exam #2 into to nursing care prep u
The nurse is caring for a client who has had a cerebrovascular accident. Prior to administering oral medications, what is the nurse's appropriate action? Consult with a speech therapist for dysphagia. Convert orders for oral medications to intravenous or intramuscular. Mix medications in applesauce or pudding. Give the client water to drink.
A
The nurse beginning a shift has received a report from the previous nurse, who reports that a client has a catheter inserted into the subclavian vein. The oncoming nurse will plan to assess which type of catheter? A.Groshong catheter B.Broviac catheter C.Hickman catheter D.peripherally inserted cutaneous catheter
D
A chant is a form of which category of meditation? A.Reflective B.Concentrative C.Receptive D.Expressive
B.
A client was administered an inappropriate dosage of medication. Which team member is responsible? A.medical technician B.pharmacist C.nurse D.health care provider
C
Which parts of the syringe and needle must be kept sterile when preparing and administering an injection? Select all that apply. A.The outside of the cap B.The outside of the barrel C.Inside the barrel D.The needle hub E.The needle
C,D,E
A client with diabetes who requires the new placement of an insulin pump asks the nurse how it works. What teaching will the nurse provide? A."This device contains long-acting insulin." B."You will wear this to receive a stream of insulin 24 hours daily." C."This will be used in addition to giving yourself injections." D."Settings can be adjusted for exercise and illness, and bolus doses can be delivered related to meals."
D
A nurse touches the client's hand while discussing the client's diagnosis. This action is: an auditory channel. a communication channel. a translation. a dynamic process.
a communication channel
allopathic medicine
: the term generally used to describe "traditional" medical care (biomedicine), dominant for about 100 years, which spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools
The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as needed dose, and the tablets in the container are not scored. What action by the nurse is best? A.Call the pharmacy to request a supply change. B.Document the medication dose as not administered. C.Administer one tablet until the issue is resolved. D.Cut the second tablet in half using a pill splitter.
A
Which statement made by the nurse providing care to a group of clients indicates that the nurse requires further education regarding negligence? a"I am going to auscultate breath sounds every 8 hours on a client receiving enteral feedings." b"I am going to assess for collateral circulation before preforming an arterial blood gas (ABG)." c"I don't need to assess distal pulses on a client after a femoral arteriography." d"Please avoid bringing fresh fruit to a client with neutropenia."
c.
A client is asking for the nurse to explain acupuncture. What would the nurse tell the client? a.Acupuncture is a dangerous option for the treatment of disease. b.Acupuncture is used to correct disharmony. c,\.Acupuncture is beneficial to creating a mood of distraction. d.Acupuncture is only done in Eastern countries.
b
A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? a.Assess the client for signs and symptoms of osteoporosis b.Perform a vision test with Snellen chart c.Arrange for a skilled home care assessment d.Arrange an audiology consult to evaluate hearing
c
Professional regulations and laws that govern nursing practice are in place for which reason? To limit the number of nurses in practice To protect the safety of the public To ensure that enough new nurses are always available To ensure that practicing nurses are of good moral standing
to protect the safety and the public
Which factor is related to the highest proportion of falls in long-term care settings? Toileting Agitation Impaired sleep patterns Polypharmacy
toileting
healing touch (HT):
uses a collection of energy techniques to assess and treat the human energy system, thereby affecting physical, emotional, mental, and spiritual health and healing
On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM? a.reconnecting the client's body, spirit, and emotions b.altering the client's perception and acceptance of reality c.restoring a healthy flow of energy along the meridians of the body d.allowing accumulated toxins to be released from the body
c
A client suffers from chronic pain. The nurse suggests the client have monthly massages. This is an example of: A.allopathic medicine. B.alternative medicine. C.adjuvant medicine. D.palliative medicine.
B
The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse? a.Ask the client "what if" questions to determine level of thought organization. b.Ask the client to read and discuss a passage from a pamphlet. c.Discuss with the client's family any concerns about his mental stability. d.Ask the client to review his medical health history to assess for the level of organization of his thought processes.
a.
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? Sympathy Empathy Pity Indifference
empathy
A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale? A.to prevent blood clot formation B.to facilitate cannulation of the central vein C.to allow increased mobility for the client D.to minimize the danger of fluid overload
A
A nurse is administering a prescribed intramuscular injection to a client by the Z-track method. Which action ensures that the medicine remains sealed? A.pulling the tissue laterally until the tissue is taut B.releasing the displaced skin as soon as the needle is inserted C,avoiding applying pressure but massaging the injection site D.inserting the needle at a 90-degree angle
A
A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection? A.Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. B.Subcutaneous injections are administered at a 30- to 45-degree angle based on the amount of subcutaneous tissue present. C.Sites commonly used for a subcutaneous injection are the inner surface of the forearm and the upper back, under the scapula. D.Pinching is advised for obese clients to lift the adipose tissue away from underlying muscle and tissue.
