Final exam review

a student nurse is discussing medicare coverage with clinical instructor. the instructor knows the student understands medicare when they make what statement

it is funded by the federal govt its for people 65 and older for pts who are disabled and/or have end stage renal disease

the us health care system is different from that of other countries in what way

it is not entirely government funded

a nurse is caring for a pt who has orthopnea. what action by the nurse is most appropriate

keep the head of the bed elevated

a group of students are discussing the impact of non-nursing theories in clinical practices. the students would be correct if they chose which theory to prioritize pt care

maslows hierarchy of needs

a nurse manager recognizes that systems theory identifies that there is a social component within an organization that affects theoverall functioning of the system. What indicator would demonstrate to the nurse manager that the social needs of an organization are being met

most employees from the organization attend an annual holiday celebration

a pt does not make eye contact with the nurse and is folding his arms at his chest. which aspect of communication has the nurse assessed

nonverbal communication

a nurse is interviewing at an agency owned by a national religious organization that serves homeless and uninsured pts. a large poster display shows a proposed addition that would add 16 beds to the facility that will be funded from profits of the previous 3 years of operation. the nurse recognizes that the agency is most likely what type

not for profit

the nurse is examining the eyes of a newborn infant. if the nurse notes the absence of the red reflex, she would

notify the physician

a nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of privacy. which situation if identified by the student, indicates an understanding of a violation of this client's right

observing care provided to the client without the clients permission

diastolic pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery

a student nurse is talking with his instructor. he asks how quality of care is evaluated. the best response by the instructor is "quality of care is evaluated

on the basis of process and outcomes

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:

outcome identification

the charge nurse is discussing a pt care plan during a team meeting. the team determines that a pt has not met the goal of "ambulating to the nurses station twice a day" and decides to revise the plan. which of the following characteristics of the nursing process most represents this decision

outcome orientation

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which of the following techniques would the nurse use to collect this data?

palpation

a nurse is explaining to a student nurse about perfusion. the nurse knows the student understand the concept of perfusion when they state

perfusion is monitored by vital signs and cap refill

the nurse is caring for a woman who had a right sided mastectomy 2 years ago. what actions by the nurse is most appropriate

place a sign above the bed: no BP on Right arm

a pt returned from a procedure and has viral sign measurements ordered every hour. the pt blood pressure has dropped from 132/82 mm hg an hour ago to 90/66. what action by the nurse is most appropriate

plan to take the viral signs more often

a post-op client asks the nurse why it is so important to deep breathe and cough after surgery. when formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a post-op client can lead to which condition

pneumonia

QSEN focuses on

pre-licensured nurses; knowledge, skills, attitudes

When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable.

provided consistent information and therefore is reliable

The patient has a nursing diagnosis of risk for falls. Which goal is most important?

pt will have no injuries during hospital stay

a definition of health policy includes which of the following elements

public policy mad to support health related goals

The nursing instructor is researching the five proficiencies regarded as essential for students and professionals. The nursing instructor identifies which organization would be found to have added safety as a sixth competency?

qsen

the nurse has just assisted a client back to bed after a fall. the nurse and the HCP have assessed the client and have determined that the client is not injured. after completing the incident report, the nurse should implement which action next

reassess the client

the nurse is caring for an adult pt with a recent below the knee amputation. during shift report, the nurse reports that the pt has urinated in the bed multiple times since the surgery. which defense mechanism best describes this behavior

regression

ANA purpose

represents, supports nurses

a student asks the instructor about health care economics. the instructor knows that the student understands when they say

resources will be needed to serve health care issues

the nurses notes documentation that a client is exhibiting Cheyne-stokes respirations. on assessment of the client, the nurse should expect to note which finding

rhythmic respirations with periods of apnea

The direction of blood flow through the heart is best described by which of these?

right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle

A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern?

risk

a nurse is planning primary prevention activities. which activity would the nurse include in this plan

safer sex education for teens

the focus for the joint commission is _________ and ________ in the delivery of health care

safety and quality

which of the following components are included in health policy at the state level

scope of nursing practice

Secondary prevention examples

screenings, mammograms, blood tests, vitals

a hospital organization is working to improve a feeling of being valued and respected among all staff members. which action by administration would reinforce the feeling of being valued.

