Nursing Fundamentals Exam One

A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship?

Exploitation The nurse is actively coaching the client toward a healthier lifestyle.

_____________ = pallor

whitish

_____________ = jaundice

yellowish

A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching?

Used properly fitted bicycle helmet

__________ is oxygen saturation level less than 90%

hypoxia

___________ pain is associated with sweating, nausea, and tachycardia from an ANS response

somatic

When does body temperature peak?

4 pm

When using therapeutic communication ensure a distance of ____________ feet to respect personal space

4 to 5

Older adults see a decrease in their heights when they reach ___________

80

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first?

Evaluate level of consciousness

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

Lower the enema fluid container.

A nurse caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate?

Routine urinalysis

Specific abnormal breath odors such as alcohol; fruity breath which can indicate ___________, malnutrition, or dehydration; and ammonia which could be possible related to ____________

diabetes kidney disease

Smoking causes the blood vessels to constrict which will cause __________ blood pressure

high

What assessment tools are used for the eyes?

inspect penlight palpate

What does ISBARR stand for?

introduction, situation, background, assessment, recommendation, read back

Older adults are hunched over known as ___________

kyphosis

Body temperature is at its lowest in ___________

morning (1-4 am)

Deep _________ pain originates in ,muscles, bones, tendons, ligaments, and blood vessels

somatic

__________ pain is often associated with musculoskeletal system

somatic

A nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non contaminated glove because

the inner edge of the cuff will lie against the skin and thus will not be sterile. Rationale: Direct contact with the skin makes the inner edge of the cuff non sterile.

What are some examples of visceral pain?

ureteral colic acute appendicitis ulcer pain colitis (inflammation of the colon) cholecystitis (inflammation of the gallbladder)

A diminished pulse could indicate ______________

weekend heart muscle hemorrhaging poor vascular flow to pulse site

A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs?

"I will be able to track my health information."

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations?

"I'm glad you decided to continue your fitness routine." This statement by the nurse builds the client's confidence and acknowledges the client's efforts to make positive changes. It is an example of the use of affirmations to acknowledge the client's efforts to make healthy behavior changes.

A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing?

"You said that you're sad. What is making you feel sad?" Motivational interviewing uses OARS (open-ended questions, affirmations, reflective listening, summarizing), which includes open-ended questions. This is an example of an open-ended question because it requires more than a yes or no answer.

How is pulse strength measured?

0 = absent 1+ = weak, thready, diminished pulse 2+ = normal, brisk pulse (expected) 3+ = increased, strong pulse 4+ = bounding, full volume pulse

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A) Check on the client B) unlock the crash cart C) begin cardiopulmonary resuscitation D) announce a code

A) Check on the client Framework: nursing process/data collection If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. Leads also could fall off.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client B) Place the client in the orthopneic position C) Perform chest percussion D) perform nasotracheal suction

B) Place the client in the orthopneic position Framework: least restrictive, least invasive Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort.

A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action? A) providing pain control B) preventing hemorrhage C) maintaining a patent airway D) ensuring adequate fluid intake

C) Maintaining a patent airway Framework: ABC An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and needs for suctioning.

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) Diarrhea

D) Diarrhea Framework: ABCs Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume.

What is the order for the head to toe assessment of the systems? A. eyes B. nose C. neck D. head E. ears F. mouth

D. head A. eyes E. ears B. nose F. mouth C. neck

A nurse is caring for a client who has Parkinson's disease and needs assistance with ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe?

Dietitian Physical therapist Occupational therapist

A nurses caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast?

Evaluate neurovascular status

A nurse is teaching a client about the benefits of a healthy diet and regular exercise to achieve weight loss. Which of the following topics is the nurse teaching to the client?

Health Promotion

________ is a toll to have clear communication for effective client care

ISBARR

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?

Immunization data

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurses priority concern?

Incomplete amputation of the foot

A nurse is taking a rectal temperature on a client. Which of the following actions does the nurse perform? (Select all that apply)

Lubricates the probe cover Inserts the probe into the rectum 1 to 1.5 in

A community health nurse is teaching a newly licensed nurse about social determinants of health. Which of the following should the newly licensed nurse identify as a physical determinant of health?

Poor air quality

A strong bounding pulse could indicate?

anxiety increased activity abnormal condition causing the heart contractility to increase blood pressure

___________ = cyanosis

blueish

__________ blood pressure is a test involves taking multiple blood pressure readings in supine, standing, and sitting positions. Allow the patient to rest for 3 minutes after positioning them

orthostatic

_____________ hypothalamus is responsible for heat production and conservation

posterior

___________ is alteration in muscle tone manifested as increased tonicity.

spasticity increased resistance when attempting to passively extend a joint

____________ data is information that the client tells you in response to assessment questions

subjective

____________ is alteration in muscle movement by opposing muscle groups that result in a rhythmic movement of one or more joints, can occur at rest or when attempting voluntary and purposeful movement

tremors

A nurse is calculating the BMI for a client who weighs 150 lbs and is 5 ft 4 in. The nurse is using the BMI formula for pounds and inches, BMI = weight(lb)/height(in)2 x 703. What is the client's BMI?

25.7

How many generations should you collect medical history about?

3

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor?

Decreased respiratory effort

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Deflate the balloon completely before removal.

The goal of surgical asepsis is to

create and maintain a micro-organism-free environment. Rationale: Surgical asepsis consists of methods and practices directed toward keeping an area free of all micro-organisms.

_____________ hypothalamus is responsible for heat loss

anterior

For which of the following diseases should you obtain family history?

Sickle-cell anemia

A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

A client who is receiving a blood transfusion and reports urticaria

A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care?

