Nursing Concepts Exam 3 Practice Questions

Informal Learning

Learning that is learner initiated, involves action and doing, is motivated by an intent to develop, and does not occur in a formal learning setting.

The nurse adheres to "the right action is determined by identifying the actions that yield the greatest good for the greatest number." What is an important weakness of the nurse's belief? a. It applies to numerous but not all situations. b. It centers of the character of the person acting. c. It draws on common rules of conduct. d. It may undermine the needs of the few.

D

The nurse is obligated to follow a physician's order unless: A. The order is a verbal order B. The physicians order is illegible C. The order has not been transcribed D. The order is an error, violates hospital policy, or would be detrimental to the client.

D

The nurse was just hired to work in a hospice day care facility. She reflects on her ethical framework and decides that she believes in establishing relationships with an emphasis on caring. Which frameworks can the nurse use? a. Deontology b. Feminist ethics c. Utilitarianism d. Ethics of care

D

A federal law passed in 1990 that requires hospitals and other health care providers to provide written information to patients regarding their rights under state law to make medical decisions and execute advance directives. A. Patient Self-Determination Act B. Health Insurance Portability and Accountability Act C. Emergency Medical Treatment and Active Labor Act D. Nurse's Bill of Rights

A

As an advocate for the client, the nurse must make sure that "safe, effective care" is given in conformity with the A. Nurse Practice Act (NPA). B. American Nursing Association (ANA) C. National Council for Lisensure Examinations D. State Board of Licensure

A

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following is an intervention? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

D

Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.

D

Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging

(Answer: ) A (Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.)

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Risk for aspiration R/T anesthesia B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Acute pain R/T surgery

(Answer: ) A (Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.) ABC's: Airway Breathing Circulatory

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall with a pillow

(Answer: ) A (Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.)

While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: A. Potential for impaired skin integrity R/T altered gland function B. Potential for impaired skin integrity R/T dehydration C. Impaired skin integrity R/T dehydration D. Impaired skin integrity R/T altered circulation

(Answer: ) C (Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.)

Which of the following is classified as subjective data? A. Client appears sleepy B. No distress noted C. Abdomen soft and non-tender D. States feels anxious and tense

(Answer: ) D (Rationale- D: Subjective data are clients' perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. a. Objective data are observation or measurements made by the data collector. In this example, the nurse is making the observation that the client appears sleepy. b. "No distress noted" is an example of objective data because it is an observation made by the nurse. c. "Abdomen soft and non-tender" is an example of objective data because it is an observation made by the nurse, not a client's perception.) Which of the following is classified as subjective data? A) Client appears sleepyB) No distress notedC) Abdomen soft and non-tenderD) States feels anxious and tense

A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment B. Planning C. Implementation D. Evaluation

(Answer: ) D (Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.)

____________ the actions of professionals that fall below standard of care for a specific professional group. a. Libel b. Slander c. Assault d. Negligence

D

Bioethical issues

-genetic testing -cloning and embryonic stem cell research -end of life care -resource access and allocation

Client education happens in which order? A. Evaluate outcomes B. Select teaching-learning strategies C. Assess the learner D. Implement the teaching plan E. Develop learning objectives

1. C 2. E 3. B 4. D 5. A

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? a. The client fell out of bed b. The client climbed over the side rails c. The client was found lying on the floor d. The client became restless and tried to get out of bed.

1. C- The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

5 rights of teaching

1. Right time 2. Right context 3. Right goal 4. Right content 5. Right method

a policy statement adopted by the ANA to identify the seven conditions that nurses should expect from their workplace that are necessary for sound professional practice A. Patient Self-Determination Act B. Health Insurance Portability and Accountability Act C. Emergency Medical Treatment and Active Labor Act D. Nurse's Bill of Rights

D

The client's right to refuse treatment is an example of _________. A. Statutory Law B. Civil Law C. Criminal Law D. Common Law

A law that governs relationships between individuals and defines their legal rights.

The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work

A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.

The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to administered. Which action should the nurse take? a. Contact the nursing supervisor b. Administer the dose prescribed c. Hold the medication until the HCP can be contacted d. Administer the recommended dose until the HCP can be located

A- If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.

