RNSG 1125 exam 1
The nurse is assessing a client who was recently diagnosed with anxiety disorder. Which question asked by the nurse conveys a concrete message?
"At what time did you take the last dose of the antianxiety drugs?"; Concrete messages use explicit wording and need no interpretation. Asking the client about the time of the last dose of the antianxiety drugs conveys the most accurate information.
A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? 1."Hold the spirometer at your lips and breathe in and out like you normally would." 2."Take a deep breath and then blow short, forceful breaths into the spirometer." 3."Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." 4."When you're ready, blow hard into the spirometer for as long as you can."
"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Explanation: The client should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The client should then exhale slowly through the mouthpiece.
In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant?
"Dispose of the disconnected IV set."
A client is discharged following an extended stay on the surgical unit. On the way out, the client hands the nurse a card containing a twenty-dollar bill. The client states this money is a gift for the nurse. Which of the following statements made by the nurse demonstrates an understanding of accepting gifts from clients? 1. "The nurses on this unit prefer a box of chocolates as a gift rather than money." 2."Thank you. This will allow me to take my husband out for dinner this evening." 3."I will let the nurse manager purchase something that all of the staff can enjoy." 4."I appreciate your generosity, but nurses are forbidden to accept gifts from clients."
"I will let the nurse manager purchase something that all of the staff can enjoy." Explanation: Sharing the gift with all the staff on the unit would be appropriate because many people were involved in the client's care, including non-nursing staff. The other options are incorrect because refusing to accept the gift or asking for something in lieu of the money might have a negative effect on the client. Twenty dollars would not be considered an unreasonable monetary gift after a prolonged hospital stay in this situation.
Nursing students are learning about the importance of therapeutic communication in their pediatric course. The nursing instructor identifies a need for further teaching when a student makes which statement?
"It is best to stand when listening to a child to demonstrate knowledge."
The nurse and a student are discussing entry into the profession of nursing. Which statement should the nurse use to describe a diploma program? 1."It is obtained through a 2-year program at a university." 2."It is obtained by a 4-year program at a university." 3."It is obtained by a 24-month program at a hospital." 4."It is obtained by a 36-month program at a community college."
"It is obtained by a 24-month program at a hospital." Explanation: Diploma programs are obtained through a hospital program and take 24 to 36 months. Associate degrees are obtained through a community college and take 2 academic or calendar years. Baccalaureate degrees are obtained through a 4-year degree at a senior college or university.
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."
A nurse is caring for a client with multiple chronic conditions and some physical disabilities. The nurse is using "people-first" language with the following statement during end-of-shift report:
"Last evening, Mr. Rudd, a 44-year-old patient with diabetes was admitted to the unit."; t is important to all people, both those with and those without disabilities, that they not be equated with their illness or physical condition.
A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate? 1.Patient reports severe headache. 2.Headache located bilaterally on both sides 3.Patient states his head started hurting about an hour ago. 4."My head feels like it is about to explode."
"My head feels like it is about to explode." Explanation: When documenting a patient's chief complaint or reason for seeking care, the nurse should record the patient's exact words. Additional information, such as location and duration, would then follow as the nurse continues the interview
A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? 1."To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" 2."To detect and treat bradycardia, which is an excessively slow heart rate" 3."To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently" 4."To shock your heart if you have a heart attack at home"
"To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" Explanation: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia. Reference: Timby, B.K., & Smith, N.E. Introductory Medical-Surgical Nursing, 11th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 26: Caring for Clients With Cardiac Dysrhythmias, p. 416. Chapter 26: Caring for Clients with Cardiac Dysrhythmias - Pag
An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response? 1."It's not unusual for clients to misreport pain to get our attention when we are busy." 2."We need to provide pain medications because it is the law, and we must always follow the law." 3."Unless there is strong evidence to the contrary, we should take the client's report at face value.'" 4."Pain often comes and goes with postsurgical clients. Please ask her about pain again in about 30 minutes."
"Unless there is strong evidence to the contrary, we should take the client's report at face value.'" Explanation: A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. Rechecking without offering an intervention would be insufficient and the law is not the sole reason for providing care.
A nurse is seeing a client who has recently been discharged from the hospital for a suicide attempt. When asked about the quality of her relationship with her husband, the client becomes silent, diverts eye contact and says, "It's okay." What is the nurse's best response?