A client who received digoxin and has a heart rate of 48/min

A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache". Which type of pain should the nurse identify this client is experiencing? A. Neuropathic B. somatic C. visceral D. referred

C

A nurse preparing to flush and change the dressing on a patients central venous catheter should understand that the primary purpose for performing this intervention using surgical asepsis is to

Control the introduction of micro-organisms at the catheter site Rationale: The primary goal of surgical asepsis is to implement methods and practices towards keeping an area or object free of all micro-organisms.

A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating?

Justice The ethical principle of justice refers to an obligation of the nurse to treat all clients the same regardless of age, sex, race, sexual orientation, or economic status.

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?

Place the probe in the posterior lingual pocket lateral to there midline.

A nurses caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse?

Preventing injury

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern?

Promoting oxygenation

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?

A client who has a fever of 38.4°C (101.2°F) with tenderness in the right lower quadrant

A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice?

"Health care should be a right for everyone." Social justice is the recognition of and fighting for equality of every individual for equal access to health care, food, housing, educational opportunity, and fair and equal treatment in all aspects of life. This statement demonstrates an understanding of the professional value of social justice.

A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make?

"I am unable to send your discharge instructions via email due to the HIPAA Privacy Act." The HIPPA Privacy Act consists of rules that govern the protection of the client's protected health information (PHI). The use of emails, texting, and faxing must occur with equipment and communication lines that are secure and encrypted. All electronic communication of PHI must have these safeguards in place. Sending the discharge instructions to a personal email outside the facility would breach this law.

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I can take a telephone prescription if a provider is directing a code for an unresponsive client."

A nurse is teaching a client about hospice care. Which of the following statements by the client indicates an understanding of the teaching?

"I understand that services provided will include just what is needed to keep me comfortable."

A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?

"This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being."

A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used?

1. BMI of 35 2. Stuffy nose 3. irregular hearth rate 4. mastectomy 2 years ago

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube

7.5 cm to 10 cm (3 to 4 in).

A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first?

A client who has an abdominal wound that is actively bleeding

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

A client who has audible wheezing during respirations

A nurse in a provider's office is speaking with a client who needs a refill for a prescription that has expired. The nurse should identify that which of the following team members can assist the client with the refill? (Select all that apply.)

APRN PA Physician

A nurse in a clinic is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Which of the following care facilities should the nurse anticipate the client be admitted to?

Acute care hospital

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?

Check pedal pulse

A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A) Administer medications w/ meals when possible B) Ensure client understanding of medication's effects C) Determine the client's ability to self-administer meds D) have the client position the head w/ chin down while swallowing

D) Have the client position the head with the chin down while swallowing Framework: safety and risk reduction Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk.

A nurse is caring for a client who reports that they have recently lost their job and do not have insurance coverage. Which of the following social determinants of health is challenging for this client?

Economic stability

What does FICA stand for when exploring a patient's spirituality?

Faith Influence Community Address

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? (Select all that apply)

Forehead Bridge of nose Earlobe

A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should the nurse include? (Select all that apply.)

Initiatives to reduce health care disparities. Activities to improve social determinants of health. Improving access to health care.

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply.)

MSO4 IU qhs

A nurse is performing an initial survey on a client in calculates a BMI of 31 kg/m2. The nurse classifies as client in which of the following weight ranges?

Obese

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.)

Observe the client's lower extremities for indications of deep vein thrombosis. Measure the client's temperature. Check the client for bruising.

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?

Observe the clients chest movements while appearing to assess their pulse.

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first?

Perform a physical assessment

A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client?

Speak to the client clearly and at a slow pace. The nurse should speak to the client who has cognitive or developmental delays clearly and at a slower pace. The nurse should also avoid the use of complicated terms or medical terminology.

A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply.)

The admitting provider The charge nurse on the unit The client

A nurse is caring for a client who reports an improved diet, exercising 30 min a day for 5 days a week, and an overall sense of improved health. The nurse should identify that the client is describing a positive state of health known as which of the following?

Wellness

While waiting for a sterile procedure to begin, how do you position your hands and arms?

With your hands clasped together in front of your body above waist level. Rationale: Holding your hands and arms in this manner keep them from contact with non sterile items.

In what order do you take vital signs?

temperature pulse pulse oximetry respirations blood pressure

A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

"CPOE systems can increase the speed of care delivery."

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient?

"I'll swab the patient's mouth with diluted hydrogen peroxide." Chlorhexidine is the correct solution to use for daily oral care for the unconscious patient because evidence-based practice indicates it improves patient outcomes by preventing microbial build-up.

A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values?

Human dignity The professional value of human dignity is recognizing that all human life has value and should be treated equally with respect, regardless of race, religion, gender, sexual orientation, culture, ethnicity, or socioeconomic status. Providing privacy to a client who has incontinence is demonstrating respect and preserving the client's human dignity.

A nurse is teaching a client about the International Self-Care Foundation's seven pillars of self-care. Which of the following client statements indicates an understanding of the teaching?

I will perform moderate exercise several times each week.

Play's the steps in the correct order to record information when using the GTPAL format

Number of pregnancies Number of term deliveries Number of preterm deliveries Number of voluntary or involuntary abortions Current number of living children

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration.

Observe the degree of the chest-wall movement during inspiration and expiration.

A nurse is caring for toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse?

Obtain an oxygen saturation level

A nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse include?

Obtain specimens from three different stools.

A nurse is preparing to auscultate a client's apical pulse a the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?

Over the fifth intercostal space at the left midclaviclular line.

Order of the full body assessment?

Overall health skin head and neck breast and lymphatics respiratory system cardiac and peripheral vascular system gastrointestinal genitourinary whole body systems

A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern?

