Exam 1

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply. Obtain a health care provider order 2 hours after restraints are applied. Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly. Continue using the restraints until discharge.

> Communicate with the family regarding the need for restraints. > Check circulation and skin condition frequently and regularly. > Offer opportunities for toileting frequently and regularly.

A client has been discharged from the hospital following orthopedic surgery and has a referral for home health care. Which actions should the home health nurse perform during the entry phase of the home visit for this client? Select all that apply. Develop rapport with the client and family Make an initial and thorough assessment Negotiate the time for the next home visit Determine the treatment prescribed for the client Collect client information

> Develop rapport with the client and family > Make an initial and thorough assessment > Negotiate the time for the next home visit

Which qualities are essential for a community-based nurse? Select all that apply. Strong knowledge foundation Effective communication skills Keen physical assessment skills Ability to delegate client care tasks to unlicensed assistive personnel Competence in assisting with minor surgical procedures

> Strong knowledge foundation > Effective communication skills > Keen physical assessment skills

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. airborne precautions droplet precautions contact precautions respiratory precautions microbial precautions body fluid precautions

> airborne precautions > droplet precautions > contact precautions

During a nursing shift, which events warrant completion of an incident report? Select all that apply. A nurse reports that a client is crying and distraught over a diagnosis of metastatic cancer. An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. A visitor slipped and fell in the hallway, but was not injured. A client falls while being transferred from the bed to the chair. A nurse asks an unlicensed assistive personnel (UAP) to feed a client.

>An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. >A visitor slipped and fell in the hallway, but was not injured. >A client falls while being transferred from the bed to the chair.

Which are components of the nursing case management process? Select all that apply. Coordinating Making referrals Monitoring medical progress Prescribing medications Driving a client to appointments Filing and completing paperwork

>Coordinating >Making referrals >Monitoring medical progress >Filing and completing paperwork

A nurse has applied soft wrist restraints to a client following endotracheal intubation. Documentation of which information is essential when using restraints on a client? Select all that apply. Findings from client assessment, performed every 2 hours Family presence at the bedside Foley catheter draining clear yellow urine 0.9 normal saline infusing intravenously at 100 mL/hr Chest physiotherapy completed

>Findings from client assessment, performed every 2 hours >Foley catheter draining clear yellow urine >0.9 normal saline infusing intravenously at 100 mL/hr

Root cause analysis would identify an active error in which adverse event? A. A nurse drew up 20 units of insulin rather than 2 units by misreading the lines on the syringe. B. A client contracted Clostridium difficile because the labeling system for clean and dirty commodes was changed. C. Several blood glucose readings were inaccurate because glucometers were not calibrated for several weeks. D. A client was not returned to the unit from radiology for several hours because the communication protocol between departments was changed.

A. A nurse drew up 20 units of insulin rather than 2 units by misreading the lines on the syringe.

A nursing educator is encouraging nurses on a unit to evaluate their practice in light of the Quality and Safety Education for Nurses (QSEN) project. What nursing action best demonstrates the QSEN competencies? A. A nurse regularly asks clients and their families about their preferences for care. B. A nurse exceeded the minimum level of continuing education over the past year. C. A nurse works in more than one area of specialty in order to broaden her experience base. D. A registered nurse begins working on a masters degree part time.

A. A nurse regularly asks clients and their families about their preferences for care.

Which is an emerging trend in health care delivery? A. Active involvement of consumers B. Resolution of the nursing shortage C. Simplification of client care D. Reduction in the use of technology at the bedside

A. Active involvement of consumers

During the initial visit to a client's home, the nurse should provide the client and family with what information? A. Available community resources to meet their needs B. Information on other clients in the area with similar health care needs C. The nurse's phone number and home address D. Dates and times of all future home care visits

A. Available community resources to meet their needs

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies? A. Health care institution B. Federal legislation C. State legislation D. Board of nursing

A. Health care institution

Which statement best describes health? A. Health is individually defined by each person. B. Health is experienced by each person in exactly the same way. C. Health is the opposite of illness. D. Health is the absence of disease.