"What you are saying and how you say it does not seem to match."
A nurse is conducting a health history. The client's spouse is answering the interview questions. What question would be appropriate to ask the client before proceeding with the remainder of the interview?
"Who manages health care-related issues in your family?"
The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?
"You can use writing or a communication board to communicate."
While undergoing a health history and physical assessment, a patient states, "I'm really afraid this pain in my belly is cancer." Which response by the nurse would be MOST appropriate? 1. "So you think you have cancer?" 2. "Let's not worry about that now. I need to get your information first." 3. "You seem upset about the pain. Tell me what's happening." 4. "We can't say yes or no until the doctor does some testing."
"You seem upset about the pain. Tell me what's happening." Explanation: During the interview, it is essential that the nurse establish rapport, put the patient at ease, and listen to the patient carefully. The nurse's statement about the patient seeming upset is most consistent with these goals. Telling the patient not to worry now dismisses the patient's concerns. Questioning the patient about cancer focuses on the diagnosis, not the patient's current feelings and concerns. Although telling the patient that more testing is necessary can be helpful, the response does not address the patient's feelings and concerns.
healthcare errors Identified by IOM pioneer Lucian Leape
1. Diagnostic errors are the result of a delay, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring and testing. 2. Treatment errors occur in the performance of an operation, procedure or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test. 3. Preventative errors occur when there are failures to provide prophylactic treatment and inadequate monitoring or follow-up of treatment. 4. Communication failure (meaning a lack of communication) can lead to many types of errors.
Components of Standard Precautions-
1. Hand Hygiene 2. Personal Protective Equipment -Gloves - Mask, goggles, face shield, gown 3. Respiratory Hygiene 4. Sharps Disposal 5. Low Level Disinfection of Equipment 6. Adequate Environmental Controls 7. Room Assignments
A client has been placed on droplet precautions for meningococcal meningitis. The nurse must wear a mask when entering the room and especially within how many feet when taking care of the infected client? Record your answer using a whole number.
3 feet
The need for university-based nursing education programs was brought to light during which important historical time? 1. Spanish-American 2. War World War I 3. World War II 4. Korean War
3. World War II Explanation: Esther Lucile Brown, in her report on nursing education published at that time, wrote that nursing education belonged in colleges and universities, not in hospitals. Reference: Timby, B. K. Fundamental Nursing Skills and Concepts, 11th ed., Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017, Chapter 1: Nursing Foundations, p. 9.
Which time waster does the manager have least control over? 1. Failure to set objectives 2. Inability to say no 3. Procrastination 4. Meetings
4. Meetings Explanation: Meetings are an external time waster; the others are time wasters created by the manager. Reference: Timby, B.K., & Smith, N.E. (2014). Introductory Medical-Surgical Nursing, 11th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 6: Leadership Roles and Management Functions, p. 60.
The LVN/LPN suspects narcotic diversion when a particular nurse volunteers to administer medication to clients when they call for pain medication and the clients continue to report pain. What should the nurse do? 1. Pull the nurse to the side and discuss concerns with him or her. 2. Talk to colleagues about these observations. 3. Complete an incident report. 4. Notify the nursing supervisor.
4. Notify the nursing supervisor. Explanation: Nurses have an obligation to report suspected cases of chemical abuse for proper investigation. An incident report is not required in this case. Talking to colleagues does nothing to resolve the issue at hand but may create a hostile work environment. It is a good idea to pull the nurse to the side; however, this option does not address the issue at hand. An investigation is required to establish if a problem exists.
What is the legal source of rules of conduct for nurses? 1. Agency policies and protocols 2. Constitution of the United States 3. American Nurses Association 4. Nurse Practice Acts
4. Nurse Practice Acts Explanation: Nurse Practice Acts are examples of statutory law, enacted by a legislative body in keeping with both the federal constitution and the applicable state constitution. They are the primary source of rules of conduct for nurses. Standards of practice, which differ from rules of conduct, are made by agency policies and protocols and by the American Nurses Association. Reference: Timby, B. K. Fundamental Nursing Skills and Concepts, 11th ed., Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017, Chapter 3: Laws and Ethics, p. 36.
Which client is most likely to develop prostate cancer according to a nurse working at a health screening at the local mall? 1. A 35-year-old African American man 2.A 17-year-old Caucasian man 3.A 56-year-old African American man 4.A 60-year-old Asian American man
A 56-year-old African American man Explanation: Age over 40 and African American race are both risk factors for prostate cancer. Age younger than 40 and Asian heritage reduce the risk of prostate cancer.
