Foundations Exam 1 Practice Exam
The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request? A. Identify and recommend some credible websites appropriate to the spouse's learning needs. B. Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. C. Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. D. Provide the spouse with print-based materials that are clearly referenced and reflect the spouse's learning style.
A
Which documentation by the nurse best supports the PIE charting system? A. Vomiting 250 mL undigested food, antiemetic given, no further vomiting B. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given C. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg D. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea
A
The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client? A. When the meal tray arrives B. As the client is sitting quietly, reading a book C. At the time of pain medication administration D. Immediately before discharge to home
B
216 Which client would be the best candidate for the nurse to engage in motivational interviewing? A. A 44-year-old client who brought a food log to weight loss counseling B. A 28-year-old client with elevated blood glucose for 8 months C. A 38-year-old client training to walk a half marathon D. A 66-year-old client who is showing improvement in range of motion
B
Which learning domain is the focus for instruction when the nurse educates a new mother about the breast and its role in milk production for feeding the newborn? A. Affective B. Psychomotor C. Cognitive D. Behavioral
C
When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which aspect related to learning is the nurse targeting in this approach to teaching the client? A. Motivation B. Attention and concentration C. Learning readiness D. Learning needs
B
While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse? A. "Use words that begin with 'f,' 's,' 'k,' and 'sh' to communicate." B. "Use flash cards and writing pads." C. "Limit communication to avoid frustration." D. "Encourage family members to increase their vocal pitch."
B
175 When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is: a. notifying the client's response to interventions b. conveying information c. reducing legal liability risks d. assisting in organization of care
B
183 The nurse should consider which client aspect as nonverbal communication? a. The client's tone of voice b. The client's religious practices c. The client's values and beliefs d. The client's accent
A
The nurse is caring for a client who speaks Chinese, which the nurse does not speak. An appropriate approach to communicating with this client would be: A. using a caring voice and repeating messages frequently. B. speaking directly and loudly to the client. C. avoiding the use of gestures or play-acting. D. writing messages for the client and offering a dictionary for translation.
A
The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply. A. Meal planning B. Community resources C. Appropriate use of a glucometer D. Instructions to follow up with the health care provider E. Ways to pay for hospitalization and outpatient care charges
A, B, C, and D
Which are high-risk errors in documentation? Select all that apply. A. Charting in advance B. Batch charting C Inadequate admission assessment D Falsifying client records E Failure to document completely
A, C, D, and E
172 The nurse observing an interaction between a mother and daughter appropriately identifies the interaction as which communication zone? a. personal b. public c. intimate d. social
C
205 In the provision of care and the establishment of the therapeutic relationship, the nurse must first: A. understand the client's response. B. avoid labeling clients. C. treat the client with dignity. D. be aware of one's own personality.
D.
181 A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Transtheoretical Model of Change, which stage of change is the client in related to diet? a. Precontemplation b Preparation c. Contemplation d. Maintenance
A
189 The nurse completed education with a client. Which documentation entry represents the most complete teaching plan? a. Start warfarin therapy initiated as prescribed; instructed to return to clinic for testing in 2 weeks. b. Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled. c. Discussed "Therapeutic Lifestyle Changes," printed materials reviewed, follow-up scheduled. d. Written and oral instructions given. Return demonstration performed accurately.
B
A client who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the client to expand on this and express concerns in more specific terms? A. Remaining silent B. "Feel like a woman . . ." C. "Do you feel like you are not a woman?" D. "Do you want more children?"
B
The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy? A. "I know how you feel. I was the primary caregiver for my father when he was dying." B. "It's okay to cry. Sometimes that helps us to feel better." C. "Just take your time. I am listening." D. "It is difficult when family members are ill. It helps if you take some time for yourself."
C
224 Nurses on a hospital burn unit meet as a group to discuss procedures. Which statements accurately describe effective functioning in a group? Select all that apply. A. The group leader alone uses individual talents and interpersonal strengths to assist the group to accomplish goals. B. The group's effectiveness depends on only the group leader's sensitivity to the needs of the group and its individual members. C. Group members use power to fix immediate problems without considering the needs of the powerless. D. Group members support, praise, and critique one another. E. The leader or other group members confront any member who dominates or thwarts the group process. F. Group members elicit mutually respectful relationships.