Nursing Practice Act is a _________ law. A. Statutory Law B. Administrative Law C. Criminal Law D. Common Law

A. Statutory Law A statute (law) written in 1909 by Texas Legislature. Defines the scope of nursing practice. -Establishes the Board; gives it the authority to make rules about professional nursing -Only the Legislature can amend the Nurse Practice Act

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?

The philosophy sometimes called the code of ethics of care suggests that ethical dilemmas can best be solved by attention to: A. Relationships B. Ethical principles C. Clients D. Code of ethics for nurses.

A. The ethic of care explores the notion of care as a central activity of human behavior. Those who write about the ethics of care advocate a more female biased theory that is based on understanding relationships, especially personal narratives ethics-of-care nursing philosophy directs attention to the specific situations of individual patients, viewed within the context of their life narrative. - Nursing's responsibility to care in ethical situations - Principles + feelings

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A. American Nurses Association's (ANA's) Code of Ethics B. Nurse Practice Act (NPA) written by state legislation C. Standards of care from experts in the practice field D. Good Samaritan laws for civil guidelines

A. This set of ethical principles provides the professional guidelines established by the ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to establish rules and then incorporate guidelines for accountability and responsibility of each nurse within the practice setting.

Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it

A. True outsider sees the decision be made

A nurse is preparing to teach a kinesthetic learner about exercise. Which technique should the nurse use? a. Let the patient touch and use the exercise equipment. b. Provide the patient with pictures of the exercise equipment. c. Let the patient listen to a podcast about the exercise equipment. d. Provide the patient with a case study about the exercise equipment.

ANS: A Kinesthetic learners learn best while they are moving and participating in hands-on activities. Demonstrations and role playing work well with these learners. Patients who are visual learners learn best when you use pictures and diagrams to explain information. Patients who prefer auditory learning are distracted by pictures and prefer listening to information (e.g., podcasts). Patients who learn best by reasoning logically and intuitively learn better if presented with a case study that requires careful analysis and discussion with others to arrive at conclusions.

A nurse provides teaching about coping with long-term impaired functions. Which situation serves as the best example? a. Teaching a family member to give medications through the patient's permanent gastric tube b. Teaching a woman who recently had a hysterectomy about her pathology reports c. Teaching expectant parents about physical and psychological changes in childbearing women d. Teaching a teenager with a broken leg how to use crutches

ANS: A Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients and/or family members to continue activities of daily living. Teaching family members to help the patient with health care management (e.g., giving medications through gastric tubes, doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. Injured and ill patients need information and skills to help them regain or maintain their levels of health. Some examples of this include teaching a woman who recently had a hysterectomy about her pathology reports and expected length of recovery and teaching a teenager with a broken leg how to use crutches. In childbearing classes, you teach expectant parents about physical and psychological changes in the woman and about fetal development; this is part of health maintenance.

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate? a. The patient will walk to the bathroom and back to bed using a cane. b. The patient will understand the importance of using a cane. c. The patient will learn how to use a cane. d. The patient will know the correct use of a cane.

ANS: A Outcomes often describe a behavior that identifies the patient's ability to do something on completion of teaching such as will empty colostomy bag, or will administer an injection. Understand, learn, and know are not behaviors that can be observed or evaluated.

A nurse wants the patient to begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture b. Demonstration c. Role play d. Question and answer session

ANS: C Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an effective teaching method for the psychomotor domain.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? a. The patient will administer epinephrine. b. The patient will identify the main ingredients in several foods. c. The patient will list the side effects of epinephrine. d. The patient will learn about food labels.

ANS: A Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss other topics, such as nutritional needs and side effects of medications. For example, a patient recently diagnosed with coronary artery disease has deficient knowledge related to the illness and its implications. The patient benefits most by first learning about the correct way to take nitroglycerin and how long to wait before calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about the correct way to take epinephrine. "The patient will learn about food labels" is not objective and measurable and is not correctly written.

Which statements by the nurse indicate a good understanding of patient education/teaching? (Select all that apply.) a. "Patient education is a standard for professional nursing practice." b. "Patient teaching falls within the scope of nursing practice." c. "Patient education is an essential component of safe, patient-centered care." d. "Patient education is not effective with children." e. "Patient teaching can increase health care costs." f. "Patient teaching should be documented in the chart."

