Fundamentals Exam 2 PrepU's

A mother brings an infant into the clinic for a well-infant visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding and the nurse finds that the infant is gaining weight appropriately. Which is an appropriate evaluative statement for this client?

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager?

"The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together."

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate?

"The client and family are in control of the setting, not the nurse."

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.

-38-year-old man -Height: 6 ft (1.82 m) -Weight: 195 lb (89 kg)

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply.

-A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. -Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

The nurse has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply.

-Are the interventions compatible with other planned therapies? -Are the interventions evidence-based? -Are the interventions realistic and do they require resources available to the nurse? -Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

Which are examples of objective data? Select all that apply.

-Laboratory test results -Breath sounds on auscultation -A client's temperature

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

-The client is blind. -The client denies the need for education.

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply.

-The nurse ensures that the interview environment is private and comfortable. -The nurse arranges the seating in the interview room to facilitate an easy exchange of information. -The nurse prepares to meet the client by reading current and past records and reports.

A nurse is involved in selecting the appropriate nursing diagnosis for a client. Which techniques would the nurse likely use? Select all that apply.

-cue clustering -cluster interpretation -diagnostic validation

Which attributes should be characteristic of a nurse mentor? Select all that apply.

-is supportive -is resourceful -demonstrates leadership abilities -is an experienced, licensed professional

The nurse is caring for several clients with chronic conditions that need to be evaluated for long-term care. After evaluating each client, the nurse determines which client is most appropriate to receive long-term care?

A client who suffered a stroke who has mobility issues and problems completing activities of daily living (ADLs).

A nurse demonstrates understanding of Healthy People 2030 by supporting which statement?

A client's health is affected by social, economic, and political factors.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

A prospective payment plan based on a predetermined fixed cost

Which therapist is most likely to focus on teaching a client to hold a toothbrush with an adaptive device and brush the teeth?

An occupational therapist

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check clients' blood glucose levels. The nurse manager informs the group that this is a new policy on the unit and that discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating?

Autocratic

The nurse has recently been promoted to nurse manager on an oncology unit and has decided to be the sole decision maker regarding issues that concern the unit. Which type of leadership style is the nurse embodying?

Autocratic

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code?

Autocratic leadership

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete?

Bathing a combative client

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate?

Clients play a large role in helping themselves in the home care setting.

The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which conflict resolution style does the nurse manager display?

Collaborating

Two staff nurses on a unit disagree with one another over certain key aspects of providing client care. The nurse manager of the unit arranges a meeting with the charge nurse and the two staff nurses at a mutually agreed-upon time to discuss this situation. This activity is most accurately described as what?

Conflict resolution

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?

Discovering a problem

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP?

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A client who is scheduled for coronary angioplasty is concerned about whether the surgery is safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's condition?

Fear related to potential risk and surgical outcomes

The nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP) for a client who recently had a stroke and is suffering from mil hemiplegia. Which task would be inappropriate for the nurse to delegate to the UAP?

Feeding

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

A nursing facility has recently implemented new policies regarding nurse-to-client ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change?

Hold a unit meeting to discuss how the changes will benefit staff.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

Impaired Comfort

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

Which is the primary criterion for admission to a long-term care facility?

Inability to provide self-care

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client?

Introduce oneself to the client.

Which is a characteristic of person-centered care?

It is a framework for providing care.

The nurse manager calls a staff into a unit meeting to discuss client satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying?

Laissez-faire

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

The health care provider has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation?

Process evaluation

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client?

Refer the client to a social worker to determine eligibility for assistance.

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?

Relief from physical, mental, and spiritual distress

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

Review the client's recent food and fluid intake.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?

Support system

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

The nurse is caring for a mother and newborn infant couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the infant is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role?

The charge nurse is providing support for the staff nurse in new responsibilities.

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education?

The client demonstrates administration of insulin.

The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the infant while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the infant again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?

The new mother attempts to breastfeed the infant again using the new techniques and is successful.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

It is important for home health care nurses to remember which point?

The nurse is the guest in the client's home.

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution?

The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment

A home health nurse is scheduled to make a visit to a client who was discharged from the hospital yesterday following an appendectomy. The nurse understands that the scope of practice for a home health nurse allows the nurse to perform which psychomotor tasks?

Wound care, medication administration, teaching, and ensuring a reasonably safe environment

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The nursing assistant has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to:

gather information and complete the admission database.

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface.

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:

outcome

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

outcome

A nurse manager reviews an employee's contribution to the nursing division annually. This process is:

performance appraisal.

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

physical changes

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

reflection

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

risk for falls

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

The home health care nurse is providing information to a client and family on medication changes. What role is the nurse performing?

Client and family educator

A nurse is assisting with the transfer of a client from the acute care facility to the rehabilitation facility for continued care. Which skill would be most important for the nurse to use to promote continuity of care?

Communication

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

A staff nurse works on a medical unit where staff retention is very high. There is a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which leadership style?

Democratic

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and health care providers is exhibiting what style of leadership?

Democratic

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

A nurse leader on a unit allows the staff to make all decisions and direct themselves, including filling out the work schedule. The nurse leader is practicing which leadership style?

Laissez-faire

A nurse is caring for a client with pneumonia. Which task is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

Obtaining vital signs every 4 hours

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident?

Speech pathologist/therapist

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting?

The discharge home of clients who are more critically ill

The case manager works in a facility that supports a participative leadership style. Which action should the nurse recognize as an example of democratic leadership style?

The interdisciplinary health care team collectively developing plans of care for clients

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?

Tracheobronchial suctioning

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?

anxiety

Which is the best source of information for the nurse when collecting data for an assessment?

client