D, E, and F
208 A client states to the nurse, "I understand that I need a mastectomy for the treatment of my breast cancer, but I am fearful of learning about the drains I will need to empty." When responding to the client, the nurse will need to address which type of learning? A. Affective B. Behavioral C. Cognitive D. Psychomotor
A
231 The nurse is providing education to a group of clients with diabetes about the benefits of healthy food choices. What type of learning is the nurse using with this client group? A. Affective B. Technical C. Psychomotor D. Cognitive
A
A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client? A Assessing importance B Eicit-provide-elicit C. Evoking change talk D.Prioritizing
A
A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship? A. Reviewing health changes B. Attending to physical health care needs C. Establishing trust and rapport D. Developing solutions that will be enacted
A
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? A. Kinesthetic B. Verbal C.Visual D. Body language
A
220 To ensure accurate charting, which actions should the nurse perform? Select all that apply. A. Documents interventions as close as possible to the time of execution B. Checks to make sure that the nurse has the correct chart prior to making an entry C. Places a label with the client's name and identification number on each page of the client's chart D. Includes interpretations of client behavior E. Charts that the client is ingesting sufficient quantity of food and fluids
A, B, and C
171 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. delegating oral medication administration to the LPN/LVN b. calling the health care provider about abnormal lab results c. asking the LPN/LVN to teach a new diabetic client how to administer insulin d. obtaining vital signs on a newly admitted client
C
The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment? A. "I think all went well with your physical, don't you? B. "Do you have any questions about all that was discussed during the exam?" C. "We reviewed your plans for your new diet and medications. Do you have any other questions?" D. "Will we see you in 6 months to see how your diet has progressed?"
C
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
What is the most critical element to document regarding client education? A. A summary of the education plan B. The implementation of the education plan C. The client's need for learning D. Evidence that learning has occurred
D
Which is a drawback to the type of documentation known as charting by exception? A. Interference with standardized assessments B. Less interdisciplinary communication C. Increased time required to document information D. Issues related to high-quality care should a negligence claim arise
D
164 A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? a. a variance b. an adult c. a never event d. a sentinel event
A
176 A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. In this case, the nurse plays the role in the process of communication of the: a. sender b. receiver c. target d. decoder
A
177 Which statement accurately describes the concept of feedback as it pertains to the process of communication? a. The sender and the receiver use one another's reactions to produce further messages. b. The receiver listens to the sender in an unassuming way. c.The sender sends a clear message that is understood by the receiver. d. The sender's message is translated into a code, using verbal and nonverbal communication.
A
The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. A. "I will use only agency-approved abbreviations." B. "I will draw a straight line through any blank space." C. "I will elaborate on the details on my entry in the clients' records." D. "I will stay logged in on the computer until the end of my shift." E. "I will write, print, or type information legibly."
A and E
169 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 frustrated because you are too tired to perform normal activities." b. "You are hoping to figure out the cause of your extreme fatigue during this hospital stay." c. "You are unsure of what helps or prevents your fatigue." d. "You have been having a great deal of fatigue for the last 3 months."
B
201 A home health nurse is visiting a 40-year-old client who has had abdominal surgery. The client is unable to change a dressing because of obesity. The nurse is to instruct the client's spouse on the sterile dressing technique. During the visit, the nurse notes that the spouse has limited abilities due to mental disabilities. One assessment to determine the spouse's literacy would be: A. to assess her manner of speech. B. to assess her reading with WRAT. C. to assess her motivation to provide care. D. to assess her educational records.
B
Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn? A. "May I have something to eat?" B. "The pain in my chest has gone." C. "I am having difficulty breathing." D. "Finally, I am getting medical attention."
C. I am having difficulty breathing
162 A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized? a. when admitting the client b. when performing follow-up care c. when discharging the client d. when providing treatment
D
225 What is the primary purpose of FOCUS charting? A. To make it easier to identify nursing diagnoses for each client B. To make it easier to identify successes in meeting expected outcomes in the chart C. To help nurses identify client responses to medical problems D. To concentrate on the client and client concerns in documentation
D
A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse? A. Are you worried about the pain? B. Why don't you want to do this? C. Most people are afraid of sticking themselves. D. Tell me what you know about these tests.
D
Which situation is an example of battery that the nurse may witness while performing duties at the health care facility? A. Telling the client that the client may not leave the hospital B. Performing a surgical procedure without getting consent C. Taking the client's photograph without consent D. Witnessing a procedure done on a client without the client's consent
D
200 Which is important to remember when teaching adult learners? A. A focus on the immediate application of new material B. That all students, regardless of age, learn the same C. That older students may feel inferior in terms of new learning D. A need for support to reduce anxiety about new learning
A
When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? A. Assess for cultural differences. B. Boost the morale of the client. C. Delegate the health education to a colleague. D. Replace one-on-one teaching with written materials.
