NURS 201 Prep U Exam #2

Which is the proper way to document midnight in a client's record?

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Chapter 11: 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)

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.

Chapter 11: Which is the main focus of care for a school nurse?

Community care

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record, Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment

Document this assessment based on the client's behaviors.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

A registered nurse is providing community-based health care for a client diagnosed with early onset dementia. Which strategy is best for the nurse to employ to facilitate the family participating in the client's care?

Encourage active participation of the client and family in health care decisions.

Chapter 11: A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed?

Enroll the client in Meals on Wheels.

Chapter 11: The goals of health care reform include which?

Focusing on cost containment with improved access and quality of services for everyone

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 unlicensed assistive personnel has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. Which is the nurse's priority action?

Gather information and complete the admission database.

A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take?

Have the social worker visit the client to discuss care options.

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 action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

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

Perfomance appraisal

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

A client is newly diagnosed with diabetes and prescribed insulin injections. The nurse identifies the client's knowledge deficiency regarding insulin injection. Which intervention is appropriate to address this deficiency?

Teach the client how to administer insulin.

Which organization audits charts regularly?

The Joint Commission

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.

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

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

The registered nurse (RN) wants to delegate a task to an unlicensed assistive personnel (UAP) but is unsure if the task can be delegated. What is the best resource for the RN to use in determining if the task is appropriate?

The nurse practice act or facility's policy and procedures

The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task?

The stability of the client's condition, potential for harm, and complexity of the activity

Chapter 11: The nurse shares with the healthcare team the need for a client, diagnosed with cancer and receiving chemotherapy, to attend an adult child's wedding. What discussion does the nurse have with the health care team to advocate for the client attending the wedding?

To affirm that the decision is consistent with client goals

A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply.

altered mobility, altered nutrition, ineffective coping

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

clarity

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success?

coordinator

Public health nursing is the branch of nursing that:

provides health care for the community.

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

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

Chapter 11: The nurse is a member of the multidisciplinary team in a large primary healthcare setting. Does the nurse understand which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident?

Speech pathologist/therapist

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply.

The client is crying, The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."

The nurse is preparing to begin the discharge planning process with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process?

The client's identified needs and goals

A client, who has limited finances and limited capacity for education, requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, the nurse must first:

implement critical thinking skills

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked?

"I want to understand what your desires are."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

Chapter 11: Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

"The system should be safe, effective, efficient, patient centered, timely, and equitable."

Chapter 11: Which client would a nurse correctly refer to Medicare services?

A 66-year-old client with diabetes

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart.

Chapter 11: 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

Chapter 11: Which statement regarding hospice care and the role of a hospice nurse is most accurate?

After the hospice client's death, the nurse assists the family with the bereavement process up to one year.

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with the nurse identifies the nursing concern of altered nutrition that is less the required. What is the most appropriate intervention for this client?

Administer a high-calorie diet, excluding wheat, rye, and oats.

Chapter 11: Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge?

Affordable Care Act

Chapter 11: 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

Chapter 11: Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price.

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?

Asses the clients vital signs again

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 is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

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 nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care?

Better client outcomes

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

Chapter 11: Which is the primary reason extended care facilities have proliferated in recent years?

Clients being discharged from the hospital while their care requirements remain beyond the scope of home care

Chapter 11: A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects the outcome of this program?

Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting.

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

Clients with high home care needs are being discharged into the community.

Chapter 11: Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role?

Collaborating with all agencies to provide for the client's home health needs

The nurse is working to enhance time management skills and has to administer pain medications to several clients, obtain vital signs, and assist clients with bathing. What should the nurse do next?

Delegate bathing and vital signs tasks.

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 has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying?

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

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

Chapter 11: What role does the nurse assume when gathering information for a community assessment?

Epidemiologist

Chapter 11: 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.

Chapter 11: A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate?

Hospice

Chapter 11: Which is the primary criterion for admission to a long-term care facility?

Inability to provide self-care

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP?

Initiating intravenous therapy

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

Interpretation of 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 17-year-old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client?

Make a referral to the social services department.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report?

Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated?

Provide the teaching

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.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

Which of these statements reflects the expected functioning at a hospital that has achieved Magnet status?

Staff nurses are developing innovative solutions to problems.

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 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.

The ability to communicate clearly through documentation is a critical nursing skill. Which statements accurately describe the role of documenting in the nursing process? Select all that apply.

The client record is the chief means of communication among members of the interdisciplinary team, A nursing action not documented is a nursing action not performed, It is helpful to practice documentation while learning any given nursing activity, The content of the client report and nursing documentation helps to establish nursing priorities in practice.

Which of these statements regarding a nurse manager role is accurate?

To effectively manage the nursing unit, the nurse manager should also be a leader.

A nurse is caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form?

To release the health care provider and the institution from any legal responsibility

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

activity and rest

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to:

communicate these feelings to family and friends.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

When educating clients in the community on health promotion and prevention of disease, it is important to stress:

health education can benefit individuals and groups.

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

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

is supportive, is resourceful, demonstrates, demonstrates leadership abilities, is and experienced licensed professional

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

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.

Which are examples of subjective client information? Select all that apply.

marital status and occupation, smoking and alcohol history, list of medications

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as:

providing continuity of care that is goal directed.

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

reflection

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

repositioning the client

The nurse works in a unit where the staff nurses can pick their own work schedule in exchange for being on call at least one weekend in a month. However, once the staff nurse refuses to come in when called in to work, the staff nurse loses the flexibility to choose their work schedule for the next 2 months. The institution implements a ____ leadership style as evidenced by the ________ ________.

transactional, task and reward orientation

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.

On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine:

whether the client has a document describing wishes for care when the client is no longer able to make decisions.