Exam One Quiz

The nurse is performing vital signs for several clients. When assessing body temperature, what should the nurse take into consideration? Select all that apply. - Temperatures should be taken orally in infants. - Obtaining temperatures should only be performed by an RN - Temporal artery thermometer readings may be affected by perspiration or air blowing over the face. - An oral temperature may be taken if the client has oxygen by nasal cannula. - Tympanic temperature readings closely reflect core body temperature.

- Temporal artery thermometer readings may be affected by perspiration or air blowing over the face. - An oral temperature may be taken if the client has oxygen by nasal cannula. - Tympanic temperature readings closely reflect core body temperature.

The Quality and Safety Education for Nurses (QSEN) initiative has identified which key competencies for nurses? Select all that apply. -Client-centered care -Teamwork and collaboration -Evidence-based practice -Quality improvement -Correct documentation

-Client-centered care -Teamwork and collaboration -Evidence-based practice -Quality improvement

The nurse obtains a client's weight as part of the health history. The client weighs 186 lb. The nurse determines that this client weighs how many kilograms?

84.5 kg

In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual? A) Family members B) Peers C) Clergy D) Teachers and coaches

A) Family members

Which of the following is a tenet of Maslow's basic human needs hierarchy? A) People have many needs and should strive to meet them simultaneously. B) Certain needs are more basic than others and must be met first. C) A need that is unmet prompts a person to seek a higher level of wellness. D) A person feels ambivalence when a need is successfully met.

B) Certain needs are more basic than others and must be met first.

The daughter of an older adult calls the nurse practitioner to report that her mother is becoming very confused after dark. What is this type of confusion named? A) Night-time confusion B) Sundowning syndrome C) Alzheimer's disease D) Cognitive dysfunction

B) Sundowning syndrome

The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply. - "I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn." - "I can be charged with negligence if I notify the heath care practitioner about a change in a client's status, but do not follow up or document. - "I can be charged with negligence if I am following the standards of care for my specialty, which is ambulatory nursing." - "I can be charged with negligence if I follow the policy for administering insulin and the client has a reaction to it." - "When I am using a new piece of equipment for the first time, I must make sure I know how to properly operate it."

- "I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn." - "I can be charged with negligence if I notify the heath care practitioner about a change in a client's status, but do not follow up or document.

Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice? Select all that apply. - A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). - A nurse forgets to put the side rails up on a crib and the toddler falls out. - A nurse does not report a change in client condition in a timely manner. - A nurse seeks employment in a hospital after falsifying credentials on a resume. - A nurse threatens to hit an older client who has dementia and is screaming. - A nurse places a client who is a fall risk in restraints without an order from the health care provider.

- A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). - A nurse seeks employment in a hospital after falsifying credentials on a resume. - A nurse threatens to hit an older client who has dementia and is screaming. - A nurse places a client who is a fall risk in restraints without an order from the health care provider.

The student nurse is practicing communication skills by talking with several different clients in the hospital. In which instances would silence be appropriate? - After asking the client a question - Allowing the client time to reflect on his thoughts - When the nurse doesn't know the answer to a question - Reflecting on the communication that has occurred - When the client is upset and needs time to compose himself

- After asking the client a question - Allowing the client time to reflect on his thoughts - Reflecting on the communication that has occurred - When the client is upset and needs time to compose himself

The evening nurse received a change-of-shift report from the day nurse. The day nurses' report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F. A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability? Select all that apply. - Breach of duty has occurred. - Duty has not occurred since the evening nurse just started the shift. - The spouse was notified of the change in condition. - The facility will have to fire the nurse for malpractice. - The facility will settle the case.

- Breach of duty has occurred.

The nurse is caring for several client's on a telemetry unit. Which clients' pulse rates need to be assessed for 1 full minute? Select all that apply. - Clients with fast pulse rates - Clients recovering from anesthesia - Clients with regular rhythms - Clients with irregular pulse rates - Clients with abnormally slow pulse rates

- Clients with fast pulse rates - Clients with irregular pulse rates - Clients with abnormally slow pulse rates

A nurse is being sued for malpractice in a court of law. What elements must be established to prove that malpractice or negligence has occurred? Select all that apply. - Duty - Intent to harm - Breach of duty - Causation - Punitive damages - Fraud

- Duty - Breach of duty - Causation

A nurse is engaged in a nurse-client relationship. Which communication techniques would be important for the nurse to avoid? Select all that apply. - Giving advice - Exploring - Summarizing - False reassurance - Silence

- Giving advice - False reassurance

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? Select all that apply. - The client states, "I feel lightheaded when sitting up." - Erythema is present on the bilateral lower extremities - Client reports feeling dizzy when sitting up from a supine position. - The client has a temperature of 100.4 F - Pallor - Client reports feeling palpitations when rising from a supine to a standing position.

