Fundamentals of Nursing Exam 1

What is the legal source of rules of conduct for nurses?

nurse practice acts

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Which client statement from the health history would be a cue to a nursing diagnosis for this problem?

"I get out of breath when I walk a few steps."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?

"Leaning forward may help you to breathe better."

The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required?

"Nursing interventions must be approved by other members of the health care team."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment?

"Unable to palpate femoral pulse in left leg."

A nurse from the postanesthesia care unit (PACU) transports a client in the elevator with a nurse from the intensive care unit (ICU). There are staff members and visitors in the elevator as well. Which response from the ICU nurse is appropriate when the PACU nurse begins the report?

"Wait and give me a report in the room at the bedside."

The client experienced cardiac arrest, was resuscitated, and has now been on a ventilator for several days. The client had a written advance directive, which the spouse brought from home. The primary care provider (PCP) is encouraging the spouse to consent for placement of a percutaneous endoscopic gastrostomy (PEG) tube, which is contrary to the client's advance directive. After the PCP leaves, the spouse states, "I wish I knew what my spouse wanted." What is the best reply by the nurse?

"Your spouse did tell you in the advance directive."

Which provides the nurse with the most reliable basis on which to formulate a nursing diagnosis?

A cluster of several significant cues of data that suggest a particular health problem

Which is inappropriate to include in an outcome?

A flexible time frame

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document?

A living will

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

Which clinical events constitute areas of potential liability for the nurses involved? Select all that apply.

An elderly client develops skin breakdown on his coccyx because he was turned infrequently. A client experiences a seizure after a missed dose of his scheduled anticonvulsant medication. A confused client experiences a fall because her bed rails were left in a lowered position.

A nurse develops the nursing diagnoses "Appendicitis" and "Acute Pain" for a client. Which of the diagnoses is a medical diagnosis?

Appendicitis

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

The 40-year-old client is admitted for repair of a femoral fracture. The client discloses a history of an addiction to painkillers and asks that the nurse assist in adhering to the recovery from this addiction by not administering any opioids. As the nurse reviews postoperative prescriptions for the client, the nurse notes that the health care provider has prescribed codeine 30 mg p.o. q6 hours for pain. How does the nurse best approach this situation?

Ask the health care provider to remove this prescription from the client's chart.

While walking down the hall, a nurse manager overhears a staff member telling a client, "If you don't stay in this chair and stop wandering, I'm going to tie you to it." The nurse manager pulls the staff member aside and discusses what was said. The nurse manager intervenes because the staff member's statement is which type of tort?

Assault

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

Which group of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgment, client outcomes

Which ethical principle is related to the idea of self-determination?

Autonomy

Which ethical principle refers to the obligation to do good?

Beneficence

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

A client has been in the emergency department for 3 hours for treatment of a migraine headache. Care has been delayed due to a multiple fatality car accident. The client gets up to go to the bathroom unattended, faints, and suffers a subdural hematoma. The family threatens to sue for malpractice. Which element of malpractice will be the most difficult for the attorney to prove?

Causation

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

Which is the nurse's best legal safeguard?

Competent practice

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

Which aspect of nursing would most likely be defined by legislation at the state level?

Differences in scope of practice between registered nurses and licensed practical nurses

The nurse is concerned about a potential malpractice or negligence lawsuit regarding a client who was cared for on the unit. What specific elements must be established to prove that malpractice or negligence has occurred in this client? Select all that apply.

Duty Breach of duty Causation Damages

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?

Encourage hourly use of the incentive spirometer.

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?

Invasion of privacy

The client is a 2-month-old infant extremely ill from herpes simplex virus (HSV) sepsis. The parents have decided to stop additional medical intervention and allow the infant to pass away naturally. One parent does not want relatives to know that they plan to stop pursuing aggressive medical treatment because it is against their family's religious beliefs to withdraw medical support. What does the nurse tell the client's parent?

