RN 100 - ATI Weeks 4-7
statements by the nurse describes how culture effects a client's definition of health and illness?
"Health and illness can be defined by individual clients"
A nurse is teaching a group of 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"
A nurse is admitting a client for surgery. Which of the following questions should the nurse ask to determine the client's health literacy level and learning needs?
"How comfortable are you with filling out medical forms by yourself?"
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 directing a code for an unresponsive client"
A nurse is providing teaching to a client who has a recent diagnosis of pancreatic cancer. The nurse is using strategies in the affective domain of learning. Which of the following client statements is part of the affective domain?
"I have been crying a lot since I learned about my diagnosis. I'm worried about everything."
A nurse is teaching a client about hospice care. Which of the following statements by the client indicates an understanding of the teaching?
"I understand that services provided will include just what is needed to keep me comfortable"
A nurse is talking with a client about their electronic health record (HER) at the facility. Which of the following client statements indicates an understanding of EHRs?
"I will be able to track my health records"
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."
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."
A nurse is teaching a client about advance directive. 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"
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?
"Needle-less IV tubing for IV infusion 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 opprotunities"
A nurse is preparing an in-service about HIPPA. Which of the following information should the nurse plan to include?
"Personnel can be terminated for breaching a client's confidentiality"
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"
14. A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American nursing association (ANA) standards for documentations?
"The client vomited 240 mL of clear emesis but denies pain or nausea"
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"
17.A nurse is completing the Minimum Data Set (MDS) assessment for a resident in a skilled- nursing facility. Which of the following information should the nurse include in the assessment? (Select all that apply.)
- Input from members of the client's interdisciplinary team - The client's cognitive status - Each physical therapy visits - The client's need for assistance with ADLs
Documentations End of Module Quiz 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? (Select all that apply)
- MSQ4 - IU - Qhs
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?
- Reduces medical errors - Makes client medical history more easily available - Increase accuracy of coding procedures
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? (Select all that apply)
- The admitting provider - The charge nurse on the unit - The client
A graduate nurse notes that a hospital with Pathway to Excellence® recognition is hiring staff. Which of the following should the nurse expect from this facility? (Select all that apply.)
- The facility has practices in place that lead to a healthy workplace environment - The facility emphasizes shared provenance - The facility emphasizes practices that positively affect a nurse's well-being
A nurse is assisting with the teaching client about remote patient monitoing (RPM) devices. Which of the following information should the nurse? (Select all that apply)
- The transfer of data is accomplished using wireless devices - Clients can participate in their health by using RPM - A clients health rhythm can be transferred using RPM
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
A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record? (SATA)
Allergies, alcohol use, spiritual beliefs
A nurse is caring for a client who asks why they choose 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
A nurse is 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)
An African American adolescent who is pregnant A low-income family A female who is Latina and has type 2 diabetes mellitus
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and reports discomfort and nausea. The nurse notes minimal bowel sounds on auscultation. The nurse should anticipate that the client may have which of the following conditions?
An ileus (Minimal peristalsis, nausea, and mild discomfort are an indication that the client may have developed an ileus)
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?
Apply chlorhexidine and ethanol to the hands
A nurse is assessing a client's health literacy prior to providing education. Which of the following actions should the nurse take? (SATA)
Ask questions regarding the client's health care needs and concerns is correct. The nurse should assess the client's health literacy by asking questions, obtaining a health history, and obtaining information regarding previous health literacy skills. Obtain a health history is correct. The nurse should assess the client's health literacy by asking questions, obtaining a health history, and obtaining information regarding previous health literacy skills. Assess the client's education level is correct. The nurse should assess the client's health literacy by asking questions, obtaining a health history, and obtaining information regarding previous health literacy skills.
A nurse is providing teaching about performing blood glucose checks to a client who has a new diagnosis of diabetes mellitus. Which of the following actions indicates the nurse is usimg the affective domain for learning?
Ask the client how they feel about checking their blood glucose levels
A nurse is providing teaching to a client who has a new prescription for eye drops. Which of the following teaching strategies is an example of using the psychomotor domain of learning?
Ask the client to teach-back about how to use the medication
A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan? (SATA)
Ask the client what interventions they prefer, determine how the client has responded to analgesics in the past, include nonpharmacological methods to reduce pain
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
A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia?
