example of transactional leadership?
The staff members who complete their online learning courses before the deadline will receive a gift card. (Transactional leaders use rewards or punishments to encourage compliance for an established goal. They communicate specific expectations, focusing on tasks and completion of short-term goals.)
A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. Which of the following information should the nurse include? (Select all that apply.)
The transfer of data is accomplished using wireless devices. Clients can participant in their health by using RPM. A client's heart rhythm can be transferred using RPM.
A nurse is assisting with teaching a class about using simulation for clinical education. Which of the following information should the nurse include?
The use of simulation improves communication skills.
A nurse is teaching a newly licensed nurse about the purpose of peer review in scholarly publications. Which of the following statements should the nurse make?
This process ensures scientific quality and rigor.
A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include?
To convert g to mg, move the decimal point 3 places to the right.
A nurse is teaching a client about modifiable risk factors to their health. Which of the following should the nurse include as an example of a modifiable risk factor?
Tobacco use
A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care?
Urgent
A nurse is teaching a class about searching the internet for research articles to use for evidence-based changes. Which of the following information should the nurse include?
Use Quackwatch to verify credible websites.
A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?
Use an alternative method for determining the client's pain level. Medications such as general anesthesia can cause cognitive deficits that could make it difficult for the client to communicate their needs. The nurse should use an alternative method for determining the client's pain level by observing facial expressions (grimacing or clenching of the teeth); body movements, including restlessness, muscle tension, or resisting movement; and vocalizing discomfort by moaning, grunting, or crying.
A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include? (Select all that apply.) Use deep breathing to promote relaxation in clients. Encourage clients to use guided imagery to decrease pain. Apply essential oils to treat anxiety in clients. Treat one medical issue for clients at a time. Discourage family involvement in client care.
Use deep breathing to promote relaxation in clients. Encourage clients to use guided imagery to decrease pain. Apply essential oils to treat anxiety in clients.
A nurse is assisting with teaching a class about using health information technology for client care. Which of the following examples should the nurse include?
Using a barcode to verify a client's medication
A nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles?
Veracity The ethical principle of veracity refers to the nurse's obligation to provide truthful information to the client, the provider, and the nursing supervisor. Truthfully answering a client's questions about their laboratory results is demonstrating the ethical principle of veracity.
A nurse is assisting with teaching a client about food choices that promote immunity and healing. Which of the following foods is the best source of vitamin C? a. 1 cup grapes b. 1 cup strawberries c. 1 cup sliced apple d. A small banana
b. 1 cup strawberries
A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.)
Verbal is correct. The nurse planned on teaching in a face-to-face presentation of the information. The verbal mode of communication occurs during face-to-face communication between the sender (the nurse) and the receiver (the APs). It can also occur during a telephone call. Written is correct. The written mode of communication is any form of communication in which the receiver reads the message from the sender. The nurse plans to use both face-to-face verbal communication and a written mode of communication. Nonverbal is correct. The nonverbal mode of communication is comprised of body language. Actions such as eye contact, facial gestures, posture, and overall appearance all send messages to the receiver in addition to what the sender is saying. The nurse will be sending and receiving messages with the AP as they deliver the verbal information in a face-to-face environment.
A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?
Wear clean gloves to apply the transdermal medication.
A nurse is caring for a client who reports an improved diet, exercising 30 min a day for 5 days a week, and an overall sense of improved health. The nurse should identify that the client is describing a positive state of health known as which of the following?
Wellness
A nurse is speaking with a client who is non-compliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make?
What is preventing your consistency with your daily blood glucose checks?" The nurse is using an open-ended question to encourage the client to talk more about what is hindering them from the process for daily blood glucose testing.
A nurse is assisting with providing an in-service for staff members about complementary and integrative health. Which of the following statements by a staff member indicates an understanding of the teaching? a. "Scented oils might decrease discomfort." b. "Natural substances do not have adverse effects." c. "Acupressure and acupuncture are the same thing." d. "Meditation involves the use of an electronic device to regulate body function."
a. "Scented oils might decrease discomfort."
A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following statements should the nurse make to implement a complementary health strategy? a. "Try to take slow, deep breaths in and out." b. "Would you like a prescription for an anti-anxiety medication?" c. "Why are you feeling anxious?" d. "You'll have that appendix out in no time, then you'll feel better."
a. "Try to take slow, deep breaths in and out."
A nurse is completing a preoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report? a. Ginkgo biloba b. Echinacea c. Valerian d. Aloe vera
a. Ginkgo biloba
A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement? a. Massage therapy b. Chemotherapy c. Teletherapy d. Brachytherapy
a. Massage therapy
A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients should the nurse recommend? a. A client who has a sinus infection b. A client who has shoulder pain c. A client who has appendicitis d. A client who has heart failure
b. A client who has shoulder pain
A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns? a. Green tea b. Aloe vera c. Lavender d. Milk thistle
b. Aloe vera
A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement? a. Offer a massage with lavender oil. b. Request a prescription for vitamin B12 supplements. c. Give the client a cup of chamomile tea. d. Provide peppermint oil for the client to inhale.
b. Request a prescription for vitamin B12 supplements.
