Fundamentals Unit 2 (Professional Standards in Nursing)

The nurse finds the client laying on the floor. The nurse called the register nurse, who checks the client, and then cause the nursing supervisor in the primary healthcare provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection?

Psychosocial

A client has died, and the nurse ask a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the clients arms and buttocks. The nurse asked the client how the bruises versus stand. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

" I have a legal obligation to report this type of abuse."

And antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower blood pressure. Which statement by the nurse is most important to provide to the client?

" You will need to talk to your primary healthcare provider (HCP) before using an herbal substance."

A client is diagnosed with cancer and is toad that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complimentary therapies. Do you think I should try any?" the nurse should respond by making which appropriate statement?

" tell me what you know about complementary therapies."

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply.

-Many choose not to have health insurance - They believe that health is a gift from God - They use both traditional and alternative health care, such as healers, herbs and massage - Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment

The nurse observes that a client received pain medication one hour ago from another nurse, but the client still has severe pain. The nurse has previously observe the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor

The nurse arrived at work and his told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify test that can be safely performed.

The nurse consult with a dietitian regarding the dietary preferences of an Asian American client which food. Should the nurse suggest to include in a diet plan?

Rice

The nurse is caring for a group of clients who are taking herbal medication at home. Which client should be given instructions with regard to avoiding the use of herbal medication?

A 10-year-old female client with a urinary tract infection

The nurse is preparing to assist a client of orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting a client with the meal?

Allowing the client to unwrap the utensils and prepare his own meal for eating

The nurse enters a client room and notes that the client lawyer is present, and that the client is preparing a living will. The living will requires that the client signature be witnessed, and the client asked the nurse to witness the signature. Which is the appropriate nursing action?

Call the hospital lawyer

The licensed practical nurse (LPN) enters a client's room and finds the client laying on the bathroom floor. The LPN called the registered nurse, who checks the client thoroughly, and then assist the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary healthcare provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African-American heritage.

Fried foods

A nurse lawyer provides an education session to the nursing staff regarding client right with emphasis on invasion of client rights. The nurse lawyer ask a staff nurse to identify situation that represents an example of invasion of claim privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client, right?

Taking photographs of the client without consent

Which identifies accurate nursing documentation notations? Select all that apply.

The client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?

Touching the child during the examination

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the clients life. With regard to inform consent for the surgical procedure, which is the best action.

Transport the client to the operating department immediately without obtaining an informed consent

The client asked the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary healthcare provider.

Valerian