Exam 6 FlexiQuiz 1of2
Mark the client's walker with a large, easily readable label.
A client admitted to a health care facility uses a walker for support. What is the nurse's responsibility with regard to the walker when admitting the client to the nursing unit?
Gather the garment and work it up and over the body.
A nurse is caring for a client with a fracture in his hand. How should the nurse assist the client to change his clothes?
"You said that you do not smoke, but you have an open package of cigarettes in your pocket."
A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?
The client needs to repeat the admission procedure.
During a round at night, the nurse finds that a client is missing from his room. The client returns early next morning. What procedure is followed by the health care facility with regard to this client?
It provides quick access to abnormal findings
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?
No later than 24 hours
Once a client is admitted and all the admission data are collected, the nurse is expected to develop an initial plan for the client's care. By what point after admission should the nurse develop the plan?
Skilled
The client lives in a skilled nursing facility and has had an acute exacerbation of multiple sclerosis symptoms. What type of facility will provide the most appropriate care for this client?
assessing the client's level of pain
The nurse enters the room and the client is grimacing and guarding the abdomen. The client reports, "I have pain." What is the nurse's first priority?
"I will start an IV that will add fluids directly to the blood stream."
The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?
ensuring quality of care over time
The nurse is caring for the same client this week as last week, and the week before. Continuity of care is the process in which the client and the care team are involved in ongoing healthcare management. What is the function of continuity of care?
client, supervisor, and nurse
When keeping a client's personal belongings in a locker, the nurse should ensure that the envelope is sealed and signed by which of the following people?
SOAPcharting
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?
The client needs to sign a form releasing the physician and agency from responsibility.
A client states that the client is "fed up" with the care that the client has been receiving in the hospital and plans to leave immediately. What procedure is followed with regard to this client?
0800 and 2000
A client who is bedridden is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as
Communicate clearly and frequently with other care providers.
A client with medically complicated pregnancy has expressed frustration about the disparities in advice and treatment that the client has received at various sites over the past several months. How can the nurse best ensure that there is continuity in the care that the client receives?
Empathy
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?
The resident has developed pressure ulcers on the backs of the heels.
An 81-year-old resident of an intermediate care facility has been assessed and the nurse believes that a move to a skilled nursing facility may be justified. What aspect of the resident's health would warrant a move to a skilled nursing facility?
Skilled nursing facility
An elderly client with a tracheostomy is to be discharged from a health care facility. Which of the following extended care facilities should the nurse suggest to the client for continued care until complete recovery?
Client's physical assessment
During the admission phase, the nurse is required to assess the client and collect information for the data base. The nurse can also delegate some part of the work to other ancillary staff. Which of the following can the nurse delegate to the other staff?
"According to HIPAA legislation, you have a right to request changes to inaccurate information."
A client made a formal request to review their medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?
"The physician wants to monitor you and control your pain."
A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply?
The nurse tries to avoid hampering the client's independence.
A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?
Come prepared with material required to take notes.
A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?
Cross out the incorrect statement with a single line and place nurse's initials above it.
A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. What is the best technique for recording the error made in documentation?
"Tell me more about the aspects that make you feel as if it happened yesterday."
A nurse visits a female victim of sexual assault for the fourth 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?
Participate actively in the planning and execution of their care.
A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?
minimum data set (MDS)
The nurse is performing a comprehensive assessment of functional capability on a client that lives in a certified nursing home. What federally mandated process is the nurse completing?
nursing kardex
While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom. The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source?
Information is documented in separate forms by each health care personnel.
A nurse caring for a client who is being treated by three physicians uses the source- oriented format for documentation. What are the benefits of using this format of documentation?
attention and concentration
A nurse is asking a client health-related questions during a medical assessment. The client has developed lesions on the skin and warts around the mouth. Which factor affects oral communication?
The nurse arranges for a client with a diabetic foot ulcer to see a podiatrist in community.
A nurse is aware that clear and accurate communication is necessary whenever clients are transferred or referred. Which situation best demonstrates a referral?
Provide a written review of the client's status.
A nurse is caring for a client who is to be transferred to another unit in the same facility. Which of the following is a responsibility of the nurse during the transfer of the client?
Repeat what the client has said to verify the meaning.
A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which communication strategy is an effective one for this client?
Encouraging the client to talk about the clients life. Asking the client when the client would like to have the bed linens changed
A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions made by the nurse will promote the development of a therapeutic relationship? (Select all that apply.) A. encouraging the client to talk about the client's life B. calling the client by their first name C. asking the client when the client would like to have the bed linens changed D. assisting the client with the completion of all activities of daily living E. talking with the nurse during bedside change of shift report
providing paper and pencil for written communication assessing how the client would like to communicate
A nurse is completing a health history on a client who has a hearing impairment. Which actions can the nurse take to enhance communication? (Select all that apply.) A. providing paper and pencil for written communication B. speaking loudly and with exaggerated facial movements C. using facial and hand gestures D. contacting a person skilled in American Sign Language E. assessing how the client would like to communicate
progress notes
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
Reinforce a post-surgical abdominal dressing. Administer oral aspirin and lisinopril to the client with hypertension. Insert a nasogastric tube in a client with absent bowel sounds.
A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate to delegate to the LPN/LVN? (Select all that apply.) A. Reinforce a post-surgical abdominal dressing. B. Change an intravenous catheter for a client with an infiltrated IV. C. Administer oral aspirin and lisinopril to the client with hypertension. D. Insert a nasogastric tube in a client with absent bowel sounds. E. Teach a client with diabetes how to administer insulin
Nurse as collaborator
A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?
The student feels insecure during the interview
A nursing student is conducting a client interview in order to determine the client's health history. The student's instructor observes that the student frequently twists her hair with her fingers while asking the client questions. What is the most plausible meaning of the student's nonverbal communication?
rule out
A physician is examining the client during the client's initial physical examination. After collecting all the data, the physician writes R/O in the medical records and suggests some more tests and examinations. What does the physician mean by R/O?
