EXAM 2: 1811
Which factor contributes to the risk for client violence toward nurses in an impatient setting? Select all that apply.
- Disturbed personal space caused by a lack of privacy - Improper management of care caused by insufficient staffing - Close physical contact with the nurse caused by the required care
Which action would the nurse preform when receiving a verbal prescription from the health care provider? Select all that apply.
- Ensure the client's medical record is open - Enter the prescription word for word as it is given. - Make an entry in the nurse's notes describing the situation.
Which statement made by a client is accurate regarding the electronic health record (EHR)
"Errors caused by poor handwriting are prevented."
Which statement represents objective data documented by the nurse?
"Eyes downcast, flat effect"
Which addition is recommened by the American Association of Colleges of Nursing (ACCN) to improve the Situation, Background, Assessment, and Recommendation (SBAR) form of communication? Select all that apply.
- Introduction - Read-back
Which transmission prevention precaution is recommended when the nurse is caring for a client who is positive for hepatitis A?
Using gloves when removing the client's bedpan
Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision? Select all that apply.
- Put the call light within reach. -Orient the client to surroundings.
Which system is essential for the nurse to auscultate while performing the physical assessment? Select all that apply. One, some, or all responses may be correct.
- Respiratory - Cardiovascular - Gastrointestinal
Which interaction by the nurse could be considered inappropriate in some cultures? Select all that apply.
- Silence - Touching - Eye contact - Invasion of personal space
Which information will the employee health nurse include when teaching about ways to prevent transmission of influenza in the workplace?
- Sneeze or cough into the upper sleve - Use alcohol- based hand sanitizers after blowing the nose - Turn the head away when coughing or sneezing
The nurse finds that a patient has reduced muscle tone and absence of pupillary reflex.Which coma stage would this be?
IV : 4
After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococcus (VRE), which step would the nurse take to ensure proper disposal of soiled dressing?
Place the dressing in a RED/ HAZARDOUS materials bag.
Which nursing action displays the use of evidence- based practice according to the institute of Medicine 21st century competencies when caring for a client with Parkinson disease who belongs to a distinct culture?
- The nurse refers to several journals to understands the client's cultural practices. - The nurse collaborates with an interpreter to teach the client about medical procedures. - The nurse evaluates data about the incidences of Parkinson disease in the client's client's community. - The nurse customizes the care plan based on extensive research about the client's culture.
Which part of the nursing process is documented in discharge and transfer forms?
Assessment
Which nursing action will promote a healthier intake for an African American patient with a diet high in fat who has developed severe hypertension and cardiovascular disease?
Suggesting baking and broiling instead of frying
Which term does the nurse use to describe a patient's heart rate of 130 beats per minute?
Tachycardia
Which term would the nurse use to describe an abnormally rapid rate of breathing during assessment of the lungs?
Tachypnea
Which essential data would be collected before the primary health care provider begins the medical assessment?
The patient's vital signs
Which element is essential when a nurse is informing the health care provider of a blood pressure of 180/105 mHn in a client who is scheduled for discharge? Select all that apply.
- Clearly communicating what the concern is - Stating the safety issue involved - Explaining why this is a concern
Which goal would the nurse suggest to be included in the nursing plan of care for a client diagnosed with preeclampsia? Select all that apply.
- Client will remain free of injury. - Client will remain alert and oriented. - Client will exhibit normal liver enzymes. - Client will exhibit normal levels of clotting factors. - Client identifies symptoms to report to health care provider.
Which asset of the nurse as a licensed health care professional helps in planning effective nursing care? Select all that apply.
- Critical thinking - Diagnostic reasoning - Ability to synthesize information
An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determine that the parent understands the teaching about contact precautions when the parent makes which statement?
"My gloves must be changed each time I change the baby's diaper."
Which response will the nurse give when a client in the clinic is offered the influenza vaccine and states, "I had the vaccination already last year, so I won't need it now"?
"The immunization changes, so you need to get the vaccine annually to stay protected."
Which statement made by the nurse would help reduce the risk of falling in an older adult with decreased perception of touch? Select all that apply.
- "Hold on to handrails while ambulating." - "Look where your feet are places while walking." "Wear shoes with good support while walking." "If you are unable to change your position frequently, request assistance."
When caring for a client with varicella and disseminated herpes zoster, which type of precaution would the nurse implement? Select all that apply. One, some or all responses may be correct
- Airbone - Contact - Standard
The student nurse asks the nurse the rationale for obtaining baseline vital signs. How would the nurse respond?
Baseline data provide a means of comparison for subsequent vital signs.
Which information would be placed in the medical record before implementing the use of restraints?
A prescription from the health care provider
Which characteristic is the nurse displaying when he or she accepts a patient's cultural and religious beliefs and is aware of his or her own beliefs?
Cultural competence
Which term is defined as a set of learned values, beliefs, customs, and practices taught, shared by a group, and passed from one generation to another?