Oxygen saturation of 90% on oxygen at 2 L per nasal cannula

A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?

PRN

__________ occurs to decrease blood flow to the extremities and skin

vasoconstriction

____________ conserves the core temperature and prevent heat loss

vasoconstriction

_________- pain travels along the autonomic nervous system

visceral

__________ pain is associated with sweating, nausea, and vomiting

visceral

__________ pain is often described as cramping, squeezing, dull pain

visceral

___________ pain begins in the larger internal organs

visceral

A fecal breath odor can indicate _____________-

vomiting due to problems of the bowels

A nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

"My health care surrogate will make health care decisions for me if I am unable." The client chooses a health care surrogate who maintains the client's durable power of attorney for health care. This document allows the health care surrogate to make health care decisions on the client's behalf if they are unable to do so.

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse?

"Oral care is still important even though you are not eating." Bacteria are still present in the oral cavity regardless of NPO status. It is important to perform oral care to help reduce oral bacteria and keep the oral cavity moist.

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?

"Personnel can be terminated for breaching a client's confidentiality."

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.)

"Respect the client during the conversation" is correct. The nurse should respect the client during the conversation to enhance communication. "Allow time for reflection during the conversation with the client" is correct. The nurse should allow time for reflection. This would enhance communication with the client. "Show empathy during the conversation with the client" is correct. Showing empathy during the conversation enhances communication with the client.

An assistive personnel (AP) is collecting a 24-hour urine specimen from a client. Which of the following statements by the AP indicates that the specimen collection will have to be restarted?

"The client just told me that they forgot to put the urine in the container."

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation?

"The client vomited 240 mL of clear emesis but denies pain or nausea."

Which of the following is a close-ended question?

"What time do you usually get up in the morning?"

A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make?

"Your income will determine if you are eligible for Medicaid."

Diaphragm of stethoscope is used for?

(larger side) high-pitched noises (breath sounds, bowel sounds, and normal heart sounds

bell side of stethoscope is used for?

(smaller side) soft, low-pitched sounds (extra heart sounds, murmurs

Conditions that may have a genetic component?

- blood disorders (sickle cell anemia) - obesity - kidney disease - cancer (breast, ovarian, colon, prostate) - behavioral health (suicide, depression, bipolar, schizophrenia) - stroke - substance use disorder - seizure disorder - dementia / alzheimer's -heart disease ( myocardial infarction, hypertension, hyperlipidemia) - diabetes (type 1 & 2) - thyroid ( hyperthyroid, hypothyroid) - arthritis - tuberculosis - asthma - food allergies - medication allergies

What could negatively affect a pulse oximetry reading?

- carbon dioxide poisoning, jaundice, painted finger nails, recent injection of dyes in the circulatory system, dark skin tone - clients movements during testing - clients who have impaired circulation (peripheral vascular disease, hypothermia, vasoconstriction, hypotension, peripheral edema)

A nurse preparing a sterile field knows that the field has been contaminated when, select all that apply

-A cotton ball dampened with sterile normal saline is placed on the field. -The nurse turns to address the patients questions concerning the procedure. -The procedure is postponed for 30 minutes to accommodate the patient. -Recommended pouring distance is 4 to 6 inches to remain within the sterile field.

A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

-Gather all necessary supplies -place a rubber mat on the tub floor -assist the patient into the bathroom -instruct the patient on using safety bars when getting in and out of the tub -instruct the pt to remain in the tub for no longer than 20 mins

Prior to entering the surgical-scrub areas, what PPE does the team members don?

-Protective eyewear -Hair cover -mask -shoe cover Rationale: a gown used for a sterile procedure is considered sterile and is not donned until the surgical hand scrub has been completed and the hands have been dried.

A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take.

1. Wipe the port with an alcohol swab or agency specified antiseptic. 2. Attach a syringe to the collection port of the indwelling catheter. 3. Withdraw 3 to 30 ml of urine. 4. Transfer the urine to a sterile specimen container. 5. Transport the specimen to the lab.

What are some therapeutic communication techniques?

1. redirect the client as needed 2. keep questions focused and relevant to the context and situation 3. be vigilant throughout the conversation 4. clarify to see if the information is accurate 5. keep any emotionally charged conversations for last

You are about to open a sterile pack. Place the following steps in the proper sequence for opening the sterile pack.

1.The flap furthest from you 2.the side flaps 3.the flap closest to you Rationale: You would open the flap furthest from your body first, followed by the side flaps, and finally the flap closest to your body. Any other order would risk your gown coming into contact with the sterile wrap or your arm reaching over the sterile field, both of which would result in contamination.

A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds to the nurse count the client's respirations?

60

Therapeutic communication involves which of the following? (select all that apply) A. touch B. open-ended questions C. sharing you own personal experiences with the client D. if the client speaks a different language than the nurse, finding someone in the facility that speaks their language

A B

Which of the following factors are included in health literacy? (select all that apply) A. basic reading skills B. basic writing skills C. competency using numbers D. understanding how to use literacy E. ability to follow verbal instructions F. ability to use a computer

A C E

A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first?

A client following knee replacement surgery complaining of pain and warmth in the calf

A nurse in a providers office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurses priority concern?

A client who is 34 weeks of just station and reporting abdominal tenderness

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization?

A client who is in the ICU for a GI bleed.

A nurses caring for a group of pediatric clients. Which of the following clients requires immediate intervention?

A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting

A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment?

A client who reports new chest pain

A nurse is teaching a newly licensed nurse about health literacy. Which of the following information should the nurse include?

A client's comprehension of education can be affected by low health literacy.

