EXAM 4 prepu etc

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? A. The client reports waking up this morning with a severe headache. B. The client has symptoms in the morning associated with a heart attack. C. The client is coughing and experiencing severe heartburn in the morning. D. The client has a history of severe complaints in the morning.

A. The client reports waking up this morning with a severe headache.

A hospital owned by a Catholic order of nuns will not allow tubal ligations to be performed. This is considered to be: A. personal morality. B. personal values. C. institutional policy. D. legal obligation.

C. institutional policy

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? A. "I will take insulin until my blood sugar levels are normal." B. "I will take my medications between meals for maximum effect." C. "I will mix insulin glargine with insulin lispro at bedtime." D. "I will test my glucose level before meals and use sliding scale insulin."

D. "I will test my glucose level before meals and use sliding scale insulin."

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? A. Orientation phase B. Working phase C. Termination phase D. Evaluation phase

A. Orientation phase

An informatics nurse specialist has been involved in obtaining feedback about a clinical information system recently implemented in the facility. The information gathered provided recommendations for improving the satisfaction of the end users when using the system. Which aspect is the informatics nurse specialist addressing? A. Usability B. Optimization C. Interoperability D. Meaningful use

B. Optimization

The nurse makes a contract with the client during which phase of the nurse-client relationship? A. Intimate phase B. Orientation phase C. Working phase D. Termination phase

B. Orientation phase

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others? A. Purposive communication B. Intrapersonal communication C. Metacommunication D. Therapeutic communication

D. Therapeutic communication

A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach? A. "Surgery is your only option. You need this operation." B. "If you don't have the surgery you may not live. Your family needs you." C. "It's your choice about the surgery. What do you understand about the situation?" D. "Your grandchildren would be very upset if they lost their grandfather."

A. "Surgery is your only option. You need this operation." --An authoritarian approach assumes that the professional will make decisions for the client. The statement about surgery being the only option and that the client needs it reflects an authoritarian approach.--

The school nurse is participating in a program to immunize students against human papillomavirus (HPV). What benefit should the nurse describe to students and their families? A. Reduced risk for cervical cancer B. Reduced risk for polycystic ovary syndrome C. Protection against several viral sexually transmitted infections D. Reduced risk for pelvic inflammatory disease (PID)

A. Reduced risk for cervical cancer

To practice ethically, the nurse should avoid: A. allowing an ethics committee to guide the nurse's practice. B. reviewing past cases before making decisions about practice. C. allowing the nurse's own judgment to guide practice. D. asking the client's family about their views on caring.

A. allowing an ethics committee to guide the nurse's practice.

Which nursing situation is an example of an ethical dilemma? A. Administering pain medication as ordered B. Transferring a client to a step-down unit C. Deciding whether to perform cardiac compressions against a client's wishes D. Discussing care of a comatose client with the family

C. Deciding whether to perform cardiac compressions against a client's wishes

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating? A. Altruism B. Social justice C. Integrity D. Autonomy

C. Integrity

what is NLN

National League of Nursing Human Flourishing Nursing Judgment PROFESSIONAL IDENTITY SPIRIT OF INQUIRY

what is the QSEN

Quality and Safety Education for Nurses Developed to help prepare future nurses with the knowledge skills and attitudes necessary to continue safety of the pt

what are the 6 safety standards of QSEN

Quality-Centered Care Evidence-Based Practice Teamwork & Collaboration Safety Quality Improvement Informatics

Aphasia

which is deterioration of language function

Apraxia

which is impaired ability to execute motor functions despite intact motor abilities

Agnosia

which is inability to recognize or name objects despite intact sensory abilities

executive functioning

which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior

Which example most accurately depicts the ethical principle of autonomy? A. Describing a surgery to a client before the consent is signed B. Changing a dressing on a wound as needed C. Administering a morning dose of insulin before breakfast D. Transporting a client to a scheduled physical therapy appointment

A. Describing a surgery to a client before the consent is signed --the pt has to make a choice--

When working with the family of an older adult client recently diagnosed with vascular dementia, the nurse's primary educational concern is to what? A. Discuss the speed of progression of the disease's symptoms B.Determine ways to minimize caregiver stress C. Explain the onset can be related to exposure to infection D. Explain the medication therapy the client has been prescribed

A. Discuss the speed of progression of the disease's symptoms

Which action should the nurse take during the evaluation phase of the nursing process? A. Document reassessment of pain after medication administration. B. Provide the client with a follow-up appointment after discharge. C. Have the client give input into plan of care upon admission. D. Discontinue the indwelling urinary catheter per the provider's order.

