foundations final review

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured above, what is the highest prioritized nursing diagnosis?

Decreased cardiac output

A nurse is explaining A1C diagnostic testing to a client with diabetes. What level of health care delivery does this test suggest?

Primary

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

A nurse is caring for a client who sustained a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." What is the nurse's best response to the client?

The nurse says, "I can only imagine how hard this is on you. How can I help you?"

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:

critical thinking.

A nurse at a busy hospital is learning how to perform respiratory care interventions that used to be done by specialists only. What term does this represent?

cross-training

What is a component of nonverbal communication?

paralanguage

Nurses use assessment skills in their care of clients. What is the best example of an assessment skill?

taking the temperature of a sick child

A competent adult client is scheduled for surgery. Who signs the informed consent form to allow the surgery?

the client

A nurse is concerned about the practice of routinely ordering an extensive series of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate entity for addressing this ethical dilemma would be:

the institutional ethics committee.

The nurse is caring for a client on a postsurgical unit. At change of shift, the nurse will have completed documentation for this client that includes which component(s)? Select all that apply.

-specific times of day when the client's surgical dressing was assessed and changed

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information?

6 units of insulin administered

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7

Which age group in the population is expanding most rapidly, resulting in changes in the delivery of health care?

older adults

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity

A client who is cognitively impaired is scheduled to undergo surgery. The nurse demonstrates understanding of the principle of autonomy and checks the client's health record to ensure that consent has been obtained from which person?

surrogate decision-maker

A nurse is assessing a client's nutritional intake prior to admission the client has lost 10 lb (4.5 kg) over the last 2 months. Which example best represents therapeutic communication technique?

"Tell me about the type of foods you like to eat."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."

A client scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response by the nurse?

"What questions do you have about the surgery?"

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?

"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

A client with chronic hyperparathyroidism expresses that she is fed up with her diet and can no longer continue with it. What should the nurse's appropriate response to the client be?

"You may be having a difficult time staying on that diet; let's discuss it."

The nurse is completing an admission assessment with a client. The client looked down and became tearful when asked about feeling safe at home. How would the nurse respond to the nonverbal communication displayed by the client?

"You seem upset. You are safe here and can talk to me confidentially."

A nurse is showing an older adult client with severe diabetes the correct method of self-administering an insulin injection. What comment(s) is acceptable if the client continues making mistakes when learning how to self-administer an insulin injection? Select all that apply.

-"First-time learners often have this same concern." -"You have just about figured out how to give yourself an injection." -"Try to angle the syringe a little more this way."

The nurse is assigned to various clients on a medical unit. Which statement(s) made to a client by the nurse constitutes assault? Select all that apply.

-"I am going to insert a catheter in you, if you do not get up to go to the bathroom." -"Hold still for these stitches; otherwise, I am going to have to hold you down."

Which statements made by the nurse acknowledge the client as a human being? Select all that apply.

-"Mr. Smith, I will be taking you to x-ray now." -"I have your medications ready for you, Ms. Jackson."

The nurse is planning to conduct preoperative teaching for a client and a family member, both of whom speak and understand primarily a nondominant language. What activity(ies) will promote learning for the client and the family? Select all that apply.

-Determine availability of a professional interpreter. -Ensure the room is quiet. -Leave time at the end of the session to answer questions. -Listen to any concerns the client and family may have. -Provide verbal instructions and printed materials in the client's language.

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.

-Documenting entries that are up to date and comprehensive -Recording the date and time of all entries -Using approved agency abbreviations

A nurse has applied soft wrist restraints to a client following endotracheal intubation. Documentation of which information is essential when using restraints on a client? Select all that apply.

-Findings from patient assessment, performed every 2 hours -Foley catheter draining clear yellow urine -0.9 normal saline infusing intravenously at 100 mL/hr

A nurse is caring for a client in the community who is at risk for sudden death from a chronic health condition. To reduce the legal risks associated with working with this client, the nurse carries out which action(s)? Select all that apply.

-Follow the prescribed plan of care for the client. -Explain every nursing intervention in detail. -Document nursing actions shortly after completion.

Which are high-risk errors in documentation? Select all that apply.

-Inadequate admission assessment -Failure to document completely -Charting in advance -Falsifying client records

What are attributes of a professional nurse? Select all that apply.

-Is willing to learn from clients -Is aware of how beliefs and values influence others -Is motivated to provide the best of one's abilities -Accepts responsibility for one's actions

Which statement accurately describes a characteristic of ethics? Select all that apply.

-It is important to distinguish ethics from religion, law, custom, and institutional practices. -Values are intimately related to, and direct, ethical conduct.

A nurse has started a new job and is weighing the pros and cons of obtaining professional liability insurance. Why would the nurse choose to obtain professional liability insurance? Select all that apply.