A nurse is teaching a client about the Affordable Care Act (ACA). Which of the following information should the nurse include?

A focus of the ACA is disease prevention.

A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care?

A nurse did not read back a verbal medication prescription to a provider. Standards of care guide nursing practice to perform safe and effective care. Failing to verify a medication prescription can result in harm to a client and is therefore a breach of the standard of care.

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity?

A nurse keeps a promise to a client not to tell their family about their diagnosis. The ethical principle of fidelity refers to the nurse's obligation to keep a promise. Keeping a promise to a client promotes trust between the client and the nurse.

A nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy?

A nurse respects a client's wish to discontinue a treatment. The professional value of autonomy refers to respecting the client's right to make their own decisions regarding their health care, including the right to refuse care.

A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task.

A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention?

A preschooler who is post operative following a tonsillectomy and is experiencing frequent swallowing

A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting?

A young adult client who is positive for tuberculosis Diseases and illnesses that are considered a threat to public health, such as tuberculosis, HIV, and influenza, require mandatory reporting to the health department to track and develop prevention and protection protocols.

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster? A) immediate B) delayed C) minimal D) expectant

A) Immediate Framework: survival potential priority Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received.

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG. B) Administer oral potassium C) Encourage potassium-rich foods D) Monitor I & O

A) Obtain an ECG Framework: Maslows Hierarchy of needs Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range.

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A) Place the infant in a supine position when sleeping B) place the infant on a firm mattress when sleeping C) avoid covering the infant with loose bedding while sleeping D) avoid leaving stuffed animals in the crib with the sleeping infant

A) Place the infant in a supine position when sleeping Framework: safety and risk reduction This intervention has had the greatest impact on reducing the occurrence of SIDS.

A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment?

ABCDE

A nurse is caring for a client who is 48 hr post operative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?

Absent dorsalis pedis pulse

A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category? (Select all that apply.)

Access to foods that support healthy eating patterns. Crime and violence Environmental conditions

A nurse obtains a capillary blood glucose result of 180 mg/dL from a client who has diabetes mellitus, Which of the following actions should the nurse take?

Administer insulin according to the patient's sliding scale orders.

A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values?

Altruism The professional value of altruism is the selfless desire to help someone else without any benefit.

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last?

Anus

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include?

Ask the patient in what order she typically performs her morning routine. The patient's plan for routine morning care should be tailored to the uniqueness of the patient's typical routine.

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take?

Ask the provider to discuss the procedure with the client. If the client states that they are unclear about a procedure, the nurse should contact the provider to return to answer the client's questions. The nurse should verify that the client has adequate knowledge to make the treatment decision before the client signs the informed consent form.

What part of the nursing process is the PN involved in?

Assessment: assist RN by collecting data, reviewing information about the client, and communicating it to the appropriate health care team members, notify RN of unexpected findings Analysis: this step is outside of the PN scope of practice Planning: participate by assisting the RN in the development of expected outcomes and interventions and use their problem solving and decision- making skills Implementation: provide planned nursing care to accomplish expected outcomes, reinforces client teaching and provide educational material Evaluation: can compare the actual outcome with the expected outcomes. Assist in updating nursing interventions and maintains communication with the RN regarding revision

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles?

Autonomy Autonomy refers to the nurse's obligation to respect the client's right to make their own decisions regarding their health care, including the right to refuse care. A client who has chosen to sign a blood product refusal form is demonstrating autonomy or the right to make their own health care decisions.

A nurse is collecting data during a review of systems and asks the client how many pillows are required to sleep comfortably at night. This question involves assessment of which of the following systems? A. musculoskeletal B. cardiovascular C. neurological D. endocrine

B

Which of the following are researched-validated reasons to conduct a health history using an interpreter? (select all that apply) A. to increase the self-esteem of the client B. to increase the accuracy of the communication C. to decrease the cost of care D. to increase the client's satisfaction with care

B D

Which of the following tolls used with auscultation? (select all that apply) A. dorsal sides of hands B. stethoscope C. penlight D. doppler E. tape measure

B D (dorsal sides of hands are used with precision)

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit? A) obtain an arterial pH level B) check the HR and BP C) insert an indwelling catheter D) collect a serum BUN and creatinine

B) Check the heart rate and blood pressure Framework: least restrictive, least invasive An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit.

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? A) Administer an anticoagulant B) Check the leg for warmth and Edema C) Apply elastic stockings D) Promote bed rest & extremity elevation

B) Check the leg for warmth and edema Framework: Nursing process/data collection If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis.

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A) Provide assistance w/ ambulation when indicated B) determine the mobility status of each patient C) Maintain the side rails of each be in the raised position D) Plan a fall prevention program for clients at risk

B) Determine the mobility status of each patient Framework: nursing process Determining the mobility status of each client will help to identify those patients who are at risk for falls.

A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mmol/L B) Digoxin 3.0 ng/mL C) Peak serum gentamicin 6 mcg/mL D) Magnesium sulfate 4 mEq/L

B) Digoxin 3.0 ng/mL Framework: unstable vs. stable This digoxin level is above the expected reference range and indicates digoxin toxicity The therapeutic range for lithium has been established at 0.6 - 1.2 mmol/L. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Conventional dosing of gentamicin: Peak: 4-10 mcg/ml. Magnesium sulfate therapeutic level of 3.5 to 7 mEq/L.

A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? A) Cholesterol 220 mg/dL B) Platelets 95,000 mm^3 C) BUN 20 mg/dL D) Potassium 3.5 mEq/L

B) Platelets 95,000 mm3 Framework: unstable vs. stable This platelet level is below the expected reference range and indicates the client is at risk for bleeding. A normal platelet count ranges from 150,000 to 450,000 platelets per mm^3. Total cholesterol levels less than 200 mg/dL are considered desirable for adults. A reading between 200 and 239 mg/dL is considered borderline high. A normal BUN is around 7 to 20 mg/dL. The normal potassium level in the blood is 3.5-5.0 mEq/L.