After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that 1.membership is open to all nurses in the United States. 2.ANA invites students showing excellence in scholarship to become members. 3.Members include nurses, other health care providers, and lay people. 4.ANA aims at fostering high standards of nursing in the United States.
ANA aims at fostering high standards of nursing in the United States. Explanation: ANA aims at fostering high standards of nursing in the United States. Membership is not open to all nurses in the U.S; only registered nurses (RNs) can become members. Members of the National League for Nursing, not the ANA, include nurses, other health care providers, and lay people. Sigma Theta Tau, not ANA, invites students showing excellence in scholarship to become members.
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? 1.Absence seizure 2.Focal seizure 3.Generalized seizure 4.Unclassified seizure
Absence seizure Explanation: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.
The LPN is in the midst of a client's assessment when the client mentions not having had a bath yet today. The LPN asks the CNA to complete the client's bath before lunch. Just before lunch the LPN checks in with the client about the bath. What does this behavior demonstrate? 1.All of the responses are correct. 2.Supervision 3.delegation 4.accountability
All of the responses are correct. Explanation: Primary functions of LPN/LVNs as leaders/managers include delegation, supervision, responsibility, and accountability. In certain settings, LPN/LVNs may be team leaders and thus assigned to oversee the work of unlicensed assistive personnel (UAP). These roles require the LPN/LVN to delegate responsibility for certain tasks and supervise the accomplishment of the work. The LPN/LVN is accountable for determining if the task is accomplished and if there are any issues associated with completing or not completing the task. The LPN has delegated a task and is supervising its completion. When the LPN/LVN delegates a task, he or she is accountable for determining if the task is accomplished.
Therapeutic communication techniques between client and nurse facilitate continuity of care. Which of the following identifies the value of therapeutic communication? Select all that apply.
Allows the nurse to display interest in the client and the communication Helps the nurse to assist the client to explore and understand his or her problems
What nursing organization first legitimized the use of the nursing process? 1.International Council of Nursing 2.American Nurses Association 3. State Board of Nursing 4. National League for Nursing
American Nurses Association Explanation: Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance.
Which organization is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice? 1. National League for Nursing (NLN) 2. American Association of Colleges in Nursing (AACN) 3. International Council of Nurses (ICN) 4. American Nurses Association (ANA)
American Nurses Association (ANA) Explanation: The ANA produced the 2015 Nursing: Scope and Standards of Practice, which defines the activities specific and unique to nursing. The AACN addresses educational standards, while the NLN promotes and fosters various aspects of nursing. The ICN provides a venue for national nursing organizations to collaborate, but does not define standards and scope of practice.
The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification? 1. Associate degree 2. Diploma 3. Graduate degree 4. Baccalaureate
Associate degree Explanation: An associate degree in nursing is typically a 2-year program that is offered at a community college or junior college. Such a degree allows a nurse to plan and provide care, but further education is often necessary for administrative positions. A diploma is often provided under the auspices of a hospital, while both baccalaureate and graduate degrees involve a minimum of 4 years of education; both degrees qualify a nurse to act in a supervisory role.
A home health nurse is preparing to make the initial visit to a new client's home. When planning educational interventions, what information should the nurse provide to the client and his or her family? 1. Dates and times of all scheduled home care visits 2.Information on other clients in the area with similar health care needs 3.Available community resources to meet their needs 4.The nurse's contact information and credentials
Available community resources to meet their needs Explanation: The community-based nurse is responsible for informing the client and family about the community resources available to meet their needs. During initial and subsequent home visits, the nurse helps the client and family identify these community services and encourages them to contact the appropriate agencies. When appropriate, nurses may make the initial contact. It is inappropriate to ever provide information on other clients to a client. The nurse's credentials are not normally discussed. Giving the client the dates and times of their scheduled home visits is appropriate, but may not always be possible. It is more important to provide information about resources available within the community.
A client with a 25-year history of smoking is diagnosed with emphysema. Physical assessment reveals an increased anterior-posterior chest diameter. Which term should the nurse use to document this finding?
Barrel chest
A nurse is providing an educational event to a local men's group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group? 1. Native Americans/First Nations 2. Caucasians 3. Asians 4. Blacks
Blacks Explanation: Black men have a high risk of prostate cancer.