A. Health is individually defined by each person.

Which of the following is a principle of Therapeutic Touch (TT)? A. Human beings have natural abilities to transform and transcend their conditions of living. B. Human beings are a closed energy system. C. Human beings are unilaterally symmetrical. D. Illness is a balance in an individual's energy field.

A. Human beings have natural abilities to transform and transcend their conditions of living.

A hospital visit by an accreditation body has revealed that many of the clients in a hospital are not receiving the daily assistance with hygiene that they are entitled to. Which strategy is most likely to ensure that all necessary care is consistently provided? A. Introduce a checklist where daily hygiene tasks are specifically listed. B. Remind nurses of the standards of nursing practice and their relationship to care. C. Report this situation to the Joint Commission. D. Introduce a care bundle that includes hygiene tasks.

A. Introduce a checklist where daily hygiene tasks are specifically listed. (Care bundles are generally used for more complex and multidimensional aspects of care.)

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

A. Nonmaleficence

The client's plan of care is created by the nurse using which guideline for nursing practice? A. Nursing process B. Nursing's Social Policy Statement C. Nurse practice act D. ANA Standards of Nursing Practice

A. Nursing process

While providing client care, a nurse determines that a client adheres to the health belief model. What would the nurse need to assess as a factor possibly affecting the client's response to illness? A. Personality characteristics B. Nutritional awareness C. Stress management D. Environmental sensitivity

A. Personality characteristics

A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints? A. Take a health care provider's order for restraining. B. Administer chemical restraints first. C. Put padding below the restraints. D. Reassess the client's condition every 2 hours.

A. Take a health care provider's order for restraining.

Which is the best definition of ethics? A. The formal, systematic study of moral beliefs B. The informal, systematic study of moral beliefs C. The adherence to formal personal values D. The adherence to informal personal values

A. The formal, systematic study of moral beliefs

A nurse exits the room of a confused client without raising the side rails on the bed. The failure to raise the side rails would constitute which element of liability related to malpractice? A. breach of duty B. duty C. causation D. damages

A. breach of duty (Breach of duty is failing to meet the standard of care, and in this case, it was the failure to execute and document the use of appropriate safety measures. Causation is the failure to use appropriate safety measures, which results in injury to the client.)

A focus of health care today is community-based care. What is community-based care? A. care provided to a population within a defined geographic area B. a focus on providing appropriate care for problems that cannot be treated in a hospital setting C. care that is primarily focused on the social and spiritual health of the community D. a form of population-based care that is exclusively provided by nurses

A. care provided to a population within a defined geographic area

A nurse has begun working on a hospital unit where there are a large proportion of clients who have limited mobility and who require assistance with transfers. Nurses' risks for back injury can best be reduced by: A. educating them about safe client handling practices. B. acquiring mechanical devices to assist with transfers and lifts. C. screening clients for reduced mobility on admission. D. assigning stronger nurses to the clients with reduced mobility.

A. educating them about safe client handling practices. (Education is key to safe nursing practice and to risk reduction. Without adequate education, having the correct equipment is of no benefit.)

A hospital client's urine output is 35 mL over the past 5 hours, so the nurse has chosen to inform the client's primary care provider by telephone. The nurse will use the SBAR tool to communicate, so will begin the dialogue by: A. giving an overview of the client's circumstances and the exact reason for the call. B. describing the major objective signs that the client is exhibiting. C. explaining the client's symptoms and suggesting a preliminary plan. D. introducing the client and listing the client's current medications.

A. giving an overview of the client's circumstances and the exact reason for the call.

Which of the following illustrates the activity of acting in values clarification? A. respecting the human dignity of all clients B. seeking public affirmation for actions C. disregarding several alternatives when choosing D. considering consequences of actions

A. respecting the human dignity of all clients (When one values something, one chooses freely from alternatives after careful consideration of the consequences of each alternative. Acting incorporates the choice one makes for behavior and follows that choice consistently (e.g., respecting human dignity for all clients).