-It provides for an attorney to represent the nurse in malpractice cases. -It covers incidents that occur during employment even after the nurse has left that employment. -It covers advice and care given outside the employment area. -It covers issues such as libel and slander.

Nurses are working in an emergency department (ED). Which nurses are acting in a moralizing manner? Select all that apply.

-The client frequently visits the ED for various reports of pain. The nurse tells another nurse, "That client is drug seeking." -The client is found to be at fault in a motor vehicle accident in which others are injured. The nurse delays treatment for this client.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply.

-The client is crying. -The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."

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.

-The client will achieve optimal health. -The client will cope with alterations in health status.

Which information should the nurse include in a client's plan of care? Select all that apply.

-The client's problems, goals, and nursing orders -Routine care, such as the client's bath and mouth care -The client's level of activity and current medical orders

The nurse is caring for a client living in a long-term care facility who has a diagnosis of dementia. While caring for this client, which action(s) taken by the nurse would constitute malpractice? Select all that apply.

-leaving bedrails down when the client is sleeping -informing the client he or she must use the nurse call bell to receive care -holding the client's dinner meal until the client agrees to take medication -sharing the client's health status with all inquiring family members

A client who is a single parent of two small children is working two part-time jobs. The client comes into the clinic for an appointment looking disheveled and fatigued. Which health promotion activities would this client benefit from? Select all that apply.

-reduction of stressors -perfection reduction

A nursing student is preparing for an oral class presentation on the types of communication. Which characteristics would the student include as nonverbal communication? Select all that apply.

-silence -tone of voice -facial expression

The nurse studies Dorothea Dix, an individual who organized women volunteers to care for the Civil War troops. For which other groups did Dorothea Dix improve health care? (Select all that apply.)

-the mentally ill -the blind -the deaf -the homeless

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

The nurse is providing education for a client who will be providing self-care at home. The client states, "I just do not think I can do all of this. It is too much to learn." What is the best response by the nurse?

"I understand that you feel overwhelmed with all of the information. Tell me what I can do to help."

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it."

The nurse participates in a religion that prohibits abortion. The nurse is to provide care to a client who is seeking an abortion because continuing the pregnancy will threaten the client's life. Place in order the steps the nurse should use to guide ethical decision-making. Use all options.

1. Assess the client's overall situation. 2. Identify the nurse's ethical problem. 3. List options and weigh consequences. 4. Implement one's decision. 5. Evaluate one's decision.

A couple has just learned that their newborn infant has a congenital cardiac anomaly that will require many lifestyle modifications, surgical corrections, and hospital stays. Place the following aspects of the couple's client education in the correct order that nurses should conduct them.

1. Determine their emotional readiness to learn. 2. Draft learning outcomes. 3. Select educational strategies. 4. Implement various educational techniques. 5. Revise the learning plan if needed.

The nurse is discharging several clients from an acute surgical unit on the same day. The nurse will prioritize teaching based on how much time is required for each client. Place the clients in the order, from first to last, in which the nurse will carry out discharge teaching. Use all options.

1. client who is learning to draw up and inject insulin for the first time 2. client who indicates the live-in partner is a registered nurse 3. client who is being discharged to a long-term care facility 4. client who is being transferred to another unit in the hospital

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

The nurse prepares to give the change-of-shift report. The nurse provides the oncoming nurse with the intake and output record of the client for the shift, pictured above. What is the client's fluid balance in milliliters? Record your answer using a whole number.

485

A nurse has completed 4 hours of an 8-hour shift on a medical-surgical unit when the nursing supervisor calls. The nursing supervisor directs the nurse to give a report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with client assignments and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources

Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?

American Nurses Association

Which organization is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice?

American Nurses Association (ANA)

Which is a characteristic of a person-centered or helping relationship?

An unequal sharing of information

While assessing an older adult client's upper back, the nurse notes round, raised red spots along the client's back. The client's daughter says, "Oh, that is just cupping." What action should the nurse take?

Ask about the practice of cupping.

The alert and oriented client has just been notified of a terminal cancer diagnosis and the need for surgery to extend life. The client tells the nurse, "I am leaving. I am not having the surgery." The client refuses to wait and talk to the primary care provider. What is an appropriate action by the nurse?

Ask the client to sign a form stating that the client is being discharged against medical advice.

A nurse is providing care to a client who is diagnosed with a condition, for which surgery is recommended. The client is unsure about whether to have the surgery. Which actions by the nurse best reflect actions the nurse can take to promote advocacy?

Ask the client what concerns the client has about the surgery.

A middle-aged adult discusses the loss of a job due to frequent illness. Which will the nurse discuss with the client to assist in problem-solving the loss?

Attending church or praying to a higher power

The nursing supervisor is giving a performance evaluation to an employee. Which communication technique by the nursing supervisor sends the message of disinterest in the employee?

