ATI Nurse Logic 2.0 ~ Nursing Concepts (Beginner Test)

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? A. Including in a client's nurses' note that an incident report was completed after a medication error B. Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature C. Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet D. Documenting the provider was contacted to clarify a questionable prescription

A. Including in a client's nurses' note that an incident report was completed after a medication error Rationale: A. The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record. B. The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is an appropriate action and does not require intervention from the nurse preceptor. The nurse should draw a horizontal line through blank spaces in the nurses' notes to prevent incorrect information being added by another individual. C. The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is an appropriate action and does not require intervention from the nurse preceptor. The nurse should not chart vital signs taken by another nurse. The vital signs might not be accurate and the nurse is accountable for the information she documents. D. The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is an appropriate action and does not require intervention from the nurse preceptor. The nurse should document when a provider is contacted to clarify a questionable prescription because the nurse is legally responsible, and liable, for carrying out the prescription.

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? A. Lithotomy B. Dorsal recumbent C. Prone D. lateral recumbent

A. Lithotomy Rationale: A. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is the appropriate position for the nurse to place the client. The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment. B. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is not the appropriate position for the nurse to place the client. The dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck, lungs, breasts, axillae, heart, and abdomen. C. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is not the appropriate position for the nurse to place the client. The prone position is used to assess hip joint extension, skin, and buttocks. D. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is not the appropriate position for the nurse to place the client. The lateral recumbent position is used to detect heart murmurs when assessing the heart.

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid and ethambutol. Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? A. Loss of color discrimination B. Nausea and vomiting C. Red-orange discoloration to body fluids D. Edema of feet and hands

A. Loss of color discrimination Rationale: A. The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops. B. The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. Ethambutol is well absorbed from the GI tract in either the presence or absence of food. Adverse GI effects are not common. C. The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. This side effect is not reported in relation to ethambutol therapy. D. The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. Edema of the feet and hands is not an adverse effect of ethambutol therapy.

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following healthcare professionals should attend the client's next interdisciplinary team meeting to address this complication? A. Speech pathologist B. Occupational therapist C. Social worker D. Respiratory therapist

A. Speech pathologist Rationale: A. The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident. B. The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. An occupational therapist works with clients who have limited functional abilities to develop skills that are necessary to complete activities of daily living. The occupational therapist should not attend the next interdisciplinary team meeting to address difficulty swallowing in a client who has had a cerebrovascular accident. C. The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A social worker offers education and counseling to clients and families to provide links to community resources, plan for discharge, or resolve conflict. A social worker should not attend the next interdisciplinary team meeting to address difficulty swallowing in a client who has had a cerebrovascular accident. D. The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A respiratory therapist provides specialized therapy to clients who have respiratory difficulties, such as oxygen therapy, inhalation therapy, administering pulmonary function tests, collection of sputum specimens, and collection of arterial and venous blood specimens. A respiratory therapist should not attend the next interdisciplinary team meeting to address difficulty swallowing in a client who has had a cerebrovascular accident.

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? A. States that pain is an 8 on a scale of 0 to 10 B. States that her partner should be given the information C. Expresses concern about the exercises causing pain when performed after surgery D. Expresses uncertainty about the benefits of the exercises

A. States that pain is an 8 on a scale of 0 to 10 Rationale: A. The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education. B. The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client believes that learning how to deep breathe and cough is the responsibility of her partner should indicate to the nurse that additional teaching is needed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. C. The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications and can be uncomfortable. The fact that the client is expressing concern about the exercises causing pain when performed after surgery should indicate to the nurse the need for additional explanation, such as mechanisms that will be used to control the pain. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. D. The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client is expressing uncertainty about the benefits of the exercises should indicate to the nurse that reinforcing the importance of the exercises, and a description of possible negative outcomes, should be discussed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching.

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? A. Justice B. Autonomy C. Veracity D. Fidelity

B. Autonomy Rationale: A. The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Justice is the use of fairness, which is not the ethical principle the nurse is illustrating by making the referral as requested. Examples of justice in nursing practice includes advocating for fair distribution of resources or providing all clients with the same level of care regardless of his or her level of health benefits. B. The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustrating by making the referral as requested. C. The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Veracity is the act of truth-telling. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of veracity in nursing practice includes telling a client of his terminal diagnosis when he asks, even if it goes against the wishes of the family. D. The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Fidelity is the act of keeping promises. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of fidelity includes following through on a promise to return with pain medication in a specified period of time.

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? A. Inform the nurse manager. B. Determine the client's condition. C. Notify the provider. D. Complete an incident report.

B. Determine the client's condition. Rationale: A. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is not the first action the nurse should take when discovering a medication error. While informing the nurse manager is important, there is another action that better ensures the safety of the client. B. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care. C. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is not the first action the nurse should take when discovering a medication error. While notifying the provider is important, there is another action that better ensures the safety of the client. D. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is not the first action the nurse should take when discovering a medication error. While creating an incident report is important and should typically occur within 24 hr of the incident, there is another action that better ensures the safety of the client.