How can you ensure safety?
By following KSAs outlined by QSEN The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. Using the Institute of Medicine competencies, QSEN faculty and a National Advisory Board have defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency. These definitions are shared in the six tables below as a resource to serve as guides to curricular development for formal academic programs, transition to practice and continuing education programs.
A nurse provides client care within a philosophy of ethical decision making and professional expectations. What is the nurse using as a framework for practice? 1.Code of Ethics 2.Definition of Nursing 3.Standards of Care 4.Values Clarification
Code of Ethics Explanation: A professional code of ethics provides a framework for making ethical decisions and sets forth professional expectations. Codes of ethics inform both nurses and society of the primary goals and values of the profession.
Which is the nurse's best legal safeguard? 1.Written or implied contracts 2.Collective bargaining 3.Client education 4.Competent practice
Competent practice Explanation: Competent practice is the nurse's most important and best legal safeguard. Each nurse is responsible for making sure her educational background and clinical experience are adequate to fulfill the nursing responsibilities laid out in the job description. Collective bargaining, written or implied contracts, and/or client education do not provide the best legal safeguard.
A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? 1. Ask the mother if the infant's heart rate is higher than normal. 2. Consult reference materials to determine the normal vital signs for 1-month old infants. 3. Perform a complete physical assessment to determine the cause of the elevated vital signs. 4. Report the vital signs and allow the emergency room physician to determine the significance.
Consult reference materials to determine the normal vital signs for 1-month old infants. Explanation: It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary a this time.
subconcepts of safety
Culture of Safety Sentinel Events National Patient Safety Goals Adverse Events Near Miss Events
positive consequences of safety
Culture of Transparency Uneventful Discharge No Harm
negative consequences of safety
Death Injury Extended Hospitalization Cost Liability Cost Emotional anguish of patient, family, and nurse
After observing a code blue situation, a nursing student asks a member of the code team what the treatment of choice is for witnessed ventricular fibrillation. The best response by the nurse is which of the following? 1. Defibrillation 2. Cardiac catheterization 3. IV bolus of dobutamine 4. IV bolus of lidocaine
Defibrillation Explanation: Because there is no coordinated cardiac activity, cardiac arrest and death are imminent if the dysrhythmia is not corrected. Early defibrillation is critical to survival.
National Patient Safety Goals-
Developed by TJC, established to help accredited organizations address specific areas of concern in regard to patient safety. Patient Safety Advisory Group, composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals with hands-on experience in addressing patient safety issues in a variety of healthcare settings, update yearly.
While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? 1.Ignore the comment because the patient is unconscious. 2.Discourage the colleague from making such comments. 3.Realize that humor is needed in the workplace. 4.Report the comment immediately to a supervisor.
Discourage the colleague from making such comments. Explanation: Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.
An adult client scheduled for surgery chooses to waive the right to informed consent. What should the nurse do? 1.Document that the client waived the right in the medical record. 2.Obtain consent from another family member. 3.Inform the client that the hospital will not be liable if anything goes wrong. 4.Decline to send the client for the surgery until consent is assigned.
Document that the client waived the right in the medical record. Explanation: A client who waives the right to informed consent does not waive accountability for the hospital to provide competent care. The client only declined to hear the details of the procedure and did not refuse treatment. Accepting to go for surgery is implied consent; therefore, the nurse should not decline to send the client for surgery. Because the client is of legal age, another family member should not be asked for consent. This may violate the client's right to confidentiality. The client has a right to self determination; therefore, the correct action is to document that the client waived their right to informed consent.
A client states that his recent fall was caused by the fact that his scheduled antihypertensive medications were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? 1. Consult with practice advisors from the state board of nursing. 2. Consult with the hospital's legal department as soon as possible. 3. Document the client's claims and the events surrounding the alleged incident. 4.Enlist support from nursing and non-nursing colleagues from the unit.
Document the client's claims and the events surrounding the alleged incident. Explanation: It is imperative for nurses to carefully and accurately document assessment findings and the nursing care that they provide, a fact that is especially salient when legal action is anticipated. This thorough and accurate assessment should precede consultation with the legal department, the state board of nursing, and colleagues.
Medication Administration-
Everything Lab Professors Say and Have Said!!! -Six Rights -Seven Parts of a Complete Order -Agency Policies -Recording and Reporting -What Else???