A nurse is preparing to insert a peripheral intravenous (IV) into a client who requires IV fluids. How can the nurse best demonstrate the skills that indicate the nurse meets the Quality and Safety Education for Nurses (QSEN) competency of safety? A. selecting an appropriate vein and establishing access aseptically B. being aware of the signs of infiltration and other complications of therapy C. having empathy for the client and recognizing that the procedure is painful D. knowing the assessment findings that indicate therapy has been successful

A. selecting an appropriate vein and establishing access aseptically

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the health care provider and completes the incident report. Which statement should the nurse document in the incident report? A. The client was trying to lower the side rails. B. The client was found lying on the floor. C. The client was trying to get out of the bed. D. The client was not aware that the client had fallen.

B. The client was found lying on the floor.

A nurse prepared a client's medication, brought it to the client's bedside and then realized at the last minute that the medication was for another client of similar age and appearance. Follow-up to this event should include: A. a suspension for the nurse, pending the completion of remedial education. B. completing an incident report describing this near miss. C. documenting this latent error and reporting it to relevant state agencies. D. revising the procedures by which medications are distributed on the unit.

B. completing an incident report describing this near miss.

A nurse is providing care for a client with cancer. The client's spouse requests that the client not be told that the client is terminal. The nurse complies with this request. The nurse's action is a breach of which ethical principle? A. justice B. fidelity C. beneficence D. nonmaleficence

B. fidelity (The principle of fidelity involves the nurse being faithful to the client, who has the right to the truth. By not telling the client, the nurse is not being faithful to the client. Justice is acting fairly. In this scenario, the nurse do not need to recognize any bias or discrimination in the distribution of care. Beneficence is the act of doing of good. The nurse is not doing good by withholding the information. Nonmaleficence means not harming or inflicting the least harm possible to reach a beneficial outcome. The nurse is inflicting harm by not being faithful to the client.)

A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. The nurse helps the client to get up, makes him comfortable, and then informs the health care provider. The health care provider advises the nurse to prepare an incident report. What is the purpose of an incident report? A. to provide a method of deciding the nurse's fault in the incident B. to evaluate quality care and potential risks for injury to the client C. to provide information to local, state, and federal agencies D. to evaluate the immediate care provided by the nurse to the client

B. to evaluate quality care and potential risks for injury to the client

Which action by hospital nurses is the best example of an at-risk behavior? A. A nurse documents that a set of vital signs were taken even though they were not. B. A nurse falsifies the time of a client's glucometer reading so it doesn't appear to be late. C. A nurse brings two clients' medications into their room to save time and makes a drug error. D. A nurse forgets to taper down a client's supplementary oxygen during a busy shift.

C. A nurse brings two clients' medications into their room to save time and makes a drug error. (Mixing up two clients' medications because of a misguided effort to save time would likely be considered an at-risk behavior. Forgetting to do an ordered intervention would likely be considered a human error. Falsifying records to cover up lapses in care is a serious violation that would be considered to be reckless.)

What type of law regulates the practice of nursing? A. Common law B. Public law C. Civil law D. Criminal law

C. Civil law

A nurse is pouring a client's scheduled medications at the medication cart outside the client's room when a colleague asks for assistance with transferring another client from the commode. What is the nurse's most appropriate response? A. Secure the medication in the cart and administer it promptly after assisting the colleague. B. Label the medication, secure it in the cart, and administer it promptly after assisting the colleague. C. Help the colleague after administering and documenting the medication. D. Ask another nurse to help the colleague so that the client's medication can be administered.

C. Help the colleague after administering and documenting the medication.

What is the primary ethical dilemma posed when using restraints on an older adult client in a long-term care setting who is confused? A. It limits personal safety. B. It increases confusion. C. It threatens autonomy. D. It prevents self-directed care.

