Exam 1 Review

What can't you disclose to a parent about a minor?

Anything related to pregnancy or STDs.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? "Information about a client can be disclosed to family members at any time." "A client's address would be an example of personally identifiable information." "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." "HIPAA is a federal law, not a state law."

"Information about a client can be disclosed to family members at any time."

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

Interpersonal

A nurse is providing teaching to a newly licensed nurse about the purpose of documentation. What should she include in the teaching?

It allows the healthcare team to document and communicate client care

Good Samaritan Law

Provides limited protection to someone who voluntarily chooses to provide first aid

After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedureon assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation? a. Scientific knowledge b. Traditional knowledge c. Authoritative knowledge d. Philosophical knowledge

a. Scientific knowledge

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation? a. safety b. self-actualization c. physiological d. self-esteem

c. physiological

A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education? a. To help the client develop self-care abilities b. To ensure the client will return for follow-up care c. To facilitate complete recovery from the disease d. To implement ordered teaching and counseling

a. To help the client develop self-care abilities

EMTALA

a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay,

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? a. "Documentation is a communication tool for the interprofessional health care team." b. "Documentation provides information to the client about financial charges for care provided." c. "Documentation provides information for a client audit." d. "Documentation allows providers to monitor the nurse's activities."

a. "Documentation is a communication tool for the interprofessional health care team."

A primary health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the primary health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take? a. Contact the nursing supervisor b. Ask the nurse assigned to care for the client to administer the medication c. Verify the prescribed dose with the client before administering the medication d. Continue to transcribe the prescriptio

a. Contact the nursing supervisor

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? a. Performing hand hygiene before, during, and after direct contact with the client. b. Placing the client in a room with positive-pressure airflow. c. Changing the client's bed linens each day. d. Encouraging the client to consume a high-protein diet.

a. Performing hand hygiene before, during, and after direct contact with the client.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the clients death. Which of the following ethical principle should the nurse used to support the decision not to administer the medication? a. fidelity b. utilitarian c. veracity d. nonmaleficence

a. nonmaleficence

A nurse is providing discharge instructions to a client who lives in subsidized housing and is concerned about being able to afford their medications. Which of the following factors should the nurse identify is affecting the client's health? a. socioeconomic factors b. cultural factors c. environmental factors d. health literacy

a. socioeconomic factors

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client?

autonomy

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? a. "The client should be seen by a neurologist." b. "The client was found unconscious on the floor in her home." c. "There are no provider's prescriptions available." d. "The client is disoriented. Pupils are slow to respond to light."

b. "The client was found unconscious on the floor in her home."

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? a. Adjust the water temperature to feel hot. b. Apply 4 to 5 mL of liquid soap to the hands. c. Hold the hands higher than the elbows. d. Rub hands and arms to dry

b. Apply 4 to 5 mL of liquid soap to the hands.

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? a. Implementation b. Assessment c. Planning d. Evaluation

b. Assessment

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? a. Veracity b. Autonomy c. Fidelity d. Justice

b. Autonomy

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification? a. The health care proxy does not go into effect until I am incapable of making decisions b. I have to choose a family member as my health proxy c. I can change who I designate as my health care proxy at any time d. If i become incapacitated, end of life choices will be made by my proxy

b. I have to choose a family member as my health proxy

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain.

b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? a. The AP's ability to prioritize b. The AP has the knowledge and skill to perform the task c. The AP's rapport with clients d. The AP's ability to complete the task without assistance

b. The AP has the knowledge and skill to perform the task

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? a. The client will list foods that are high in calcium, which should be avoided. b. The client will walk for 30 min 5 days a week. c. The client will increase calorie intake by 200 cal per day. d. The client will replace cigarettes with smokeless tobacco products.

b. The client will walk for 30 min 5 days a week.