A nurse is reinforcing teaching about traditional Chinese medicine (TCM) to a client. Which of the following statements by the client demonstrates an understanding of the teaching? a. "I will take my blood pressure medication every morning." b. "I will have my heart rate checked once a month." c. "I will practice Tai Chi every day." d. "I will weigh myself weekly."
c. "I will practice Tai Chi every day."
A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following client statements indicates an understanding of the teaching? a. "I will take kava to reduce my eye pain." b. "I will find a Rolfing practitioner to help decrease my alcohol cravings." c. "I will practice meditating when I feel stressed." d. "I will take niacin to promote healing for my eyes."
c. "I will practice meditating when I feel stressed."
A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients should the nurse recommend? a. A client who is receiving anticoagulants following a mitral valve replacement b. An older adult client who has osteoporosis c. A client who has postpartum depression d. A client who has a thrombophlebitis
c. A client who has postpartum depression
A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include? a. Holistic nurses use herbal supplements because they do not cause adverse effects. b. The goal of holistic nursing is to cure a client's illness. c. Holistic nurses empower clients to actively participate in their own care. d. A holistic nurse discourages the use of prescribed medications for clients.
c. Holistic nurses empower clients to actively participate in their own care.
A nurse is discussing responsibility, which of the following actions should the nurse include as an example of responsibility?
checks client to determine if pain meds worked (this action represents responsibility bc nurse identified client need, intervened, and is now determining the outcome of intervention)
A nurse is reviewing the health history of a client during a routine office visit. Which of the following observations by the nurse is an example of the client demonstrating health literacy? - client states they want to improve their current knowledge about their health - client asks for information that will help them improve their eating habits - client states they understand their health care information and treatment - client requests a meeting w/ nurse, physical therapist and provier
client states they understand their health care information and treatment
A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience? - advanced beginner - proficient -competent - novice
competent
A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role? - coordinating & overseeing the care the client is receiving - helping to develop nursing knowledge for clinical interventions - providing knowledgeable & compassionate care to promote health & address illness - instructing the client on specialized topics such as diabetes care
coordinating & overseeing the care the client is receiving
A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching? a. "Homeopathy uses traditional Chinese medicine to treat diseases." b. "Homeopathy uses imagery to promote wellness." c. "Homeopathy uses incantations to treat diseases." d. "Homeopathy believes a substance that can cause a disease can also cure it."
d. "Homeopathy believes a substance that can cause a disease can also cure it."
A nurse is assisting with teaching a class about U.S. Food and Drug Administration (FDA) regulation of nutritional supplements. Which of the following information should the nurse include in the teaching? a. A nutritional supplement can be applied topically. b. If a nutritional supplement contains natural products, it is considered safe. c. The FDA approves nutritional supplements for safety before they are placed on the market. d. A nutritional supplement contains at least one nutritional component.
d. A nutritional supplement contains at least one nutritional component.
A nurse is assisting with an in-service for staff members about culturally competent care. Which of the following information should the nurse include about traditional Native American beliefs? a. There should be a balance between yin and yang. b. Cupping is used to promote wellness. c. Use biofeedback to reduce stress. d. Music can produce healing energy.
d. Music can produce healing energy.
A nurse is caring for a client who is receiving palliative care. Which of the following non-pharmacological nursing interventions should the nurse provide the client? a. Acupuncture b. Acupressure c. Chiropractic therapy d. Therapeutic touch
d. Therapeutic touch
A nurse educator is planning a presentation for nurses about the opioid epidemic. Which of the following is a strategy promoted by the U.S. Department of Health and Human Services to address this epidemic? - continue to evaluate to determine if the use of opioids improves on its own - educate nurses and other health care personnel about naloxone - keep the issue private to avoid embarrassment - reduce efforts to explore alternative pain management practices until the opioid epidemic is over
educate nurses and other health care personnel about naloxone
A nurse is caring for a client who reports experiencing chills ad not well. The nurse informs the client that they will need to have their temp taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research? - evidence based practice - competencies - lifelong learing - change agent
evidence based practice
A nurse is preparing a poster describing leadership styles for a unit in-service. Which of the following terms should the nurse use to describe a nurse manager who exerts little control over the decisions made by the charge nurse?
laissez-faire (Under a laissez-faire style of leadership, nurses are given the freedom to work independently to accomplish goals with little control asserted by the nurse manager.)
A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address the client's questions. Which of the following describes the Healthy People Initiative? - program for health care practitioners to get healthy - social media platform for nurses - set of objectives for improving the health of Americans - rehabilitation program for clients who have substance use disorders
set of objectives for improving the health of Americans
A nurse has accepted a position at a hospital in the state where they live. The nurse should identify that which of the following regulates the nurse's actions when they begin working? - American Nurses Association (ANA) code of ethics for nurses with interpretive statements - state nurse practice act - national student nurses association (NSNA) - national league for nursing
state nurse practice act
A nurse in a long-term care facility took a picture of a client and posted it on the internet. This action by the nurse is an example of which of the following? - serving as an advocate for the client - violating the code of ethics for nurses - participating in the Healthy People 2030 - demonstrating collaboration
violating the code of ethics for nurses