Avoiding eye contact

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

A nurse will be finishing work for the day at 1900. Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty at 1900?

Change of shift reports

Alice Jones, a registered nurse, is documenting pain assessment after the administration of pain medication in the client's medical record. How should the nurse document this assessment?

Client rates pain at 2 on a scale of 0-10. A. Jones, RN

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice?

Code of ethics

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?

Cognitive

A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

Disturbed Body Image related to the incision scar

The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching?

During the admission process

A nurse is experiencing difficulty obtaining the client's cooperation in performing exercises after surgery. Which would be the best method for the nurse to obtain the client's cooperation?

Explain the purpose and benefit of the postsurgical exercises.

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity

Who is considered to be the founder of professional nursing?

Florence Nightingale

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

An unemployed, middle age client detects a lump in the testicle. What is the expected outcome for this client?

He is likely to delay treatment due to limited access to health care.

A man runs into the emergency room with an 18-month-old boy in his arms. The man screams, "Help, my son is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

High priority

The nurse is educating a group of clients in the community about safe sex practices. When is the best time to evaluate teaching effectiveness?

Immediately after the education session

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done.

Which nursing diagnosis has priority?

Ineffective Airway Clearance related to retention of secretions

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

Integrity

During a health teaching session, the nurse notes that the client is not attentive and loses concentration easily. Which of the following techniques is most appropriate to grab the attention of the client during the education?

Involve the client in an active way.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?

It helps deliver holistic, goal-oriented, individualized care.

A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which ethical principle is the nurse attempting to practice?

Justice

A nurse is providing care to two clients who are sharing the same room. The nurse is preparing to give one of the clients a complete bed bath. Which action by the nurse would suggest liability related to invasion of the client's privacy?

Keeping the curtain between the two clients in the room open

Recent staffing shortages on a hospital unit have resulted in unlicensed care providers being assigned to duties that are beyond their scope of practice. This has resulted in a number of near misses involving client safety. How should a nurse best respond to this trend in care?

Make the appropriate hospital authorities aware of this practice.

The nurse is planning to teach a 75-year-old client about administering medication. How can the nurse enhance the client's ability to learn?

Make the information relevant to the client's condition.

Which provides the best framework for prioritizing client problems?

Maslow's hierarchy of needs

A woman always thanks clerks at the grocery store. The woman's daughter, age 6 years, echoes the thank you. The child is demonstrating what mode of value transmission?

Modeling

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

Nausea

A nurse does not assist with ambulation a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse?

Negligence

A nurse is caring for a client with hypertension whose blood pressure has increased from 154/78 mmHg to 196/98 mmHg with a heart rate of 110 beats per minute during the past hour. The nurse goes to lunch without reporting the change to the health care provider, and the client experiences a cardiac arrest. What tort has the nurse likely committed?

Negligence

A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as?

Nonmaleficence

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective

The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action?

Obtain a medical interpreter.

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record?

Place one line through the entry and initial it.

The community health nurse is teaching an 89-year-old community-dwelling client about the care of the client's venous leg ulcer. In light of this client's age, the nurse should make which adaptation to this client's education?

Plan education sessions that are briefer than those intended for younger clients.

The nurse is assessing a toddler of Asian- American ethnicity and notes dark blue spots on the infant's lower back . What action should the nurse take?

Press lightly on the pigmented area and observe the toddler's reaction.

Which is an example of nonmaleficence?

Protecting clients from a chemically impaired practitioner

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?

Psychomotor

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment.

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

Return demonstration

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the plan of care.

The nurse is caring for a client in the intensive care unit who must be administered multiple medications. The client is often unresponsive and cannot offer information during assessment. When administering the medication, which step by the nurse is most important to avoid confusion and ensure safety?

Scan the client's wristband prior to administering medication to verify it is the correct client and correct medication.

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse says that the surgeon is rude and that the surgeon's clients always end up with infections. The nurse is at risk of being accused of which?

Slander

A nurse is caring for a very weak client with multiple pregnancies. Which view would a teleologist have in such a situation?

Support the procedure of selective abortion.

A 7-year-old child has been the victim of abuse. The child appears stoic and disconnected while being interviewed by the nurse. Although the child currently has a painful injury, the child does not cry or flinch when the area is touched. Which explains the child's stoic behavior?

The child has learned to cope by shutting off feelings.

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction?

The client belongs to a different culture.

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room on hearing the client calling for help. The nurse finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report?

The client was found lying on the floor.

A nurse is caring for a child with Huntington's chorea, a hereditary condition. Which statement is true of hereditary conditions?

The condition is acquired from genes of one or both parents.

What best describes the utilitarian theory of ethics?

The consequences of an action determine if it is right or wrong.

Which action by the nurse demonstrates respect for the client as an individual?