A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception

Which of the following factors are included in health literacy? (select all that apply)

Basic reading skills Competency using numbers Ability to follow verbal instructions

A nurse is preparing to insert an indwelling urinary catheter. Which of the following actions should the nurse instruct the client to perform during the insertion procedure?

Bear down

A nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles?

Beneficence The ethical principle of beneficence refers to the nurse's obligation to implement actions that minimize harm and benefit clients. Beneficence includes meeting a client's physical, social, or emotional needs. The nurse is demonstrating beneficence by providing comfort and praying with the client who is alone

A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next?

Blood pressure

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth

A nurse is reviewing the vital signs for a client who's admitted with shortness of breath. The nurse notes the client's respiratory rate is 24/min. The nurse should use which of the following items when documenting this finding? A. hypoventilation B. apnea C. tachypnea D Chryne-stokes respirations D labored

C

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first?

Check the catheter for kinks.

A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? A) establishing a sense of achievement B) contributing to society C) creating meaningful social relationships D) enhancing self- confidence

C) Creating meaningful social relationships Framework: Maslows Hierarchy of needs Social relationships are a component of friendship, which would be included in the 3rd level.

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A) homelessness B) lack of family support C) Hypoxic D) under nourished

C) Hypoxic Framework: Maslow's Hierarchy of needs Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level.

A nurse is collecting data on four clients. Which of the following findings is the most urgent? A) bladder distension and urgency B) pedal edema C) warmth and pain in the calf D) hypoactive bowel sounds

C) Warmth and pain in the calf Framework: urgent vs. non-urgent Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism.

A nurse is collecting data during a review of systems and ask the client how many pillows are required to sleep comfortably at night. This question involves assessment of which of the following systems?

Cardiovascular

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection?

Cleaning the least-soiled areas prior to cleaning the most-soiled areas The least-soiled areas should be cleaned first to prevent moving more contaminants into the cleaner areas.

A nurse is assessing a client's behavior during the initial survey. Which of the following does the nurse include in this assessment? (Select all that apply)

Client's clothing Client's speech

Match each question to its correct question type

Closed-ended Do you have any numbness or tingling in your hand? When was your last bowel movement? Can you rate your pain on a scale of 0 to 10 with zero being no pain and 10 being the worst pain you can imagine? How many flights of stairs can you climb before you become short of breath? Open-ended What is your goal for treatment? How are you feeling today? What brings you to the clinic? Do you have questions about your scheduled surgery?

A nurse is reviewing a report by the Institute of Medicine (IOM). Which of the following competencies should the nurse identify health care professionals need in order to reduce errors? (Select all that apply.)

Cooperation Communication Coordination

A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first?

Cover the IV site with an elastic bandage.

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request?

Cultural factor Death-related rituals might be very closely tied to cultural factors such as religion. The nurse should recognize that this client is expressing a death ritual of the last rites, which is associated with Catholicism.

A nurse is performing an initial assessment on a client's skin. Which of the following observations will require further assessment of the client' s circulation?

Cyanosis is notes on fingers

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular disease and reports numbness in the toes B) client who has depression & is easily distracted C) A client who has Alzheimer's disease and is unable to complete ADLS D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop Framework: acute vs. chronic Clients often report feeling the incision pop, indicating either dehiscence or evisceration has occurred.

A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A) a client who is has a history of HF B) a client who has type 1 DM C) a client who is reporting pain associated w/ osteoarthritis of the knees D) a client who is having a nosebleed associated w/ hypertension

D) A client who is having a nosebleed associated with hypertension Framework: acute vs. chronic A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this may indicate blood pressure above the reference range requiring further assessment/intervention.

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A) Initiate oxygen therapy B) encourage an increase in oral fluids C) provide room humidification D) Assist client to cough effectively

D) Assist client to cough effectively Framework: ABC Assisting the client to cough effectively opens the airway by removing secretions.

A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A) Ensure all 4 side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints D) Move the client to a room near the nurses' station

D) Move the client to room near the nurses station Framework: least restrictive, least invasive Moving the client to a room near the nurses station allows for more frequent observation and promotes client safety.

A nurse is speaking to a client who smokes tobacco and has a child living in the home. The nurse should identify that the child's exposure to second-hand smoke is an example of which of the following types of risk factors?

Environmental

Drag the dialogue statement to place it in the correct interview technique category

Directive How often do you exercise? Did the medication help your discomfort? Have you had an influenza vaccination this year? When was the last time you had anything to eat or drink? What causes you to become short of breath? Nondirective Tell me about the voices you are hearing What questions do you have for me? How do you feel about the diagnosis? Please describe the chest pain

A nurse is preparing to administer an influenza vaccine to a client. The client states that they understand being immunized will help protect them against the influenza virus. Which of the following concepts is the nurse demonstrating by administering the vaccine?

Disease prevention

A nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care?

Document that the medication was not administered. Standards of care guide nursing practice to perform safe and effective care. Accurate documentation facilitates communication to members of the client's health care team and is a component of expected standards of care. Documenting client data, interventions, and client responses promotes continuity of care and decreases the risk for error. The nurse should return to check the client to determine if the client requires the PRN pain medication.

A nurse is assessing a client's respiration. Which of the following actions should the nurse take?

Elevate the head of the clients bed 45 degree to 60 degree.

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 celsius (102 degrees f). Which of the following other vital signs should the nurse expect?

