Exam 2 Review

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development.Place Erickson's stages of psychosocial development in order from birth through age 18 yrs (adolescence). A. Autonomy vs. shame and doubt B. Industry vs. inferiority C.Identity vs. role confusion D. Initiative vs. guilt E. Trust vs. mistrust

Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Identity vs. role confusion

The nurse is discussing interprofessional collaboration with a group of nurses. The nurse should include that which of the following is a core competency of the Interprofessional Education Collaborative (IPEC)? Decision-making Values and ethics Shared governance Autonomy

Values and ethics

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure, Room 212 is a semi-private positive-pressure airflow room; Room 214 is a negative-pressure, semi-private room; Room 216 is a private, positive-pressure airflow room.Which of the following rooms should the nurse assign to the client? a. 208 b. 214 c. 216 d. 212

a. 208

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychological needs according to Erikson? a. Encourage the client to complete school work. b. Vary the child'd schedule each day. c. Discourage visits from the client's friends. d. Provide a daily session with a play therapist.

a. Encourage the client to complete school work.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? a. Large building blocks b. Hanging crib toys c. Modeling clay d. Crayons and a coloring book

a. Large building blocks

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first? a. Review the events leading up to each medication administration error. b. Develop a quality improvement program for nurses involved in medication administration errors. c. Require staff nurses to demonstrate competency by passing a medication administration examination. d. Provide an inservice on medication administration to all the nurses.

a. Review the events leading up to each medication administration error.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? a. ask the patient their full name and date of birth b. Verify the clients room c. Check the clients name on the medication record d.

a. ask the patient their full name and date of birth

One of the adverse events that medicare will no longer reimburse the hospital for is an in-hospital fall. Fall prevention is a major part of nursing and risk management. In order to reduce the risk of falling, the nurse must: a. assess the patient's fatigue level. b. ensure that the patient wears his prescription glasses when up. c. post signs to alert staff to the patient at high risk for falls. d. monitor gait and balance. e. always assist every patient with ambulation.

a. assess the patient's fatigue level. b. ensure that the patient wears his prescription glasses when up. c. post signs to alert staff to the patient at high risk for falls. d. monitor gait and balance.

The nurse is preparing to administer a medication. At which point does the nurse do the final check?

a. at the bedside right before administration

A nurse is educating coworkers about how to minimize back pain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? a. avoid prolonged sitting b. apply cold packs frequently c. sleep in a side-lying position d. sleep on a soft mattress e. try shoe insole

a. avoid prolonged sitting c. sleep in a side-lying position e. try shoe insole

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (select all that apply) a. more difficulty seeing due to a greater sensitivity to glare b. decreased cough reflex c. decreased bladder capacity d. decreased systolic blood pressure e. dehydration of intervertebral discs

a. more difficulty seeing due to a greater sensitivity to glare b. decreased cough reflex c. decreased bladder capacity e. dehydration of intervertebral discs

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? a. "I am thinking of getting a second opinion" b. "I'm hoping this will limit my discomfort" c. "This treatment should help me live a little longer" d. "This is not working and I plan to stop treatment"

b. "I'm hoping this will limit my discomfort"

A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? (Select all that apply.) a. "music therapy will increase her basal metabolic rate." b. "music therapy can help her verbally express emotions." c. "music therapy will improve her appetite and decrease the nausea." d. "music therapy works as a distraction and can help alleviate her pain." e. "music therapy can help facilitate movement in some clients who have mobility limitations."

b. "music therapy can help her verbally express emotions." d. "music therapy works as a distraction and can help alleviate her pain." e. "music therapy can help facilitate movement in some clients who have mobility limitations."

A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take? a. Ask the client's partner to translate questions and answer for the client b. Arrange to complete the assessment with only the client and a translator's present c. Use an internet website ending in.com to translate for the client d. Ask a male student nurse to translate for the client

b. Arrange to complete the assessment with only the client and a translator's present

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a. Critically analyze client data to determine priorities. b. Collect and organize client data c. Determine effectiveness of interventions. d. Set client-centered, measurable and realistic goals.

b. Collect and organize client data

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? a. Discard the dressing in the bedside trash receptacle. b. Dispose of the dressing in a biohazardous waste container. c. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. d. Double-bag the dressing in clear bags and label it "biohazard".

b. Dispose of the dressing in a biohazardous waste container.

A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? a. The client joined a bowling league 2 months ago. b. The client has kept his partner's closet untouched since her death. c. The client exercises at a local health facility 3 days each week. d. The client meets his daughter for dinner every week.

b. The client has kept his partner's closet untouched since her death.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should recognize the client is demonstrating which stage of Kubler-Ross's stages of grieving? a. bargaining b. denial c. anger d. depression

b. denial

A nurse is providing postmortem care for an adult client. Which of the following actions should the nurse take a. place the client lying flat on the bed b. determine whether the client has an autopsy c. cover the body with a clean sheet & place the arms outside of the sheet d. identify if the client had significant trauma, discourage family and friends from viewing the body e. give the client's personal belongings to the family

b. determine whether the client has an autopsy c. cover the body with a clean sheet & place the arms outside of the sheet e. give the client's personal belongings to the family

A nurse is caring for several clients at various development stages. The nurse understands that according to Erickson, acceptance of death occurs at which of the following stages of psychosocial development? a. autonomy v. shame & doubt b. integrity v. despair

b. integrity v. despair

A nurse is planning care for a client who has manifestations of Clostridium difficile (C.Difficile) infection. Which of the following actions should the nurse plan to take first? a. place a surgical mask on the client during transport b. place the client on contact precaution c. use an alcohol based agent when performing hand hygiene when caring for the client d. obtain a blood specimen for cdiff

b. place the client on contact precaution

A nurse is teaching a class about barriers to inter-professional collaboration between health care professionals. The nurse should include that which of the following is a barrier? a. trust in the ability of a team member b. unresolved conflicts between team members. c. effective communication between team members d. cultural competency within team members

b. unresolved conflicts between team members.