- The client states, "I feel lightheaded when sitting up." - Client reports feeling dizzy when sitting up from a supine position. - Client reports feeling palpitations when rising from a supine to a standing position.

Which nursing actions help improve listening skills when conversing with clients? Select all that apply. - The nurse listens for themes in the client's comments. - The nurse uses appropriate facial expressions and body gestures to indicate attention to what the client is saying. - The nurse always maintains eye contact with the client in a face-to-face pose. - The nurse thinks before responding to the client, even if this creates a lull in the conversation. - If an action being performed does not allow for conversation, the nurse pretends to listen to the client rather than interrupting the client's conversation. - The nurse sits with the client with arms crossed.

- The nurse listens for themes in the client's comments. - The nurse uses appropriate facial expressions and body gestures to indicate attention to what the client is saying. - The nurse thinks before responding to the client, even if this creates a lull in the conversation.

A nurse is providing care to an older adult with moderate cognitive impairment. When interacting with the client, which actions would be most appropriate? Select all that apply. - Speak in a loud tone of voice. - Use short, simple words when conversing with the client. - Ask the client "Do you remember me?" when interacting - Avoid identifying yourself each time. - Call the client by name.

- Use short, simple words when conversing with the client. - Call the client by name.

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states which of the following? A) "I do not need to wash my hands if I am using gloves." B) "I should wash my hands after touching the client's surroundings." C) "I should wash my hands before a clean procedure." D) "I should wash my hands before touching a client."

A) "I do not need to wash my hands if I am using gloves."

The nurse is caring for an older adult client in a long term care facility that is incontinent of urine. The client is very upset about this loss of dignity and expressing anger to the nurse providing care. He states, "Get away from me. I can get to the restroom on my own. You don't know what I need." Which response would be the most therapeutic for the nurse to say? A) "It sounds as if you are angry. Let's talk about it" B) "Go ahead and go to bathroom. Let me know if you need anything." C) "If you try to get to the bathroom by yourself you will fall." D) "Remember that you are having problems with getting to the bathroom in time. Can I help you?"

A) "It sounds as if you are angry. Let's talk about it"

A nurse is explaining the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client? A) Bathing reduces the possibility of infection. B) Bathing maintains the body temperature. C) Bathing prevents skin from peeling. D) Bathing keeps mucous membranes soft and moist.

A) Bathing reduces the possibility of infection.

After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice? A) Being licensed by the State Board of Nursing B) Filing NCLEX results in the county of residence C) Having a signed letter confirming graduation D) Enrolling in an advanced degree program

A) Being licensed by the State Board of Nursing

A nurse is taking care of an older adult client who was admitted for pneumonia. The client feels very weak and tired but has soiled the linens with urine and feces. What would be the most appropriate action by the nurse? A) Cleanse the perianal area and change the linens with the client in the bed. B) Have the client go to the bathroom and shower while the linens are changed. C) Cover the soiled area and wait until the client has more energy to change the linens. D) Don't do anything at this time and wait until the client has rested to change the linens.

A) Cleanse the perianal area and change the linens with the client in the bed.

A nurse is performing a home assessment for a 90-year-old widower who lives in a third story apartment. As the nurse considers his home environment, the nurse knows that the greatest risk of injury-related death or disability for the client comes from: A) Falls. B) Dementia. C) Myocardial infarction. D) Fire.

A) Falls.

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? A) If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. B) Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant. C) If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. D) An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection.

A) If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment? A) Penlight or flashlight B) Doppler ultrasound C) Syringe D) Bladder scanner

A) Penlight or flashlight

The nurse is assigned to take care of a client with rheumatoid arthritis. She notices that the client is wearing a copper bracelet. When she asks him about the bracelet, he says, "I believe that the bracelet will relieve the arthritis pain in my hands." Which action by the nurse is the most appropriate? A) Respect the client's beliefs associated with the copper bracelet and allow him to wear it. B) Inform the client that copper bracelets have not been medically proven to relieve arthritis pain. C)Inform the client that he must remove the copper bracelet before taking a shower. D) Encourage the client to use anti-inflammatory medication, like ibuprofen (Motrin).

