Review Quiz for Exam 1

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the clients temperature. Which step is the nurse doing? (A.) Validation (B.) Assessment (C.) Interpretation (D.) Documentation

(A.) Validation

Which factors may help in providing excellent health care services to the client? select all that apply. One, some, or all responses may be correct. (A.) cultural sensitivity (B.) high client literacy (C.) competent health care (D.) one-way communication (E.) interprofessional teamwork

A, C, E

Which step in the research process is similar to the assessment step of the nursing process? (A.) analyzing the results (B.) conducting the study (C.) developing hypothesis (D.) identifying the problem

(D.) identifying the problem

A client who was involved in an accident says, "i have a Dream of conquering the worlds's highest mountain range." According to Maslow's hierarchy of needs, to which level of need does the given scenario refer? (A.) physiological needs (B.) self-esteem needs (C.) self-Actualization needs (D.) safety and security needs

(C.) self actualization needs

Which pharmacokinetic condition would result in a high intensity and long duration of response? (A.) when both absorption and elimination are rapid (B.) when both absorption and elimination are rapid (C.) when absorption is rapid but elimination is delayed (D.) when absorption is delayed but elimination is rapid

(C.) when absorption is rapid but elimination is delayed

Which physical assessment situation is appropriate for use of alcohol-based hand sanitizer for hand hygiene? (A.) before and after palpating a pulse (B.) assessing a client with norovirus (C.) if the hand brushes a seeping dressing (D.) when the hands have contacted sputum

(A.) before and after palpating a pulse

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? (A.) planning (B.) evaluation (C.) assessment (D.) implementation

(D.) implementation

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.. (A.) Nursing diagnoses involve the client when possible (B.) Nursing diagnosis are based on results of diagnostic tests and procedures (C.) Nursing diagnoses are the identification of a disease condition in the client (D.) Nursing diagnoses involve the sorting of health problems with the nursing domain (E.) Nursing diagnosis involve clinical judgment about the client's response to health problems

A, D, E

When a client with heart failure reports frequent sudden waking during the night with shortness of breath, how will the nurse document this finding? (A.) orthopnea (B.) Hemoptysis (C.) Dyspnea and exertion (D.) Paroxysmal Nocturnal Dyspnea

(D.) paroxysmal nocturnal dyspnea

Which nursing action is most effective in planning culturally sensitive care for a client from another culture? (A.) reviewing information from the clients culture (B.) Notifying the medical interpreter that translation is needed (C.) Requesting that a male nurse provide care because of the documented culture (D.) Asking the client and family if there is any special care related to their culture

(D.) asking the client and family if there is any special care related to their culture

Which activities would the nurse perform to met the client safety and security needs based on Maslow's hierarchy of needs?Select all that apply. One, some, or all responses may be correct. (A.) providing a cold bath to reduce the client's body temperature (B.) positioning the bed in a low position and keeping the side rails up (C.) monitoring vital signs, such as blood pressure to decrease the risk of falls (D.) observing a client who has suicidal tendencies to prevent adverse incidents (E.) collaborating with family members to provide emotional support for the client post-surgery

B, C, D

Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? (A.) use standard precautions (B.) employ airborne precautions (C.) plan interventions to limit direct contact (D.) discourage long visits from family members

(A.) use standard precautions

Which nurse statement reflects positive cultural sensitivity to help reduce potential health disparities? (A.) which type of food do you usually eat at home? (B.) you need to ask your family to bring food of your choice (C.) the hospital staff will not be able to cook food with your requirements (D.) you need to eat the food that the hospital provides

(A.) which type of food do you usually eat at home?

Which parameter describes the maximum volume of air a clients lungs may contain? (A.) vital capacity (B.) total lung capacity (C.) inspirations capacity (D.) functional residual capacity

(B.) total lung capacity

Which is the nurse demonstrating when labeling the African-American client a drug abuser for requesting pain medications? (A.) ethnocentrism (B.) multiculturalism (C.) cultural encounter (D.) cultural imposition

(A.) ethnocentrism

Which criteria would the nurse consider when determining if an infection is a health care-associated infection? (A.) originated primarily from an exogenous source (B.) is associated with a medication-resistant microorganism (C.) occurred in conjunction with treatment for an illness (D.) still has the infection despite completing the prescribed therapy

(C.) occurred in conjunction with treatment for an illness

Which nursing action reflects Leiniger's caring theory in practice? (A.) the nurse supports and acccepts the clients feeling (B.) the nurse promotes beauty, comfort, dignity, and peace (C.) the nurse learns culturally specific behaviors to meet the clients needs (D.) the nurse believes that every caring process has subparts that should be considered while creating an effective strategy