A
A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works? a.Helps to increase the effects of parasympathetic nervous system on the mind and body b.Slows circulation throughout the body c.Activates natural pleasure centers d.Increases the body's natural immunity
A
The nurse has given medications to four clients. Which client will the nurse monitor mostclosely for a possible reaction to occur? A.client with infection who received a bolus of Lactated Ringer's solution B.Blient with headache who received ketorolac intramuscularly for headache C.client with congestion who received a nasal corticosteroid D.client with allergies who received diphenhydramine by mouth
A,
A nurse practitioner is conducting a presentation at a local community center about complementary health approaches. One of the participants asks the nurse practitioner, "Everybody is talking about relaxation. Just how does relaxation help a person?" The nurse responds, integrating which effect as being associated with relaxation? Select all that apply. a.Reduced muscle tension b.Improved sense of well-being c.Better sleep and rest d.Lowered immune response e.Less anxiety
A,B,C,E
A nurse who has incorporated complementary and alternative medicine (CAM) into nursing practice is caring for a client in a short-term care facility. Which examples of nursing interventions are based on CAM? Select all that apply. A.The nurse investigates herbs that may stimulate the client's immune system. B.The nurse encourages the client to join a yoga class. C.The nurse schedules diagnostic tests for the client. D.The nurse administers pain medication prescribed by the primary care provider. E.The nurse teaches the client how to meditate. F.The nurse uses guided imagery to relieve client anxiety.
A,B,E,F
A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use? Select all that apply. A.Assess for fever prior to application. B.May cause injury with defibrillation. D.Dispose of transdermal patches in the trash. E.Use a heating pad to increase absorption. F.Apply patches at the same location for consistency. G.Remove the patch prior to magnetic resonance imaging (MRI). H.Fold the patch in half before disposal. I.Monitor the client for early identification of adverse effects.
A,B,G,H,I
A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation? A.medications that need to be infused over 20 to 60 minutes B.medications that are toxic if given over short periods C.medications that are given over 1 minute for rapid therapeutic effect D.medications that can be given through a capped intravenous port
A.
A client who is receiving chemotherapy and experiencing significant nausea asks the nurse about using aromatherapy to help alleviate the nausea. Which essential oil would the nurse most likely suggest to address the client's nausea? A.Ginger B.Lavender C.Chamomile D.Cedarwood
A.
The nurse assesses that a client uses accessory muscles, breathes shallowly, and has a pulse oximetry reading of 94%. Which nursing diagnosis will the nurse assign? A.ineffective breathing patterns B.ineffective airway clearance C.impaired gas exchange D.impaired spontaneous ventilation
A.
The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students? A.Holism perspective B.Integrative perspective C.Medical system perspective D.Allopathic perspective
A.
A client has been prescribed a new medication that is costly and not fully covered by the client's insurance plan. What can the nurse suggest to the client to address the concern? A."See if you can call a family member to borrow the money for the prescription." B."Request that the pharmacy partially fill the prescription to evaluate the drug's effectiveness before full purchase." C."Ask the provider if they will prescribe a less expensive drug even if it is not as effective." D."I know that the medication is expensive, but your health care provider knows what is best for you."
B
A nurse needs to instill eye medication in a client with conjunctivitis. Which action is best to distribute the medication over the surface of the eye? A.The nurse should gently rub the client's eyelids. B.The client should blink the eye. C.The nurse should instill medication drops in the upper eyelid. D.The nurse should make a pouch in the lower eyelid.
B
The nurse is caring for a client who is having a central venous access line inserted into the subclavian vein. The client becomes short of breath and the nurse doesn't hear breath sounds on the left side of the chest. What complication from the procedure does the nurse identify has occurred? Apneumonia Bpneumothorax Cvenous thrombosis D bacteremia
B
Which actions would the nurse take when instilling eyedrops correctly? Select all that apply. A.Place the thumb near the margin of the lower eyelid and exert pressure upward over the bony prominence of the cheek. BWash hands and put on gloves. CHave the client look up and focus on something on the ceiling. DTilt the client's head back slightly if sitting, or place the head on a pillow if lying down. ESqueeze the container and allow the prescribed number of drops to fall into the cornea.
B,C,D
The nurse plans discharge teaching for a client leaving the medical center with new medication prescriptions. Which action(s) does the nurse include in the discharge teaching? Select all that apply. A.Tell client to always choose brand name over-the-counter medications to ensure consistency in color, shape, and size of pills B.Explain the benefit in placing medications in a place that links to normal events in the client's life such as brushing teeth or going to bed CProvide client with a list of medications and directions for taking them D.Confirm that the client understands the reason for the medications ETeach client and caregivers how to fill a pill box using the medicine list as a guide
B,C,D,E
Which actions would the nurse perform when administering a subcutaneous injection correctly? Select all that apply. If using the outer aspect of the upper arm, place the client's arm over the chest with the outer area exposed. A.After removing the needle, do not massage the area to prevent hematoma formation. B.Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. C.Remove the needle cap with the dominant hand, pulling it straight off. D.Inject the needle quickly at an angle of 45 to 90 degrees. E.If blood appears when aspirating, withdraw the needle and reinject it at another site.
B,D,A
A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? A.Briefly postpone the application in the second ear. B.Ask the client to maintain the position for some time. C.Instill the medication in the opposite ear if prescribed. D.Place a cotton ball in the ear to absorb excess medication.
B.
A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate? A.Apply a topical anesthetic. B.Select another site. C.Apply a warm compress for 5 minutes. D.Loosen the tourniquet slightly.
B.
The nurse explains to the client which statement is true regarding the difference between allopathic therapy and complementary and alternative therapy? A.Allopathic therapy is the absence of illness. Complementary and alternative therapy states health is the imbalance of the body systems. B.Allopathic therapy emphasizes treatments for diseases..Complementary and alternative therapy emphasizes treatments for health. D.Allopathic therapy integrates mind and body. Complementary and alternative therapy separates mind and body.