C. It threatens autonomy.

A nurse makes a medication error and fills out an incident report. What will the nurse do with the safety event report once it is filled out? A. Place it in the client's medical record. B. Take it home and keep it locked up. C. Maintain it according to agency policy. D. Include it with documentation of the error.

C. Maintain it according to agency policy.

The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion? A. Primary B. Secondary C. Tertiary D. Chronic

C. Tertiary

The manager of a geriatric medicine unit is reviewing some of the incident reports that have been filed over the past several months. One report describes an event where a nurse raised all four side rails of a confused client's bed, causing the client to fall when he tried to climb over them to go to the restroom. Which of the following statements about this incident is most accurate? A. The root cause of the incident was the client's decreased cognition. B. The root cause of the incident was the nurse's flawed decision-making. C. The client's nurse committed an active error by raising all four of the side rails. D. The location of the restroom relative to the client's bed was a latent error.

C. The client's nurse committed an active error by raising all four of the side rails. (The nurse erred in raising the client's side rails and facilitating a fall. The location of the restroom does not constitute a latent error because this is not a systemic or procedural flaw that makes an error possible. Root cause analysis would have to be undertaken to determine the true root causes, but the client's diagnosis and the nurse's decision making are likely to be considered to be contextual factors, not the ultimate causes of the event.)

A nurse wishing to learn about techniques of Therapeutic Touch (TT) is referred to a trained practitioner to observe the technique. While the practitioner is in the centering stage, which activity would the nurse most likely observe? A. practitioner moves the hands 2 to 6 in (5 to 16 cm) from the client's skin surface B. practitioner gathers information about energy fields and energy flow C. practitioner brings attention inward to a peaceful state of consciousness D. practitioner modulates energy with the goal of restoring balance

C. practitioner brings attention inward to a peaceful state of consciousness

Which method involves using a special machine to become alert to body processes and to learn to control them? A. Reflexology B. Magnetism C. Acupuncture D. Biofeedback

D. Biofeedback

A nurse is reviewing information on holistic health care about "Being" and "Doing" therapies. Which of the following would the nurse identify as a characteristic feature of "Being" therapy? A. It is measurable. B. It has linear outcomes. C. It is unaffected by consciousness. D. It is a bridge between individuals.

D. It is a bridge between individuals. (The "Doing" therapies have measurable, linear outcomes. "Being" therapies recognize the less measurable effects of consciousness both within the person and as a bridge between individuals.)

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? A. The nurse adds the information in the safety event report to the client health record. B. The nurse calls the primary health care provider to fill out and sign the safety event report. C. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. D. The nurse details the client's response and the examination and treatment of the client after the incident.

D. The nurse details the client's response and the examination and treatment of the client after the incident.

Which social force has most significantly impacted the future supply and demand of nurses? A. economics B. technology C. science D. aging

D. aging

During a busy shift at a long-term care facility, three call lights are illuminated simultaneously. A nurse is walking toward the closest of the three rooms and notices a colleague preparing medications in the hallway. The nurse should: A. ask the colleague if any of the medications must be urgently administered. B. ask the colleague to respond to the call light in the room that is nearest the medication cart. C. ask the colleague to respond to a call light as soon as the medications have been given. D. avoid talking to the colleague unless there is evidence of an urgent client need.

D. avoid talking to the colleague unless there is evidence of an urgent client need.

Which of the following is a current trend affecting nursing education and practice? A. overabundance of graduating nurses B. office-based care delivery systems C. increase in length of hospital stay D. increase in chronic health conditions

D. increase in chronic health conditions

What is the legal source of rules of conduct for nurses? A. agency policies and protocols B. Constitution of the United States C. American Nurses Association D. nurse practice acts

D. nurse practice acts

Nurse Practice Act

State guideline that governs the practice of professional nursing

health

State of well-being and optimal functioning; (b) Interactive process between the person and the internal and external environment