Aspiration
A nurse is assisting a postsurgical client who has had previous trouble swallowing prepare for a meal. Which of the following actions should the nurse take?
Assist client to sit upright to eat
A nurse is preparing for a teaching session with a client. Which of the following actions should the nurse take to provide the client with unbiased care? (SATA)
Avoid assumptions about the client is correct. Making assumptions about clients indicates biased care and can add previous thoughts, feelings, or experiences into the nursing care. Control personal thoughts about the client is correct. Controlling personal feelings about clients reduces the risk for personal bias. Collaborate with another nurse to develop teaching strategies is correct. Identifying self-bias (personal perceptions or stereotypes regarding situations, people, or actions) allows nurses to collaborate with the client and other nurses to develop teaching strategies and educational materials that best meet clients' needs.
A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (SATA)
Blood transfusion incompatibility is correct. The nurse should identify that a blood transfusion incompatibility is a hospital-acquired injury that can occur to a client while in the hospital. Wrong site surgery is correct. The nurse should identify that a wrong site surgery is a hospital-acquired injury that can occur to a client while in the hospital. Ineffective insulin usage is correct. The nurse should identify that ineffective insulin usage is a hospital-acquired injury that can occur to a client while in the hospital.
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
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?
Centers for Disease Control (CDC)
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 identity this system as which of the following documentation methods?
Charting by exception
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)
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (SATA)
Clients full name, Date of birth and telephone number
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 participating in a question-and-answer session with a client. Which of the following domains of learning uses this type of client education?
Cognitive domain
A 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
1. 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
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?
Coordinate fold care treatments with modern medical treatments
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?
Droplet
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?
Droplet (The nurse should include in the teaching that pertussis is transmitted through large droplets in the air from coughing or sneezing. The client should be placed in a private room. The nurse should wear a surgical mask when providing care for clients who are on droplet precautions)
A nurse is caring for a client who reports that they have recently lost their job and do not have insurance coverage. Which of the following social determinants of health is challenging for this client?
Economic stability
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety?
Edges of stairs are marked with brightly colored tape
A nurse is planning a teaching session for a client. Place the steps in order of the teaching process in the correct order.
Elements of an effective teaching plan are much like the elements of the nursing process: assessment, analysis, planning, implementation, and evaluation.
A nurse in a provider's office is speaking with a client about a Press Ganey survey. The nurse should inform the client that this survey will be conducted by which of the following methods?
A nurse helping to develop an in service about culture 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?
Emic Knowledge
A nurse is reviewing information about client's education with a newly licensed nurse. Which of the following information should the nurse include as the focus of client education?
Empowering clients to be accountable for self-care
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
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 to for further treatment?
Long-term care hospital (LTCH)
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.
A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following indicates the medication can be taken as needed?
PRN
A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk?
Parkinsons disease
A nurse is caring for a newly admitted client. Which of the following actions should the nurse take first?
Perform a cultural health assessment
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a health-associated infection?
Perform hand hygiene
A nurse is assessing a postoperative client prior to a teaching session. The nurse notes that the client is grimacing and restless. Which of the following barriers to learning is the client exhibiting?
Physical discomfort
A nurse is caring for a client who is on contact precaution. Which of the following actions should the nurse take?
Place the client in a private room
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (SATA)
Place the client on round-the-clock surveillance is correct. The nurse should place the client on round-the-clock surveillance to reduce the risk of client injury. Remove objects from the room that the client could use to harm themselves is correct. The nurse should remove any objects in the client's room that the client could use to harm themselves to reduce the risk of client injury. Search items brought into the client's room by visitors is correct. The nurse should search and remove any items brought into the client's room by visitors that the client could use to harm themselves to reduce the risk of client injury. Screen the client for suicidal ideation is correct. The nurse should screen the client for suicidal ideation using a validated screening tool to assess the client and provide interventions to protect the client from injury.
A community health nurse is teaching a newly licensed nurse about social determinants of health. Which of the following should the newly licensed nurse identify as a physical determinant of 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 assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include?
Preoperative teaching can reduce the length of the clients hospital stay.
A nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication?
Prescribed anticholinergics (causes delirium)
A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?
Remove the restraints with each vital sign check in
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?