B.
The nurse has finished teaching a client about medications that have been prescribed for administration. Which client statement reflects that teaching about a piggyback infusion of antibiotics has been successful? A"When I am out of bed the large IV bag must be lower than the small IV bag." B"When I am out of bed the small IV bag must not be lower than the large IV bag." C"When I am out of bed the large IV bag must be disconnected so I can take the small IV bag with me." D"When I am out of bed the small IV bag must be disconnected so I can take the large IV bag with me."
B.
The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response? A."I am just curious on what types of treatments are used by people." B."It's important that we list all of your complementary health practices used to provide a full picture of what you do to manage your health. C."I want to make sure you understand all the risks of these treatments." D."It will help me so that I can recommend use of these for other clients."
B.
The nurse is caring for a client who is receiving a prescribed intravenous (IV) infusion of an antibiotic to treat an infection. The client asks the nurse, "Can I just take a pill?" What is the best response by the nurse? A."The IV infusion will treat your infection slower." B."An IV infusion maintains a therapeutic level of the medication in your blood." C."Oral antibiotics are not as effective as IV infusions." D."The health care provider can control the dose of medication you receive through IV."
B.
The nurse is preparing to administer a medication to a client when the client states, "Last time I took that medication, I broke out in hives." What is the priority action by the nurse? A.Administer the medication and monitor the client for 30 minutes after administration B.Withhold the medication and notify the health care provider that ordered the medication C.Substitute another medication with the same action D.Administer the medication, the reaction may not occur again
B.
The client who is newly diagnosed with diabetes mellitus type 2 is concerned about eating products with sugar in them. What information does the nurse explain to the client regarding the use of sugar? A.Sugar increases natural bacterial flora in the GI tract. B.Sugar assists with cellular absorption of nutrients. C.Excess sugar increases demand on the pancreas. D.Healthy amounts of sugar are usually consumed.
C
The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan? A.Basing practice on the yin-yang theory B.Including the client's shaman in the plan of care C.Helping the client to balance his or her dosha D.Preparing the client for exercises that help him or her regulate qi
C
The nurse is caring for a client with visual impairment who has been prescribed two different types of eye drops. Which nursing intervention will best assist the client in differentiating between the bottles of drops? A.Teach the client to place bottles on different ends of the table. B.Write the names of the medications on the bottle. C.Place a rubber band snugly around one of the bottles. E.Color code the bottles with different colors of pens.
C
The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students? A.Medical system perspective B.Allopathic perspective C.Holism perspective D.Integrative perspective
C
A nurse is caring for a client admitted for a prolonged stay on a medical-surgical unit. The client has been having difficulty sleeping and appears depressed. Applying the holistic health model, which action taken by the nurse would be most appropriate? A.Document the observations, and encourage the client that he or she will feel better once going home B.Reassure the client how lucky he or she is to have family visit often and reassure the client that he or she will be going home soon C.Suggest the client try some meditation and contact the health care provider to request medication to help with sleep D.Ask the client's family to bring some items from home, such as a blanket, pillow, or pictures
D
The charge nurse on the medical/surgical unit is reviewing physician orders for a client with a diagnosis of congestive heart failure. Which infusion orders would the nurse question? A.20 mL 0.9 NaCl to run in 20 minutes B.250 mL 0.9 NaCl to run in 60 minutes C.50 mL D5W to run in 60 minutes D.1000 D5W to run in 30 minutes
D
A client with stage IV colon cancer reports back pain and appears to be anxious. What response should the nurse provide when asked if therapeutic touch may be beneficial? A."What do you currently know about therapeutic touch and why do you think this type of therapy will help?" B."Therapeutic touch is based on the concept of qi and uses energy fields from the heavens and earth to restore a healthy state, but it will not cure your illness." C."How often are you prepared to engage in therapeutic touch as it is an ongoing pain relief therapy?" D."Therapeutic touch is a holistic practice that works to redirect energy in the body and may help with pain and anxiety."
D.
A nurse is caring for a client on IV therapy. The IV tubing has a volume-control set. Which of the following is a function of the volume-control set? A.It is used when IV medications are irritating to peripheral veins. B.It is used to administer medication only to older adult clients. C.It is used to administer medication in a large volume of blood. D.It is used to administer small volumes of IV medication.
D.
A nurse is caring for a client with pancreatic cancer who is receiving continuous morphine for pain. Which intervention would be the most effective method to administer this medication? A.Administer a piggyback intermittent intravenous infusion of morphine. B.Administer morphine by intravenous bolus or push through an intravenous infusion. C.Administer orally. D.Administer a continuous subcutaneous infusion of morphine.
D.
The nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered? A.D5 ¼ NS B.0.45% NS C.3% NS D.0.9% NS
D.
What action should the nurse take when giving an intramuscular injection using the Z-track method? A.Withdraw the needle within 5 seconds of injecting the medication. B.Inject the medication quickly, and steadily withdraw the needle. C.Use a needle at least 1 inch (2.5 cm) long. D.Do not massage the site because it may cause irritation.
D.
When preparing to start an intravenous infusion on an adult, the nurse should: A.apply sterile gloves before inserting the intravenous device. B.place a cold cloth over the intended site for greater access. C.place a tourniquet 2 inch (5 cm) below the selected site. D.prepare the skin with 70% alcohol and povidone-iodine.