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? A. Blood glucose 150 mg/dL B. Potassium 2.5 mEq/L C. Total protein 5.2 g/dL D. Urine specific gravity 1.040

B. Potassium 2.5 mEq/L Rationale: A. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding does not require immediate intervention. While this blood glucose level is above the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. B. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time. C. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding does not require immediate intervention. While this total protein level is below the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. D. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding does not require immediate intervention. While this urine specific gravity is above the expected reference range, it will not cause life-threatening complications. A natural mechanism of the body is to conserve urine when fluids are being lost in other places. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.

A nurse on a coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? A. "I know this must be frightening, but you are going to be fine." B. ​"Let's talk for a minute about your concerns." C. "You were transferred because it is in your best interest." D. "Why do you feel a family member should be with you?"

B. ​"Let's talk for a minute about your concerns." Rationale: A. The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "I know this must be frightening, but you are going to be fine" is not an appropriate response by the nurse. Offering false reassurance avoids the client's concerns and discourages expression of feelings, which does not establish an environment of open communication. B. ​The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Let's talk for a minute about your concerns" is an appropriate response by the nurse. Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication. C. The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "You were transferred because it is in your best interest" is not an appropriate response by the nurse. Becoming defensive ignores the needs of the client, which does not establish an environment of open communication. D. The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Why do you feel a family member should be with you?" is not an appropriate response. Asking the client to explain the reasons for her concerns can result in mistrust and resentment, which does not establish an environment of open communication.

A nurse is reinforcing teaching about transdermal nitroglycerin to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? A. "I should leave the patch on for 16 to 20 hours each day." B. "I will apply a new patch in the same location each day." C. "The patch should be effective within an hour of being applied." D. "The medication is not absorbed as well when placed on the abdomen."

C. "The patch should be effective within an hour of being applied." Rationale: A. The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is untrue and does not indicate teaching has been effective. The client should only wear the patch for 12 to 14 hr each day for the medication to remain effective and prevent the development of tolerance. B. The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is untrue and does not indicate teaching has been effective. The patch should be applied to a new location each day to prevent development of local irritation. C. The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed. D. The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is untrue and does not indicate teaching has been effective. Adequate results are attained when the patch is applied to the chest, back, abdomen, or anterior thigh.

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? A. Placement of computer systems in restricted areas B. Installation of firewall software on each computer C. Ability of staff to access electronic health records of clients throughout the facility D. Occurrence of an automatic log-off after a period of inactivity

C. Ability of staff to access electronic health records of clients throughout the facility Rationale: A. The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is appropriate and should not result in a violation of client confidentiality. Placing computers in restricted areas is a physical security measure that will prevent unauthorized access to clients' electronic health records. B. The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is appropriate and should not result in a violation of client confidentiality. Installing firewall software on each computer is both a logical and physical restriction that protects client information from outside hackers, network damage, and theft or misuse. C. The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality. The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works. D. The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is appropriate and should not result in a violation of client confidentiality. An automatic log-off is a logical restriction that prevents an unauthorized person from viewing confidential client information in the event an assigned caregiver did not log-off properly.

A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? A. Mammogram every year to detect breast cancer B. Colonoscopy every 10 years to detect colon cancer C. Dermatologist evaluation every 3 years to detect skin cancer D. Complete eye examination every year to detect eye disorders

C. Dermatologist evaluation every 3 years to detect skin cancer Rationale: A. The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A mammogram every year is not an appropriate screening to recommend to a 35-year-old client. Women ages 40 or older should have annual mammograms. B. The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A colonoscopy every 10 years is not an appropriate screening to recommend to a 35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10 years. C. The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations. D. The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A complete eye examination every year is not an appropriate screening to recommend to a 35-year-old client. Clients ages 40 or below should have a complete eye examination every 3 to 5 years. Clients between the ages of 40 and 64 should have a complete eye examination every 2 years, and clients older than 65 should have a complete eye examination annually.

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? A. Painful swallowing B. Hoarse voice C. Difficulty breathing D. Blood-tinged sputum

C. Difficulty breathing Rationale: A. The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure. When the reflex returns, the client may experience some discomfort and difficulty when swallowing. B. The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea. C. The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication. D. The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding may require intervention if it doesn't resolve within a specified time frame; however, it does not require immediate intervention. Blood-tinged mucus and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted.

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? A. Medications will eliminate HIV in most clients. B. Adolescents are at a lower risk for developing HIV. C. Initial HIV symptoms are often similar to the flu. D. Using condoms ensures the prevention of HIV during sexual intercourse.

C. Initial HIV symptoms are often similar to the flu. Rationale: A. The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is not appropriate for the nurse to include. Medications can reduce the HIV viral load, and possibly delay the development of AIDS, but medications do not eliminate HIV. B. The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is not appropriate for the nurse to include. Adolescents are currently one of the fastest growing populations of clients with newly acquired HIV infections. C. The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include. HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client become symptomatic and has a severely compromised immune system. D. The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is not appropriate for the nurse to include. The use of a condom reduces the risk of contracting HIV, but does not ensure prevention. Condoms can break or leak, and just as they are not foolproof at preventing pregnancy, they are not 100% effective in preventing the spread of HIV.