The nurse is administering medication to a client she addressed as "Mrs. Taylor."

What situation would permit the nurse to disclose information without the client's approval?

The nurse suspecting that a client is being abused or neglected

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?

The nurse tries to avoid hampering the client's independence.

The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?

They must take a licensure exam.

Which is not a purpose of the client care record?

To serve as a contract with the client

A nurse tells a client, "Are you going to get out of bed, or are you just going to sleep all day and night?" This is an example of which barrier to communication?

Using judgmental or belittling language

Which phrase best describes a value?

a belief about the worth of something to guide behavior

Which of the following is an example of an illness prevention activity by the nurse?

administering immunizations

The nurse is pulled to a unit where functional nursing is performed. Which nursing actions are appropriate when providing client care this medical-surgical unit?

administering medications to all assigned clients while a colleague provides all treatments, such as wound care to the same group of clients

A nurse is assigned a client who has been admitted to the health care facility with high fever. Which nursing skill should the nurse use at the first contact with the client?

assessment

A client reports to the emergency department with ankle pain due to a minor road accident. By asking the client to describe the accident, which type of nursing skill is the nurse using?

assessment skills

A nurse is caring for a client with quadriplegia who is fully conscious and able to communicate. What skill of the nurse would be the most important for this client?

caring

Which type of learner processes information more adequately by listening or reading facts?

cognitive

What ensures continuity of care?

communication

Two children need a kidney transplant. One is the child of a famous sports figure, whereas the other child comes from a low-income family. What ethical consideration is relevant to the nurse as an advocate for these clients?

cost-effectiveness and allocation

A nurse is caring for a client with alcohol use disorder. The nurse educates the client about the harmful effects of alcohol and educates the family on how to cope with the client and the client's disorder. Which type of skill is the nurse using?

counseling

The nurse is providing education to a client recently diagnosed with diabetes. Which action should the nurse take first to address the client's educational needs?

creating a plan with the client based upon needs

A nurse is teaching the importance of personal hygiene and proper bowel movement to a group of clients using gerogogy. Which client is the nurse addressing?

elderly people

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

The nurse is administering immunizations to a group of teens in a county health clinic. The nurse correctly identifies this action as:

illness prevention.

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation?

immediately report the suspected abuse of the client.

When the nurse is administering furosemide 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent?

implementation

Which of the following is a current trend affecting nursing education and practice?

increase in chronic health conditions

A nurse is performing a wet to dry dressing change on a client's lower abdomen. The nurse should be aware that he or she will be encroaching on which zone?

intimate zone

A group of nursing students is reviewing the ANA's current code of ethics. A code of ethics is important in the nursing profession because:

nursing practice involves numerous interactions between laws and individual values.

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

objective data.

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques?

open-ended question

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?

participate actively in the planning and execution of their care

An occupational health nurse at an oil refinery on the Gulf Coast of Texas performs client education with an adult client. The client is being seen after having suffering a chemical burn in an accident at the refinery. Which type of stressor has this client been exposed to?

physiologic

A nurse conducts a smoking cessation program for clients of a neighborhood clinic. This is an example of which of the following aims of nursing?

preventing illness

Which of the following illustrates the activity of acting in values clarification?

respecting the human dignity of all clients

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

retrieval of information is more efficient.

The nurse educator is providing a demonstration of the electronic medication administration cart to the student nurses on the clinical unit. Which level of human proxemics would be appropriate for the nurse educator at this time?

social

A medical-surgical unit manager intends to have licensed practical nurses (LPNs) in the unit administer intravenous push (IVP) medications. What source would the manager contact to include this procedure in the LPNs' practice?

state nurse practice act (NPA)

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

the public health department

What is the primary purpose of standards of nursing practice?

to ensure knowledgeable, safe, comprehensive nursing care

When documenting subjective data, the nurse should:

use the client's own words placed in quotation marks.

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan

A nurse is conducting a health history interview for a client at an assisted-living facility. The client says, "I have been so constipated lately." How should the nurse respond?

"Do you take anything to help your constipation?"

An adolescent expresses concern that a friend is under "a lot of stress" with home life, classes, clubs, community service, and part-time work. The adolescent asks the nurse what medication the friend should take to "calm down." Which response by the nurse will be supportive of the client?

"Do you think your friend would be willing to sit down and talk with me? I would like to get to know your friend better so I can suggest some healthy alternatives."

A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. What statement by the nurse communicates concern and caring about the client?

"I can imagine you have many concerns about your health. Tell me what is on your mind."

The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The beginning nurse is managing a team alone for the first time. Several ethical situations have occurred throughout the day that have caused the nurse to question the nurse's career choice. What actions should the nurse take to build resilience? Select all that apply.

-Cultivate relationships with other people who are supportive. -Ensure that the nurse takes entitled breaks and a lunch during the shift.