D.
Which scenario is an example of tertiary prevention? Linda is having her first colonoscopy because she just turned 50. A.A pamphlet on nutrition for children is given to all clients in a pediatric clinic. B.A school nurse is giving a talk about good handwashing to a first-grade class. C.A hearing test is done on a newborn in the hospital. D.Sam is prescribed an antihypertensive medication to control his newly diagnosed high blood pressure.
D.
While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention? A.Physiotherapy B.Allopathy C.Therapeutic Touch (TT) D.Acupuncture
D.
A nurse is caring for a client admitted to the hospital for dehydration. Which physical findings should the nurse acknowledge as nonverbal communication concerning this diagnosis? a.easy wrinkling of the skin and sunken eyes. b.cold intolerance and brittle nails. c.pallor and diaphoresis. d.slow heart rate and prolonged capillary refill.
a
The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing? a"You are hoping to figure out the cause of your extreme fatigue during this hospital stay." b."You are unsure of what helps or prevents your fatigue." c"You are frustrated because you are too tired to perform normal activities." d"You have been having a great deal of fatigue for the last 3 months."
a
The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client? a."It sounds as though you are most concerned about how your children will feel." b."This is so sad and I feel so bad that you are in this situation." c."I am so sorry that I am crying with you when you need my support the most." d."This just is not fair at all and I do not understand why this is happening to you."
a
The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client? a.Approach the client with empathy and understanding and allow the client to share feelings without being judged. b.Practice active listening by allowing the client to express fears and concerns then restating in the nurse's own words to demonstrate understanding. c.Use strategic pauses to allow the client to provide information that will be used to help officials in their investigation. d.Exhibit a professional demeanor while examining the client and obtaining specimens, asking questions that are not intrusive.
a
The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication? a.Identify oneself by name and title with each entry into the client's room. b.Obtain the client's attention by calling out the client's first name. c.Remove the COVID protection face mask while speaking with the client. d.Speak in a loud voice over the volume of the television set.
a
Which is an example of an unintentional tort? a.A nurse gives the client a medication, and the client has an adverse reaction to it. b.A nurse threatens to restrain a client if the client does not stop talking. c.A nurse tells a client that the client cannot leave the hospital until the client pays the bill. d.Nurses discuss a client's laboratory values in the elevator.
a
Which statement made by the nurse providing care to a group of clients indicates that the nurse requires further education regarding negligence? a."I don't need to assess distal pulses on a client after a femoral arteriography." b."I am going to assess for collateral circulation before preforming an arterial blood gas (ABG)." c."Please avoid bringing fresh fruit to a client with neutropenia." d."I am going to auscultate breath sounds every 8 hours on a client receiving enteral feedings."
a
While at a coworker's house, a nurse discusses with the coworker a client whom the nurse suspects of physically abusing the client's child. The next day, the client is moved to another nursing unit after a surgical procedure and comes under the care of the coworker, who is also a nurse. The coworker confronts the client about the alleged physical abuse. The client is shocked and angered by the accusation and denies it categorically. What would be the charge if the client were to file a suit? a.The first nurse could be charged with slander. b.No charges are valid because both nurses are involved in the client's care. c.No charges are valid because the revelation took place during off-duty hours and off-site. d.The second nurse could be charged with libel.
a
During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: a."What did your health care provider tell you about your need to be admitted?" b."Are you allergic to any medications?" c."Can you tell me the medications you take on a daily basis?" d."Do you have an advanced directive or a living will?"
a When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses. The greatest advantage of this technique is that it prevents the client from giving a simple "yes" or "no" answer, which limits the client's response. The questions related to medication use, allergies, and an advanced directive are examples of closed communication, in which only one or a few words are required for an answer. Reference:
The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply. a.Use a large plant or piece of furniture as a barrier to limit wandering from the designated area. b.Use simple, clear explanations and directions. c.Place all four side rails up. d.Reduce stimulation, noise, and light. e.Distract and redirect in a commanding voice. f.Provide a safe environment.
a , b , d , f Reducing environmental stimuli, using simple directions, using furniture as safety barriers, and concealing necessary health care devices are appropriate alternatives to restraints. Teaching restraint application to significant others and using a commanding voice are not appropriate measures. Provide a safe environment for the client.
The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply. a.Obtain order from a licensed provider within minutes of restraint application. b.Withhold information from family regarding restraints due to HIPAA. c.Check circulation and skin condition every 2 hours. d.Offer regular, frequent opportunities for toileting. e.Maintain restraints until discharge.
a , c , d n order for restraints from the licensed health care provider must be obtained within minutes after the restraint is applied. Frequent and regular nursing assessments are required of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing the restraint. The nurse must explain the need for restraints with the family. When the assessment findings indicate that the client has improved, restraints must be removed.
Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply. a.The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes. b.The nurse uses the Internet to find new nursing techniques for the care of a client with cystic fibrosis. c.The nurse coordinator calls a meeting of all the health care professionals involved in the care of a client. d.The nurse listens to a client who is having trouble adjusting to a long-term care facility and treats the client with compassion and respect. e.The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. f.The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions.
a e f The QSEN concept of quality improvement recommends use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes. Early introduction of quality improvement concepts helps to continuously improve the quality and safety of health care systems. Some these concepts include the following: new ideas generated by meeting with the staff to review client care outcomes; scheduling meetings to update policies for client admissions; and committee review of procedure manuals. Calling a meeting to discuss a specific client and listening to the client's concerns are examples of the QSEN client-centered care competency
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? a.Leave outlets and switches open so air circulates through them. bRefrain from using extension cords. cAll machines that are used infrequently are to remain plugged in. dRemove the plug from the wall by pulling the electric cord.
b
An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action? a.Obtaining vital signs on a newly admitted client b.Asking the LPN/LVN to teach a new diabetic client how to administer insulin c.Delegating oral medication administration to the LPN/LVN d.Calling the health care provider about abnormal lab results
b ( never delegate education!!!!!)
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. a.If there is no response, the nurse does not repeat what is said and takes a break. b.The nurse shows patience with the client and gives the client time to respond. c.The nurse maintains eye contact with the client. d.The nurse communicates in a busy environment to hold the client's attention. e.The nurse gives lengthy explanations of the care that will be given. f.The nurse keeps communication simple and concrete.
b , c , f
The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply. a.A client experiences a reaction to a unit of blood, resulting in itching and hives. b.A client's baby is misidentified and receives breast milk from another mother. c.The nurse administers a lethal dosage of medication in error. d.A client reports plans to file a complaint concerning the amount of time it took for a nurse to respond to a call light. e.A client faints during ambulation with the nurse, resulting in a concussion.
b, c, e
A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? a.Respond to the past history of the client (including previous falls) to determine the need for restraints. b.Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. c.Individualize the use of restraints and choose the most easily used device. d.Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse.
b.
A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? a.The nurse informs the family about advance directives. b.The nurse informs the family about the living will. c.The nurse confirms that the client's family has signed the consent form. d.The nurse confirms that the client has signed the consent form.
c
A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? a.The client looks at the nurse and states, "I am still not feeling my best." b.The client is sitting in a chair and states, "I feel a lot better than I did yesterday. c.The client stares at the floor and states, "I feel fine." d.The client smiles at the nurse and states, "I cannot wait to go home."
c
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should: a.ignore the statement and empty the urinary catheter. b.smile at the client and apologize. c.sit at the bedside and allow the client to explain the statement. d.inform the client that the unit was very busy that day.
c
A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client? a.The hospital b.The nurse instructor c.The student nurse, the nurse instructor, and the hospital d.The student nurse
c
Which scenario is an example of certification? a.An education program that meets the standards of the National League for Nursing b.A graduate of a nursing education program who passes the NCLEX-RN c.A nurse who demonstrates advanced expertise in a content area of nursing through special testing d.A hospital that meets the standards of the Joint Commission
c
An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? a.Obtain an order for insertion of an indwelling urinary catheter. b.Limit the client's fluid intake during the evening. c.Provide a bedside commode and ensure adequate lighting. d.Accompany the client to the bathroom every 4 hours around the clock.
c.
A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening? a."I understand you are not sure about having the surgery. Why do you think you really do not need the surgery?" b."I understand your confused, what do you think you should do?" c."You seem unsure, please let me know if you decide to postpone the surgery until you are no longer unsure." d."You seem unsure. Tell me your concerns about your surgery."
d
A nurse visits a female victim of sexual assault. During the visit the client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse? a."Can you do something to alleviate the fear of being assaulted again?" b."In reality, the sexual assault did not occur yesterday; it has been over one month now." c."We should move on from the strong feelings associated with this incident." d."Tell me more about the aspects that make you feel as if it happened yesterday."
d
While walking down the hall, a nurse manager overhears a staff member telling a client, "If you don't stay in this chair and stop wandering, I'm going to tie you to it." The nurse manager pulls the staff member aside and discusses what was said. The nurse manager intervenes because the staff member's statement is which type of tort? a.Battery b.False imprisonment c.Invasion of privacy d.Assault
d
A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? a."Sitting in the dark is not going to cure your cancer. Let's open the curtains." b."Can you please tell me why you are crying?" c."I am so sorry you are going through this. Can we talk?" d."I know this is hard for you. Is there any way I can help?"
d Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes. By retaining this quality, you can establish successful helping relationships without appearing cold or stern. The statement "I am so sorry you are going through this" demonstrates sympathy. Sympathy differs from empathy because it shifts the emphasis from the client to the nurse as the nurse shares feelings and personal concerns and projects them onto the client, limiting the ability to focus objectively on the client's needs. Asking about why the client is crying is part of information gathering but is not empathy. Stating that sitting in the dark will not cure cancer is an abrasive statement that may work against the nurse-client relationship.
The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply. a"When I am using a new piece of equipment for the first time, I must make sure I know how to properly operate it." b"I can be charged with negligence if I am following the standards of care for my specialty, which is ambulatory nursing." c"I can be charged with negligence if I follow the policy for administering insulin and the client has a reaction to it." d"I can be charged with negligence if I notify the health care practitioner about a change in a client's status but do not follow up or document. e"I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn."
d, e
Which are areas of potential liability for the nurse? Select all that apply. a.The nurse notifies the health care provider of the client's adverse reaction to a medication. b.The nurse administers the client's preoperative medication after the informed consent is signed. c.The nurse documents that the client accurately prepared the correct amount of insulin after instruction was given. d.The nurse fails to document refusal by the client to ambulate following surgery. e.The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour.
d, e
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should: a.consult with the social worker regarding inpatient drug rehabilitation. b.ask if the client realizes the infection is a direct result of the drug use. c.ask the client for a urine specimen for urine drug use screening. d.remain honest, open, and frank.
d.