Report needlestick injuries to the nursing supervisor.
A nurse is assisting in planning postoperative care for a client who is scheduled for surgery. Which of the following interventions should the nurse include in the plan?
Reposition the client every hour.
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 procedures (P&P) manual
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
A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take?
Rinse the client's skin with water
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 what the nurse should include?
Saves time
A nurse is preparing a client for surgery and needs to scrub the surgical site. Identify the sequence the nurse should follow.
Scrub the surgical site in a circular fashion with an antiseptic is the first step. The nurse should first scrub the surgical site in a circular fashion with an antiseptic. Start at the center and move to the area away from the site is the second step. When scrubbing, the nurse should start at the center and move to the area away from the site. Scrub the outer edge and discard the sponge is the third step. Once the nurse reaches the outer edge, the sponge is considered to be contaminated and the nurse must discard it. Repeat with a new sponge is the fourth step. Next, the nurse repeats the scrubbing process with a new sponge. Drape the client is the fifth step. After scrubbing the site, the nurse should drape the client.
A nurse is caring for a client who is scheduled for surgery and is at risk for postoperative venous thromboembolism (VTE). Which of the following prescriptions should the nurse anticipate to reduce the risk of VTE?
Sequential compression devices
A nurse is discussing the time-out procedure with a newly licensed nurse. The nurse should include that a time-out is performed at which of the following times?
Several times throughout the procedure
A nurse is performing hand hygiene after caring for a client who has Clostridium Difficile. Which of the following hand hygiene methods should the nurse use?
Soap and water
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medications entries should the nurse identify as being written correctly?
Synthroid 100 mg PO every morning ac
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
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
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
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 "S" in SOAP
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.
A nurse is planning care for a client who is a veteran. Which of the following information should the nurse consider?
The client is at an increased risk for poor health outcomes
A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should the nurse's priority concern?
The client takes medications that cause dizziness.
A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) - tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR?
The client's laboratory test results
A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (SATA)
The date medication was mixed, dose of the mixed medication, time the medication was mixed
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?
The door to the AIIR should remain closed
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 ids the provider violating?
The emergency Medical Treatment and Labor Act (EMTALA)
A nurse is discussing the history of electronic health records (EHRs) during a staff in service. The nurse should identify which of the following agencies advocated for nationwide use of EHRs?
The institute of Medicine
A nurse is assisting with a teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?
The nurse holds onto the plug to unplug a client's electronic blood pressure machine.
17.A nurse is taking an admission history from a client who us concerned about the facility using electronic documentation system. Which of 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
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 assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTI). Which of the following interventions should the nurse include in the bundle?
Try using alternatives before indwelling urinary catheters
A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing? (SATA)
Type 2 diabetes mellitis, current smoker, corticosteroid use, 68 years old
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Use a certified medical interpreter
A nurse is preparing for a teaching session with a client who has pernicious anemia. Which of the following should the nurse identify as part of the implementation step of the teaching process?
Use demonstration to teach the client about vitamin B12 injections
A nurse is planning to implement the Transforming Care at the Bedside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan?
Use standardized communication tool
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 ethnical principals?
Veracity
A nurse is reinforcing reaching with a newly licensed nurse about informed consent. The nurse should include that which of the following is the nurses responsibility when obtaining informed consent from a client? (SATA)
Verify the client has signed the consent, check that the client is of legal age to provide consent, confirm the client is competent
A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?
"CPOE systems can increase the speed of care delivery"
A nurse is orienting a newly licensed nurse to the unit. Which of the following statements by the newly licensed nurse indicates an understanding of the importance of documentation of client education?
"Client documentation can increase staffing and services"
A nurse is reviewing the use of electronic documentation which a newly licensed nurse. Which of the following statements should the nurse take?
"Electronic documentation provides evidence of care provided"
A nurse is speaking with a client who is noncompliant 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?"
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? (Select all that apply.)
- Access to foods that support healthy eating patterns - Crime and violence - Environmental conditions
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? (Select all that apply.)
- Advanced practice registered nurse (APRN) - Physician assistant (PA) - Physician
A nurse is reviewing a report by the Institute of Medicine (IM). Which of the following competencies should the nurse identify health care professionals need in order to reduce errors? (Select all that apply.)