A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse? a. We could develop a plan for how to talk about this with your partner b. You should try to see your partners point of view before your own c. Relationship difficulties are stressful and require effort to resolve d. Tell me about the concern you have regarding your relationship

b. You should try to see your partners point of view before your own

The following are included in the model of communication except what? a. receiver b. environment c. message d. sender

b. environment

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? a. vital signs b. self-report of pain c. severity of condition d. nonverbal behavior

b. self-report of pain

Planning is a category of nursing behaviors in which: a. The nurse determines the health care needed for the client. b. The Physician determines the plan of care for the client. c. Client-centered goals and expected outcomes are established. d. The client determines the care needed.

c. Client-centered goals and expected outcomes are established.

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? a. Discussing alternate treatment options b. Determining the client's level of understanding about the procedure c. Ensuring the charge nurse is available to witness the client's signature on the consent form d. Explaining the risks involved with the procedure

c. Ensuring the charge nurse is available to witness the client's signature on the consent form

The nurse has misplaced her computer password. She asks if she can borrow yours "just for a moment" to view patient data and promises she will not document anything. Your best course of action is: a. Allow her to use your password, just this once b. Sit with her and assess the data together c. Inform her to contact the IT Department to obtain a new password d. Tell her you're busy and to ask someone else

c. Inform her to contact the IT Department to obtain a new password

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? a. situation b. background c. assessment d. recommendation

c. assessment

A nurse is performing a blood pressure screening for a client who has family history of hypertension. Which of the following concepts is the nurse demonstrating? a. health promotion b. health education c. holistic care d. disease prevention

d. disease prevention

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? a. "There were no injuries sustained." b. "An incident report was completed." c. "An incident report was forwarded to risk management." d. "The provider was notified."

d. "The provider was notified."

A nurse is providing teaching with a nursing colleague about sentinel events. Which of the following statements bythe nursing colleague indicates an understanding? a. administering client medication 30 min late b. documenting vital signs at the wrong time and in the ehr c. the nurse provides a sedative to a client with insomnia d. An example of a sentinel event is administering incompatible blood products to a client.

d. An example of a sentinel event is administering incompatible blood products to a client.

A nurse is discussing types of communication styles with a group of staff nurses. Which of the following information should the nurse include? a. passive communicates clearly and honestly b. assertive communicators use resentment in a secretive way c. passive communicators become hostile when they are challenged d. Assertive communicators are confident in their communications.

d. Assertive communicators are confident in their communications.

A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice. b. Stand directly in front of the client c. Rephrase statements the client does not hear. d. Determine if the client uses hearing aids.

d. Determine if the client uses hearing aids.

When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs

d. Health-related beliefs

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make? a. you know this is not the right time for me to do this b. everyone knows there are others who can chair this committee better than i could c. can you tell me why you chose me? d. I decline the opportunity at this time

d. I decline the opportunity at this time

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of thefollowing tasks should the charge nurse avoid assigning to the volunteer? a. Delivering meal trays to clients in their rooms b. Assisting a client who has difficulty seeing the foods on the tray while eating c. Delivering a routine urine specimen to the laboratory d. Observing a postoperative client who is confused

d. Observing a postoperative client who is confused

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? a. Able to speak the patient's native language b. Possesses some basic knowledge of the patient's cultural background c. Applies the underlying background knowledge of a patient's culture to provide the best possible health care d. Understands and attends to the total context of the patient's situation

d. Understands and attends to the total context of the patient's situation

A Nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include? a. offer approval or disproval b. ask for explanation c. offer sympathy d. asking open ended questions

d. asking open ended questions

A charge nurse is providing an in-service to a group of nurses about self care. Which of the following information should the nurse include in the teaching? a. exercise at least once a week b. get at least 5 hours of sleep every night c. restrict water intake d. bring your own food for lunch

d. bring your own food for lunch

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification? a. chart b. order sheet c. medication administration record d. identification wristband

d. identification wristband

HIPPA

prevents abusive information through healthcare the best way to manage and protect healthcare information applies to all forms of information (written, verbal etc)