seek staff input when planning a remodeling project of patient rooms

a student nurse and clinical instructor are discussing quality in health care. the instructor knows the student understands when the student says, "quality is

seen and unseen in health care

strategies to include in a community program for senior citizens related to dealing with cold winter temps would include

shopping at an indoor mall

which assessment made by the nurse should be addressed first

shortness of breath

The nurse is caring for a patient with swallowing concerns and decreased levels of consciousness. The nurse knows to put the patient in what position for oral care?

side lying

a sentinel event refers to an event that

signals the need for immediate investigation and response

a nurse is conducting a health interview on a newly admitted pt. to establish a trusting relationship with the pt, the nurse

sits close and leans in slightly towards the pt

nursing staff members are sitting the the lounge taking their morning break. a UAP tells the group that she thinkgs that the unit secretary has AIDS and proceeds to tell the nursing staff that the secretary probably contracted it from her husband who is supposedly a drug addict. which legal tort has the UAP violated

slander

tertiary prevention examples

special diets, disease process

the nurse on the day shift walks into a clients room and finds the client unresponsive. the client is not breathing and does not have a pulse, and the nurse immediately calls out for help. which is the NEXT nursing action

start chest compressions

the scope of professional nursing practice is determined by the rules promulgated by

state board of nursing

When updating a client's chart, a nurse erroneously documents a wrong medication. Upon realizing the mistake, what does the nurse do?

strike with a single line, tag as an error, initial, document correct meds

a nurse observed a student taking an adult pt tympanic temp.what action by the student requires the nurse to intervene

student pulls the pinna down and back

a student nurse is preparing to auscultate a pt lungs. which action by the student leads the instructor to intervene

student using the stethoscope bell to listen to bowel sounds

the visiting nurse observes that the older male client is confined by his daughter-in-law to his room. when the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, my daughter-in-law needs me to stay here". which is the MOST important action for the nurse to take

suggest appropriate resources to the client and daughter in law, such as respite care and a senior center

the patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. to provide recreational activities during the rehab phase, the nurse should

suggest the use of talking books

a female pt is admitted to the emergency department after being raped by a neighbor. the pt refuses to discuss the circumstances surrounding the event with the sexual assault nurse examiner. this pt is most likely using the defense mechanism

suppression

a nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. the nurse should implement which assessment technique to assess for muscle weakness in the eye

test the 6 cardinal positions of gaze

which identifies accurate nursing documentation notations. SELECT ALL THAT APPLY

the client slept through the night, abdominal wound dressing is dry and intact without drainage, the clients left lower medial leg wound is 3 cm in length without redness, drainage, or edema

a nursing student is preparing study notes from a recent lecture in nursing history. the student would credit florence nightingale for which definition of nursing

the imbalance between the pt and the environment decreases the capacity for health

which pt scenario describes the best example of professional collaboration

the nurse and physician discuss the pts muscle weakness and initiate a referral for physical therapy

the nurse is caring for pts on the unit that uses EHRs. what action by the nurse protects personal health information

the nurse should never share any password with anyone

which statement by the nurse correctly identifies the UAP role in patient restraint use?

the uap can assist with applying and monitoring of a physical restraint

which of the following statements is true about health care in the US

the us spends more money on health care than any other nation

the nurse is providing instruction to the UAP regarding care of an older client with hearing loss. which should the nurse tell the UAP about older clients with hearing loss

they respond to low pitched tones

A client is brought to the EMS after being hit by a car. the name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. an emergency craniotomy is required. regarding informed consent for the surgical procedure, which is the best action

transport the victim to the OR for surgery

a new nurse is conducting a pt interview. what behaviors observed by the experienced nurse require education on this process

typing intently on a keyboard when asking questions providing nonverbal cues to negative thoughts

