PrepU Questions: Week 3-- Safety, Intro to Documentation, Post Mortem Care

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response?

"Advertised remedies that promise a cure may be a scam."

The chief nursing officer (CNO) wants to encourage nurses in the hospital to become clinical nurse leaders (CNL) and is reviewing a roster of nurses working on the medical-surgical unit. Which nurse should the CNO recognize as being qualified to take the CNL examination?

An RN with an MSN who is a nurse manager, has 7 years of nursing experience, is supportive, and is engaged in community service activities (The American Association of Colleges of Nursing requires an RN to have at least a master's degree to be eligible to become a CNL.)

A nurse manager is trying to resolve a conflict between the day and night shifts. The nurse manager wants to convince the involved persons to set aside their differences, determine a priority common goal having to do with improved client care, and accept mutual responsibility for achieving this goal. The nurse manager is using which type of conflict resolution?

Collaborating (Collaborating has all parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal.)

Which is the primary purpose of client records?

Communication

To adequately direct client care and maintain effective decision making, the nurse manager requires knowledge of what?

Economics (A knowledge of economics provides a foundation for effective decision making.)

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter. (The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground.)

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

The nurse provides care for a female client having difficulty urinating after a vaginal hysterectomy. Which strategy(ies) does the nurse use to assist the client with urinary elimination? Select all that apply.

-Turn on the water in the bathroom -Pour warm water over the perineum -Place client in sitting position -Provide a sitz bath

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

-Use filtering software to block objectionable information. -Investigate any public chat rooms used by the children. -Be alert for downloaded files with suffixes that indicate images or pictures.

A female client with a Foley catheter requires perineal care. Which intervention(s) does the nurse use to prevent a health care-acquired infection? Select all that apply.

-Use front-to-back cleaning technique -Turn folded washcloth over to new area each time a section of perineal area is cleaned -Spread labia majora and wipe down the center, working from inner to outer areas -If the catheter is soiled, clean with soap and water using proximal-to-distal technique

An older adult client is reporting dry, itching skin. The nurse should assess:

how often the client is bathing.

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?

"Those are senile lentigines and are common in older adults."

The nurse is getting accustomed to the role of nurse manager. What are requirements for this nursing role? Select all that apply.

-Creating schedules for the unit -Managing the unit's operational budget -Introducing methods to improve staff efficiency -Evaluating the success of the unit policies

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:

Although not written, the nurse must know or question the rationale before performing an action.

The charge nurse on a postoperative surgical unit is responsible for making client assignments for staff nurses. Two staff nurses have voiced not wanting to assume care for any new postoperative surgical clients during their shifts. How can the charge nurse resolve this conflict using the strategy of compromise to address the immediate concerns of the two staff nurses?

Approach both nurses to discuss incentives that can be given for agreeing to accept new postoperative surgical clients.

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code?

Autocratic leadership (Autocratic leadership involves the leader assuming control over the decision and activities of the group. During code blue, a leader is needed to direct the actions needed and make quick decisions to positively affect the client.)

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member. (Getting information from other health care providers violates client privacy.)

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

It provides quick access to abnormal findings. (Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information.)

A nurse manager has asked the staff to create a plan to improve patient outcomes. In the past, the staff have not met deadlines. How can the nurse manager use transactional leadership style to ensure that the deadline is met?

Offer 2 days of paid vacation. (The transactional leadership style involves a task and reward system.)

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions (Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting.)

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

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

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

a referral.

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

pulling the razor against the direction of hair growth

A nurse leader is working with a client with hypertension who needs to learn about a low-sodium diet. The nurse recognizes that the client is in the unfreezing stage of Lewin's Change theory with which client statement?

"I understand why I need to eat a low-sodium diet." (Lewin's Change theory involves three phases, which include unfreezing, moving, and freezing. With the unfreezing stage, the person recognizes the need for change.)

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

-Takes furosemide daily -Admits to drinking wine through the evening -Has history of diabetic neuropathy

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entries follow the recommended guidelines for communicating and documenting client information? Select all that apply.

-The client rates pain as 2 compared to a 7 yesterday. -Vital signs returned to normal. -Radial pulse 72, strong and regular (Focus on objective data)

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first?

Administer a dose of digoxin that is two hours behind schedule. (Digoxin is a critical med.)

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A staff nurse works on a medical unit where staff retention is very high. There is a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which leadership style?

Democratic (The democratic leadership style is characterized by a sense of equality among the leader and other participants and shared decision making.)

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated. (Emollient prevents skin breakdown)

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

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

The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which?

Laissez-faire

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?"

The client will demonstrate safety measures to prevent falls.

A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints?

The client's vital signs must be assessed every hour.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill?

The nurse researches new technological advances in the treatment of cancer. (The QSEN definition specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care.)

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records. (HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures that a health care institution has made for the purposes of treatment, payment, and health care operations.)

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client to avoid that is on the dietary tray?

jelly to go on the toast

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." (Some signs of substance use in adolescents include mood swings, withdrawal from the family, and failing school grades.)

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

-Client-centered care -Teamwork and collaboration -Quality improvement (QI)

The nurse is making the initial assessment of a client following a surgical procedure with sedation. Place in order the nurse's assessment actions. Use all options.

1. airway, breathing, and circulation 2. level of consciousness and orientation 3. intravenous access and IV fluids 4. wounds and tubes 5. items within the client's reach

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids (A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water.)

The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which?

Laissez-faire (With laissez-faire leadership, the leader relinquishes power to the group.)

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to help prevent motor vehicle accidents? Select all that apply.