The nurse is on the way to work and witnesses a motor vehicle accident. The nurse has a first aid kit in the car. No emergency medical personnel have arrived. What actions by the nurse would be protected by Good Samaritan laws? Select all that apply.

-Splints an extremity in which a broken bone is present -Applies a gauze dressing to an open wound -Initiates cardiopulmonary resuscitation (CPR) for a person who has stopped breathing -Fails to obtain consent to provide treatment to a victim who is unresponsive

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

-documenting continuity of care -qualifying health care providers for government funds -ensuring client safety -facilitating health education and research

Which abbreviation is correct for use in documentation?

PO

A nurse is educating a home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction?

The message will likely be misunderstood.

A client nearing the end of life requests that the client be given no food or fluids. The physician orders the insertion of a nasogastric tube to feed the client. What is the primary concern of the nurse providing care?

The nurse faces an ethical dilemma about inconsistent courses of action.

A client who is scheduled for abdominal surgery gives informed consent. While reviewing the client's medical record, the nurse identifies the consent form, interpreting it as most reflective of:

protection of the client's right to self-determination in decision-making.

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle?

relevance

Which nursing role is the nurse exhibiting when collecting data about the number of urinary tract infections on the nursing unit?

researcher

A nurse pulls the curtains closed before changing the dressing of the surgical wound on the abdomen of a postsurgical client. What value is served?

Dignity

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist.

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating?

basic respect for human dignity

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

battery

Which nursing action is most dependent on technical skill?

changing a client's wound dressing while maintaining asepsis

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

The nurse is caring for a client. When does the nurse determine that nursing care will be most effective related to nurse-client communication?

common understanding

Which word is most closely associated with the term "ethics"?

conduct

A nurse has taught a client with asthma how to administer a daily inhaler. How would the nurse evaluate the teaching-learning process?

directly observing the client using the inhaler

The nurse is administering an antibiotic to a client with community-acquired pneumonia. This activity encompasses which aim of nursing?

restoring health

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist, and learns that the nurse wrongfully attributed the disease to the client's contact with sex workers. With what legal action could the nurse be charged?

slander

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.

-"I will write, print, or type information legibly." -"I will use only agency-approved abbreviations." -"I will draw a straight line through any blank space."

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse?

"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."

Which nursing assessment guideline is most accurate?

"Collect assessment data about the client continuously."

The nurse is readmitting a client who was discharged 1 week ago with complications from diabetes mellitus. The client states, "I really did not understand what I was supposed to do to care for myself from those papers that I was sent home with." What question will the nurse ask to promote the client's self-esteem?

"How do you learn best and what can we do to provide you with that information?"

The nurse is reviewing the health history of a Native American/First Nations client. Which statement made by the client would require immediate follow-up by the nurse?

"I drink alcohol occasionally, but all my family members do."

The following information appears on a client's medical record:Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area.When documenting this information using the SOAP method, which part would the nurse document as "S"?

"I have a fair amount of pain in my belly near my incision"

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

The primary care provider is yelling at the nurse in the client's room because the client has not received an intravenous antibiotic. Which statement by the nurse demonstrates assertiveness?

"Let's go to the nurses' station, and I will explain."

The nurse is caring for a client diagnosed with asthma. The client reports drinking herbal tea to treat illnesses. Which additional question(s) will the nurse ask during the assessment? Select all that apply.

-"Do you take any other supplements?" -"How many cups of herbal tea do you drink in one day?" -"Have you shared this information with your health care provider?"

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

A client reports to a primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

An older adult client is advised to undergo a 12-lead electrocardiogram (ECG) assessment. The client seems to be anxious because this is the first time undergoing such a procedure. What explanation should the nurse provide to the client?

"The ECG electrodes are painless and will record electrical activity of the heart."

A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

A nurse is educating a client about how the general adaptation syndrome (GAS) theory works in the human body. What statement(s) made by the client indicates to the nurse that further education is required? Select all that apply.

-"The alarm reaction alerts my family that I need to slow down." -"I often get exhausted when I do too much yardwork." -"The fight-or-flight reaction is initiated by growth hormone released in my brain." -"The alarm reaction may last for days."

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply.

-"The client demonstrates additional signs of hypovolemia including slow capillary refill." -"The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." -"The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery."

The adult children of a client diagnosed with brain death are trying to come to terms with this diagnosis. Which statement(s) by the children exhibits normal grieving to the nurse? Select all that apply.

-"We have to accept this is really happening right now." -"She would want us to donate her organs to others." -"I am so angry with mom for leaving all of us so suddenly." -"I just need to get out of here right now and go for a walk." -"We should start thinking about the funeral arrangements."