- Cooperation - Communication - Coordination
A nurse is caring for a client who has Parkinson's disease and needs assistance with ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe? (Select all that apply.)
- Dietician - Physical therapist - Occupational therapist
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 the nurse include? (Select all that apply.)
- Initiatives to reduce health care disparities - Activities to improve social determinants of health - Improving access to health care
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 - Nutritional supplements the client takes - Over-the-counter medications the client uses
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 - Improves practice efficiencies - Is capable of being overridden by a nurse - Improves clinical outcomes
A nurse is assisting with teaching a class about HIPPA. Which of the following information should the nurse include? (select all that apply)
-HIPPA protects the unauthorized release of a clients protected health information - The loss of a providers cell phone that contains a clients protected health info is considered a data breach - A breach in HIPPA should be reported within 60 days after the breach is discovered
A nurse educator is planning an in-service for staff nurses about psychomotor client teaching strategies. Which of the following activities requires the use of gross motor skills? (SATA)
A client walking with crutches and using a manual wheelchair
A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (SATA)
A client's visitor falls in the hallway, a client develops an unexpected reaction to a medication, a clients dentures are lost
A nurse is teaching a client about the Affordable Care Act (ACA). Which of the following information should the nurse include?
A focus of the ACA is disease prevention
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
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
A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include?
A nurse who delegates a task to an AP will review the charting for that task
A nurse is discussing problem-oriented medical record with a group of newly licensed nurses. Which of the following information should the nurse include?
A problem-oriented medical record promotes information sharing among members of the interdisciplinary team
A nurse is caring for a client who is postoperative following a femur fracture repair. The client suddenly reports chest pain and is experiencing shortness of breath. Which of the following conditions should the nurse suspect?
A pulmonary embolism
A nurse in an emergency department is caring for four clients. Which of the following requires mandatory reporting?
A young adult client who is positive for tuberculosis
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next?
Activate the alarm.
A nurse in a clinic is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Which of the following care facilities should the nurse anticipate the client be admitted to?
Acute care hospital
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 phase?
Administering
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)
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?
After changing a dressing on a client and before documenting findings on a computer.
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?
Airborne
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?
Airborne
A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign blood product refusal form is an example of the following ethical principles.
Autonomy
11. A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?
Bacteria
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)
Being Bullied Depression Using illicit drugs
A nurse is caring for a client who's 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
A nurse is caring for a client who is preoperative and reports a history of regular tobacco use. The nurse should identify that the client is at the greatest risk for which of the following postoperative complications?
Blood clots
A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding?
Blood pressure 88/60 mm Hg
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?
C-reactive protein
Surgical attire for the surgical suite consists of which of the following items? (SATA)
Cap, Shoe covers, gown, mask and gloves
A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare associated infections (HAI's). Which of the following infections should the nurse include?
Catheter associated urinary tract infection, central line associated bloodstream infection, surgical site infection
Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use?
Certified surgical technologist
A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching?
Client education can improve self-care at home
A nurse is preparing to educate a client about the proper procedure for a dressing change. Which of the following indicates an understanding of Knowle's fundamental principles of client readiness?
Client is engaged and alert
A nurse is assessing the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound? (SATA)
Client states the wound is painful, edges of the wound is red, client has a fever
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?
Conduct a self-assessment
A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?
Contact
A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement?
Contact
A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?
Convalescence
A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (SATA)
Cooking oil, oxygen, heat
A nurse is reviewing info about culture w/ 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?
Culture can include language and communication
A nurse is evaluating a clients plan of care. The desired outcome of having the client sit on the side of the bed by the end of the shift was not met. Which of the following actions should the nurse take?
Determine if different nursing interventions are required
A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Which of the following actions should the nurse take during client education?
Direct the education to the caregivers as well as the client
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 standards of care.
Document that the medication was not administered
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
The nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP), which of the following information should the nurse include?
Facilities can establish their own rules for documentation methods
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (SATA)
Fall history, medical diagnosis, use of assistive devices, mental status
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 actions?
Falsification of records
A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include?
Frequent reports of not being treated fairly
A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?
Gloves
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?
Gloves should be removed from the inside out.
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 the accident?
Good Smartian laws
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
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?