A nursing student has established a strong therapeutic rapport with a patient who was admitted to the hospital with a perforated appendix. The patient is similar in age to the student and is interested in a career in nursing. Before being discharged, the patient asks if she can add the student as a contact on a social networking site in order to ask her more questions about nursing. How should the student respond to the patient's request? 1. Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged. 2. Offer to answer the patient's questions by e-mail rather than through contact on a social networking site. 3. Explain why nursing ethics does not allow online contact between nurses and patients. 4.Explain why she cannot fulfill the patient's request but offer to meet her in person to answer questions about nursing school.
Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged. Explanation: Nurses are not permitted to have social contact with patients, whether by electronic or face-to-face means. However, there is no reason not to answer the patient's queries about nursing school and the nursing profession prior to the patient's discharge.
Hospitals Must Have Plans For-
Exposure Control PPE Regulated Waste Containment Post Exposure Evaluations and Follow Up Fire and Safety Fire Drills and Alarm Notifications Maintenance of Fire-Safety Equipment and Building Features Hospital Physical Security Emergency Preparedness
A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process?
Flight of ideas
A famous pregnant client comes to the health care provider's office for a routine prenatal examination. While the client is in the office, the media arrives asking for information about the client. What should the nurse do? 1.Ask the media to wait until the client is finished with her health care provider's visit. 2.Inform the media that you can't comment about whether the person is being seen in the office. 3.Phone the police to remove the members of the media from the office. 4.Immediately notify security to have the media removed.
Inform the media that you can't comment about whether the person is being seen in the office. Explanation: The nurse should inform the media that she must maintain client confidentiality and cannot comment about whether the person is being seen in the office. It is not necessary to phone the police. Asking the media to wait until the client is done with the health care provider visit is a violation of the client's rights. The nurse should refuse to answer any questions or provide any information.
What must exist before Safety can?
Knowledge of risk Professional accountability Motivation to achieve safety Effective system processes Collaboration
What was one barrier to the development of the nursing profession in the United States after the Civil War? 1. Independence of nursing orders 2. Lack of influence from nursing leaders 3. Hospital-based schools of nursing 4. Lack of educational standards
Lack of educational standards Explanation: A lack of educational standards was one barrier to the development of the nursing profession after the Civil War. Other barriers included a male dominance of health care and the pervading belief that women were dependent on men. The location of nursing schools, a lack of influence from nursing leaders, and independent nursing orders were not barriers to the development of the nursing profession after the Civil War.
What is the legal source of rules of conduct for nurses? 1. American Nurses Association 2.Nurse Practice Acts 3.Agency policies and protocols 4.Constitution of the United States
Nurse Practice Acts Explanation: Nurse Practice Acts are examples of statutory law, enacted by a legislative body in keeping with both the federal constitution and the applicable state constitution. They are the primary source of rules of conduct for nurses. Standards of practice, which differ from rules of conduct, are made by agency policies and protocols and by the American Nurses Association.
What phrase best describes nurse-initiated interventions? 1.Interventions based on medical orders 2.Health care team interventions 3.Physician-prescribed interventions 4.Nurse-prescribed interventions
Nurse-prescribed interventions Explanation: Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from an assessment of client needs written on the plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional.
Which statement about time management is true? 1. Nurses who are self-aware and have clearly identified personal goals and priorities have greater control over how they spend their time; expend their energy, and what they accomplish. 2. Most people have an accurate perception of the time they spend on a particular task or the total amount of time they are productive during the day. 3. Writing goals down is a waste of time if the goals are limited in number. 4. It is necessary to maintain a time inventory for only 2 or 3 days to establish a pattern of time management
Nurses who are self-aware and have clearly identified personal goals and priorities have greater control over how they spend their time; expend their energy, and what they accomplish. Explanation: Nurses who are self-aware and have clearly identified personal goals and priorities have greater control over how they spend their time; expend their energy, and what they accomplish.
Environmental Safety
OSHA enforces laws and regulations to ensure protection against work exposures. Life Safety Codes are enforced by the EPA and reviewed every three years by TJC. Some states and municipalities also have laws and regulations concerning hazardous material and fire safety.
The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone? 1.Record "T.O." at the end of the order. 2.No extra documentation is necessary. 3.Have another nurse cosign the order input. 4.Tell the provider to sign the order as soon as possible.