Which are examples of breaches of client confidentiality? Select all that apply.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

A first-time mother is in her second trimester and the prenatal screening has indicated the possibility of Down syndrome. While awaiting the results of amniocentesis, the client acknowledges anxiety. Which intervention(s) by the nurse will be helpful to the client? Select all that apply.

-Actively listen to the client with full attention -Encourage the client to express emotions -Label the client's emotion, noting fear -Restate the feelings the client has expressed -Engage the client in planning the next steps

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

-Approach the client from the front. -Use the client's name. -Smile and maintain eye contact.

The nurse is caring for a 5-year-old child on the pediatric unit. Which activities would promote the psychomotor skills of this child? Select all that apply.

-Assembling blocks -Building a house with popsicle sticks -Removing the toys from the toy box

A nurse is preparing to educate about the importance of contraception and safe-sex practices to a group of college students. Which factors can affect the nurse's teaching strategies? Select all that apply.

-Availability of resources -Learning style preferences of students -Literacy level of target audience

Which action(s) will the nurse take when preparing for and conducting a teaching session for clients with visual impairment? Select all that apply.

-Avoiding the use of materials printed on glossy paper -Using a lamp that shines over the clients' shoulders -Ensuring that the clients are wearing prescription eyeglasses

To ensure accurate charting, which actions should the nurse perform? Select all that apply.

-Checks to make sure that the nurse has the correct chart prior to making an entry -Documents interventions as close as possible to the time of execution -Places a label with the client's name and identification number on each page of the client's chart

What are common elements in a state's nurse practice act? Select all that apply.

-Definition of legal scope of nursing practice -Creation of a state board of nursing -Criteria for the education of a licensed practical nurse -Requirements for the licensure of the registered nurse

A nurse is planning a seminar for the local community. Which topics are examples of health promotion discussions? (Select all that apply.)

-Examples of heart-healthy diet -Information on increasing activity and exercise

A group of nurses is participating in a community health fair and is engaged in primary prevention activities. Which activities would these nurses be leading? Select all that apply.

-Family planning services -Accident prevention education -Heart-healthy nutrition services

The nurse is teaching a 6-year-old child prior to cardiac surgery. What activity(ies) does the nurse include to facilitate learning with the child? Select all that apply.

-Involve the parents in the teaching. -Keep explanations short. -Make the teaching sessions brief. -Provide a tour of an empty pediatric ICU client room.

The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured above. Based on documentation guidelines, which suggestions would improve the nurse's charting? Select all that apply.

-Leave no blank space after each entry; draw a line. -Sign each entry. -Provide qualifiers for pain, such as quality and quantity. -Make observations of client behavior, not interpretations.

Which scenarios are examples of a nurse committing a tort? Select all that apply.

-The nurse told the client, "The doctor prescribed this medication, and you must take it. I'll force you to take it." -The nurse tells another employee, "Everyone knows the previous nurse does not do the job and charts medications not administered." -The nurse administered a sedative medication to a sleeping client because the client's child requested the parent receive it.

The client states to the nurse, "I don't know what they're doing for me. I see so many doctors. One says one thing, another says something else." What are appropriate actions by the nurse to assist the client in understanding the plan of care? Select all that apply.

-Make rounds with health care professionals when visiting the client. -Restate recommendations in simple terms that the client will understand. -Read the consultation and progress notes written by health care professionals. -Assist the client to identify and write questions for the health care professionals.

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply.

-Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. -No new labs have been ordered after surgery. -The client has a clean and dry abdominal dressing. -Pain level is currently a 3 following administration of intravenous morphine.

The spouse of a client on hospice at home is diagnosed with "caregiver burden." Which intervention(s) will the nurse use to assist the caregiver? Select all that apply.

-Problem solve with the spouse to create a plan for respite -Discuss support mechanisms available for the spouse -Offer the spouse ideas for emotional coping mechanisms -Provide the name of a local caregiver support group -Suggest ways the spouse can maximize time and effort

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

-Reviewing the agency's list of approved abbreviations -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply.

-Spoken words -Sight -Touch -Observation

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply.

-The client exhibits agitation and shouts at the nurse. -The client's blood pressure is 135/82 mm Hg. -The client's skin turgor is normal. -The client has redness around the ankles bilaterally. -The client participates in range-of-motion exercises.

Which scenario(s) exemplifies shared decision-making? Select all that apply.

-The client expresses a desire to be treated at home but agrees to hospitalization for intravenous antibiotics for cellulitis. -The nurse demonstrates to a receptive family member the proper steps to change the leg dressing when the client is at home. -The nurse asks the postoperative client which route of opioid medication is preferred for pain relief.

The nurse is conducting discharge teaching for a client who has been diagnosed with type 2 diabetes. The nurse is teaching the client how to inject insulin at home. Which cue(s) will alert the nurse that the client has poor health literacy? Select all that apply.