A
203 A nurse has been providing care to a client in the home for years. The nurse is asked to witness the client's signature on a will. What factors should cause the nurse to question whether to act as a witness on this document? Select all that apply. A. The nurse did not watch the client sign the will. B. The client knows what the client is doing. C. A relative is telling the client, "You must sign this document now." D. The client is alert and free of drugs that could distort thinking. E. The nurse is included as a beneficiary in the will.
A, C, and E
179 Which nursing actions would most likely help improve communication with clients and achieve a more effective helping relationship? Select all that apply. a. The nurse never admits a lack of knowledge to the client to avoid undermining the client's confidence in the helping relationship. b. The nurse remains focused on the topic at hand and does not allow the client to diverge to another topic. c. The nurse makes statements that are as simple as possible, gearing conversation to the client's level. d. The nurse controls the tone of voice so that it conveys exactly what is meant. e. The nurse feels free to use words that might have different interpretations when using the same language as the client. f. The nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations.
C, D, and F
163 Which note includes all elements of a SOAP note? a. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. b. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess c. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. d. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.
D
180 When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners? a. As clients, adults are the least likely to resist learning because of preconceived ideas about the teaching-learning process. b. The adult learner is not as concerned with the immediate usefulness of the material being taught as with the quality of the material. c. As an adult matures, self-concept becomes more dependent; therefore, this client must be made aware of the importance of reducing stress. d. The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.
D
185 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. Repetition of information for memorization b.Recall of the information being taught c.Involvement in the education in an active way d. Independent use of new learning
D
195 At completion of a teaching session with a client, the nurse documents the details of this education encounter in the client's health record. What should another nurse be able to determine from reading this documentation? a. The client's highest level of formal education achieved b. The client's long-term application of the health education c. The client's prognosis for recovery d. The client's response to the health education that was provided
D
206 In a helping relationship, the nurse would most likely perform what action? A. Establish goals for the client that are not set in a specific time frame. B. Encourage the client to independently explore goals that allow the client's human needs to be satisfied. C. Set up a reciprocal relationship in which both the client and nurse are giving and receiving help. D. Establish communication that is continuous and reciprocal.
D.
202 Which diagnosis would best describe a situation in which a parent has a knowledge deficit concerning child safety for a toddler who is currently being treated for burns and was previously treated for a fracture from a fall? A. Risk for Injury, related to mother's lack of knowledge about child safety B. Non-compliance: child safety, related to mother's lack of experience and socioeconomic level C. Knowledge Deficit: child safety, related to inexperience with the active developmental stage of a toddler D. Potential for Enhanced Parenting, related to child safety knowledge deficit
A
204 A nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition? A. "How are you supposed to take your medication?" B. "Are you having trouble getting your medications filled?" C. "Do you understand what asthma is?" D. "Do you have any questions about what you are supposed to do?"
A
212 Which is a characteristic of a person-centered or helping relationship? A. An unequal sharing of information B. The accountability of the person being helped for the outcomes of the relationship C. A focus on the needs of the helping person D. Spontaneous occurrence with random individuals
A
214 A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information? A. "Are you allergic to any medications?" B. "What do believe caused this current manic episode?" C. "Describe why people in glass houses should not throw stones." D. "Tell me about a time in your life when you were happy."
A
232 Which observation during the nursing assessment of a client supports the documentation of low health literacy? A. The client avoids health care screenings and seeks care in the local emergency department. B. The client complies with the medication regimen despite financial difficulties. C. The client is provides a coherent health history. D. The client's health forms are complete.
A
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? A. "Any information that can identify a person is considered a breach of client privacy." B. "You may continue to post about a client, as long as you do not use the client's name." C. "All aspects of clinical practice are confidential and should not be discussed." D. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."
A
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
The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching? A. During the admission process B. After all of the diagnostic testing has been completed C. After having venipuncture for laboratory work D. Immediately prior to discharge
A
The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan? A. Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. B. Discussed wet-to-dry dressing changes, and client stated understanding. C. Spouse taught to flush feeding tube before and after medication. Denied further instruction needed. D. Lecture provided about infection, and client stated understanding what infection is.
A
The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? A. "I will arrange access for you to review the record after you put your request in writing." B. "No, the physician will not give you access to review the records." C."Are you questioning the care of your child?" D. "Only the client has the right to review the health care records."