A. Document reassessment of pain after medication administration.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy? A. Identifying with the client's feelings B. Experiencing feelings similar to those of the client C. Conveying genuine care to the client D. Caring for the client without negative judgment

A. Identifying with the client's feelings

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? A. Make changes in the plan of care based upon assessment data. B. Ask the client's family to assist the client in following the plan of care. C. Provide information to the client on the benefits of complying with the plan of care. D. Discuss the desired outcomes with the client and the importance of the outcomes.

A. Make changes in the plan of care based upon assessment data.

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle? A. Paternalism B. Deception C. Confidentiality D. Conflict

A. Paternalism

A older adult client develops delirium secondary to an infection. Which would be the most likely cause? A. Pneumonia B. Cellulitis C. Low platelet count D. Appendicitis

A. Pneumonia

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? A. Revise the care plan to allow the client to ambulate to the bathroom independently. B. Continue assisting the client to the bathroom to ensure the client's safety. C. Consult with the physical therapist to determine the client's ability. D. Instruct the client's family to assist the client to ambulate to the bathroom.

A. Revise the care plan to allow the client to ambulate to the bathroom independently.

Which components must be included in an outcome? Select all that apply. A. The action the client will perform B. Modifiers describing the end result C. A description in subjective terms of the expected client behavior D. The particular circumstances in which the outcome is to be achieved E. The client or some part of the client F. A target time by which the client is expected to be able to achieve the outcome

A. The action the client will perform D. The particular circumstances in which the outcome is to be achieved E. The client or some part of the client F. A target time by which the client is expected to be able to achieve the outcome

A client has come to the clinic requesting a hepatitis A and B vaccination before leaving on a tropical vacation. After assessing the client, the nurse should prioritize what finding to communicate to the provider? A. The client takes corticosteroids to treat rheumatoid arthritis B. The client uses marijuana two to three times per month C. The client received the annual influenza vaccine seven days ago D. The client has type two diabetes that is controlled by diet

A. The client takes corticosteroids to treat rheumatoid arthritis

A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase? A. The client will express feelings and concerns to the nurse. B. The client and nurse will establish goals of the relationship. C. The nurse and client will determine where and when they will meet. D. The client will identify the goals that have been accomplished during the relationship.

A. The client will express feelings and concerns to the nurse.

A nurse is developing a contractual agreement with a client. Which statement is true of a contractual agreement? A. The contract serves to meet the client's learning outcomes. B. The contract is a formal agreement. C. The contract is legally binding. D. The contract serves to meet nursing goals.

A. The contract serves to meet the client's learning outcomes

The diagnosis of delirium is supported when the nurse notes which in the client? A. The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place B. The client repeatedly asks where the client is and attempts to drink the water in a flower vase C. The client spends much of the day sleeping in the dayroom and usually denies being hungry D. The client responds to most assessment questions with "I don't know" and appears apathetic

A. The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place

The clinical nurse manager is evaluating a new nurse who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? Select all that apply. A. The nurse is committed to the organization's mission and values. B. The nurse can demonstrate basic mathematical problem solving. C. The nurse is able to organize and manage time efficiently. D. The nurse performs skills safely and never makes a mistake. E. The nurse understands nursing and medical terminology.

A. The nurse is committed to the organization's mission and values. C. The nurse is able to organize and manage time efficiently. E. The nurse understands nursing and medical terminology.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? A. Their readiness to learn is often related to a developmental task or social role. B. Peer group acceptance is a critical issue for this age group. C. The material presented should focus on future application. D.Previous experiences have little impact on learning.

A. Their readiness to learn is often related to a developmental task or social role.

When describing the use of vaccines to a local community group, what would the nurse include? A. Vaccines are used to provide active immunity. B. Vaccines promote the development of antigens. C. Vaccines can result in signs and symptoms of the full-blown disease. D. Vaccines are associated with severe reactions in children.

A. Vaccines are used to provide active immunity.

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with this diagnosis that the client's general appearance can nonverbally communicate to the nurse include: A. easy wrinkling of the skin and sunken eyes. B. slow heart rate and prolonged capillary refill. C. pallor and diaphoresis. D. cold intolerance and brittle nails.