-The client has a history of several missed health appointments. -The client's hospital admission forms were incomplete. -The client has a history of medication nonadherence. -The client did not follow up on when asked to book an appointment with a specialist.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply.

-The client's blood pressure trend over the past 24 hours. -The primary reason the client was admitted to the hospital. -Objective and subjective data from the most recent assessment. -An explanation of what is needed to improve the hypotensive state.

The nurse conducts a teaching session for a group of middle-aged women. Which exercise information will the nurse share with this group? Select all that apply.

-The importance of regular exercise to maintain health -The use of exercise to improve quality of life -The use of ambulation devices to improve exercise -How to perform deep breathing exercises

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

Which are purposes of documentation in health care records? Select all that apply.

-To facilitate quality -To serve as a financial record -To support decision analysis -To assist with clinical research

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

-any abnormal occurrences with the client during the shift -identifying demographics, including diagnosis -current orders

The client states, "I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today." The client's arms are folded across his chest. His brow is furrowed, and he will not allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply.

-arms folded across chest and brow is furrowed -states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today" -will not allow morning vital sign measurements

Which current nursing action(s) aligns with Florence Nightingale's theory? Select all that apply.

-evaluating and adjusting the hospital room's ventilation -washing hands before and after all client interactions -encouraging client to meet daily caloric requirements

A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply.

-having each person responsible for documenting in the electronic health record not share his or her password -placing computer screens in locations that face away from any public areas such as hallways -ensuring that individuals log off a computer terminal when documentation is completed

The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply.

-heparin 5000U subcutaneously every day -metoprolol 25 mg po daily, hold if BP <100 mm Hg -vancomycin 750 mg IV qod

The nurse is developing a plan of care for a client. Which nursing action is defined as an activity(ies)/intervention(s)? Select all that apply

-holding the client's hand -starting an IV -educating clients

The nurse is conducting a teaching session regarding HIV/AIDS for adult clients in the community. What consideration(s) will the nurse make when teaching this type of session? Select all that apply.

-identifying the length of the session -beginning with basic concepts about HIV/AIDS -providing adequate lighting and comfortable temperature -identifying the time, place, and content for the next teaching session

Which is a targeted health goal(s) in the Healthy People 2030 initiative? Select all that apply.

-increase the proportion of health and wellness and treatment programs and facilities that provide full access for people with disabilities -reduce the number of new cases of cancer as well as the illness, disability, and death caused by cancer -reduce incidence of tuberculosis

The nurse is caring for a client who had a stroke with residual affective aphasia. What is an effective method(s) for the nurse to communicate with the client? Select all that apply.

-provide the client with a tablet or whiteboard to attempt communication -patiently await the client's responses after asking question -have the client point to common phrases or spell with alphabet letters on a laminated form

A group of students is reviewing the activities involved with the implementation and evaluation phases of the nursing process. The students demonstrate understanding of the information when they identify which activities as being included in the implementation phase? Select all that apply.

-recording nursing actions -reassessing the client -setting priorities

A student nurse asks the instructor why so much emphasis is being placed on the importance of client teaching. What benefits would the instructor identify? Select all that apply.

-reduced lengths of stay -better allocation of resources -increased client satisfaction

The nurse is preparing to create a plan of care for a client admitted with chronic obstructive pulmonary disease (COPD). Which intervention(s) will directly help the client achieve the goal of self-actualization? Select all that apply.

-teaching the client about the COPD diagnosis -educating the client about the course of the disease process -creating a treatment and prevention plan to decrease readmissions

In the computer, the nurse needs to document the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took his medication at 1530 hours?

03:30 p.m.

The client's heart rate is 160 beats per minute. The client is experiencing complications of an excessive heart rate. The primary care provider issues a verbal prescription for intravenous medication to the nurse. Place the steps of taking the verbal prescription in chronological order.

1. Record the prescription in the client's medical record, including date and time. 2. Read back the prescription to the primary care provider who initiated it. 3. Obtain verification from the primary care provider that the prescription is correct. 4. Initiate the prescription and administer the medication. 5. Obtain the signature of the primary care provider who gave the verbal prescription.

A nurse is caring for a client with a urinary tract infection. The client is anemic and has a hemoglobin count of 8 g/dl (80 g/L). Taking into consideration that the client is from a Mediterranean country, what should the nurse's most appropriate action be?

Ensure that the drug ciprofloxacin is not prescribed.

The nurse is caring for a client with different cultural practices and beliefs regarding health care. In which manner can the nurse ensure health disparities are reduced and the client receives equitable care?

Adapt care to encourage a collaborative, client-centered relationship that ensures safe practice.

A nurse realizes the dosage of hydrocodone/APAP 5-325 administered to the client has been entered incorrectly into the client's eMAR. What would be the first action for the nurse to correct this error?