-Limit the number of other adolescents in the car. -Never text while driving. -Obey the speed limit.

A client is hospitalized with uncontrolled diabetes. Which action(s) does the nurse take to promote circulation and prevent circulatory complications? Select all that apply.

-Inspect the client's feet daily. -Clean the feet daily with warm water and a mild soap. -Cut the toenails straight across and file the edges with an emery board.

The nurse manager notices a trend in nurses routinely arriving to work late. How can the nurse use the transactional leadership style to get nurses to arrive to work on time?

Monitor time clock reports on a monthly basis and enter all nurses who have not been tardy into a raffle for a paid day vacation.

A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate?

"I collaborate with health care teams to promote client care." (A clinical nurse leader is a master's-prepared nurse who has earned the certified CNL credential and works collaboratively with the health care team to facilitate, coordinate, and oversee care provided to clients.)

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction?

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it." (Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. They can document.)

An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.

-"Did you experience dizziness prior to the fall?" -"Can you tell what you were doing before you fell?" -"Did you have pain in your hip prior to the fall?" -"Is it possible you may have tripped over a rug or a cord?"

The nurse is planning hygiene measures for a client admitted with right-sided weakness secondary to a stroke. The client is alert and oriented, has difficulty moving the right side, and has minor difficulty speaking. When creating the plan of care, what nursing interventions would be important to include? Select all that apply.

-Assist the client with bathing to ensure hygiene needs are met. -Assist the client with physical mobility to preserve and promote increased function. -Assess the skin integrity for any potential alterations or breakdown. -Have the client evaluated for swallowing to prevent aspiration.

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.

-Documenting entries that are up to date and comprehensive -Recording the date and time of all entries -Using approved agency abbreviations

A nurse is making an unoccupied bed for a hospitalized client. Which actions are appropriate steps for the nurse to perform? Select all that apply.

-First, adjust the bed to the high position and lower the side rails. -Fold reusable linens on the bed in fourths and hang them over a clean chair. -Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. -Tuck the bottom sheets securely under the head of the mattress to form a corner, according to agency policy.

A nurse manager demonstrates an autocratic leadership style but does not understand why there is high turnover in the unit. What behaviors does the nurse exhibit that negatively impact the unit due to this leadership style? Select all that apply.

-The manager makes decisions without seeking input from staff. -Staff have limited opportunities to express creativity in care delivery.(Autocratic leadership involves the leader assuming control over the decisions and activities of the group.)

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

The nurse is working to enhance time management skills and has to administer pain medications to several patients, obtain vital signs, and assist clients with bathing. What should the nurse do next?

Delegate bathing and vital signs tasks.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

Breaks in skin integrity and fungal nail infection. (Clients with diabetes will be more susceptible to infection from breaks in skin integrity and nail problems. People with diabetes are more susceptible to fungal toenails and foot injury because of poor circulation and lack of feeling)

A nurse manager of a hospital unit is working within a decentralized management structure. Which nursing action best exemplifies this type of system?

Decisions are made by those who are most knowledgeable about the issue. (The best example of a nurse manager of a hospital unit working within a decentralized management structure would be that decisions are made by those who are most knowledgeable about the issue.)

The nurse is planning hygiene care for a client with self-care bathing deficit related to weakness. Which nursing intervention is appropriate?

Encourage the client to wash own face and hands.

A nurse can improve one's skill with time management by taking which action?

Evaluating success with accomplishment of goals in client care (Time management is a skill that can be improved for nurses by taking time during the day to evaluate whether goals have been accomplished and then setting new priorities based on this.)

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client?

Medication that is not administered should be documented along with the reason.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation?

Gently slide the hard lens over the cornea and remove it with gloved fingers.

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

A nurse manager is changing the policy for scheduling staff on a critical care unit. The schedules will be changed and an announcement was made regarding this to the staff. Based on Lewin's change theory, in what stage of change is the manager participating?

Moving (Lewin identified three stages of change in his change theory: Moving is when change is initiated after a careful process of planning. Unfreezing is when the need for change is recognized. Refreezing is when change becomes operational.)

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

Providing a back rub before bed

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

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

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

Rescue anyone who is in immediate danger.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying. (Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms.)

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting. (Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.)

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury. (If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital.)

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. (Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission.)

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state. (How do you know that really is the family member?)

A client's surgical wound dehisced when a nurse removed the staples before a health care provider prescription was given. Following root cause analysis, which organizational response is appropriate? Select all that apply.

The nurse will be found to have committed a human error. Systems around the documentation of prescriptions will be reviewed.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

Those directly involved in the client's care.

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:

hair should be washed as often as necessary.

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

mass trauma terrorism.

A nurse manager reviews an employee's contribution to the nursing division annually. This process is:

performance appraisal.

A nurse is planning to delegate client care to an unlicensed assistive personnel (UAP). The UAP is experienced but has limited exposure to the type of clients who are on the nursing unit. Which client should the nurse recognize as being appropriate to delegate to the UAP?

A client who is admitted for hypovolemic shock one day prior and needs to have urinary output measured. (The client requiring urinary output measure is the most appropriate client for the UAP because no additional training would be required to complete the task.)

The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care?

Better patient outcomes (Magnet® hospitals have better patient outcomes than facilities without the recognition. Magnet® hospitals have higher nurse retention and job satisfaction scores, but these do not have a direct effect on client care. Magnet® hospitals have shorter, not longer, patient stays.)

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents. (Adolescents are prone to injuries related to activities that involve high risk, such as driving.)

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

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

Create an addendum with a correction. (An addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies.)