A. easy wrinkling of the skin and sunken eyes. ---Although prolonged capillary refill is consistent with dehydration, slow heart rate is not. Pallor may be associated with dehydration but diaphoresis is not associated with this condition. ---

The nurse recognizes that identifying outcomes/goals must include: A. involvement of the client and family. B. input from the physician. C. input from the multidisciplinary team. D. involvement of the nurse manager and other staff nurses.

A. involvement of the client and family.

Which statement regarding hospice care and the role of a hospice nurse is most accurate? A. The hospice nurse's role in caring for the client and the family ends at the time of the client's death. B. After the hospice client's death, the nurse assists the family with the bereavement process up to one year. C. The focus of hospice nursing is on prolonging life and promoting dignity. D. Medicaid is the predominant source of payment for hospice care.

B. After the hospice client's death, the nurse assists the family with the bereavement process up to one year.

Meeting which type of needs is essential for physiological health and survival? A. Spiritual needs B. Basic human needs C. Monetary needs D. Educational needs

B. Basic human needs

During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case? A. Recall of the information being taught B. Independent use of new learning C. Involvement in the education in an active way D. Repetition of information for memorization

B. Independent use of new learning

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? A. Reprimand the nursing personnel responsible for the clients when the falls occurred. B. Investigate the circumstances that contributed to client falls. C. Institute a new policy on the prevention of client falls on the unit. D. Determine if client falls have increased on other units in the hospital.

B. Investigate the circumstances that contributed to client falls.

The nurse is assessing the self-care capabilities of a client who will be discharged from the hospital. Which are barriers this client will likely face in meeting established nursing goals pertaining to self-care? Select all that apply. A. Referrals to specialists B. Poor communication skills C. Inadequate emotional coping skills D. Debilitating illness E. Family's lack of interest in the plan of care

B. Poor communication skills C. Inadequate emotional coping skills D. Debilitating illness E. Family's lack of interest in the plan of care

What is the priority goal of interventions for a risk diagnosis? A. Reduce or eliminate contributing factors B. Prevent an actual problem C. Collect additional data D. Promote higher level wellness

B. Prevent an actual problem

A nurse assisting a new mother in the act of breastfeeding represents which form of learning? A. Affective B. Psychomotor C. Cognitive D. Simplistic

B. Psychomotor ---Psychomotor refers to the muscular movements learned to perform new skills and procedures, such as breastfeeding---

What should the nurse do prior to performing an initial assessment on a newly admitted client? A. Introduce the members of the health care team to the client. B. Review the records available on the client. C. Report to the charge nurse what needs to be done for the client. D. Tell the client that the nurse will do an assessment only if it's convenient.

B. Review the records available on the client. --The nurse should review records early when gathering data before the first contact with the client.--

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone? A. Spiritual needs B. Sociocultural needs C. Intellectual needs D. Emotional needs

B. Sociocultural needs

What is the term for the beliefs held by the individual about what matters? A. Ethics B. Values C. Morals D. Bioethics

B. Values --Values are ideals and beliefs held by an individual or group about what matters; values act as a standard to guide one's behavior.--

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? A. Orientation phase B. Working phase C. Termination phase D. Evaluation phase

B. Working phase

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have: A. moral agency. B. personal values. C. ethics. D. legal obligations.

B. personal values. --The only information given here tells us that this nurse has personal values on a particular issues.--

The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home? A. Provide a flexible schedule and change the activities each day. B.Use daily newspapers, calendars, and a set routine. C. Read to the client for long periods at a time. D. Use a daily current events quiz, making sure that the client participates.

B.Use daily newspapers, calendars, and a set routine.

A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as? A. Stimulus B. Source C. Message D. Channel

C. Message

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall? A. Cognitive B. Affective C. Psychomotor D. Interpersonal

C. Psychomotor --The psychomotor domain is a style of processing that focuses on learning by doing. -- The client's learning style does not fall in the cognitive, affective, or interpersonal domain. The cognitive domain is a style of processing information by listening to, or reading, facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values. The interpersonal domain is a style of processing that focuses on learning through social relationships.