Primary prevention examples

vaccines, sanitary conditions

A male patient suffered a brain injury from a motor vehicle accident and has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, "Do you think when he moves his hands he is responding to my voice?" The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states, "He can hear you, and it appears he did respond to your voice." The nurse is violating which principle of ethics? a. Autonomy b. Veracity c. Utilitarianism d. Deontology

veracity

the nurse and physician are explaining the home care that will be needed by a pt after discharge. the pts spouse states angrily that it will not be possible to provide the care recommended. what is the best response by the nurse

what concerns do you have about the prescribed care

the nurse is preparing to complete a health assessment on a 16 year old girl whose parents have brought her to the clinic. which instruction would be appropriate for the parents before the interview begins

while i interview your daughter, will you step out to the waiting room and complete these family health history questionnaires

community health vs public health

within community vs population

The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism?

you should do this because many could benefit from it

the nurse is educating parents about firearm safety. which of the following statements indicates a need for further education

"It is okay to store firearms with ammunition loaded."

the nurse is discussing care coordination with a pt. the pt asks the nurse to explain care coordination. the nurse's best response would be,

"care coordination allows health care services to work together in the community

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1, 2, 4

pt is fully alert and oriented. what is the GCS

15

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3

Aspects of safety culture that contribute to a culture of safety in a health care organization include a. communication. b. fear of punishment. c. malpractice implications. d. team nursing.

A

Sinus Arrhythmia

Appearance is ALMOST NORMAL: Respiratory - Circulatory interaction Rate INCREASES with INSPIRATION (IN=IN)

A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend? a. Stroke rehabilitation support group b. Blood pressure screening at the mall c. Bicycle safety class at the elementary school d. Drop by nutrition station at the grocery store

B

PIE, APIE, SOAP, and SOAPIE are: a. chronologic. b. examples of problem-oriented charting. c. narrative charting. d. forms of "charting by exception."

B

pulse

Beat of the heart as felt through the walls of the arteries.

systolic pressure

Blood pressure in the arteries during contraction of the ventricles.

The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that..." d. "Tell me everything from the beginning."

C

A nurse is reported for taking prescribed patient medications for their personal use. Who has direct authority over deciding if the nurse may keep their professional license to continue practicing as a nurse? a. The hospital where the nurse is currently employed b. The American Nurses Association c. The National League for Nursing d. The State Board of Nursing who issued the license

D

Many middle-aged adults are called the "sandwich" generation because they are caring for their children and their aging parents. The aging parents need care due to a. mental clarity. b. immobility. c. blindness. d. multiple chronic illnesses.

D

Mr. Smith is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. The nurse's best response would be which of the following? a. "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." b. "Notify your doctor immediately, because this is a concerning reaction to the medication." c. "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." d. "You should see an improvement in the next week or so. Call if this continues."

D

The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. The group is considered the a. global community. b. sedentary society. c. unmotivated population. d. vulnerable populations.

D

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. "This will help us to identify your baby's risk for ear infections the first year of life." b. "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." c. "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." d. "Imitation of sounds is the first step in language development, and it is important to identify alterations early."

D

nonprofit organization

Institution that functions much like a business, but does not operate for the purpose of generating profits

For-profit organizations

Making money (profits) by offering products or services

Which statement contributes to the understanding that nursing is considered a profession? (Select all that apply).

Nursing requires specialized training.Nursing has a specialized body of knowledge.Nurses make independent decisions within their scope of practice.

many health care facilities use the fire emergency resposne defined by the acronym

RACE

QSEN founded by

Robert Wood Johnson Foundation

The nurse is explaining the National Patient Safety Goals (NPSG) to the student nurse. Which of the following answers indicates that the student has a good understanding of these goals? (Select all that apply.)

The NPGS's focus on improving staff communication. The NPGS's focus on using medications safely.The NPGS's focus on identifying patients correctly.

a nurse has received the assignment for the day shift. after making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first

a client with a WBC count of 14,000 mm3 and a temp of 38.4 Celsius

the nurse is assigned to care for four clients. in planning client rounds, which client should the nurse assess first

a client with asthma who requested a breathing treatment during the previous shift

a hospital is experiencing a drop in pt admissions, resulting in the implementation of a hiring freeze. what is a potential critical consequence of this internal organizational decision

a decrease in the availability of future nurses to hire

the annual report for a hospital shows that external environment factors are affecting the amount of new staff hired. what is likely a factor contributing to this outcome

a national recession that has been occurring for 3 years

a client diagnosed with a conductive hearing loss asks the nurse to explain the cause of the hearing problem. the nurse plans to explain to the client that this condition is caused by which problem

a physical obstruction to the transmission of sound waves

the nurse is performing a neurological assessment on a client and elicits a positive rombergs sign. the nurse makes this determination based on which observation

a significant sway when the client stands erect with feet together, arms at side, and the eyes closed