A) Respect the client's beliefs associated with the copper bracelet and allow him to wear it.

A female client asks the nurse why she urinates more frequently as she is getting older. Which of the following is the nurse's best response? A) "It is your body's natural way of keeping the genital tract lubricated as you age." B) "Your bladder capacity decreases with age." C) "As you age, you have increased blood flow to your kidneys." D) "The number of filtering units (nephrons) in your kidneys increases with age."

B) "Your bladder capacity decreases with age."

A nurse working on a critical care unit was informed by a client with multiple sclerosis that she did not wish to be resuscitated in the event of cardiac arrest. The client is no longer able to express her wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may involve what? A) Paternalism B) Ethical distress C) Confidentiality D) Deception

B) Ethical distress

A client rings the call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? A) Nonmaleficence B) Fidelity C) Justice D) Autonomy

B) Fidelity

A nurse performing an integumentary inspection on a client gently pinches the skin under the clavicle. This nurse is assessing: A) Skin texture. B) Skin turgor. C) Skin moisture. D) Skin vascularity.

B) Skin turgor.

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures? A) Encourage the client to wear her dentures 24 hours a day to prevent their loss. B) Store the client's dentures in water when the client is not wearing them. C) Send the dentures home with a friend or family member until the client is discharged. D) Arrange for a minced or pureed diet for the client so that dentures are not necessary.

B) Store the client's dentures in water when the client is not wearing them.

A client continues to complain of pain despite receiving medication. The family states, "in our culture it is acceptable to complain out loud." What would be the best response by the nurse? A) It is not necessary to complain so loud. B) Tell me more about your cultural beliefs. C) The pain medication should have worked by now. D) Describe your home situation to me.

B) Tell me more about your cultural beliefs.

The nurse is reviewing discharge instructions for a client who was prescribed an antibiotic. Which statement by the client would require further teaching? A) "If I develop a rash, I will contact my healthcare provider." B) "I should avoid sharing my antibiotic with my spouse." C) "Once I start feeling better, I should stop taking the antibiotic." D) "I have a bacterial infection that requires an antibiotic."

C) "Once I start feeling better, I should stop taking the antibiotic."

The nurse is admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care? A) "Will your religion allow us to give you blood if you need it?" B) "Do you have any dietary restrictions that we should know about?" C) "What can we do to help you meet any religious needs you may have?" D)"I am a Christian and believe in Jesus. What does your religion believe?"

C) "What can we do to help you meet any religious needs you may have?"

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? A) Administering blood products B) Administering chemotherapy C) Administering bedside blood glucose testing D) Administering intravenous push medication

C) Administering bedside blood glucose testing

A registered nurse is convicted of stealing narcotics from the medical surgical unit. Which of the following actions might be taken against the nursing license? A) Issued a limited nursing license B) No action taken on nursing license C) Nursing license revoked D) Denied initial licensure

C) Nursing license revoked

Nurses must maintain the privacy of clients. Which example is a breach in privacy and would pose an ethical problem? A) Documenting the care in the client's record B) Participating in a hands-off report at the end of the shift C) Taking a picture of a client with the nurse's cell phone D) Talking to the family when they visit the client

C) Taking a picture of a client with the nurse's cell phone

During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this? A) Comprehensive assessment B) Social assessment C) Spiritual assessment D) Focused assessment

D) Focused assessment

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. Which of the following is the appropriate action by the nurse? A) Report the incident to the supervisor immediately B) Have the client tested for HIV and hepatitis C C) Go to the emergency room at the end of the shift D) Perform hand hygiene after removing the glove

D) Perform hand hygiene after removing the glove

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor? A) Using light pressure over the anatomic site for assessment B) Placing the client's arm in a comfortable resting position C) Placing the ear tips of the stethoscope downward into the ear D) Pump the blood pressure cuff up to 200 mm Hg routinely

D) Pump the blood pressure cuff up to 200 mm Hg routinely

When communicating with a client, the nurse uses reflection for which purpose? A) To investigate the situation to help problem solve B) To determine the sequence of events in the conversation C) To keep the client on the topic of concern D) To have the client elaborate on thoughts and feelings

D) To have the client elaborate on thoughts and feelings