It is the parents' decision who to inform about the family's medical decision.

Which type of nursing diagnosis is validated by the presence of major defining characteristics?

Problem-focused

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

A home health nurse performs a careful safety assessment of the home of a frail older adult client to prevent harm to the client. The nurse is acting in accord with which principle of bioethics?

Nonmaleficence

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A nursing student is discussing assessment findings of an assigned client with the instructor. The instructor determines that the student needs additional assistance and review when the student identifies which as objective data?

Nursing staff

A client is suing a nurse for malpractice. What is the term for the person bringing suit?

Plaintiff

A home health nurse reviews the nursing care plan with the client and family. Then they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

Planning

An older adult client recently admitted to a long-term care facility expresses anger and depression about the relocation. The client consumes very little food and is losing weight. Which nursing diagnosis would be most appropriate for the nurse to select to plan this client's care?

Relocation Stress Syndrome

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

A client is post-operative day six following total hip replacement. When reviewing the client's plan of care, the nurse reads the following goal: "The client will transfer from the bed to the commode with one-person assistance." However, the nurse is aware that the client has been ambulating with a walker for the past two days and is now able to climb stairs. How should the nurse follow up this observation?

Revise the plan of care in light of the client's increased mobility.

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of Congestive Heart Failure?

Risk for Body Image Disturbance

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply.

Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?

Tell the UAP that the RN will assist the UAP with the client's ambulation.

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.

The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?

The client states, "I do not know how to take care of a baby."

The nurse has been providing care to a client during a divorce. The client is now divorced from the spouse, effective 2 weeks ago. The nurse identified a nursing diagnosis of "Readiness for Enhanced Coping." What statement by the client would support this nursing diagnosis?

The client states, "I feel like I can finally get along with my life now that the divorce is final."

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?

The condition of the skin over bony prominences

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

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

Which nursing actions would take place during the diagnosis stage of the nursing process? Select all that apply.

The nurse asks, "Based on what you have told me, it seems that urinary incontinence is a problem for you. What do you think?" The nurse identifies that the client has effectively coped with health stressors in the past. The nurse identifies that the client who is on strict bed rest is at risk for impaired skin integrity. The nurse determines that the client needs to have a decrease in activity.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client

What is the term for the beliefs held by the individual about what matters?

Values

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb (action)

To practice ethically, the nurse should avoid:

allowing the nurse's own personal judgment to guide practice.

A nurse observes another nurse place an unused dose of an opioid in the nurse's pocket. If caught, the nurse could be charged with which type of crime?

felony

A nurse cares for a client with congestive heart failure. The nurse administers furosemide intravenously after noting an increase in dyspnea and audible wheezing. The nurse's action demonstrates which step in the nursing process?

implementation

A nurse is working as part of a group to develop programs that will reduce the health disparities among different groups in the area. Which principle is the nurse applying?

justice

A group of nurses working in a long-term care facility fails to keep the opioid medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the:

nurses' licenses.

A client with a diagnosis of colorectal cancer has been presented with the treatment options, but wishes to defer any decisions to an uncle, who acts in the role of a family patriarch within the client's culture. The client's right to self-determination is best protected by:

respecting the desire to have the uncle make choices on the client's behalf.

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

A client who is cognitively impaired is scheduled to undergo surgery. The nurse demonstrates understanding of the principle of autonomy and checks the client's health record to ensure that consent has been obtained from which person?

surrogate decision-maker

A community health nurse has been working with an older adult client who lives alone and who receives regular wound care for a chronic, diabetic foot ulcer. What action by the nurse most clearly demonstrates the implementation phase of the nursing process?

teaching the client to maintain asepsis while applying a prescribed topical ointment

A competent adult client is scheduled for surgery. Who signs the informed consent form to allow the surgery?

the client

A client is received in a postoperative nursing unit after undergoing abdominal surgery. During this time the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

tort

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.