(C.) the nurse learns culturally specific behaviors to meet the clients needs

An older clients asks, "how do I know that the medications that I take are safe?" Which response by the nurse is correct? Select all that apply. One, some, or all responses may be correct. (A.) ask your health care provider how and when you should be taking your medications (B.) stop taking a prescribed medication if you are not feeling better in a a few days (C.) discard medications into the toilet that have exceeded the expiration date on the bottle (D.) check the name, dose, and instructions about administration of medications each time before leaving the pharmacy (E.) Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest

A, D, E

A high school student arrives at the local blood drive to donate blood for the first time. As the site is prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instruct the student to do? (A.) Breathe into cupped hands. (B.) Pant using rapid, shallow breaths (C.) Use a rapid deep breathing pattern (D.) Hold the breath for as long as possible

(A.) Breathe into cupped hands

Which level of Maslow's hierarchy of needs is fulfilled by the nurse fitting a client who nearly dies of asphyxiation with an oxygen mask? (A.) first level (B.) second level (C.) third level (D.) fourth level

(A.) first level

Which statement by the student nurse indicates the need for further education about medication administration? (A.) I should set up and prepare medications in distraction-free areas (B.) I should advise the certified medical assistant to administer intravenous medication (C.) I should be vigilant during the entire process of medication administration (D.) I should identify each client using at least two identifiers before administering medications

(B.) I should advise the certified medical assistant to administer intravenous medication

Which level of Maslow's Hierarchy of needs will the nurse classify a client who reports working in a factory that manufactures explosives? (A.) First level, which includes physical=illogical needs (B.) Second level, which includes safety and security needs (C.) Fourth level, which includes self-esteem needs (D.) Final level, which includes self-Actualization needs

(B.) Second level, which includes safety and security needs

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of the data collected about the client? (A.) evaluation (B.) assessment (C.) implementation (D.) diagnosis

(B.) assessment

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? (A.) obtain a pulse oximeter to determine the client's oxygen saturation level. (B.) Put the client in a high Fowler position (C.) Darken the lights and provide a rest period of at least 15 minutes (D.) continue the hygiene activities while reassuring the client

(B.) put the client into high Fowler position

Which statements have been correctly stated about Nightingale's theory of nursing? Select all that apply. One, some, or all responses may be correct. (A.) focus of nursing is caring through the environment (B.) limits nursing to the administration of medications and treatment (C) suggests that every nurse would know all about the disease (D.) oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition (E.) focuses on helping the client deal with the symptoms and changes in function related to an illness

A, D, E

Which points would the nurse keep in mind when caring for a client who belongs to a different culture? Select all that apply. One, some, or all responses may be correct. (A.) be aware of his or her own cultural values and behavior patterns (B.) focus on understanding the clients tradition, values, and beliefs (C.) understand that unique cultural perceptions exist regarding health practices (D.) know that every client strictly adheres to his or her cultural beliefs and traditions (E.) Understand that a client's cultural background does not influence the nurse-client relationship

A, B, C

Which client would the nurse teach to report shortness of breath as priority care associated with the medications prescribed? -client A: hydroxychlorine -client B: infliximab -client C: methotrexate -client D: ephedrine

Client B

The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give? (A.) Prevents complications that are associated with COPD (B.) Relieves shortness of breath by increasing the breath rate (C.) Increase the amount of air that the client can inhale with each breath (D.) Keeps the airway open longer to decrease the work that goes into breathing

(D.) Keeps the airway open longer to decrease the work that goes into breathing

Which precautions would the nurse implement for herpes zoster? Select all that apply. One, some, or all responses may be correct. (A.) airborne (B.) contact (C.) droplet (D.) hazardous waste (E.) standard

A, B, E

Which statements about culturally congruent care by the student nurse are correct? Select all that apply. One, some, or all responses may be correct. (A.) it is the main goal of transcultural nursing (B.) it is provided through cultural competence (C.) it is provided in accordance with set criteria (D.) is it bound to the professional health care system (E.) it depends on the patterns and needs of an individual

A, B, E

Which are the benefits of providing culturally competent care? Select all that apply. One, some, or all responses may be correct. (A.) increased client safety (B.) limits numbers of visitors (C.) reduced health disparities (D.) increased client satisfaction (E.) ensures adequate interpreters

A, C, D

Which statements by the student nurse indicate an understanding of caring for clients of various cultures? Select all that apply. One, some, or all responses may be correct. (A.) the focus is on understanding the traditions, beliefs, and values of the client's culture (B.) care would be provided strictly on the basis of the traditions, beliefs, and values of the clients community (C.) generalized education and information would be provided to clients belonging to a different community (D.) the cultural background of the client has no effect pm his or her health, wellness, and illness (E.) i will be aware of my own cultural background and beliefs when attending to clients who belong to different cultures