ANS: A, B, C, F Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential component of providing safe, patient-centered care. It is important to document evidence of successful patient education in patients' medical records. Patient education is effective for children. Different techniques must be used with children. Creating a well-designed, comprehensive teaching plan that fits a patient's unique learning needs reduces health care costs, improves the quality of care, and ultimately changes behaviors to improve patient outcomes.

A patient with heart failure is learning to reduce salt in the diet. When would be the best time for the nurse to address this topic? a. At bedtime, when the patient is relaxed b. At lunchtime while the nurse is preparing the food tray c. At bath time, when the nurse is cleaning the patient d. At medication time, when the nurse is administering patient medication

ANS: B Appropriate times to talk about food/diet changes during routine nursing care are at breakfast, lunch, and dinner times or when the patient is completing the menu. Many nurses find that they are able to teach more effectively while delivering nursing care. For example, while hanging blood, you explain to the patient why the blood is necessary and the symptoms of a transfusion reaction that need to be reported immediately. In this situation, because the teaching is about food, coordinating it with routine nursing care that involves food can be effective. At bedtime would be a good time to discuss routines that enhance sleep. At bath time would be a good time to describe skin care and how to prevent pressure ulcers. At medication time would be a good time to explain the purposes and side effects of the medication.

Which nursing action is most appropriate for assessing a patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the goals of patient care.

ANS: B Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient's health literacy before providing instruction. The nursing process requires assessment of all sources of data to determine a patient's total health care needs. Evaluation of the teaching process involves determining outcomes of the teaching/learning process and the achievement of learning objectives, not patient care. Assessing the goal of meeting patient care is the evaluation component of the nursing process.

A student nurse learns that a normal adult heartbeat is 60 to 100 beats/minute. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor

ANS: B Cognitive learning includes all intellectual behaviors and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. The student nurse acquired knowledge, which is cognitive. Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Psychomotor learning involves acquiring skills that require integration of mental and muscular activities, such as the ability to walk or to use an eating utensil.

Which action best indicates that learning has occurred? a. A nurse presents information about diabetes. b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient.

ANS: B Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. Complex patterns are required if the patient is to learn new skills, change existing attitudes, transfer learning to new situations, or solve problems. A new mother exhibits learning when she demonstrates how to bathe her newborn. A nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of teaching. A family member listening to a lecture does not indicate that learning occurred; a change in knowledge, attitudes, behaviors, and/or skills must be evident.

A nurse is preparing to teach a patient about heart failure. Which environment is best for patient learning? a. A darkened, quiet room b. A well-lit, ventilated room c. A private room at 85 F temperature d. A group room for 10 to 12 patients with heart failure

ANS: B The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature. Although quiet is appropriate, a darkened room interferes with the patient's ability to watch your actions, especially when you are demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information being presented. Learning in a group of six or fewer is more effective than in larger groups and avoids outburst behaviors.

Which situation will cause the nurse to postpone a teaching session? (Select all that apply.) a. The patient is mildly anxious. b. The patient is fatigued. c. The patient is asking questions. d. The patient is hurting.e. The patient is febrile (high fever).f. The patient is in the acceptance phase.

ANS: B, D, E Any condition (e.g., pain, fatigue) that depletes a person's energy also impairs his or her ability to learn, so the session should be postponed until the pain is relieved and the patient is rested. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. A mild level of anxiety motivates learning. When patients are ready to learn, they frequently ask questions. When the patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan.

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which purpose of patient education is the nurse fulfilling? a. Restoration of health b. Coping with impaired functions c. Promotion of health and illness prevention d. Health analogies

ANS: C As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose.

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which purpose of patient education is the nurse fulfilling? a. Restoration of health b. Coping with impaired functions c. Promotion of health and illness prevention d. Health analogies

ANS: C As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose.

Which situation indicates to the nurse that the patient is ready to learn? a. A patient has sufficient upper body strength to move from a bed to a wheelchair. b. A patient has the ability to grasp and apply the elastic bandage. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

ANS: C Motivation or readiness to learn sometimes results from social task mastery, or physical motives may be involved. Often patient motives are physical. Some patients are motivated to return to a level of physical normalcy. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices. Do not confuse readiness to learn with ability to learn. All the other answers are examples of ability to learn because this often depends on the patient's level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe.