A nurse is caring for a client who has nausea and a prescription for promethazine 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? A. Use a filter needle to administer the promethazine. B. Expel air bubbles back into the ampule. C. Set the ampule on a flat surface to withdraw the promethazine. D. Break the ampule toward the body.

C. Set the ampule on a flat surface to withdraw the promethazine. Rationale: A. The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is not appropriate. A filter needle should be used to withdraw the medication from the ampule, but should be replaced with a regular needle before administering the medication to the client. B. The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is not appropriate. Expelling air bubbles back into the ampule creates pressure in the ampule, which forces the medication out, wasting it. Air bubbles should be expelled by removing the needle from the ampule and tapping the side of the syringe, then pulling back on the plunger, and finally pushing the plunger up gently to remove the air. C. The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is appropriate. To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle. D. The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is not appropriate. The ampule should be broken away from the body to prevent injury from the shattering glass.

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in the discussion with the client? A. Acupuncture is loosely regulated by the federal government. B. Acupuncture has been discredited by scientific research. C. Acupuncture is thought to be effective only as a placebo. D. Acupuncture has been proven to reduce pain and increase function.

D. Acupuncture has been proven to reduce pain and increase function. Rationale: A. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should not include this information in discussions with the client. The practice of acupuncture is regulated at the state level. In some states there is no regulation at all, and in others licensure and advanced educational training is required. The nurse should know what the laws are in the state he or she practices in order to best act as a client advocate. B. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should not include this information in discussions with the client. Research shows that acupuncture can be effective for pain relief. C. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should not include this information in discussions with the client. Research shows that acupuncture can be very effective for pain relief. D. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain. " Upon review of scientific evidence, the nurse should inform the client of which of the following? A. Celecoxib is contraindicated in clients taking valproic acid. B. Celecoxib is contraindicated in older adults. C. Celecoxib is contraindicated in clients with a seizure disorder. D. Celecoxib is contraindicated in clients with an allergy to sulfonamide.

D. Celecoxib is contraindicated in clients with an allergy to sulfonamide. Rationale: A. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib is not contraindicated for clients who are taking valproic acid. B. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib is not contraindicated for older adults. C. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Seizures are neither a side effect of nor a contraindication of celecoxib. D. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? A. Self-reporting the ability to perform the procedure B. Answering appropriately when questioned orally C. Responding accurately on a written examination D. Demonstrating independent performance of the procedure

D. Demonstrating independent performance of the procedure Rationale: A. The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is not the best indicator of teaching effectiveness. Self-reporting and self-monitoring are effective evaluation tools for cognitive learning, which is the process of acquiring, comprehending, applying, analyzing, synthesizing, and evaluating new knowledge. Self-reporting is often used as a method of evaluation during follow-up phone calls or home visits with the client. B. The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is not the best indicator of teaching effectiveness. Answering oral questions is an effective evaluation tools for cognitive learning, which is the process of acquiring, comprehending, applying, analyzing, synthesizing, and evaluating new knowledge. Oral questioning can be accomplished by asking the client to respond verbally to questions or to restate information. C. The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is not the best indicator of teaching effectiveness. Written measurements, such as tests, are effective evaluation tools for cognitive learning, which is the process of acquiring, comprehending, applying, analyzing, synthesizing, and evaluating new knowledge. Prior to using this method of evaluation, the nurse should determine the client's literacy level. D. The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is the best indicator of teaching effectiveness. Return demonstration is the best evaluation tool for psychomotor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? A. Raising her voice level when speaking to the client B. Asking the client open-ended questions C. Clarifying client statements with the family as needed D. Having the client use eye blinks to indicate yes or no

D. Having the client use eye blinks to indicate yes or no Rationale: A. The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Raising her voice level is not an appropriate action by the nurse when communicating with a client who has aphasia. A client who has aphasia has difficulty producing or understanding language, which has no impact on his ability to hear. B. The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Asking open-ended questions is not an appropriate action by the nurse when communicating with a client who has aphasia. A client who has aphasia has difficulty producing or understanding language and should be asked simple yes or no questions. C. The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Clarifying client statements with the family is not an appropriate action by the nurse when communicating with a client who has aphasia. The nurse should inform the client if she did not understand his statement or comment instead of asking the family to clarify. D. The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? A. Support the client's relationship with his caregivers. B. Encourage the client to express his feelings. C. Determine who is responsible for the abuse. D. Protect the client from further abuse.

D. Protect the client from further abuse. Rationale: A. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. While it can be necessary to support the client's relationship with his caregivers, this is not the nurse's priority goal. There is a more immediate need of the client that should be addressed first. B. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. While it is important to encourage the client to express his feelings, this is not the nurse's priority goal. There is a more immediate need of the client that should be addressed first. C. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. While it can be necessary to assist in determining who is responsible for the abuse, this is not the nurse's priority goal. There is a more immediate need of the client that should be addressed first. D. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.