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

bend at the knees when picking up an object

A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following comments made by the adolescent should be the nurses' priority to address? a. "My parents treat me like a baby sometimes." b. "I haven't gotten my period yet and all of my friends have theirs." c. "None of the kids at this school like me, and I don't like them either." d. "There's a big pimple on my face, and I worry that everyone will notice it."

c. "None of the kids at this school like me, and I don't like them either."

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? a. I will begin 48 hours before the client is discharged. b. I will begin once the client's discharge order is written. c. I will begin upon the client's admission to the facility. d. I will begin once the client's insurance company approved the discharge.

c. I will begin upon the client's admission to the facility.

A nurse is teaching a client who reports insomnia about prompting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I will walk briskly for 30 minutes before bedtime b. I will have a cup of hot cocoa immediately before bedtime c. I will no longer have a glass of wine before bedtime d. I will do my muscle relaxation techniques each afternoon

c. I will no longer have a glass of wine before bedtime

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

c. Maintain it according to agency policy.

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the surgical procedure? a. Nurse b. Anesthesiologist c. Surgeon d. Surgical suite nurse

c. Surgeon

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses.Which of the following information should the nurse include? a. The nurse caring for the client at the time of death requests organ donation. b. Donation costs are the responsibility of the donor's family and estate. c. The nurse may serve as a witness to informed consent for organ donation. d. Clients are placed on artificial life support before organ and tissue donation can occur.

c. The nurse may serve as a witness to informed consent for organ donation.

A nurse is caring for a client who is experiencing chronic stress. Which of the following is an expected finding? a. Hypotension b. Increased energy c. Viral infection d. Increased cognitive awareness

c. Viral infection

a nurse is performing a mobility assessment on a client. which of the following actions should the nurse take first? a. Ask the client to stand for 5 seconds b. ask the client to place their feet on the floor c. ask the client to sit on the edge of the bed for 2 minutes d. ask the client to march in place

c. ask the client to sit on the edge of the bed for 2 minutes

A nurse is caring for a client in the emergency department who had a traumatic amputation of his left arm in an industrial accident. The nurse should expect the client to be experiencing which of the following of Kubler-Ross's stages of grief? a. bargaining b. depression c. denial d. acceptance

c. denial

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following statements by the client indicates that the client is in the denial phase of the grief process? a. "the doctor has been so good to me, I know he has tried everything, it is just my time." b. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer." c. the doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." d. "even though I am not hurting right now, I don't feel like I have the energy to get out of bed."

c. the doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

A nurse is caring for a client who was involved in heavy combat & observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements? a. "I check any room I enter because the enemy is still after me & could be hiding anywhere." b. "My child was born with a birth defect due to an exposure I had overseas." c. "I killed four enemy soldiers with my bare hands & saved my entire battalion." d. "In my dreams, all I can see are the wounded reaching out & trying to grab me."

d. "In my dreams, all I can see are the wounded reaching out & trying to grab me."

According to Erikson's stages of development, in the middle adult, what happens if generativity vs stagnation is not achieved? a. Is more motivated to learn new material b. Denys changes in the body that are related to aging c. has an increase of awareness of their mortality d. Becomes more concerned about ones own health needs.

d. Becomes more concerned about ones own health needs.

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? a. enteral b. IM c. topical d. IV

d. IV

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? a. Ask the x-ray technician to come to the client's room to obtain a portable x-ray. b. Have the client wear a fitted N95 mask. c. Notify the x-ray department that the client requires airborne precautions. d. Wear a filtration mask and gloves during transport.

d. Wear a filtration mask and gloves during transport.

A nurse is discussing error reduction during the medication administration process. Which of the following phases of the medication administration process does error detection occur after reaching the client? a. dispensing b. transcribing c. ordering d. administration

d. administration

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? a. when the AP closes the door b. measuring the clients vital signs routinely c. ask for a group of nurses in the hall to speak quietly d. flushes the client's toilet after emptying the urinary catheter's drainage bag.

d. flushes the client's toilet after emptying the urinary catheter's drainage bag.

A nurse is discussing informatics with a newly licensed nurse. The nurse identifies that informatics is defined as the use of information and technology for which of the following? a. preventing burnout b. providing a safe place for provided care c. producing client pathways d. managing knowledge

d. managing knowledge

At completion of the health education for a client, the nurse documents the details of the health education in the client's medical record. What can be determined by this documentation by another nurse? a. if the clients level of formal education is achieved b. the clients response to health education was provided c. the patients long term advocation of health education d. the clients response

d. the clients response

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

intimacy v. isolation

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.

B. Scatter rugs are present in the kitchen.