Elevated pulse rate

A nurse in a provider's office is speaking with a client about a Press Ganey survey. The nurse should inform the client that this survey will be conducted by which of the following methods?

Email

A nurses caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?

Engage the client in physical activity

A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take?

Ensure the client is wearing their glasses during teaching. The nurse should take steps to facilitate learning, such as ensuring the client's assistive devices, including eyeglasses or hearing aids, are being used.

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning?

Ensure the room is well lit. The nurse should identify that a well-lit room can allow the participants to better see the presentation as well as the nurse during the teaching.

A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expect to perform?

Facilitate transfer of clients to meet the req'd level of care.

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods.

A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action?

Falsification of records The nurse is falsely documenting that a medication was administered to the client, which is an example of falsification of health records. Falsification of health records can include not documenting care that occurred, documenting inaccurate data, or documenting care or events that did not occur. This action can lead to client injury and is considered failure to adhere to the standards of nursing practice.

A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of following components of the model?

Feedback In the Schramm model, one of the three components is feedback. Feedback is demonstrated when the receiver is allowed to let the sender know that the message was properly received.

A nurse stops at the side of the road to provide care to a person involved in a motor-vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident?

Good Samaritan laws Good Samaritan laws protect people who provide aid in the event of an emergency from being held liable for their well-intentioned actions. The actions the nurse takes should be within their scope of practice as a licensed nurse and should not be considered grossly negligent.

A nurse is caring for a client who needs to collect a midstream urine specimen. Which of the following actions should the nurse take?

Have the client uninate a small amount of urine before starting the collection.

Place the steps in the correct order to conduct a review of systems

Head Eyes Ears Nose Mouth Neck

A nurse who has been working 12-hr shifts on a busy unit is experiencing nurse fatigue. Which of the following effects can result from nurse fatigue?

Increase in medication errors Nurse fatigue can result in an increase in risk for medication errors that can result in client injury.

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first?

Initiate a bladder training schedule

A nurse is completing the Minimum Data Set (MDS) assessment for a resident in a skilled-nursing facility. Which of the following information should the nurse include in the assessment? (Select all that apply.)

Input from team members of the client's Interdisciplinary team. The client's cognitive status. Each physical therapy visit. The client's need for assistance with ADLs.

A nurse is taking an adult client's temperature rectally. Which of of the following actions should the nurse take?

Insert the prob about 1.27 cm (0.5 in) into the client's anus

A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values?

Integrity The professional value of integrity involves showing honesty and choosing to do what is right and fair, even when the situation is difficult. The nurse who admits that they administered the wrong medication to a client is demonstrating the professional value of integrity.

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?

It might not follow with the fitfh Korotkoff sound.

A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred to for further treatment?

LTCH

A home health nurse is visiting a client who lives in an older home and is concerned about their child's exposure to lead paint in the house. The nurse should identify that which of the following is a potential health risk from exposure to lead paint?

Learning disabilities

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take?

Leave a space between the penis and sheath portion tip.

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?

Left lateral with the right leg flexed

A nurse is caring for a client who has a suspected urinary tract infection (UTI). Which of the following urinalysis results should the nurse identify as a manifestation of a UTI?

Leukocyte esterase

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?

Lift the penis perpendicular to the body.

A nurse at a hospital is interviewing a newly admitted client. The client tells the nurse they would like to adhere to their cultural beliefs during their hospitalization. Which of the following actions should the nurse take to provide the client with culturally competent care? (Select all that apply.)

Listen to the client's request with respect and compassion. Reassure the client that they can practice their cultural beliefs if safe to self and others. Provide resources to meet the client's culture needs.

A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take?

Lower the volume on the television. The nurse should minimize the noise in the environment by decreasing the volume on the television when communicating with the client. Auditory communication is what the receiver hears when the sender speaks a message. It can be affected by environmental noise. The loud television presents a barrier to communication and the nurse should reduce the environmental noise.

A nurses caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor?

Maternal respirations

A nurse is caring for a patient who is on long-term bedrest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes?

Moisture from excessive diaphoresis can cause skin breakdown.

A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.)

Move the client to a quiet area or private room is correct. The nurse should reduce environmental noise as much as possible to enhance communication with this client. Speak at a slower pace is correct. Speaking at a slower pace might help the client to be able to better understand and communicate with the nurse. Avoid using medical terminology is correct. The nurse should avoid using medical terminology. These words are unfamiliar and can impede communication with all clients.

A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication?

Nonverbal The nurse should recognize the client is exhibiting nonverbal communication through their physical gestures. Nonverbal communication, also known as body language, plays an important role in interactions among nurses, clients, and their families. For instance, not making eye contact, not being engaged in the conversation, or having closed posture (folded arms, slouching) can portray a negative message.

A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating?

Passive-aggressive During the phone call while talking with the oncoming nurse, the charge nurse was pleasant and accepting that the nurse would be late. However, once the phone call ended, the charge nurse then complained about the nurse always being late to the other staff. The charge nurse exhibited a passive-aggressive style of communication.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

Perform fingersticks for glucose levels on clients who have diabetes mellitus

A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority. Use all the levels.)

Physiological Safety Love/Belonging Esteem Self-actualization

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient?

Place the patient in the dorsal recumbent position on a bedpan.

A nurse is teaching a client about collecting stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period?

Poultry (can cause a false positive)

A nurse in a provider's office is calling a client's insurance company to obtain permission prior to scheduling a magnetic resonance imaging (MRI) test. Which of the following is the nurse obtaining?

Precertification

A nurse is discussing hospice care with a newly licensed nurse. Which of the following should the nurse identify as the goal of hospice care?