Culture
Which plan would the nurse implement when working for a team in a long-term care facility who wants to decrease the incidence of influenza?
Administer flu vaccination
Which step of the licensed practical nurse (LPN) nursing process is the nurse using when conducting a client's preoperative nursing interview?
Data collection
A pulse deficit is described as a difference between which rates?
Apical and Radical
Which physical assessment technique is used to listen to sounds produced by the body?
Auscultation
Which principle would the nurse take into consideration when preparing to apply restraints to a client?
Charges of assault and battery may be leveled against nurses who use restraints improperly
Which other factor would be considered when planning care for a group of clients besides making priority decisions based on physiologic needs of clients?
Client expectations
Which information is MOST important for the nurse to document after teaching a client about a low-fat diet?
Client's ability to plan a low-fat meal
A pregnant client needed a cesarean section due to the presence of the active genital herpes. During her postpartum recovery, which type of isolation will the nurse institute for this client?
Contact
The influenza vaccine changes to best suit the strains circulating during a particular flue season. Therefore, people need to be vaccinated annually. The flu vaccine is safe for most adults, but some people with allergies to components of the vaccine cannot receive it. One influenza vaccination is not adequate for lifetime immunity; an annual vaccination is not recommended. Although it is especially important that higher-risk individuals such as adults older than 50 are vaccinated, annual influenza vaccination is recommended for all individuals older than 6 months.
Contact precautions
Which term would the nurse use to refer to the permanent shortening and rigidity of the elbow for a patient who has been cared for the past several years in the home after a stroke?
Contracture
Which diagnosis in a patient's history would support a health care provider's instruction to avoid measuring the temperature of the patient orally?
Convulsions
Who would the nurse plan to include in a discussion about the dangers of social media with a group of adolescents and their parents?
Counselor
The client is about to leave the hospital with an order for home health nursing. Where should the nurse document the physiologic status of the client?
Discharge form
A patient with emphysema tires easily and is not able to tolerate an entire session of range-of-motion (ROM) exercises. Which action would the nurse take to address the patient's fatigue?
Divide the ROM exercises into two or more tolerable sessions.
Which infection control measure would the nurse take for a client with infectious pulmonary tuberculosis?
Don an N95 respirator mask before entering the room
In which position would the nurse place a patient to facilitate an abdominal assessment?
Dorsal Recumbent
Which pulse point does the nurse use when assessing circulation to the foot?
Dorsalis Pedis
A client had a rubella infection (German Measles) during the fourth month of pregnancy. At the time of the infants birth, the nurse places the newborn in the isolation nursery. What type of infection - control precautions should the nurse institute?
Droplet
Which strategy would the nurse recommend to a patient whose family will eat only foods of their culture?
Eat the food of your culture, but find healthier ways to cook them.
Which joint would the nurse identify as a hinge joint if reviewing joint range-of-motion exercises with the unlicensed assistive personnel (UAP)?
Elbow
Which type of documentation uses a modified list of nursing diagnoses as an index for nursing documentation instead of a problems list"
Focus charting format
Which order would the nurse use to perform full range-of-motion (ROM) exercises with an immobilized patient?
Follow a head-to-toe sequence.
Which precaution is needed when caring for a 7 year old child who is human immunodeficiency virus (HIV) positive?
Gloves when in contact with bodily fluids
Which personal protective equipment would the nurse use when changing the bed linens of a client with a draining would infected with methicillin- resistant Staphylococcus aureus (MRSA)
Gown and gloves
An elderly patient comes to the clinic wearing layers of clothing. The patient's temperature on assessment is 99.8° Fahrenheit (F). Which action would the nurse take next?
Have the patient remove some of the layers and reassess.
A female Muslim patient has been assigned to a male nurse and the patient is very upset.The nurse understands that the patient is upset because of which situation related to this patient's religious beliefs?
Her nursing care prover is not a female.
Which center in the brain regulates body temperature?
Hypothalamus
Which action would the nurse take when developing a care plan to ensure that it is culturally sensitive?
Incorporate the patient's cultural behaviors into the plan.
Which intervention would the nurse preform when an adolescent client is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis?
Initiate droplet precautions
Which nursing action is most appropriate to reduce falls in older adults in the hospital?
Instructing the client to call the nurse before going to the bathroom
The patient's temperature rises and falls between fever and normal temperature severa times within a 24-hour period. Which characteristic of fever is the nurse observing in this patient?
Intermittent
Which location would the nurse select as the best placement for the child admitted to the pediatric unit with diagnosis of tuberculosis?
Isolation room
Which condition might an infant born to an American Indian family be affected by?
Lactose Deficiency
Which factor is most important to consider when assessing a patient from a different culture?
Languages spoken
Which step is ESSENTIAL for the nurse to take before transferring a patient to a wheelchair?
Locking the wheelchair
Which food custom would the nurse consider when developing an educational plan for an African American patient?