Health Disparities
A nurse is providing privacy for a client who has incontinence, the nurse is demonstrating which of the following professional values?
Human dignity
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
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
A nurse is revewing the goals of client education with a newly licensed nurse. Which of the following information should the nurse include? (SATA)
Improvement of health is correct. One of the goals of client education is to improve or maintain the client's health status. Provide knowledge about an illness or injury is correct. One of the goals of client education is to provide the client with knowledge about their illness or injury. Health promotion is correct. Nurses educate clients on medications, medical and health treatments, health conditions, health promotion, and prevention strategies.
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 error
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 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?
Inquire about any special cultural beliefs or practices
A nurse is planning care for a client who has distended bladder and has not voided 8 hr after surgery. Which of the following interventions should the nurse plan to take?
Insert a straight urinary catheter into the client
A nurse is preparing to use a video-enable 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
A nurse is providing equal care to a group of clients who have varying economic statues. Which of the following ethical principles is the nurse demonstrating?
Justice
A nurse conducting a cultural assessment which of the following factors are incorporated in Leininger's sunrise enable (select all that apply)
Kindship and social factors Biological factors Economic factors Political and legal factors
A nurse is teaching a client about how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach-back method of learning?
Let me show you how I will take my blood pressure at home each day.
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (SATA)
Locks the brakes on the client's bed, checks maximum weight of the lift before using it, performs a safety check before lifting the client
A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority?
Monitor the clients oxygen saturation
A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events?
Near-miss event
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 discussing the nurses role in client education with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of a nurses role?
Nurses make up the greatest percentage of members on a health care team.
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.
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?
Open the first flap on the sterile package away from their body
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hours. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?
Prodromal (The prodromal stage is the second stage of infection. In this stage, the client begins having vague, nonspecific manifestations, such as fever, chills, headache, and malaise, as the infectious agent replicates. The incubation stage is the first stage of infection in which the client might not feel sick yet or have visible manifestations. The convalescent stage is the last stage of infection in which the client returns to a previous or a new, stabilized state of health. In the acute illness stage of infection, manifestations of a specific infectious disease process are obvious and most severe)
A nurse is discussing hospice care with a newly licensed nurse. Which of the following should the nurse identify as 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 planning a 30 min group education class. Which of the following actions should the nurse plan to take to address various learning styles related to the domains of learning?
Provide games, discussion, and question and answer.
A nurse is planning a smoking cessation program for a client. Which of the following actions is a component of SMART outcome goals?
Providing a time frame to accomplish the outcome
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?
Rebound tenderness noted in RLQ of the abdomen
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
Record the time and length of the seizure
A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following findings is a manifestation of an infection?
Redness around the incision site
A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing?
Regional
A nurse is teaching a newly licensed nurse about Medicare reimbursement. Which of the following should the nurse include in the teaching?
Reimbursement amounts will be adjusted for clients who contract hospital-acquired conditioned (HAC)
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?
Remove nail polish on your fingernails if it is chipped.
A nurse is providing teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Request medical interpreter to be present
A nurse is caring for a client who acquired an infection after touching a facuet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?
Reservoir
A home health nurse is caring for a client who is receiving hospice care. The client's partner reports feeling overwhelmed from caring for the client. Which of the following types of facilities should the nurse recommend?
Respite care
A nurse is reviewing information to enhance their own cultural awareness. The nurse should identify the need to examine which of the following?
Self-bias
A nurse is preparing a low stimulus environment for an educational session on smoking cessation. Which of the following should the nurse implement?
Set the thermostat to a comfortable temperature
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of following links in the chain of infection?
Susceptible host
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?
Swab the back of the clients pharyngeal wall
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 teaching a newly licensed nurse about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include?
The HCAHPS is issued to measure client satisfaction with the health care service.
A nurse is interviewing a client who states that they are transgender. Their records indicate they were assigned male at birth. Which of the following information should the nurse plan to incorporate when assisting with the clients plan of care?
The client associates their identity to something different from their sex assigned at birth
A nurse is using a question-and-answer session to teach a client about a diabetic diet. Which of the following outcomes is an example of cognitive learning?
The client understands a diabetic meal plan
A nurse is reviewing a clients plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome?
Timed
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Turns off the faucet with a towel