A, E

Which actions by the nurse increase safety in the clinical setting? Select all that apply. One, some, or all responses may be correct. (A.) wearing a mask when performing daily hygiene (B.) keeping current with evidence and best practices (C.) using only quality resources, especially websites (D.) reporting faulty equipment as soon as described (E.) sterilizing all intravenous pumps between clients

B, C, D

Which client's care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? Client A - dental caries Client B - oral cancer Client C - jaw fracture Client D - thrombocytopenia

Client A

According yo Maslow' s hierarchy of needs, which level of need did the nurse prioritize when assisting an older postoperative client to the restroom to prevent falling? (A.) first level (B.) second level (C.) third level (D.) fourth level

Second level

Which infection would the nurse identify as requiring a client to be placed on droplet precautions? (A.) Human Immunodeficiency Virus (HIV) (B.) Influenza (C.) Tuberculosis (TB) (D.) MRSA

(B.) influenza

Which category of isolation would the nurse implement for a client who is positive for clostridium difficile? (A.) airborne precautions (B.) droplet precautions (C.) contact precautions (D.) protective environment

(C.) contact precautions

Which nursing-sensitive indicator can be used to evaluate the process of nursing care? Select all that apply. One, some, or all responses may be correct. (A.) client falls (B.) pressure ulcers (C.) nurse job satisfaction (D.) supply of nursing staff (E.) skill level of nursing staff

(C.) nurse job satisfaction

The health care team is caring for a population according to the functional model of nursing. Which health care team member is most appropriate for the delegation of hygiene care? (A.) unit secretary (B.) registered nurse (C.) nursing assistant (D.) licensed practical nurse

(C.) nursing assistant

The nurse leader states, "the people in rural America dress and act differently from those in urban centers." Which concept describes this statement? (A.) acculturation (B.) ethnocentrism (C.) cultural imposition (D.) cultural marginality

(D.) cultural marginality

Which step in the nursing process would involve promoting a safe environment for the client? (A.) planning (B.) Diagnosis (C.) Assessment (D.) Implementation

(D.) implementation

A client with heart failure reports waking suddenly and feeling short of breath during the night. How will the nurse document this information? (A.) orthopnea (B.) sleep apnea (C.) exertional dyspnea (D.) paroxysmal nocturnal dyspnea

(D.) paroxysmal nocturnal dyspnea

Which findings indicate that the nurses are providing safe health care? Select all that apply. One, some, or all responses may be correct. (A.) exhibits good decision- making skills (B.) acts within the scope of practice of their license (C.) provides cost-effective interventions to the clients (D.) offers both curative and preventive interventions for the clients (E.) executes interventions that have reduced the duration of hospital stays of the clients

A, B

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the clients vital signs? (A.) Planning (B.) Diagnoses (C.) Assessment (D.) Implementation

(C.) assessment

The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent? (A.) delegation (B.) implementation (C.) case management (D.) interprofessional teamwork

(A.) delegation

In providing effective nursing care to clients from different cultural backgrounds, which strategy would the nurse follow? (A.) advise clients that some cultural practices may be harmful to health (B.) provide care that fits the clients cultural beliefs (C.) strictly adhere to organization policies regarding nursing care (D.) ignore the cultural aspect and focus on the medical aspect of care

(B.) provide care that fits the clients cultural beliefs

While talking with a 60-year-old client, the nurse learns that the client immigrated 15 years ago from China and likes to live independently away from the clients grown children. The client eats only Chinese foods at home. Which would the nurse infer from these findings? (A.) the client has undergone assimilation (B.) the client has undergone biculturalism (C.) the client has undergone acculturation (D.) the client has undergone enculturation

(B.) the client has undergone biculturalism

Which information must be clearly documented in the medication administration record (MAR) before administering a medication? Select all that apply. One, some, or all responses may be correct. (A) dosage and route (B) clients full name (C) time to be administered (D.) frequency of administration (E.) full name of prescribed medication

A, B, C, D, E

The nurse is assisting the registered nurse with delegation decisions regarding management of a client with shortness of breath. Which action by the nurse indicates a need for correction? (A.) asking questions about the client's respiratory rate (B.) asking the client to perform breathing exercises regularly (C.) administering oxygen to the client with shortness of breath (D.) providing constructive feedback about client care management

(D.) providing constructive feedback about client care management

Which level of Maslow's hierarchy of needs would the nurse need to follow for a client brought to the emergency department with severe breathing difficulty? (A.) first level (B.) second level (C.) their level (D.) fourth level