Many meats and vegetables are high in fat.
Which action indicates a need for further teaching in regard to various record-keeping forms?
Mentioning filing an incident report in the client's nursing notes
Which type of disease is described as an abnormal growth of new tissue, either malignant or benign?
Neoplastic
If a light is shined in a patient's eyes during a physical assessment and the pupils are noted to be equal, round, and reactive to light and accommodation, which system is being assessed?
Neurologic
The nurse is planning care using a multidisciplinary approach for an anxious client admitted to the hospital the night before a planned total knee replacement. Which intervention will be solely the responsibility of the nurse?
Obtaining a history of previous hospitalizations
Which part of the nurse's hand would the nurse use to palpate a patient's lymph nodes?
Pads of the fingers
Which data documented in a patient's record is one of the cardinal signs of a wound infection?
Pain
Which intervention would the nurse perform to prevent external rotation of hips in the patient placed in the supine position?
Place trochanter rolls parallel to lateral surface of thighs.
How would the nurse measure a patient's pulse rate?
Place two or three fingers lightly over the radial artery.
Which action would the nurse recommend to a child care center owner to minimize further transmission of bacterial conjunctivitis when it has affected several children?
Preform thorough handwashing before and after any child in the child care center.
Which use of a restraint is inappropriate?
Prevent an older adult client from getting up at night when there is insufficient staffing on the unit.
The nurse understands that when an American Indian mother requests to give the her newborn baby a back massage, she is demonstrating a ritual that serves which purpose?
Promotes the bonding process
Which strategy does the nurse adopt to ensure effective communication while interacting with parents who are unable to read or write?
Provide instructional material supported by illustrations.
Which precaution would the nurse take for a a client with aplastic anemia whose new laboratory results show low red blood cell (RBC), white blood cell (WBC), and platelet counts?
Removing flowers and live plants from the client's room
Dyspnea indicates a problem with which body system?
Respiratory
If the nurse assumes that a patient is a heavy drinker and poorly educated based on his culture, these preconceived notions about a culture are identified as which concept?
Stereotyping
The nurse notices that the client is not responding to the antibiotics and documents the changes to the original plan of care. Which chartinf format is appropriate to document these changes?
SOAPIER
Which level of Maslow's hierarchy of needs is the nurse addressing when teaching a client how to use the call bell/call light system?
Safety
The nurse will respond with which intervention when caring for a Muslim patient who prays several times a day?
Schedule patient care around these prayer times.
A client had a postpartum hemorrhage and is to receive one unit of packed red blood cells (RBC'S). The nurse completes the intravenous (IV) insertion and blood setup without wearing gloves. Which statement about this behavior is correct?
She should have worn gloves for self- protection.
Which statement correctly illustrates good posture?
The abdominal muscles are tightened
Which characteristic of vital signs of an older patient is MOST important to consider when assessing the vital signs of a resident in a long- term residential facility?
The core temperature averages 97.2 degrees F (36 degree C)
Which statement is true regarding the initial physical assessment and the ongoing physical assessment of a patient?
The initial assessment identifies problems, and the ongoing assessment determines the effectiveness of the care.
Which data can indicate that a patient is experiencing problems with the cardiovascular system?
The jugular vein in the neck is swollen.
The nurse places a child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions?
To keep the child away from uninfected people
Providing culturally sensitive and appropriate patient care is a characteristic of which type of nursing?
Transcultural
Which term would the nurse use when documenting a high- pitched, drum - like sound after completing percussion during a physical assessment?
Tympany
An infant with diarrhea requires contact precautions. Which is the MOST effective nursing action to control the spread of this infant's pathogens?
Washing hands before and after contact with the infant
Which blood pressure reading would be considered hypertension?
148/92 Hg
How often will the staff change the position of an immobile patient?
Every 2 hours
Which assessment is essential for the nurse to complete before the administration of medications for a patient with a diagnosis of hypertension?
The patients blood pressure
Which nursing action will address the self-care deficit in a patient who lives at home alone?
Allow the patient to practice self-care activities that will be carried until the patient fully recovers.
A patient walks up two flights of stairs to the clinic. The nurse assesses the vital signs, and a pulse rate of 110 beats/min is noted. Which action would the nurse take next?
Allow the patient to rest and then retake the pulse.
A culturally sensitive nurse understands that silence can serve which purpose for a Chinese patient?
Allows the patient to consider what the nurse has said before continuing
Which interventions would the nurse implement when responding to a patient with a low blood pressure who is experiencing an increased pulse rate, weakness, and vertigo?
Encourage the patient to assume the supine position to prevent a fall.
While assessing for a pulse deficit, the registered nurse (RN) signals and begins counting the apical pulse. Which pulse rate would the licensed practical nurse/licensed vocational nurse (LP/LVN) count to assist the RN in determining whether a pulse deficit is present?
Radial