When communicating with a client, the nurse uses reflection for which purpose? a.To determine the sequence of events in the conversation b.To keep the client on the topic of concern c.To investigate the situation to help problem solve d.To have the client elaborate on thoughts and feelings
d. The reflective question technique involves repeating what the person has said or describing the person's feelings. It encourages clients to elaborate on their thoughts and feelings. Exploring helps clients express their concerns and solve their problems by investigating the situation, exploring how they feel about it, and what some alternatives might be. Focusing helps the client stay on the topic. Sequencing determines events in chronological order.
A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints? a.The restraints can be ordered by the nursing supervisor in emergency situations. b.Chemical restraints should be tried before using physical restraints. c.The client's order for restraints must be renewed by the health care provider every 4 hours. d.The client's vital signs must be assessed every hour.
d. the client's vital signs must be assessed every hour when restrained. Restraints must be ordered by a health care provider. Orders for restraints may be renewed every 4 hours for adults 18 years of age or older but must be renewed every 24 hours. Chemical restraints do not necessarily have to precede the use of physical restraints.
A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit? Negligence Battery Assault Malpractice
malpractice
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? Termination phase Evaluation phase Orientation phase Working phase SUBMIT ANSWER
working
A client comes to the clinic for an evaluation. The client reports that "I have been having such problems with getting to sleep and then staying asleep. But I do not want to take any medications." After a discussion of possible complementary health approaches, the client decides to try aromatherapy. Which essential oil will the nurse suggest to address the client's problem? a.lavender b.peppermint c..lemon d.ginger
A
A client requests more medication for pain at the surgical site rated 8 out of 10. There is a PRN prescription for 10 mg PO of oxycodone for pain greater than 6 out of 10 on the pain scale. Which action should the nurse take first? Verify clients name and date of birth Administer the prescribed amount of oxycodone. Determine if the prescription is appropriate. Review file for adverse effects
A
The nurse is writing a script to use in guided imagery. To be most effective, this script should include which component? A.Locations familiar to most people B.Random references to places and people C.Use of all five senses D.Scenes that move from stimulating to relaxing
C
The client has been diagnosed with a disease and is seeking information about naturopathy. The nurse, explaining about naturopathy, encourages the client to do what? A.Exercise at least once per week. B.Include well-cooked processed foods in diet. C.Concentrate on the implications of the disease. D.Obtain adequate sleep each night.
D.
Which is the most important role of the nurse in using complementary and alternative therapies? A.Practicing guided imagery prior to surgery B.Providing nutrition supplements for weight gain C.Administering herbal supplements for anxiety D.Educating the public about safety and effectiveness
D.
The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? a.Assess the need for assistance with ambulation. b.Put the client's bedside rails up. c.Arrange furniture so that the client has something to hold on to. d.Apply socks to the client's feet.
a
The nurse cares for a client who is sharing a personal health story. Which behavior(s) demonstrates active listening? Select all that apply. a.The nurse makes eye contact while the client is sharing a personal story. b.The nurse observes the nonverbal behavior of the client as the client speaks. c.The nurse offers multiple solutions while the client is sharing a personal story. d.The nurse paraphrases what the client has stated before generating a response. e.The nurse shares a personal story about experiences with hospitalization.
a , b , d
Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement? a."Board of nursing rules keep unlicensed people from practicing nursing." b."The rules made by the board of nursing don't reflect my practice." c."The board of nursing exists to protect the safety of the public." d."The board of nursing is established by state legislation."
b
A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a health care provider's order or the client's consent. The nurse is at risk of being accused of which action? Malpractice Negligence Battery Slander
battery
It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy? a.Caring for the client without negative judgment b.Experiencing feelings similar to those of the client c.Identifying with the client's feelings d.Conveying genuine care to the client
d.
Which nursing action(s) promotes safety in the preparation of medication? Select all that apply. A.Return medications with obscured labels to the pharmacy. B.Ensure a second nurse cosigns all medications. C.Prepare medications in well-lit conditions. D.Take verbal prescriptions for medications whenever possible. E.Note the expiration dates on liquid medications.
A,C,E
A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application? A.Do not bathe or rinse off for 24 hours. B.Apply medication in a thick layer and cover with gauze or sterile wrapping. C.Use gloves to apply. D.Remove medication every 12 hours and reapply.
C.
The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client? A.metered-dose inhaler B.turbo-inhaler C.spacer D.nasal drops
C.
The nurse is preparing to withdraw liquid medication from an ampule for injection into an IV. What is the appropriate action for the nurse to take when withdrawing the medication? A.choose a smaller needle for injection so no particles will enter the syringe B.withdraw the medication and then squirt some of the medication out before injecting C.use a filter needle to withdraw the medication D.use a needleless IV injector
C.
The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? Extremity restraint Elbow restraint Mummy restraint Waist restraint
The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.
termination phase
The last phase of the nurse-client relationship is the termination phase. Evaluation of goals and termination of the therapeutic relationship occur during this phase. This can occur at the end of the nurse's shift or when the client is discharged. The client's ability to verbalize understanding of what signs indicate infection and when to contact their health care provider, allows the nurse to evaluate the client's goal progression as well as assess their readiness for discharge.