Provide care for a client who has less than 6 mos to live.

A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply.)

Psychosocial factors is correct. The nurse should recognize that psychosocial factors are influencing communication with the client. Psychosocial factors include the client's financial situation. The client is working two jobs and going to dialysis appointments twice a week, which might require them to miss work time and pay. Furthermore, the client is the only income for this household. Situational factors is correct. The nurse should recognize situational factors, such as the new prescription for dialysis, influencing the communication with the client. Situational factors that can affect communication cause emotions including fatigue, anxiety, grief, and fear. This client's verbal and nonverbal communication are indicators of worry, anxiety, sadness, and grief.

A nurse is preparing to use a tympanic thermometer to acquire a clients temperature. Which of the following actions actions should the nurse take to ensure an accurate reading?

Pull the pinna back and upward gently

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?

Pulse pressure

It is the responsibility of the ___________ to validate and analyze the information collected by the PN (LPN) and plan and initiate the interventions to address the client's health care needs

RN

A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen.

A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply.)

Reduces medical errors Makes client medical history more easily available Increases accuracy of coding procedures

A nurse is teaching a newly licensed nurse about Medicare reimbursement. Which of the following should the nurse include in the teaching?

Reimbursement amounts will be adjusted for clients who contract HACs.

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request assistance from the facility's interpreter. The nurse should request a facility-approved interpreter to assist with the communication barrier. This would also ensure that the information is correct and gives both the nurse and client an opportunity to ask questions.

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?

Respirations 30/min

A home health nurse is caring for a client who is receiving hospice care. The client's partner reports feeling overwhelmed from caring for the client. Which of the following types of facilities should the nurse recommend?

Respite care

A nurse is preparing to administer an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for

at least 30 min, but preferably as long as he can.

A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using?

Restating The nurse is summarizing, paraphrasing, or restating the client's thoughts to confirm the nurse understands what the client is attempting to communicate.

A nurse is caring for a client who has a stage IIl pressure injury on the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury?

Rotate a sterile swab in the area of drainage.

A nurse is collecting a blood specimen for culture from a client. Which of the following actions should the nurse take?

Rub the client's arm at the selected site prior to venipuncture.

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use?

Schedule a face-to-face unit staff meeting. In-person communication of this important policy would permit for both verbal and nonverbal modes of communication between the sender (the nurse manager) and the receiver (the unit staff).

A nurse at a clinic is providing free blood pressure screenings for clients. Which of the following levels of health prevention is the nurse demonstrating?

Secondary prevention

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs?

Self-esteem

A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating?

Sender The nurse is initiating the message; therefore, the nurse is the sender.

Which aspect of life is assessed using the FICA approach?

Spirituality

Which of the following is considered an unexpected finding for a 40 year old client's pulse?

Stronger radial pulse on left compared to right

A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mg PO every morning ac

A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include?

TJC ensures organizations remain up-to-date with state guidelines.

A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client's respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding?

Tachypnea

A nurse is teaching a group of guardians about primary prevention techniques. Which of the following topics should the nurse include as an example of primary prevention?

Taking measures to decrease the risk of childhood injuries within the home.

A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take?

Tell the charge nurse that the coworker might be impaired. The nurse should report their suspicion to the charge nurse or supervisor to protect the safety of the clients. If the charge nurse suspects the coworker is impaired, they should remove the impaired employee from the work environment.

A nurse is teaching a client who has a new prescription for an antihypertensive medication.

Tertiary prevention

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry?

The "S" in SOAP

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task?

The AP reuses the patient's blanket and spread.

A nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating?

The Emergency Medical Treatment and Labor Act (EMTALA) The EMTALA was enacted to allow clients to access the emergency departments of hospitals for equal care regardless of their ability to pay. Refusing to accept clients who do not have health insurance is a violation of the EMTALA.

A nurse is teaching a class about the Hospital-Acquired Condition Reduction Program (HACRP). Which of the following information should the nurse include?

The HACRP links Medicare payments to health care quality.

A nurse is teaching a newly licensed nurse about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) tool. Which of the following information should the nurse include?

The HCAHPS tool is issued to measure client satisfaction with the health care service.

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs?

The Institute of Medicine

Which area of the hand requires special attention before you begin a surgical hand scrub?

The area under each fingernail. Rationale: The area under the fingernails, called the subungual area, harbors micro-organisms. You must clean it thoroughly during the first scrub of the day and whenever visibly soiled.

A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority?

The client reports dizziness when standing

A graduate nurse notes that a hospital with Pathway to Excellence® recognition is hiring staff. Which of the following should the nurse expect from this facility? (Select all that apply.)

The facility has practices in place that lead to a healthy workplace environment. The facility emphasizes shared governance. The facility emphasizes practices that positively affect a nurse's well-being.

A nurse is discussing the Healthy People initiative with a newly licensed nurse. Which of the following information should nurse include?

The program focuses on providing goals and data for improved public health.

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation?

The system alerts providers of possible actions that could cause client harm.

__________ is alteration in muscle movement characterized by involuntary, repetitive movement of a muscle group related to a neurological or psychogenic cause.

Tic grimaces, winks, shoulder shrugs

Which of the following is a purpose of obtaining a health history?

To establish a baseline of the client's health status

Which of the following are research validated reasons to conduct a health history using an interpreter? (Select all that apply)

To increase the accuracy of communication To increase the client's satisfaction with care

A nurse is teaching a client about modifiable risk factors to their health. Which of the following should the nurse include as an example of a modifiable risk factor?

Tobacco use

A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care?

Urgent

A nurse is preparing to obtain a clients blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

Use a cuff of the appropriate size for the client

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?