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. In this situation, which element represents feedback? a. The nurse b. The patient c. The nurse teaching about healthy food choices d. The patient stating that eating yogurt is better than eating cake

ANS: D Feedback should show the success of the learner in achieving objectives (i.e., the learner verbalizes information or provides a return demonstration of skills learned). The nurse is the sender. The patient is the receiver. The teaching is the message.

Which statement indicates that the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Learning consists of a conscious, deliberate set of actions designed to help the teacher." d. "Teaching is most effective when it responds to the learner's needs."

ANS: D Teaching is most effective when it responds to the learner's needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

A nurse is teaching the staff about nursing and teaching processes. Which information should the nurse include regarding the teaching process? During the teaching process, what should the nurse do? a. Assess all sources of data. b. Identify that it is the same as the nursing process. c. Perform nursing care therapies. d. Focus on a patient's learning needs.

ANS: D The teaching process focuses on the patient's learning needs and willingness and capability to learn. Nursing and teaching processes are not the same. All the rest are components of the nursing process: Assess all sources of data and perform nursing care therapies

A primary care provider prescribes on tablet, but the nurse accidentally administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for malpractice? 1. No, the client was not harmed 2. No, the nurse notified the primary care provider 3. Yes, a breach of duty exists 4. Yes, foreseeability is present

Answer: 1 Rationale:All elements such as duty, foreseeability causation, harm/injury and damages must be present for malpractice to be proven. Malpractice involves: 1) duty owed the patient 2) breech of duty by professional 3) patient has to be injured 4) injury caused by breach of duty

Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions are most appropriate? Select all that apply 1. The nurse needs to know the Good Samaritan Act for the state. 2. The nurse is not held liable unless there is gross negligence 3. After assessing the situation, the nurse can leave to obtain help. 4. The nurse can expect compensation for helping. 5. The nurse offers to help but cannot insist on helping.

Answer: 1,2,5 Rationale: The nurse is subject to the limitations of state law and should be familiar with the Good Samaritan laws in the specific state. Gross negligence would be described by the individual state law. Unless there is another equally or more qualified person present, the nurse needs to stay until the injured person leaves. The nurse should ask someone else to call or go for additional help. The same client rights apply at the scene of an accident as well as those in the workplace.

Which nursing actions could result in malpractice? Select all that apply 1. Learns about a new piece of equipment 2. Forgets to complete the assessment of a client 3. Does not follow up on client's complaints. 4. Charts client's drug allergies5. Questions primary care provider about an illegible order

Answer: 2 and 3 Rationale:Standards of practice require a complete assessment. A nurse needs to be sure the client's needs have been met. They both can impact client safety and do not follow standards of care.

A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in school. When the UAP says yes, the nurses asks him to help her by doing a urinary catheterization on a post surgical client. What is the best response by the UAP? 1. "Let me get permission from the client first." 2. "Sure, which client is it?" 3. "I can't do it unless you supervise me." 4. "I can't do it. is there something else I can help you with."

Answer: 4 Rationale:A sterile invasive procedure that places the client at significant risk for infection is generally outside the scope of practice of a UAP. Even though the UAP is a nursing student, the agency job description should be followed.

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Fluid volume excess related to peripheral vascular disease C. Risk for injury related to edema D. Altered peripheral tissue perfusion related to venous congestion

Answer: D Rationale: This answer takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion

Deontology

Approach to ethics that judges the morality of an action based on the action's adherence to rules. Described as duty or obligation, because rules 'binds you to your duty'

a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. A. Patient Self-Determination Act B. Health Insurance Portability and Accountability Act C. Emergency Medical Treatment and Active Labor Act D. Nurse's Bill of Rights

B

statute in each state and territory that regulates the practice of nursing; Includes Nursing licensing, credentialing, and disciplinary action. A. Patient Self-Determination Act B. Nurse Practice Act C. Emergency Medical Treatment and Active Labor Act D. Nurse's Bill of Rights

B

a nurse practicing _______ would notify the provider about a concerning change in a patient's condition. a. beneficence. b. Advocacy c. respect for autonomy. d. veracity.

B advocacy is to promote and protect the patient's rights, health, and safety. In other words, nurses must advocate for their patients' best interest.

The nurse explains and directs a patient to ambulate after a recent hip surgery. Before ambulation, the nurse administers pain medication. The nurse demonstrates practice of a. beneficence. b. nonmaleficence. c. respect for autonomy. d. veracity.