Add the correct information, making a notation of why the error occurred with the date of correction.

Which encounter represents nursing negligence?

Administering a new antibiotic without subsequently reassessing the client.

The nurse discovers that a recently admitted client does not speak the same language as the nurse. Which action would the nurse take?

Arrange for a trained language interpreter.

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

Assessing

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?

Assessing importance

A nurse enters a client's hospital room to begin a teaching session. When the nurse enters, the client says, "Nurse, I am really cold. Could you get me another blanket? My side is really aching, too, and I'm thirsty." Based on this information, what should the nurse do next?

Attend to the client's needs for warmth, pain relief, and thirst.

Which note includes all elements of a SOAP note?

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.

A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education?

Cognitive, affective, and psychomotor

A nurse is sitting with friends in a coffee shop while working on a plan of care for a client. The client's name is written at the top of the plan. Which ethical responsibility is the nurse violating?

Confidentiality

A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation?

Cross out 86/132 with a single line and place the nurse's initials above it.

An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take?

Ensure that the client does not eat or drink anything.

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase?

Examine goals of the relationship to determine whether they were achieved

The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

False reassurance

The nurse is conducting a health interview with an older adult client. During this introductory phase, which action should the nurse take to effectively establish of the nurse-client relationship?

Greet the client by asking by which name he or she prefers to be addressed.

The nurse is using an assessment guide that includes a hierarchy of five life requirements universal to all persons. Which model for organizing assessment data is the nurse using?

Human Needs (Maslow) model

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client?

Medication that is not administered should be documented along with the reason.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

A 22-year-old woman who recently immigrated to the country has been admitted to the hospital with an ovarian cyst. Both the client and spouse do not speak the dominant language of the new country, and this has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take to communicate with the client?

Organize professional interpretation, either in person or by telephone.

The nurse is caring for a 65-year-old widower whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with him about his spouse. Which is the nurse's priority intervention for this client?

Refer the client to a support group

An on-duty nurse discovers that a colleague is pilfering medicines. According to the Nurse Practice Acts, what should the nurse do?

Report the incident to the supervisor.

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response?

Reteach the length of time to take the prescription.

A nurse needs to bathe a client at the health care facility. What is the most appropriate action of the nurse before washing the client's hair?

Seek permission from the client.

A nurse is caring for a client with decreased secretory immunoglobulin A (SIgA). Which health problem might the client face because of this condition?

The client is at a risk for severe infections or cancer.

Fifteen years ago, a client lost the right leg in a motor vehicle accident. Since then, the client and the client's spouse have formed a walking group to raise money for the homeless. Why would the client be considered healthy?

The client is experiencing a high quality of life within the limits of their physical condition.

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?

The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.

During the Crimean War, which was fought between Russia and the alliance of England, Turkey, France, and Sardinia, what was the major achievement for nursing?

The nursing care resulted in a decrease of the death rate of soldiers to 1% from 60%.

A client is dealing with the death of a spouse 10 days ago. The client tells the nurse about not feeling like eating and struggling to get food in. What does the nurse identify is occurring with the client?

This is part of the normal sympathetic stress response.

A client arrives at a health care facility complaining of pain in the abdomen and diarrhea. The physician diagnoses the client with colitis, an acute illness. Why is colitis considered an acute illness?

The onset is sudden.

A client arrives at a health care facility reporting diarrhea and abdominal pain for the past 24 hours. The health care provider diagnoses the client with gastritis, an acute illness. Why is gastritis considered an acute illness?

The onset is sudden.

Which definition best describes acute illness?

The rapid onset of symptoms lasting a relatively short time

A client gets out of bed following hip surgery, falls, and re-injures the hip. The nurse caring for the client knows that it is the nurse's duty to make sure an incident report is filed. Which statement accurately describes the correct procedure for filing an incident report?

The report should contain all the variables related to the incident.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

Which nurse broadened the definition of nursing to encompass health promotion?

Virginia Henderson

Positive client outcomes are the goal of nurse-client interactions. What is an influential factor directly related to positive client-care outcomes?

health education

A nurse has recently completed the administration of seasonal influenza vaccinations for the residents of a long-term care facility. Which aim of nursing has the nurse most clearly demonstrated?

preventing illness

A client with a diagnosis of colorectal cancer has been presented with the treatment options, but wishes to defer any decisions to an uncle, who acts in the role of a family patriarch within the client's culture. The client's right to self-determination is best protected by:

respecting the desire to have the uncle make choices on the client's behalf.

A nurse has been assigned to the ICU by a supervisor because of a number of sick calls. However, the nurse is not highly experienced in providing intensive nursing care. What would be the most appropriate action by the nurse?

to report to the nurse in charge for duty but explain the nurse's practice limitations

A client is received in a postoperative nursing unit after undergoing abdominal surgery. During this time the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

tort