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care? A. Provision of a dignified death experience B. Physical rehabilitation C. Relief from physical, mental, and spiritual distress D. Occupational therapy

C. Relief from physical, mental, and spiritual distress

Which nursing diagnosis would be the priority for the client experiencing acute delirium? A. Acute confusion related to delirium of known/unknown etiology B. Fall precautions related to acute confusion C. Risk for injury related to confusion and cognitive deficits D. Risk for self-mutilation related to confusion and cognitive deficits

C. Risk for injury related to confusion and cognitive deficits

Which outcome for a client with a new colostomy is written correctly? A. Explain to the client the proper care of the stoma by 3/29/20. B. The client will know how to care for the stoma by 3/29/20. C. The client will demonstrate proper care of the stoma by 3/29/20. D. The client will be able to care for stoma and cope with psychological loss by 3/29/20.

C. The client will demonstrate proper care of the stoma by 3/29/20. --this is the correct answer . because it is measurable--

The patient has just received a central venous catheter placed by the physician. Which of the following should the nurse anticipate next? A. The patient will become short of breath. B. The patient will develop an arrhythmia. C. The patient will have an X-ray to confirm placement of the device. D. The patient will have a stat order for lab tests.

C. The patient will have an X-ray to confirm placement of the device.

Which is a characteristic of the care-based approach to bioethics? A. The need to emphasize the relevance of clinical experience B. The rightness or wrongness of an action independent of its consequences C. The promotion of the dignity and respect of clients as people D. The need for an orientation toward service

C. The promotion of the dignity and respect of clients as people --The care-based approach to bioethics focuses on the specific situations of individual clients, and characteristics of this approach include promoting the dignity and respect of clients as people.--

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? A. Verbally report the finding to the charge nurse at the change of shift. B. Inform the unlicensed assistive personnel to document the finding. C. Verbally report the finding immediately to the client's physician. D. Reassess the client's temperature in 2 hours and chart this data.

C. Verbally report the finding immediately to the client's physician. --The nurse should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse-- . The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the physician

A nurse touches the client's hand while discussing the client's diagnosis. This action is: A. a dynamic process. B. a translation. C. a communication channel. D. an auditory channel.

C. a communication channel. ---A communication channel is a carrier of the message; touch can be a channel. Communication is a dynamic process, but simply touching one's hand is not.----

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: A. staring into the neonate's eyes and smiling. B. softly humming a song near the neonate. C. swaddling the child and gently stroking its head. D. offering the neonate infant formula.

C. swaddling the child and gently stroking its head. ---Touch is the most highly developed sense at birth.---

The nurse is preparing to teach four clients. Which client will the nurse plan to teach using principles associated with gerogogy? A. 4-year-old who likes to play with blocks B. 31-year-old who continuously used the internet C. 56-year-old who likes to take notes on paper D. 79-year-old who has slight cognitive changes

D. 79-year-old who has slight cognitive changes

The parents of an infant with apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents? A. Educational levels B. Home environment C. Infant bonding D. Baseline knowledge of these concepts

D. Baseline knowledge of these concepts

An exacerbation refers to the reactivation of a disease. Which condition is associated with exacerbation? A. Congenital illness B. Hereditary illness C. Acute illness D. Chronic illness

D. Chronic illness --Exacerbation is the increase in activity of a disease and aggravation of symptoms. This occurs periodically in clients with chronic diseases--

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect? A. Care provider B. Counselor C. Educator D. Coordinator of care

D. Coordinator of care

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? A. Check the client's skin turgor. B. Formulate a plan of care based on risk for dehydration. C. Administer an additional liter of intravenous fluids. D. Determine whether the prescribed treatment was effective.

D. Determine whether the prescribed treatment was effective.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? A. Surveillance B. Maintenance C. Supervisory D. Educational

D. Educational

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique? A. Restating B. Clarification C. Reflection D. Encouraging elaboration

D. Encouraging elaboration

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

D. Evaluation

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client? A. Insomnia B. Fatigue C. Agitated Movement D. Ineffective Impulse Control

D. Ineffective Impulse Control

When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration? A. It is administered at 1 to 2 months. B. It is administered at 3 to 4 months. C. It is administered at 5 to 6 months. D. It is administered at 12 to 15 months.

D. It is administered at 12 to 15 months.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? A. It documents assessments on separate forms. B. It records progress under problems, intervention, and evaluation. C. It provides and refers to a client's problem by a number. D. It provides quick access to abnormal findings.