(A.) first level

Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. (A.) measles (B.) influenza (C.) clostridium difficile (D.) Bacterial Meningitis (E.) MRSA

(A.) measles

Which level of Maslow's hierarchy of needs is the nurse using when she teaches the client about the call light system? (A.) safety (B.) self-stem (C.) physiological (D.) interpersonal

(A.) safety

Which characteristic would the nurse use during the nursing process as a guide for delegation? (A.) leadership (B.) critical analysis (C.) psychomotor task (D.) time management

(B.) critical analysis

A client who just completed ambulating in the hallway and reports shortness of breath at the same time that the meal tray has been delivered and the laboratory technician has arrived to perform routine blood testing. Which intervention would the nurse recognize as priority? (A.) because the client is short of breath, assist with feeding (B.) position the client for comfort with head of the bed elevated (C.) ask the laboratory technician to draw and run the laboratory testing stat. (D.) Guide the client to a sitting position on the floor of the hallway

(B.) position the client for comfort with head of the bed elevated

Which situations belong to the first level of needs according to Maslow's hierarchy? Select all that apply. One, some, or all responses may be correct. (A.) a client is homeless (B.) a client reports feeling dizzy for 2 days (C.) a client reports that he or she is unable to consume food because of throat pain (D.) an amputee informs the nurse that he or she will walk one day (E) a client states that they are beaten up repeatedly by a neighbor

A, B, C

Which nurses are taking actions that contribute to the nursing goal of achieving cultural competence? Select all that apply. One, some, or all responses may be correct. (A.) Nurse A examines own beliefs about mental health (B.) Nurse B reads an article about interpreting nonverbal behavior (C.) Nurse C volunteers at a clinic that serves an immigrant population (D.) Nurse D teaches children of immigrants about eating healthy food (E.) Nurse E uses a cultural assessment tool to gather client data

A, B, C, E

Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply. One, some, or all responses may be correct. (A.) use a pill organizer (B.) read all medication labels (C.) place pills in unlabeled bottles (D.) review medications with pharmacist (E) Empty medicine cabinet every 2 years

A, B, D

Which questions would the nurse ask the client when obtaining the health history? Select all that apply. One, some, or all responses may be correct. (A.) tell me about your food habits (B.) do you use alcohol or tobacco (C.) have you sustained any personal loss recently (D.) Have you ever experienced any allergic reactions? (E.) does any family member have a long-term illness

A, B, D

Which definition is correct to explain the nursing process? (A.) procedures used to implement client care (B.) sequence of steps used to meet the client's needs (C.) activities employed to identify a client's problem (D.) mechanisms applied to determine nursing goals for the client

(B.) sequence of steps used to meet the client's needs

The nurse is caring for a client who is positive for hepatitis A. Which precautions would the nurse take? (A.) wear a gown when entering the clients room (B.) use gloves when removing the clients bedpan (C.) clean eating utensils with bleach after use (D.) wear a high-efficiency particulate air (HEPA) respirator when entering the clients room.

(B.) use gloves when removing the patients bedpan

For a client with difficulty swallowing, the nurse will crush which medication? (A.) metoprolol extended release (B.) felodipine sustained release (C.) acetaminophen extra strength (D.) potassium chloride extended release

(C.) acetaminophen extra strength

How would the nurse explain the purpose of standard precautions to the nursing assistant on a surgical unit? (A.) decrease the risk of transmitting unidentified pathogens (B.) used by staff when clients are suspected of having a communicable disease (C.) ensure clients perform hygiene practices in a universal way (D.) create categories requiring the client to follow additional precautions

(A.) decrease the risk of transmitting unidentified pathogens

The nurse is assessing a client who reports shortness of breath. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? (A.) assess the client's lungs (B.) assess the client for pain (C.) obtain details for smoking habits (D.) ask about the onset of shortness of breath

(A.) assess the client's lungs

Which nursing action is the priority action for decreasing the risk for a client developing a hospital -acquired infection? (A.) droplet precautions (B.) contact precautions (C.) airborne precautions (D.) standard precautions

(D.) standard precautions

Which nursing actions reflect the curative factor of promoting and expressing positive and negative feelings, according to Watson's theory of transpersonal caring? Select all that apply. One, some, or all responses may be correct . (A.) supporting and accepting the client's feelings (B.) learning together while educating the client to acquire self-care skills (C.) creating a healing environment at the physical and non physical levels (D.) applying the nursing process in systematic, scientific problem-solving and decision making (E.) showing a willingness to take risks in sharing in the relationships when connecting with clients

A, D