Record "T.O." at the end of the order. Explanation: Recording "T.O." at the end of the order indicates that this was a telephone order. Another nurse should not cosign. Reminding the provider to sign the order as soon as possible is helpful, but does not indicate that this was a telephone order.
A nurse accidentally sustains a needlestick injury. Which would the nurse do first? 1. Report the injury to a supervisor. 2. Receive post-exposure drug treatment prophylaxis. 3. Obtain the client's HIV and hepatitis B virus status. 4. Document the injury in writing.
Report the injury to a supervisor. Explanation: If an accidental injury occurs with a needlestick, the nurse should first report the injury to a supervisor. This would be followed by documenting the injury in writing, identifying the client if possible, obtaining HIV and hepatitis B virus client status results, if legal to do so, obtain counseling on the potential for infection, and receive the most appropriate post-expsoure drug treatment prophylaxis.
A nurse brings gifts and flirts with a 16-year-old male client who's undergoing rehabilitation after sustaining a spinal cord injury that left him paralyzed below the waist. When a coworker confronts the nurse, the nurse replies, "He knows it's just in fun." How should the coworker handle this ethical dilemma? 1. Discuss her concerns with the client. 2. Inform the client's parents of the nurse's inappropriate behavior. 3. Report the situation to the nursing supervisor. 4. Do nothing because the situation doesn't concern her.
Report the situation to the nursing supervisor. Explanation: After confronting the nurse, the coworker should report the situation to the nursing supervisor. It's inappropriate for the coworker to involve the client or his parents. Failure to intervene can be considered neglect.
As a result of a needlestick inury, a hospital nurse has experienced percutaneous exposure to the blood of a client who is HIV-positive. The nurse has informed the supervisor and identified the client. What action should the nurse take next? 1. Follow up with the nurse's primary care provider. 2. Flush the wound site with chlorhexidine. 3. Report to the emergency department or employee health department. 4. Apply a hydrocolloid dressing to the wound site.
Report to the emergency department or employee health department. Explanation: After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurse's own primary provider would require an unacceptable delay.
A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response? 1.State, "I cannot give medications for other nurses." 2.Ask another staff nurse to give the medications. 3.Hold the medications for Nurse A. 4.Administer the medications.
State, "I cannot give medications for other nurses." Explanation: Nurses must never administer medications prepared by another nurse. Nurse B will professionally reply, "I cannot give medications for you." Nurse B should not hold the medications, nor ask another nurse to give the medications.
The nurse has confirmed the client's identity and provided a client with oral medications to take. What is the next appropriate nursing intervention? 1. Leave the room 2. Assess for therapeutic effect of medications. 3. Stay with the client while medications are taken. 4. Document medication administration.
Stay with the client while medications are taken. Explanation: The nurse must wait with the client to personally acknowledge that medications have been taken (or refused). Other actions are taken after the client has taken the medication. Reference: Timby, B. K. Fundamental Nursing Skills and Concepts, 11th ed., Philadelphia, Wolters Kluwer. Chapter 32: Oral Medications, p. 765.
Which sign or symptom suggests that a 5-year-old boy who does not maintain eye contact or speak may have autism spectrum disorder (ASD)?
The child constantly opens and closes his hands.; Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for ASD
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
The client appears mildly ill, listless, and disheveled.
The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?
The client reports waking up this morning with a severe headache.
You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client?
The client's preferred method of communication
The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis? 1.The most common cause of anaphylaxis is penicillin. 2.Systemic reactions include urticaria and angioedema. 3.Anaphylactoid (anaphylaxis-like) reactions are commonly fatal. 4.The most common food item that causes anaphylaxis is chocolate.
The most common cause of anaphylaxis is penicillin. Explanation: The most common cause of anaphylaxis is penicillin, accounting for about 75% of fatal anaphylactic reactions in the United States. Although possibly severe, anaphylactoid reactions are rarely fatal. Food items that are common causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Local reactions usually involve urticaria and angioedema at the site of the antigen exposure. Systemic reactions, which occur within about 30 minutes of exposure, involve cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.
Which personnel are legally responsible for obtaining the client's informed consent for a surgical procedure? 1.The licensed practical nurse 2.Any licensed person 3.The admissions clerk 4.The registered nurse 5.The surgeon
The surgeon Explanation: The surgeon is legally responsible for obtaining the client's informed consent.