A
Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? a. FOCUS b. Narrative c. Exception d. PIE
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. The second nurse could be charged with libel. C. No charges are valid because the revelation took place during off-duty hours and off-site. D. No charges are valid because both nurses are involved in the client's care.
A
223 A nurse and client are working together to help the client make lifestyle changes to promote improved health. The nurse is having the client sign a contractual agreement for the work they will do together. Which statements by the nurse reflect the proper purposes of such agreements? Select all that apply. A. "Our goals are defined, as are ways to meet them." B. "This is a formal, legally binding document." C. "Because you signed this contract, you agree to follow the contract forever." D. "When you sign this agreement, you must meet all goals." E. "With this contract, we show that we are both dedicated to improving your health."
A and E
The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply. A. Touch B. Sight C. Spoken words D. Observation E. Intuition F. Telepathy
A, B, C, and D
A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply. A. "Cheer up. Tomorrow is another day." B. "Your doctor knows best." C. "That's a lot of information to take in. Would you like to talk about it?" D. "Don't worry. You will be just fine in another day or two." E. "Everything will be all right."
A, B, D, and E
165 The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply. a. Include the V.O. with the physician name on the order b. read back the order. c. mark the date and time of the order d. have the physician review and sign the order e. record the order on the pharmacy discrepancy sheet
A, B, and C
178 A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply. a. The nurse is careful what is said in the client's presence because hearing is the last sense to go. b. The nurse speaks with the client before touching the client. c. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. d. The nurse speaks to the client in a louder-than-normal voice. e.The nurse raises environmental noises to help stimulate the client. f. The nurse does not use touch to communicate with the client.
A, B, and C
194 A client is requesting to view all medical record information regarding the care received while hospitalized. What rights does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply. a To copy the health record b To see the health record c.To restrict certain disclosures of the health record d.To cross out sections of the health record e. To make additions to the health record
A, B, and C
A charge nurse has implemented staff education on nursing values. The nurse would determine that further education is required when which statement(s) are overheard? Select all that apply. A. "I can't believe the client is giving that precious baby up for adoption." B. "The gonorrhea test was positive. That's what the client gets for sleeping around." C. "If that was my mother, I sure wouldn't agree to a no-code." D. "If you are going to have extramarital sex, please protect yourself by using a condom." E. "Smoking has been shown to be a risk for many illnesses, including heart disease and cancer."
A, B, and C
161 A nurse educating a new mother on how to bathe an infant uses the acronym TEACH to maximize the effectiveness of the education plan. Which actions are guidelines based on this acronym? Select all that apply. a. edit client information b. act on every teaching moment c. always refer a client to counseling d. tune out the individual client e. clarify often
A, B, and E
196 A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. a Recording the date and time of all entries b Documenting entries that are up to date and comprehensive c Documenting entries that have unidentifiable writers' names and titles d Documenting entries that are subjective e Using approved agency abbreviations
A, B, and E
197 A nurse suspects that a client is a prostitute. The nurse documents this suspicion in the medical record and includes it in report to the oncoming shift. The nurse also mentions the suspicion to the nurse's sister saying, "I had a client named Susan in room 126 today who I think is a prostitute." Which violations has this nurse committed? Select all that apply. a Libel b. Slander c. Assault d. Battery e. HIPAA
A, B, and E
210 For which purposes would observing silence be appropriate? Select all that apply. A. To allow the client time to formulate an answer after asking the client a question B. To allow the nurse time to think of something to say when the nurse doesn't know the answer to a question C. To allow the client time to reflect on communication that has occurred D. To allow the client time to reflect on the client's thoughts E. To allow the client time to compose oneself when the client is upset
A, C, D, and E
218 Which information should the nurse include in a client's plan of care? Select all that apply. A. The client's level of activity and current medical orders B. The client care assignment of the nursing and support staff C. The client's problems, goals, and nursing orders D. Routine care, such as the client's bath and mouth care E. The minutes of the most current team conference meetings
A, C, and D
A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by: A. asking the client to provide a stool specimen for guaiac testing. B. asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate. C. determining whether the client has any food or drug allergies. D. insisting that the client not eat or drink anything until further instructed.
B
A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse: A. creating an educational opportunity for the future. B. creating an atmosphere for discussion of feelings. C. creating specific learning sessions for new information. D. creating an opportunity for rational thought and learning.
B
A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to: A. call the nursing supervisor to address the situation at hand. B. ask to speak to the physician in private and address the disrespectful remark. C. return to the nurse's home unit and ask to meet with the charge nurse. D. write a written account of what transpired and contact an attorney.