Five Rights of Delegation

a) Right Task b) Right Circumstance c) Right Person d) Right Direction/Communication e) Right Supervision

the nurse enters the client's room and finds the wastebasket on fire. the nurse immediately assists the client out of the room. what is her next nursing action?

activate the fire alarm

dependent nursing interventions include

administer antipyretic medications as appropriate

the nurse is caring for a pt who is unable to take oral meds because of persistent nausea and vomiting. The nurse decides to call the primary care physician and ask for a different medication administration route. This demonstrates the act of:

advocacy

a nurse is caring for an unconscious pt. what objective assessments does the nurse use to help evaluate pain in this pt

agitation restlessness vital signs

the nurse is caring for an older client in a long term care facility. which action contributes to encouraging autonomy in the client

allowing the client to choose social activities

during a staff meeting, the nurse manager announces that the hospital will be seeking magnet status. in order to explain requirements for this award, the nurse manager will contact the

american nurses credentialing center (ANCC)

a nurse is orienting to a new job in a HHC agency and is told that most of her pts need tertiary prevention. what activity does this nurse plan to include in the daily routine

antibiotic administration

the nurse is caring for a confused, combative pt. which action would be considered last by the nurse to control the behavior

apply restraints

The nurse is caring for a patient who has gone undergone abdominal surgery. The patient stated prior to surgery, "I don't think I will be able to handle this I get colostomy. I won't know how to manage it. There is no "next to kin" listed in the patient record. Which is the correct way to address nursing diagnosis first?

assess pain

the nurse receives a telephone call from a post anesthesia care unit stating that a client is being transferred to the surgical unit. the nurse plans to take which action FIRST on arrival of the client

assess the patency of the airway

a nurse has assessed a pt cap refill, which was 5 seconds. what action by the nurse is most appropriate

assess the pt for signs of hypoxia

A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best?

assess the pts ability to read and understand

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene?

assessing the dorsalis pedis pulse by palpating behind the pt knee

the nurse is assessing a pt whose chart indicates a grade 3 heart murmur. what action is best to hear the murmur

auscultate the chest with a stethescope

the nurse is using a stethoscope to assess a pts cardiac status. this assessment technique is known as

auscultation

a pt suffered a brain injury from a motor vehicle accident and has no brain activity. the pt has a living will which states no heroic measures. the family has requested that no additional heroic measures be instituted for their son. the nurse respects this decision in keeping with the principle of

autonomy

during a shift report, a staff member briefly describes the history of a pt admitted with chronic gi bleeding. in which SBAR topical area would this info be presented

background

A patient states, "I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response by the nurse would be an example of interpersonal therapeutic communication?

can you give me an example of what you mean by a "bad nightmare"

a pt tells the nurse that she has abdominal pain for the past week. what would be the nurses best response

can you point to where it hurts

A Pre-op client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is MOST LIKELY to stimulate further discussion between the client and the nurse?

can you share with me what youve been told about your surgery

which statement correctly describes the nurses role in collaboration

collaboration may occur in health related research

two nurses are discussing health care quality. they agree on the statement that health care quality requires

collaboration of multiple health care agencies

a nurse notes a pt has abnormal vital signs. what action by the nurse is best

compare with prior readings

the nurse faculty member is observing a student taking a pt carotid pulse. what action requires the nurse to intervene

compares pulse in both carotid arteries at the same time

after the nurse completes a pts initial assessment and develops a plan of care

continual reassessment of the pt is required

interrelated concepts regarding pt attributes that a nurse manager would consider when addressing concerns about the quality of health promotion include which type of attribute

culture

the LTC nurse is performing assessments on several of the residents. which are normal age-related physiological changes the nurse should expect to note? Select all that apply