B is to avoid causing harm. For example, a nurse demonstrating nonmaleficence would perform multiple checks before administering medication to avoid a dangerous medication error.

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnosesE. Develop client goals

B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.

B. Care and interventions may be provided by an interdisciplinary team to include PT, OT, Nurses, Physicians

The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician

B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of assault. A. True B. False

B. False Rationale:Battery is physical in nature. Assault is a threat.

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain.

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.

moral distress when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action A. True B. False

B. True when a patient had made a moral decision but is unable to carry out the chosen action. Cues include expressions of powerlessness, guilt, frustration, anxiety, self-doubt, and fear.

Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed

C

The client has right-sided hemiplegia as a result of a stroke (brain attack) and wants a cup of hot coffee. Even though the client is insistent, the nurse does not permit her to drink the coffee unsupervised. This nurse is using the ethical principle of a. Autonomy b. Fidelity c. Nonmaleficence d. Justice

C

_________________ defines 3 responsibilities of participating hospitals (defined as hospitals that accept Medicare reimbursement): Provide all patients with a medical screening examination (MSE) Stabilize any patients with an emergency medical condition. Transfer or accept appropriate patients as needed A. Patient Self-Determination Act B. Health Insurance Portability and Accountability Act C. Emergency Medical Treatment and Active Labor Act D. Nurse's Bill of Rights

C

The Nurse reassures a patient with terminal illness by saying "Everything will workout, just wait, the medicine will help cure you." Which ethical principle is the nurse violating? a. beneficence. b. Advocacy c. respect for autonomy. d. veracity.

D Veracity means to tell the truth—to never lie to patients or give them knowingly false reassurance, which is also lying.

The nurse cares for a 54-year-old patient who was recently diagnosed with renal disease. What teaching strategy best demonstrates the use of humanistic theories? The nurse would a. discuss the disease process in simple terms. b. integrate previous knowledge and skills. c. provide available information materials and support. d. reinforce instructions and encourage compliance.

C Humanism: A belief that emphasizes faith and optimism in human potential and creativity requires support and advocacy. Emphasizes learners active involvement in learning. learning leads to realization of self potential

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome

C - Planning phase (ADPIE)

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure b. Ask the EMS team to sign the informed consent c. Transport the victim to the operating room for surgery d. Call the police to identify the client and locate the family.

C- In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing clear liquid, in the antecubital area. Which is the most appropriate action by the nurse? a. Call security b. Call the police c. Call the nursing supervisor d. Lock the co-worker in the medication room until help is obtain

C- Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

The nurse notes that an advance directive is in the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case? A. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state B. A living will allows an appointed person to make health care decisions when the client is in an incapacitated state. C. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. D. The client cannot make changes in the advance directive once the client is admitted into the hospital.

C. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. Rationale:A living will directs the client's healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time.

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implementation phase. Option 4 represents the planning phase.

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation

C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

The distribution of nurses to areas of "most need" in the time of a nursing shortage is an example of: A. Utilitarianism theory B. Deontological theory C. Justice D. Beneficence

C. Justice is defined as the fairness of distribution of resources. However, guidelines for a hierarchy of needs have been established, such as with organ transplantation. Nurses are moved to areas of greatest need when shortages occur on the floors. No floor is left without staff, and another floor that had five staff will give up two to go help the floor that had no staff.

When a client is confused, left alone with the side rails down, and the bed in a high position, the client falls and breaks a hip. What law has been broken? A. Assault B. Battery C. Negligence D. Civil tort

C. Knowing what to do to prevent injury is a part of the standards of care for nurses to follow. Safety guidelines dictate raising the side rails, staying with the client, lowering the bed, and observing the client until the environment is safe. As a nurse, these activities are known as basic safety measures that prevent injuries, and to not perform them is not acting in a safe manner. Negligence is conduct that falls below the standard of care that protects others against unreasonable risk of harm.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing care plan D. Write a new nursing diagnosis

C. Reexamine the nursing care plan Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

58. In most ethical dilemmas, the solution to the dilemma requires negotiation among members of the health care team. The nurse's point of view is valuable because: A.Nurses have a legal license that encourages their presence during ethical discussions. B. The principle of autonomy guides all participants to respect their own self-worth. C. Nurses develop a relationship to the client that is unique among all professional health care providers. D. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care.