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "Have you been hospitalized this year for your back pain?" This is an example of which type of question? Sequencing question Closed question Open-ended question Reflective question
closed question An open-ended question is often used when the nurse is obtaining a nursing history and allows the client to reply with a wide range of possible responses, thus encouraging free verbalization. A closed question is answered by one or two words, often "yes" or "no." A sequencing question is used to place events in a chronological order and to investigate a possible cause-and-effect relationship. A reflective question involves repeating what the person has said or describing the person's feelings.
acupuncture
procedure consisting of placing very thin, short, sterile needles at particular acupoints, believed to be centers of nerve and vascular tissue, along a meridian to either increase or decrease the flow of chi along the meridian, restoring the balance of yin and yang, and thereby contributing to healing
chiropractic health care:
profession that focuses on the relationship between the body's structure—mainly the spine—and its functioning; its practitioners primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself
The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurological checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed? Background Assessment Recommendation Situation
recommendation
Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority? Confine the fire. Rescue the client. Extinguish the fire. Raise an alarm.
rescue the client
The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document? a.A will b.Proof of health care power of attorney c.A proxy directive d.A living will
d
orientation phase
The orientation phase is the initial phase of the nurse-client relationship. During this phase, specific client and nurse roles are discussed, including the duration of the therapeutic relationship. The nurse also orients the client to the room and environment as well as identify oneself by name. After the initial orientation, the client should be able to verbalize understanding of the room including being able to demonstrate how to use the call light and identify the nurse by name.
During a nursing shift, which events warrant completion of an incident report? Select all that apply. a.A client falls while being transferred from the bed to the chair. b.An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. c.A nurse reports that a client is crying and distraught over a diagnosis of metastatic cancer. d.A nurse asks an unlicensed assistive personnel (UAP) to feed a client. e.A visitor slipped and fell in the hallway, but was not injured.
a, b, e
An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? a.Reduce distressing environmental stimuli to maximize client safety b.Promptly document the change in client status c.Leave to notify the health care provider concerning a change in client status d.Apply limb restraints to ensure client safety
a.
Which process evaluates and recognizes educational programs as having met certain standards? Certification Credentialing Licensure Accreditation
accreditation
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be: aggressive. nurturing. passive. assertive.
agressive
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? a.CMS may choose to divert clients to other health care facilities in the future. b.The hospital must bear any costs incurred for treating the client's injury. cThe hospital will be fined by CMS because the client developed a pressure injury. d.CMS will bear the hospital's costs if the client chooses to sue the hospital.
b
A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask: a."Do you check your blood pressure and pulse before you take your medication?" b."Were you tired and depressed before starting the new medication?" c."Have you tried exercising at all in the last week or two?" d."Tell me about the foods you are eating."
b
A health care provider is called to see a client with angina. During the visit the health care provider advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the health care provider is late for another visit, the health care provider requests that the nurse write down the order for the health care provider. What should be the appropriate nursing action in this situation? a.The nurse should remind the health care provider later to write the work order. b.The nurse should ask the health care provider to come back and write the order. c.The nurse should write the order and implement it. d.The nurse should inform the client of the change in medication.
b
A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment? aBring the client into the hallway to discuss the treatment plan. bPull the curtain dividing the two beds. cAsk all visitors to leave the room. dDirect the client in the other bed to walk in the hallway.
b
What is the primary role of the nurse in the care of clients who experience domestic violence? a.Identifying health education and counseling measures for the family b.Providing prompt recognition of the potential or actual threat to safety cCalling the police d.Serving as a witness in court
b
A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a health care provider's order or the client's consent. The nurse is at risk of being accused of which action? Malpractice Negligence Slander Battery
battery
An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor? Defamation of character Battery Assault Fraud
battery
The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?
breach of duty
Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? a.A nurse describes a client on Twitter by giving the room number rather than the name of the client. b.A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name. c.A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. d.A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo.
c
What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States? a.World Health Organization b.American Nurses Association c.Centers for Disease Control and Prevention d.American Medical Association
c
Which principle does not encompass the basic goals of integrative medicine? aEstablish a partnership between client and practitioner. bFocus on promoting health and preventing illness, as well as treating disease. cReject allopathic medicine and embrace CAM practices. dFacilitate the body's innate healing abilities.
c
integrative health:
combination of complementary health and conventional health approaches in a coordinated way
A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent at this point, which element of informed consent would be violated? Comprehension Voluntariness Competence Disclosure
competence The client under conscious sedation would not be considered competent to make a decision to undergo an invasive procedure such as a colonoscopy. Disclosure ensures that the following information has been given to the client: the nature of the treatment, possible alternative treatments, and potential risks and benefits of the treatment. Comprehension is met when the client demonstrates understanding by describing in the client's own words to what he is consenting. The client's consent must be given voluntarily.
The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? a.Notify the organization's leader that a disaster has been called b.Identify the resources available for the nursing unit c.Provide simple explanations to maximize client safety d.Establish the nurse's role during a disaster
d
An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should: a.provide detailed findings of the head-to-toe assessment. b.discuss the client's situation and request a chest x-ray to assess lung function. c.detail the client's past medical history and active medication orders. d.recommend 40 mg of furosemide be administered because the client had improvement with past administration.
d. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. Discussing the situation occurs during the (Situation) component of SBAR reporting. Detailing the client's past medical history is not a component of SBAR. Providing detailed findings of the head to toe assessment does not occur during SBAR reporting.
Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? Kindness Commiseration Empathy Sympathy
empathy
working phase
he second phase of the nurse-client relationship is the working phase. Participation and cooperation between the nurse and the client are the highlights of this phase. In addiiton, verbalization of concerns and feelings also occur in the working phase. The nurse takes on the role of teacher during this phase by instructing and motivating the client to implement health-promoting activities meant to facilitate the client's ability to execute the nursing plan. The client 's statements, "I know I have to get up and moving so I do not get pneumonia," and "Using the pillow to splint my abdomen when I cough, really helps" indicates understanding of the nurse's teachings.
The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client? Body language Verbal Kinesthetic Visual
kinesthetic
Which level of health care provider may make the decision to apply physical restraints to a client? senior personal care assistant nurse practitioner RN nurse manager LPN team leader
nurse practitioner Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistan
When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? Orientation phase Termination phase Intimate phase Working phase
orientation
A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? Termination phase Evaluation phase Working phase Orientation phase
orientation phase
A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? Libel Malpractice Negligence Slander
slander
Nurses complete incident reports as dictated by the agency protocol. What is the primaryreason nurses fill out an incident report? To document the need for disciplinary action To initiate litigation To document everyday occurrences To improve quality of care
to improve quality care
When educating families on fire safety, it is important to: have a meeting place outside the home. account for all members and then exit. use extension cords to prevent shock. keep a fire extinguisher in a closet.
a
A nurse is calling a health care provider to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation? a."My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." b."I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!" c."My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital." d."Good morning, I am calling about Mrs. Jones, who is a client of yours."
a
A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse? a."Take it with you. It is recognized universally in the United States." b."A living will can only be used in the state in which it was created." c."We have it on file here, so any hospital can call and get a copy." d"As long as your family knows your medical wishes, you will not need it."
a
A client presents to the urgent care clinic with ear pain. The client reports a medical history of trigeminal neuralgia. The nurse is not familiar with trigeminal neuralgia. When the client asks whether the two conditions could be related, which response by the nurse is best? a."I honestly do not remember specific details regarding trigeminal neuralgia; let me research it." b."I am not sure. I am not familiar with trigeminal neuralgia and it could be that the trigeminal neuralgia is causing the ear pain." c."That is a good question. You should ask the health care provider if the two conditions could be related." d."When you were diagnosed with trigeminal neuralgia, did you have ear pain?"
a
A nurse is performing an admission assessment with a client who does not speak the dominant language. Which action(s) can the nurse take to enhance communication? Select all that apply. a.Use an electronic translator. b.Contact a telephone-based medical interpreter. c.Request assistance from an agency interpreter. d.Ask the client's adolescent daughter to interpret. e.Speak loudly and slowly.
a , b, c Some options for working with clients who do not speak the dominant language include requesting assistance from a trained agency interpreter. If one is not available, using a trained telephone interpreter or an electronic translator may assist in obtaining information. Using family members is not appropriate, since it is a violation of the client's HIPAA rights. In addition, clients may not feel comfortable explaining all of their symptoms using a family member, and medical terminology may not be translated correctly. Speaking loudly will not assist the client in understanding another language.
Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice? Select all that apply. a.A nurse seeks employment in a hospital after falsifying credentials on a resume. b.A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). c.A nurse threatens to hit an older client who has dementia and is screaming. d.A nurse places a client who is a fall risk in restraints without an order from the health care provider. e.A nurse forgets to put the side rails up on a crib and the toddler falls out. f.A nurse does not report a change in client condition in a timely manner.
a, b , c , d
Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature? a.A single witness is sufficient for a will. b.Witnesses to a signature do not need to read the will. c.Witnesses do not need to observe the signing of the will and can sign it at a later time. d.A beneficiary to a will is allowed to act as a witness.
b
A client in a mental health unit discusses personal thoughts and feelings with the nurse. The nurse can maintain the circle of confidentiality when reporting this information to which individuals? Select all that apply. a.The client's family b.The unit's mental health technicians c.The client's health care provider d.The client's closest friend e.The nurse from the oncoming shift
b, c, e Unless the client has specifically given permission to provide information to family and friends, this information should remain among individuals on the health care team who are directly involved with care of the client.
A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care? a.The nurse withholds the medication, retakes the heart rate, and gives the medication at a later time. b.The nurse administers the medication and reassesses the client after 30 minutes. c.The nurse administers the medication after reviewing the client's serum potassium level. d.The nurse withholds the medication and notifies the health care practitioner.
d. Nurses are responsible for following the standards of care for their particular work area. A reasonably prudent nurse would withhold the medication and notify the health care practitioner. All other options put the client's safety at risk and would not be done by a reasonably prudent nurse.
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? a.Use a quick-release knot to tie the restraint to the side rail. b.Remove the restraint at least every 4 hours, or according to facility policy. c.Apply restraints to the hands or wrists, never to the ankles. d.Ensure that two fingers can be inserted between the restraint and the client's extremity.
d. Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.
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? State legislation Federal legislation Board of nursing Health care institution
health care institution
he nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist? Intrapersonal Small-group Organizational Interpersonal
interpersonal The nurse and physical therapist are engaging in interpersonal communication, which occurs between two or more people with the goal to exchange messages. Intrapersonal communication, or self-talk, is the communication that happens within the individual. Small-group communication occurs when nurses interact with two or more individuals. Organizational communication occurs when individuals and groups within an organization communicate to achieve established goals.d
