Fundamentals of Nursing FINAL

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client.

An 18 year-old woman is in the emergency department with a fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collects blood and sputum samples for the analysis. Which standard of practice is performed?

Assessment

Root cause analysis is being performed after a client who was supposed to be on falls precautions fell while trying to walk to the toilet. Which finding of the investigation would be considered to be a latent error?

The documentation forms on the unit have no specified location where falls precautions should be noted.

When administering an injection to a client with hepatitis C in a health care facility, the nurse sustained a needlestick injury. Which ensuing action would be most important?

The nurse needs to file an incident report after the event occurs.

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety? (Select all that apply.)

area rugs kept on the stairs without carpet dimly lit hallways waxed floors

After performing neuro checks every 2 hours after an ischemic stroke, the nurse determines the client's neurological status is deterioriating. Which nursing action best prevents an adverse outcome in this client's care?

assessing the client's neurological status more frequently than ordered

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?

assisting the client to put on slippers prior to ambulation

Which action directly addresses one of the Joint Commission 2015 Hospital National Safety Goals?

A hospital has set ambitious targets for reducing the incidence of catheter-related urinary tract infections.

What is informed consent?

A voluntary agreement made by a well-advised, mentally competent patient to be treated by a healthcare provider or institution.

Which member of the therapy staff would be consulted if a patient had difficulty swallowing? A. Speech Therapist B. Physical Therapist C. Occupational Therapist D. Respiratory Therapist

A. Speech Therapist

Does a competent patient have the right to refuse meds or treatment?

Yes.

The nurse is preparing to administer medication to a client. Which validation of client information is appropriate?

full name and date of birth

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

gas stove

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?

Centers for Disease Control and Prevention

A nurse hears a client call and finds that the client's room has caught fire due to an electrical short circuit. The nurse evacuates the room and raises an alarm. Which of the following types of extinguishers should the nurse use in this situation?

Class C

An ________ _________ may result when people hold differing values.

Ethical Dilemma

The goal of evidence-based practice related to restraints is to avoid the use of restraints.

True

The clinic nurse is cleaning a child's skinned elbow from falling on the playground. The nurse is cleaning which type of wound?

abrasion

BUN

blood urea nitrogen

carcin/o

cancer

scope of practice

the limitations and allowances of what they can do as nurses

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else."

Which actions should the nurse take when changing a wet-to-damp dressing? Select all that apply.

-fluff 4x4 before placing in wound -loosely pack the 4x4 into the wound -cover the filled wound w/ damp unfluffed 4x4's

What are the parts of the Nursing Process?

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose ordered and the dose scanned. What is the nurse's most appropriate response?

Consult with a colleague and identify the source of the error signal before proceeding.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and the members of other health disciplines.

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before.

Can an LPN insert an NG tube?

Yes, it is within the scope of practice for LPNs.

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

The surgical nurse is preparing a client for surgery on the left leg. The client is awake, alert, and oriented. Who does the nurse identify that should mark the leg that will undergo the surgical procedure? (Select all that apply.)

nurse surgeon client

-algia

pain, painful condition

What is the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing?

Stress incontinence

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include?

"Clear the clutter from the stairways and walkways."

The nurse is teaching a nursing student about proper latex glove use. Which nursing student action requires intervention by the nurse? (Select all that apply.

"snapping" the gloves when applying them to ensure proper fit wearing gloves for long periods of time after procedure ends

An RN student asks a friend who is an LPN/LVN student, "Will you be able to start IVs when you get out of school?" Which is the best response? 1. "It will depend on the Nurse Practice Act of the state where I work." 2. "Sure. I'm sure I will learn how to do that in school." 3. "Maybe. If the hospital where I work allows it." 4. "No. LPNs/LVNs are never allowed to do that."

1. "It will depend on the Nurse Practice Act of the state where I work."

Holistic Nursing Assessment Includes:

1. Mind 2. Body 3. Spirit

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug abuse?

19-year-old male college student majoring in physics

Medicare

A federal program of health insurance for persons 65 years of age and older

Who is responsible for serving as the primary advocate for the patient? A. The nurse B. The health-care provider C. The nurse supervisor D. The hospital

A. The nurse

PIE

Address patients problems and what is done to solve them. Seen mostly in nurse's notes. Stands for Problem, Intervention, and Evaluation.

Which intervention to prevent client falls in the acute care setting requires collaboration with a client's primary care provider?

Avoid the use of medications that increase the likelihood of falls.

A patient who is terminally ill with cancer is no longer being treated with radiation or chemotherapy. The most appropriate level of care for this patient would be: A. Home health care B. Hospice C. A skilled nursing facility D. A long-term care acute hospital

B. Hospice

SOAP/SOAPIER

Can be used with source-oriented or problem-oriented records. Stands for Subjective data, Objective data, Assessment data, Plan/Intervention, Evaluation, and Revision

A 79-year-old client with a history of osteoporosis experienced a fall while attempting to walk independently to the hospital washroom to urinate. How can the nurse best prevent a repeat of this incident?

Encourage the client to ring the call bell when the client has the urge to void.

Florence Nightingale

English nurse remembered for her work during the Crimean War (1820-1910), Instrumental in the Establishment of the Nightingale School

The nurse is caring for a client who has an indwelling urinary catheter. A care bundle is being used to guide the client's catheter care. What are likely elements of the care bundle? Select all that apply.

Ensure that the client's meatus is cleansed at least once per day. Evaluate the client's need for the catheter on a daily basis. Apply standard precautions when providing catheter care.

A nurse finds that a fire has broken out in a client's room at the health care facility. Place the steps the nurse should take in the correct sequence, from first to last.

Evacuate the client. Raise an alarm. Confine the fire. Extinguish the fire.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

Hair dryer is placed next to the sink.

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply.

It should provide a clear, concise recording of the situation It should include factual information about the incident.

The Great Trio

Mary Adelaide Nutting, Lillian Wald, Annie Goodrich. Made great strides in Nursing education

Can LPNs perform initial assessments of patients just admitted to the unit?

No. The LPN's role is to only collect objective and subjective data. The analysis and formation of the plan is always the RN's responsibility.

The nurse is caring for a client with confusion who has been placed into soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action is appropriate? (Select all that apply.)

Obtain order from a licensed provider within 1 hour of restraint application. Offer regular, frequent opportunities for toileting.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to the Joint Commission and to relevant state agencies

An elderly client has a diagnosis of vascular dementia and has been found wandering the hospital unit at numerous times during the day and night. The nurse should assign what priority nursing diagnosis to this client's behavior?

Risk for Falls

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

The nurse is collecting data on a patient's wound drainage. The drainage is reddish in color. How would the nurse document this finding?

Sanguineous drainage present.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A nurse was injured when a client with Alzheimer's disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

The nurse instructs the family of an older adult client with a visual impairment and decreased mobility that the most common problem for these clients is related to:

falls

A nurse has been appointed to oversee safety measures in an assisted living facility that caters to older adults. The nurse should prioritize measures aimed at reducing residents' risks of:

falls.

A client went missing from a long-term care facility and an emergency code was called. After a search of one hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety?

filling out an incident report accurately after a client went missing from the unit

arthr/o

joint

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

A nurse is providing care for a client whose blood pressure has been gradually dropping over the course of a shift. The nurse has decided to inform the client's primary care provider by telephone using the SBAR tool. The nurse will end this communication by:

making a suggestion about what she believes to be the best actio

The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

temporary application of devices that reduce the client's ability to move arms

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.