B
A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? A. Aggressive B. Assertive C. Nonassertive D. Therapeutic
B
A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report? A. Vital signs B. Mental status C. Client request D. Further testing
B
The nurse is preparing to teach a client about postsurgical care after a laparoscopic cholecystectomy. Which factor should the nurse most consider when determining whether the client is ready and able to learn? A. Social and economic stability B. Physical condition C.Emotional health D. Culture
B
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication? A. The client's accent B. The client's tone of voice C. The client's religious practices D. The client's ethnicity
B
226 A nurse is educating an older adult client with diabetes and family members about the importance of a nutritious diet. What outcomes does the nurse hope to achieve in the process of educating the client and family? Select all that apply. A. The nurse will be more aware of the client's health. B. The client will cope with alterations in health status. C. The nurse will be well-informed about the client's care. D. The client will achieve optimal health. E. The nurse will be able to diagnose the client's illness earlier.
B and D
221 The nurse has performed the following activities during the shift. Which activities are violations of client privacy and/or confidentiality? Select all that apply. A. Responding to the client's questions about the plan of care with a visitor present in the room B. Discussing the client's HIV status over lunch with a friend, a nurse on another team located on the same nursing unit C. Answering questions from a client's visitor before verifying the visitor has permission to receive the information D. Leaving the mobile computer screen, which contains client information, open when a visitor asked questions E. Removing a printed report of a client from the hospital premises to write a case study for a staff meeting
B, C, D, and E
190 A nurse is teaching a 5-year-old boy who was recently diagnosed with type 1 diabetes. The client's mother, who is the primary caregiver, informs the nurse of having a fear of needles. What actions are appropriate for the nurse to take to ensure a successful education session? Select all that apply. a. Asking the client's mother to leave the room to avoid distractions b. Ensuring 20 minutes of uninterrupted teaching time c. Providing the client's mother with an informational pamphlet about insulin injection d. Using a doll to demonstrate giving an insulin injection
B, C, and D
230 The nurse uses the acronym TEACH when planning care for clients on a busy hospital ward. Which interventions accurately represent aspects of this acronym? Select all that apply. A. H—The nurse helps the client cope when education fails. B. H—The nurse honors the client as a partner in the education process. C. C—The nurse clarifies often. D. A—The nurse acts on every teaching moment. E. E—The nurse educates the client before treatment. F. T—The nurse turns to the doctor for support.
B, C, and D
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards B. Obscuring identifiable names of clients and private information about clients on clipboards C. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D. Keeping record of people who have access to clients' records E. Making the names of clients on charts visible to the public
B, C, and D
168. 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 closest friend b. the unit's mental health technicians c. the client's physician d. the client's family e. the nurse from the oncoming shift
B, C, and E
167. Which actions should the nurse take before making an entry in a client's record? Select all that apply. a. choosing the charting format the nurse prefers b. locating clients' files within an electronic health record system c. checking that the client's names are not identified within the chart forms d. identifying the form appropriate to be used for documenting e. reviewing the agency's list of approved abbreviations
B, D, and E
186 According to Rosenstock, which health beliefs are critical for client motivation? Select all that apply. a. Clients view themselves as victims of the disease in question. b. Clients believe there are actions they can take to reduce the probability of contracting the disease. c. clients believe that the risks of taking these actions are greater than the risks posed by the disease itself. d. Clients view the disease as a serious threat. e. Clients view themselves as susceptible to the disease in question.
B, D, and E
209 The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. A. Placing a note on the computer terminal with the client's name and information B. Showing the provider the trends from baseline to present in blood pressure C. Writing the hemocult result on a piece of paper and leaving it at the desk D. Informing the provider of the client's present heart rate of 116 beats/min E. Faxing the results of blood chemistry levels to the provider's office
B, D, and E
166. The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed? a. You are scheduled for surgery 4 hours from now b. I will need to draw blood from you before the operation c. do you have any questions about your cholecystectomy d. can you remove your ring do do you need help?
C
170 Which client characteristic is important to assess when using the health belief model as the framework for education? a. family support b. source of information c. motivation to learn d. developmental level
C
173 The nurse is assisting a client 55 years of age to understand the anatomy and physiology of the heart following a heart attack. What type of learning is taking place? a. affective b. pedagogy c. andragogy d. psychomotor
C
174 A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication? a. ask whether the care provider is familiar with this client b. provide the most likely diagnosis of the problem c. ask the care provider to come and assess the client d. provide the client's most recent vital signs
C
182 A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments? a. Negligence b. Malpractice c. Libel d. Slander
C
184 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. "It's your choice about the surgery. What do you understand about the situation?" b. "If you don't have the surgery you may not live. Your family needs you." c. "Surgery is your only option. You need this operation." d. "Your grandchildren would be very upset if they lost their grandfather."