C. When ethical dilemmas arise, the nurses point of view unique and critical. The nurse usually interacts with clients over longer time intervals than do other disciples.

The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock.

C. measurable, realistic, specific, attainable, its only missing time

What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice? A. Justice: Equally dividing time and other resources among a group of clients B. Beneficence: Doing no harm during the course of nursing care C. Veracity: Fully answering the client's questions without any withholding of information D. Fidelity: Upholding the American Nurses Association's Code of Ethics

Correct Response: C Fully answering the client's questions without any withholding of information is an example of the application of veracity into nursing practice. Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress. Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients. Beneficence is doing good and the right thing for the patient; it is nonmaleficence that is doing no harm.

Standard of care is derived from: A. Nurse practice acts (NPAs) B. Professional organizations C. The Joint Commission D. All of the Above

D

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer b. Refuse to float to the ICU c. Call the nursing supervisor d. Identify tasks that can be performed safely in the ICU

D- Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance obtaining a witness to the will. Which is the most appropriate response to the client? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own.' c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request."

D- Living wills, also known as natural death acts in some states, are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On assessment, the nurse notes old and new ecchymotic (bruises) areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. What is the most appropriate nursing response? a. "Oh really I will discuss this situation with your son" b. "Let's talk about the ways you can manage your time to prevent this from happening" c. "Do you have any friends that can help you out until you resolve these important issues with your son?" d. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay.

D- The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured under a legal obligation. Option 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

An example of a secondary health prevention activity would be a. Chemotherapy IV infusion b. Hepatitis B vaccine series c. Gallbladder surgery d. Flexible sigmoidoscopy at age 50

D. Colon screening

Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values it may be possible to identify a philosophy of utilitarianism, with proposes that: A. The value of people is determined solely by leaders in the Unitarian church. B. The decision to perform a lover transplant depends on a measure of the moral life that the client has led so far. C. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician. D. The value of something is determined by its usefulness to society

D. A utilitarian system of ethics proposes that the value of something is determined by its usefulness

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D. Nurse rapidly reset priorities for client care based on a change in the client's conditionRationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.

D. this goal is measurable and objective

Which step of the Clinical Judgement model most closely relates to Tanner's clinical judgement model: responding? A. Recognize Cues B. Analyze Cues C. Prioritize Hypothesis D. Generate Solutions E. Take Action

E

Communicating something untrue that damages a person's reputation (defamation) may be subject to a civil lawsuit. If the comment is written, it is called _______; if spoken, it is _______? a. Libel; slander b. Slander; libel c. Assault; battery d. Negligence; malpractice

Quasi-intentional torts A Communicating something untrue that damages a person's reputation (defamation) may be subject to a civil lawsuit. If the comment is written, it is called libel; if spoken, it is slander.

Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? a. Libel b. Slander c. Assault d. Negligence

Quasi-intentional torts B- Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (Libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below standard of care for a specific professional group

Consequentialism

an ethical system that determines the level of goodness or evil from the effect or result of an act the consequences of whatever actions

The patient newly diagnosed with type 2 diabetes mellitus needs to make lifestyle changes. In relationship to the Transtheoretical Model of Change, which nursing action would best support the patient during the "contemplation" stage? a. Showing the patient how to use the fingerstick blood glucose monitor. b. Providing information about various types of exercise to facilitate weight loss. c. Teaching the patient about the purpose for having his HbA1C tested monthly. d. Telling the patient that if he does not change his lifestyle, he will die.

b. Providing information about various types of exercise to facilitate weight loss.

Which statement made by the nurse demonstrates the use of ethical decision making? a. "The patient does not want to comply with the treatment plan and needs to be discharged." b. "Cancer is a devastating diagnosis for this patient, and if I were him, I would not want treatment." c. "The family is trying to make a choice for the patient, but the patient needs to make the decision." d. Since the time of admission, the patient has seemed distant and has not had any visitors."

c. "The family is trying to make a choice for the patient, but the patient needs to make the decision."

_________ includes a threat or attempt to injure, and ________ includes the unlawful touching of another person without consent. a. Libel; slander b. Battery; Assault c. Assault; Battery d. Negligence; malpractice

intentional torts assault includes a threat or attempt to injure, and battery includes the unlawful touching of another person without consent.