decline in visual acuity, increased susceptibility UTIs, increased incidence of awakening after sleep onset

an unconscious patient is treated in the ED for head trauma. the pt is unconscious and on life support for 2 weeks prior to making a full recovery. the initial actions of the medical team are based on which ethical principle

deontology

nursing interventions that originate from the physician or primary care

dependent

to develop critical thinking, the nurse needs to develop a critical thinking character that includes

developing honesty and confidence

A mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't understand! Why can't the doctor find out what is wrong with my child?" This behavior is most likely an example of:

displacement

a nurse manager is educating the nursing staff on the importance of security with the implementation of the electronic health record system. which points does the manager emphasize

do not share passwords with anyone do not leave the pt medical record open unattended on a computer screen do not log in with someone elses user access

the nurse is obtaining a history from a 30 year old male pt and is concerned about health promotion activities. which of these questions would be appropriate to use to assess health promotion activities for this pt

do you perform testicular self exams

the nurse is assessing a pt with mobility dysfunction and wants to gain insight into the pt functional ability. what question would be the most appropriate

do you use a cane, walker, or wheelchair to ambulate

the nurse is instructing a client how to perform a testicular self-exam. the nurse should explain that the BEST time to perform this exam is

during a shower or bath

which primary prevention nursing intervention would be implemented by the community nurse to decrease the risk of community members contracting STIs

educate about the importance of safe sex practices

a hospitalized pt complains of bilateral leg pain and asks the nurse to massage her legs. one calf is noticeably larger than the other and is warm and slightly reddened. what action by the nurse is best

educate the pt on why a massage would be contraindicated

what do the economics of health care include

equal distribution of health care

the nurse administers a med to the pt and then realizes that the med had been discontinued. the error is immediately reported to the physician. the nurse is complying with the standards of professional performance known as

ethics

the nurse administers a medication to the patient and then realizes that the medication had been discontinued. The error is immediately reported to the physician. The nurse is complying with the standards of professional performance known as:

ethics

the nurse is preparing to discharge a pt admitted with fever of unknown origin. the pt states, 'I never got past the fifth grade in school. dont read much. never saw much sense in it. but i do Ok. i can read most stuff. but my doctor explains things good, and doesnt think that my sickness is serious." the nurse should

expect that the pt may return to the hospital if the discharge process is poorly done

A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics?

fidelity

a quality improvement committee is reviewing discharge surveys. results show that pts and their families have difficulty finding departments and areas of the hospital. what action by the committee would best address this concern

form a multidisciplinary committee to identify options to help travel through the hospital

the nurse is admitting a pt with a foul smelling leg wound. which behavior by the nurse indicates an understanding of appropriate body language

gentle touching of the pt shoulder

the nurse is caring for a pt with chronic lung disease. the pt demands a cigarette after eating breakfast. the nurse responds, "if that was me, i wouldnt be asking for a cigarette. that is what has made you so sick in the first place". this nontherapeutic communication response is

giving advice

not-for-profit organizations

groups that do not pursue profit as a goal; they engage in charitable, educational, humanitarian, cultural, professional, or other activities, often with a social purpose

student nurses are being questioned by the nursing instructor about the health care coordination system. the instructor knows the students understand health care delivery when they state

health care needs are best met with a collaborative effort

A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?

health promotion

The nurse is counseling a woman who is caring for her 83 yr old father. the father has had mental changes and is becoming more confused. the father lives with the daughter in her home. the nurse knows the daughter understands the fathers care needs when she states which of the following

i can send dad to the adult daycare; that way i can work and care for him at night

a hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. the client asks the nurse for assistance in obtaining a witness for the will. which is the most appropriate response to the client

i will call the nursing supervisor to seek assistance regarding your request

a nurse is monitoring the status of a post op client in the immediate post op period. the nurse would become MOST concerned with which sign that could indicate an evolving complication

increasing restlessness

repositioning a pt, providing hygiene and active listening are examples of

independent nursing interventions

2 nurses are discussing health care in the past and present. they know which of the following to be true about health care in the present

is controlled by third party payers

accurate documentation by the nurse is necessary since proper documentation

is needed for proper reimbursement