A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure? 1. The test is noninvasive, and nothing will be inserted into the client's body. 2. The test will provide a detailed profile of the heart's electrical activity. 3. The client's pain will be managed aggressively during the procedure. 4. The client will remain on bed rest for 1 to 2 hours after the test.
The test is noninvasive, and nothing will be inserted into the client's body. Explanation: Before transthoracic echocardiography, the nurse informs the client about the test, explaining that it is painless. The test does not evaluate electrophysiology and bed rest is unnecessary after the procedure.
When assessing a toddler's language development, what is the standard against which you measure language in a 2-year-old toddler?
The toddler should speak in two-word sentences ("Me go").
standard precautions
Those precautions designed for the care of all patients in hospitals, regardless of their diagnosis or presumed infection status Used for all body fluids, secretions, and excretions regardless of whether or not they contain visible blood
The nurse has withdrawn opioid pain medication into a syringe. When preparing to administer the medication, the client refuses, stating that pain is controlled currently at a level of 2 on a scale of 1 to 10. What is the appropriate nursing action? 1. Hold the medication in cargo pocket to give later. 2. Squirt the medication down the client's sink while the client watches. 3. Waste the medication with another nurse witness present. 4. Administer the medication to control future pain.
Waste the medication with another nurse witness present. Explanation: Opioids must strictly be accounted for because they are a controlled substance. In this case, the nurse must waste that medication with another nurse witness present and document that this was done. It is inappropriate to continue to administer the medication, to hold the medication in a cargo pocket, or to waste the medication without another nurse witness present.
Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse then makes a judgment and documents a statement summarizing those findings. This statement is called:
an evaluative statement.
A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?
checking vital signs and assessing for nonverbal indications of pain
Nursing care is provided in an increasingly diverse variety of settings. Despite the variety in settings, some characteristics of professional nursing practice are required in any and every setting. These characteristics include: 1.advanced education. 2.independent practice. 3.cultural competence. 4.certification in a chosen specialty.
cultural competence. Explanation: Cultural competence is necessary in any and every care setting. The other answers are incorrect because an advanced education, specialty certification, and the ability to practice independently are not consistencies between every nursing care delivery setting.
When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:
medical terminology.
When communicating with clients nurses need to be very careful in their approach. This is particularly true when communicating using: 1. written material. 2. audio-visual material. 3. demonstration. 4. medical terminology.
medical terminology. Explanation: Another filter is the particular language system into which the person is socialized. Nurses are socialized into health care or medical jargon. To effectively educate and communicate, the nurse should limit medical jargon.
A type of comprehensive care for clients whose disease is not responsive to cure is 1. euthanasia 2. interdisciplinary collaboration 3. palliative care 4. a terminal illness.
palliative care. Explanation: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care.
What is an example of drug diverson? The nurse: 1.takes a medication from one client's container to use for another person. 2.uses stock supply for administering a medication ordered stat. 3.maintains an accurate count of narcotics every shift. 4.obtains medication for the client from the automated medication-dispensing system.
takes a medication from one client's container to use for another person. Explanation: Drug diverson refers to theft or possession of a medication for the use of someone else. It is appropriate to obtain medication for the client from the automated medication-dispensing system, use stock supply for administering a medication ordered stat, and maintain an accurate narcotic count every shift.
A laboring woman has brought her partner as her support person who is dressed in feminine attire, but when she speaks, it is clear to the nurse that the support person has a male voice. When documenting about the client's support person, which term would be most appropriate?
transgender
The nurse reports a nursing colleague on the unit who is lethargic and verbally responds in a slow manner. This is an example of: 1.ensuring adequate staffing. 2.delegating nursing care. 3.whistle-blowing. 4.collective bargaining.
whistle-blowing. Explanation: Whistle-blowing is when the nurse reports unsafe practice environments. Impaired nurses threaten the safety of clients in the clinical setting, as does inadequate staffing. Nurses may delegate or assign tasks involve in the delivery of nursing care to individuals as long as the individual has sufficient knowledge and skill to perform the assigned task. Collective bargaining is a legal process in which representatives of organized employees negotiate with employers about work conditions. Reference: Timby, B. K. Fundamental Nursing Skills and Concepts, 11th ed., Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017, Chapter 3: Laws and Ethics, p. 48. Chapter 3: Laws and Ethics - Page 48
