NURSING FUNDAMENTAL FINAL EXAM STUDY

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

What is the primary purpose of validation as a part of assessment?

To plan appropriate nursing care

What is the most important reason for the nurse to develop critical thinking and clinical reasoning?

To provide quality care with nursing ability and knowledge

What is the best example of community-based nursing?

Visiting a mother and newborn baby to ensure satisfactory bonding

A new graduate nurse is shadowing an experienced nurse providing care to a client. The new graduate nurse is observing the experienced nurse as they perform a sterile dressing change. The new graduate nurse notices that the experienced nurse is not following the exact steps that the new graduate nurse learned in school. Which response by the new graduate nurse is appropriate?

"I noticed you put the supplies on the left side, not the right."

A nurse is attending a job fair at the local community center and stops at a booth that is demonstrating technology for client care. While touring the booth, the nurse meets an informatics nurse specialist (INS). Being unfamiliar with this position, the nurse asks the INS, "How did you get this position?" Which response by the nurse would be most appropriate?

"I've had graduate-level education focusing on informatics."

The nurse maintains a journal in which to reflect on the nurse's clinical practice. Which entry is an example of reflection for action?

"Next time I will assess the client before obtaining the medication."

A nurse is evaluating the outcomes identified on the plan of care for first-time parents of a newborn. Which evaluative statement addresses a cognitive outcome?

2/6: Outcome met. Parents able to verbalize common problems associated with newborn feeding and appropriate strategies to address them

Which nursing pioneer established the Red Cross in the United States in 1882?

Clara Barton

What is the primary purpose of FOCUS charting?

To concentrate on the client and client concerns in documentation

A hospice nurse is providing care to a client with end-stage pancreatic cancer. Assessment reveals that the client's pain is not being adequately controlled. The nurse contacts the health care provider to report this finding. When communicating with the provider using the SBAR technique, which information will the nurse report first?

"The client is lying in bed, moaning and grimacing, with the knees pulled up close to the abdomen."

An informatics nurse specialist (INS) is interviewing a group of staff nurses about the facility's electronic health record (EHR). The INS determines that the nurses are having problems related to usability based on which statement?

"The system is not very intuitive. We had to constantly ask questions about whereto find the information."

A new graduate nurse asks the preceptor, "Why do we have to identify client outcomes?" Which response by the preceptor is appropriate?

"They identify thresholds that can be measured."

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 bythe 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

The nurse is performing an assessment of a client who has a small wound on the knee, collecting data about the client's health status. Which finding would the nurse identify as subjective?

A sharp pain in the knee

The client has been seeing the nurse for a month for a health issue. The client reports decreasing dietary sodium intake and has noticed decreased swelling in the legs. What stage in the Stages of Change Model is the client experiencing?

Action: Implementing the Plan

Which is a physician-initiated intervention?

Administer oxygen at 4 L/min per nasal cannula.

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do?

Ask the client whether visitors should remain in the room.

While bathing the client, the nurse observes the client grimacing. The nurse asks whether the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing?

Asking whether the client is having pain

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls.

A nurse refers a client with a new colostomy to a support group. This nurse is practicing which aim of nursing?

Facilitating coping

The nurse is caring for a client admitted to home care after total knee replacement surgery. Which home health care goal for the client will be the nurse's priority?

Help the client regain mobility and independence

A graduate nurse new to the facility asks the nurse manager about the difference between family-centered nursing and client-centered nursing. Which of the following would be inappropriate for the nurse manager to include when responding to the graduate nurse?

Illness of one family member infrequently occurs in other members.

Which action by the nurse would facilitate the nurse-client relationship during the orientation phase?

Introducing oneself to the client by name

A nurse caring for a client who is being treated by three health care providers uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each health care personnel.

What statement most accurately describes Florence Nightingale's influence on nursing knowledge?

Nightingale differentiated between health nursing and illness nursing.

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

In which way can nurses develop cultural self-awareness?

Objectively examine one's own beliefs, values, and practices.

Which guideline for composing a nursing diagnosis statement is correct?

Place signs and symptoms after the etiology and link them by the phrase "as evidenced by."

Medicare uses a prospective payment plan based on diagnosis-related groups (DRGs). What are DRGs?

Predetermined payment for services based on medical diagnoses

What role will the nurse play in transferring a client to a long-term care facility?

Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the client's current condition.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

After reviewing several research articles, the clinical nurse specialist on a medical-surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation?

Scientific knowledge

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Sitting with the client to encourage the client to talk

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 1b (0.45 kg). Which statement helps the nurse interpret these data appropriately?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.

Which is an example of a long-term outcome for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

An older adult client from a minority culture refuses to eat at the nursing home, stating, "I just do not like the food here." What factor should the staff assess for this problem?

The food served may not be culturally appropriate.

Hospice nurses provide care in a variety of settings, including clients' homes, long-term-care facilities, and hospice residences. After the client dies, what happens next

The hospice nurse continues to care for the client's family for up to 1 year.

Which statement accurately describes the legal responsibility of the nurse when making a diagnosis for a client?

The nurse must decide whether the nurse is qualified to make a nursing diagnosis and is responsible for treating any problem identified in a nursing diagnosis.

The nurse enters a client's room after receiving a morning report. The nurse rapidly assesses the client's airway, breathing, and circulation and greets the client by saying "Good morning." The client makes no reciprocal response to the nurse. How should the nurse best respond to the client's silence?

The nurse should ask appropriate questions to understand the reasons for the client's silence.

When the newly diagnosed client with insulin-dependent diabetes reports never having received instruction on the administration of injections, how will the nurse record this concern for use in care planning?

knowledge deficit regarding injection administration as verbalized by the client, related to the lack of instruction and experience

A nurse is engaged in experiential learning. Which step would the nurse likely be involved with first?

obtaining actual hands-on practice

A nurse manager has been asked to participate in hiring an informatics nurse specialist for the facility. Which candidate is a likely fit for the role?

registered nurse with a master's degree in health information technology and 2years experience with clinical information systems

A nurse is providing an educational event to a local group of citizens with physical disabilities. What is important for the nurse to be aware of when planning this event?

the health promotion needs of the attendees listening to the nurse

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?

"My grandchildren have moved in with us while their parents are going through financial difficulties."

In which situation would the nurse be most justified in implementing trial-and-error problem solving?

The nurse is attempting to landmark the apical pulse for a client whose BMI is higher than 30.

A nurse in a large metropolitan city has been working in a health clinic that has primarily served Middle Eastern clients for several years. The nurse is well-respected and effective in providing care to this population. Given this information, what can be inferred about the nurse?

The nurse is knowledgeable about Middle Eastern culture and respects and values providing culturally competent care.

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?

The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.

Which set of terms best describes nursing at the end of the Middle Ages?

purpose, direction, leadership