Use an alternative method for determining the client's pain level. Medications such as general anesthesia can cause cognitive deficits that could make it difficult for the client to communicate their needs. The nurse should use an alternative method for determining the client's pain level by observing facial expressions (grimacing or clenching of the teeth); body movements, including restlessness, muscle tension, or resisting movement; and vocalizing discomfort by moaning, grunting, or crying.

A nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles?

Veracity The ethical principle of veracity refers to the nurse's obligation to provide truthful information to the client, the provider, and the nursing supervisor. Truthfully answering a client's questions about their laboratory results is demonstrating the ethical principle of veracity.

A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.)

Verbal is correct. The nurse planned on teaching in a face-to-face presentation of the information. The verbal mode of communication occurs during face-to-face communication between the sender (the nurse) and the receiver (the APs). It can also occur during a telephone call. Written is correct. The written mode of communication is any form of communication in which the receiver reads the message from the sender. The nurse plans to use both face-to-face verbal communication and a written mode of communication. Nonverbal is correct. The nonverbal mode of communication is comprised of body language. Actions such as eye contact, facial gestures, posture, and overall appearance all send messages to the receiver in addition to what the sender is saying. The nurse will be sending and receiving messages with the AP as they deliver the verbal information in a face-to-face environment.

I nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache." Which type of pain should the nurse identify this client is experiencing?

Visceral

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure?

Warm the enema solution prior to instillation.

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

When the semilunar valves close

A nurse caring for a client who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample for point-of-care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the client's finger?

Wrap the finger in a warm cloth.

If the client's word choice is unusual this may indicate _____________

a thought process abnormality such as echolalia

A fetid (extremely unpleasant) odor can indicate _____________

dental or respiratory infection

__________ = sweaty

diaphoretic

Unintentional weight loss (5% of body weight in a month or 10% in 6 months) could indicate ______________

disease process such as: fever infection malignancy endocrine disease

If the client's word choice is appropriate but speech sounds are unclear this may indicate____________

dysarthria

__________ and _________ placement of the oximeter have shown to provide faster and more reliable results if the client has poor peripheral blood flow

earlobe forehead

During surgical handwashing, the hands are kept above the elbows to

encourage water and soap to flow away from the clean hands. Rationale: The water and soap runs by gravity from the fingertips to the elbows, thus directing the contaminated substances away from the clean hands and preventing recontamination.

Vasodilation causes ____________

evaporation radiation conduction convection

___________ is alteration in muscle movement seen as continuous, rapid twitching of a muscle at rest

fasciculation

Less hemoglobin means less oxygen and causes ____________ breathing

faster

Smoking tobacco changes the lining of the airways in the lungs, inhibiting airflow and making clients breathe _____________

faster

Where can you apply a oximeter?

finger nose forehead earlobe foot

Unintentional weight gain ( 5 lb in a day) could indicate ___________

fluid retention could lead to heart failure

If the client struggles to find words or express an idea this may indicate _____________

form of aphasia

When donning sterile gloves using the open-gloving method, it is important to remember to

grasp only the inside of the glove with your ungloved hand. Rationale: the inside of the glove is considered non sterile and will be placed against the skin of the hand, which is also considered non sterile. When donning gloves using the open-gloving method, you would use a skin-to-skin and glove-to-glove technique.

When opening a sterile package, what would break sterility?

holding the sterile pack below waist or table level. Rationale: The top of the table or sterile field is the only area that is considered sterile. Anything below waist or table level is considered non sterile.

Electronic monitoring of the blood pressure should not be used in what type of patient?

hypertension hypotension with systolic less than 90 mm Hg dysrhythmias seizures experienced trauma because the readings will not be accurate

Anxiety can make a client's breathing rate ____________ due to the stimulation of the sympathetic nervous system

increase

Sickled blood cells are malformations that reduce the oxygen-carrying ability of hemoglobin to the cells. This will cause an ___________ in respiratory rate and depth

increase

What assessment tools are used for the chest?

inspect auscultate stethoscope

What assessment tools are used for abdomen?

inspect auscultation palpate tape measure stethoscope

What assessment tools are used for feet?

inspect palpate doppler

____________ is excessive outward curvature of the spine, causing hunching of the back.an

kyphosis

If the client can only whisper or has a hoarse voice this may indicate ___________

laryngeal disease

musty body or breath odor can indicate ____________

liver disease

Why do older adults see a decrease in body weight?

loss of muscle mass & subcutaneous fat

A nurse who is administering a return-flow enema to a patient should instill 100 mL of enema fluid and then

lower the container to allow the solution to flow back out

What are the systems that are involved in the while-body systems?

musculoskeletal neurologic hematologic endocrine

__________ is alteration in muscle movement that is seen as a sudden jerking of the arm or leg when falling asleep

myoclonus

_________ data is obtained through direct assessment of a client (inspection, percussion, palpitation, and auscultation)

objective

What does OLD CARTS stand for when collecting details about a presenting problem?

onset location duration characteristics aggravating or alleviating factors related symptoms treatment severity

During orthostatic blood pressure test if the patient's systolic pressure drop 20 mm Hg or decrease of 10 mm Hg in diastolic pressure between positions this indicates _____________

orthostatic hypotension

While performing a complete bed bath for a patient, the nurse should

raise the room temperature

______________ = erythema

reddish

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

return-flow

____________ is alteration in muscle tone manifested as resistance to any manipulation of the joint

rigidity

__________ pain is often described as throbbing pain or deep achy feeling

somatic

Why do older adults see a reduce in their heights?

thinning in the vertebral disk shortening of the vertebrae kyphosis mild flexion of the knees and hips