D. It provides quick access to abnormal findings.

Which is an example of tertiary health promotion? A. Family counseling B. Water treatment C. Pap tests D. Rehabilitation

D. Rehabilitation --Tertiary health promotion and disease prevention begin after an illness is diagnosed and treated to reduce disability and to help rehabilitate clients to a maximum level of functioning.--

A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing the nurse's own judgments based on the nurse's expertise. Which type of healthcare decision making does this represent? A. Ethical decision making B. Paternalistic model C. Client sovereignty model D. Shared decision making

D. Shared decision making

A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness? A. The symptoms of the illness reappear. B. The disease is no longer present. C. New symptoms occur at this time. D. Symptoms are not experienced.

D. Symptoms are not experienced.

Which characteristic is the most important indicator of high-quality nursing practice? A. The nurse is organized and efficient in client care. B. The nurse follows the policies and procedures of the institution. C. The nurse takes measures to ensure accurate medication administration. D. The nurse considers the individual needs of clients.

D. The nurse considers the individual needs of clients. --The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care.--

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? A. The nurse writes one or two broad objectives rather than several specific objectives. B. The nurse writes general statements for learner objectives that could be accomplished in any amount of time. C. The nurse plans learner objectives with another nurse before obtaining input from the client and family. D. The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

D. The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

What are standards for decision-making that endure for a significant time in one's life? A. Beliefs B. Ethics C. Roles D. Values

D. Values

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should: A. ask questions as quickly as possible. B. use only open-ended questions. C. tell the client to rest and allow a family member to answer. D. allow the client to set the pace.

D. allow the client to set the pace.

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. ask the client for a urine specimen for urine drug use screening. B.consult with the social worker regarding inpatient drug rehabilitation. C. ask if the client realizes the infection is a direct result of the drug use. D. remain honest, open, and frank.

D. remain honest, open, and frank.

A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? A. "It's time to sleep now; you can see your family in the morning." B."We don't have your clothes; they are at home. You'll be going home when you recover." C. "Your family is fine. You need to take care of yourself now." D."You're in the hospital. You did not drink for several days, but you're getting better now."

D."You're in the hospital. You did not drink for several days, but you're getting better now."

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation? A. "Client states, 'I don't see the point in trying anymore.'" B. "Client makes statements indicating a loss of hope." C. "Client states that rehabilitation will be unsuccessful." D. "Client is demonstrating signs and symptoms of depression."

A. "Client states, 'I don't see the point in trying anymore.'" --Subjective data should be recorded using the client's own words, using quotation marks as appropriate.--

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen B. An older adult with pneumonia who is being discharged to the son's home tomorrow C. A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall D. An adult client who is being treated for kidney stones

A. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners B. Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose C. Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment D. Changing a client's advance directive after the prognosis has significantly worsened

A. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners --Standing orders and protocols often surround the management of bowel elimination.--

Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice? A. American Nurses Association B. National League for Nursing C. International Council of Nurses D. National Council of State Boards of Nursing

A. American Nurses Association

Which is a characteristic of a person-centered or helping relationship? A. An unequal sharing of information B. Spontaneous occurrence with random individuals C. A focus on the needs of the helping person D. The accountability of the person being helped for the outcomes of the relationship

A. An unequal sharing of information --The client shares information related to personal health problems, and the nurse shares information in terms of a professional role--

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client? A. Arrange for a sign language interpreter when discussing treatment. B. Talk with the client's children to determine needs. C. Consult the oncology nurse specialist. D. Use a text-telephone device (TTD) for daily communication.

A. Arrange for a sign language interpreter when discussing treatment -- A TTD line can assist in communication but is not as helpful as a medical interpreter.--

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care? A. Asking only the client's parents to be present at the education session B. Including a note about who was taught this new information in the client's chart C. Assuring the client that the conversation is confidential except under extreme circumstances D. Answering questions openly and honestly

A. Asking only the client's parents to be present at the education session --Peers are often more influential than parents, nurses, or teachers at this age--

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? A. Assess how the client would like to communicate B. Use facial and hand gestures C. Contact a person skilled in sign language D. Provide paper and pencil for written communication

A. Assess how the client would like to communicate

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond? A. Assume a position at eye level with the client and continue with the interview. B. Stop the interview and ask, "How are you feeling?" C. Sit silently until the client looks up and makes eye contact. D. Touch the client's hand and say, "You seem upset, is there something bothering you?"

A. Assume a position at eye level with the client and continue with the interview. ---Eye contact is perhaps among the most culturally variable nonverbal behaviors, and can be misunderstood as embarrassment, nervousness, or a problem with the client----

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? A. Care-based ethics B. Deontology C. Utilitarianism D. Principle-based ethics

A. Care-based ethics