C
188 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? a. Voluntariness b. Disclosure c. Competence d. Comprehension
C
191 The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain? a. Provides return demonstration of use of an inhaler b. Verbalizes key points of a brochure about diabetes that was read c. States, "I feel comfortable using my walker" d. Provides a description of how appropriate wound healing should look
C
192 A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? a. Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients b. Confused, belligerent, and uncooperative with care c. Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth d. Yelling at staff members, dementia worse today, refused breakfast
C
198 A client with a body mass index (BMI) of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time? A. Dietary intake of the client that day B. The client's understanding of BMI C. Past interventions for weight loss D. History of obesity in family members
C
207 When communicating with a client, the nurse uses reflection for which purpose? A. To determine the sequence of events in the conversation B. To investigate the situation to help problem solve C. To have the client elaborate on thoughts and feelings D. To keep the client on the topic of concern
C
211 The nurse is performing an admission assessment on a client who was just transferred from the emergency department. The client has an elevated temperature and a wound infection. The client's sensorium is decreased, but the client is responsive. When should the nurse initiate teaching for this client? A. At the time of discharge B. When the family is not present C. During the admission assessment D. When the client's infection is improving
C
213 The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. Which expectation should the nurse have when developing the relationship? A. The relationship is based on the needs of the nurse. B. The relationship will occur spontaneously. C. The nurse is accountable for the outcome. D. The nurse and client will have a social relationship.
C
222 A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse? A. "I guess you don't feel like talking today." B. "Did you sleep well last night?" C. "Is that a new shirt you're wearing?" D. "Did you like the dinner yesterday?"
C
A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting? A. Sympathy B. Curiosity C. Empathy D. Humility
C
The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement? A. Provide brochures about low-sodium foods. B. Ask a family member to do meal planning to alleviate the burden for the client. C. Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray. D. Have the client repetitively choose appropriate foods from various menus.
C
When preparing client teaching materials, how does the nurse best assess a client's preferred learning style? A. Observe the client's behaviors. B. Provide teaching that works for the broadest base of clients. C. Ask the client, "Do you learn best by observing, valuing, or doing?" D. Determine client learning needs based on age and ability to hear effectively.
C
When the newly diagnosed client with insulin-dependent diabetes reports never having received instruction on the administration of injections, an appropriately stated nursing diagnosis for the client is: A. Self-care Deficit related to lack of knowledge about injections. B. Knowledge Deficit related to lack of knowledge about injections. C. Deficient Knowledge of Injection Administration as verbalized by the client, related to the lack of instruction and experience. D. Ineffective Health Care Maintenance related to diabetic instructions.
C
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? A. Disclosing client health information for research purposes after obtaining permission from the client's physician B. Releasing the client's entire health record when only portions of the information are needed C. Submitting a written notice to all clients identifying the uses and disclosures of their health information D. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information
C
187 Which are areas of potential liability for the nurse? Select all that apply. a. The nurse notifies the physician of the client's adverse reaction to a medication. b. The nurse documents that the client accurately prepared the correct amount of insulin after instruction was given. c. The nurse fails to document refusal by the client to ambulate following surgery. d. 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. e. The nurse administers the client's preoperative medication after the informed consent is signed.
C and D
217 The nurse has completed teaching. Which client behaviors demonstrate understanding within the cognitive domain? Select all that apply. A. Expresses a belief system in a higher power B. States, "I feel comfortable using my walker" C. Provides a description of what appropriate wound healing should look like D. Provides return demonstration of use of an inhaler E. Verbalizes key points of a brochure about diabetes that was read
C and E
A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response? A. "You should follow your physician's recommendation and have the surgery." B. "When you see the physician this morning, request more information about the surgery." C. "It is a minimally invasive surgery with rapid recovery time, so you will do fine." D. "Share with me the advantages and disadvantages of your options as you see them."
D
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? A. "I am calling because the client receiving blood has developed dyspnea and had crackles." B. "This client has a medical history of heart failure." C. "It seems like this client has fluid volume overload." D. "I think the client would benefit from intravenous furosemide."
D
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? A. "I am concerned that the client might be exhibiting sepsis." B. "The client's temperature has been 102°F (38.9°C) for the last 6 hours." C. "The client was admitted today with a urinary tract infection." D. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"
D
