Professionalism Prep U
A client with diabetes has impaired sensation in the lower extremities. What education would be necessary to reduce the client's risk of injury?
"Always test the temperature of bathwater before stepping in."
The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?
"Could you tell me more about how you are feeling right now?"
Which is an example of a closed question or statement?
"Did you take those drugs?"
The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the toenails. Which is the best reply by the nurse?
"I can see how quickly the blood returns to assess blood flow."
Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home?
"I have removed all throw rugs on the floor."
The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.
"Is there any chance you might be pregnant?" "Do you smoke cigarettes?" "Are you ready to get out of bed?"
A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?
"Parents are effective role models for children when they also wear helmets while riding."
In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws?
Emergency care for a choking victim in a restaurant
In which instance may a surgeon operate without informed consent?
Emergency situations
A client tells the nurse that she is getting divorced and wants to be sure that her soon-to-be ex-husband cannot have access to her medical information. Which response would be the most accurate for the nurse to give the client?
"You have the right to say who can access your health records and who cannot."
A client preparing to be a subject in a research study informs the nurse that the client would like to withdraw from the research study immediately. What is the best response by the nurse
"You have the right to withdraw your consent for being a research subject at any time."
The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?
15-degree angle
The nurse is preparing to administer dimenhydrinate 50 mg intramuscular to a client. Place in order, the steps the nurse will follow when using the Z-track technique to administer the drug? Use all options.
2Fill the syringe with the prepared drug and then change the needle. 3Select the ventrogluteral site. 5Use the side of the hand to pull the tissue laterally about 1 inch (2.5 cm) until the tissue is taut. 4Insert the needle at a 90-degree angle while continuing to hold the tissue laterally. 1Aspirate for blood return and instill the medication. 6Withdraw the needle and apply pressure to the site.
The nurse is preparing to administer insulin to a person with excess weight. At what angle will the nurse plan to insert the needle into the client?
90 degrees
Which nurse would be at the highest risk of causing a hazardous situation?
A nurse who has worked 32 hours of overtime this week
A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?
A signed consent form from the client
Which action should the nurse implement when working with a medically homeless client?
Encourage client to utilize the free health care clinic.
A registered nurse is overseeing the care of clients in an acute mental health setting. Which task can the nurse delegate to an unlicensed assistive personnel?
Encouraging a client with depression to eat
A nurse has integrated the principles of evidence-based practice (EBP) into care. EBP has the potential to help the nurse achieve what goal?
Ensuring high-quality client care
A nurse who works in a pediatric practice assesses the developmental level of children of various ages to determine their psychosocial development. These assessments are based on the work of:
Erikson.
Following an assessment, the nurse has documented expected client outcomes. Expected outcomes will allow the nurse to perform what future action?
Evaluate the client's progress.
Which activity best helps the nurse apply theory to practice?
Evidence-based research
A pregnant client refuses treatment for an infection based on cultural beliefs. Which action by the nurse would be appropriate?
Explain to the client why the treatment is important.
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
Communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?
Communicate with the health care provider for additional orders.
A nurse is sitting with friends in a coffee shop while working on a plan of care for a client. The client's name is written at the top of the plan. Which ethical responsibility is the nurse violating?
Confidentiality
A client, who was recently diagnosed with diabetes, has been coming to the emergency room every day for hyperglycemia. The client reports not being able to self-administer insulin injections. What strategy would best educate the client and improve the client's ability to self-administer insulin?
Demonstrate the proper method and have the client mimic the demonstration.
Which of the following is an important element of implementation?
Documentation
Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment?
Florence Nightingale
A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice?
Frequent handwashing reduces transmission of pathogens from one client to another.
A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?
Giving false reassurance
A client about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse a concern that friends will learn about the upcoming surgery and pleads with the nurse to keep the surgery a secret. What response by the nurse is best?
I am not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so
The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?
Immediately activate the safety needle and place the syringe and needle into a Sharps container.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?
Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly
Allowing unauthorized people to observe a client during treatment is an example of which of the following?
Invasion of privacy
A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?
Involve family members in the client's care.
What is the ultimate goal of expanding nursing knowledge through nursing research?
Learn improved ways to promote and maintain health
A client informs the nurse that they want to discontinue treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?
Let the client go after signing a document stating that the client is going against medical advice.
An informatics nurse specialist is conducting a program for facility staff about creating strong passwords to promote secure and private data. The nurse determines that the teaching was successful when the staff identify which password as a strong password?
MaFrN610#
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Maintaining a patent airway
A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies?
Make no attempt to resuscitate the client.
A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case?
Nursing process
A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?
Obtain a medical order.
A nurse on a neurologic unit is caring for several clients. Which task should the nurse delegate to the nursing assistant?
Obtain an oxygen saturation
A nurse on a telemetry unit is admitting a client and has an unlicensed assistive person (UAP) helping with the admission process. Which task can the nurse delegate to the UAP?
Obtaining an admission weight for the client utilizing the client's bed scale
The registered nurse (RN) is responsible for delegating patient care responsibilities to licensed practical nurses (LPNs) as well as ancillary personnel. What would be the most appropriate task to delegate to a nursing assistant?
Obtaining vital signs for a patient that has been hospitalized for 3 days
An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse?
Report suspicions about the abuse to proper authorities.
A client stops in the hall after walking a short distance and tells the nurse, "I do not want to do any more exercise because I hurt too much." What is the next action the nurse should implement?
Return the client to bed and provide pain relief measures.
A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions?
Scientific rationales
In comparison with licensure, which measures entry-level competence, what does certification validate?
Specialty knowledge and clinical judgment
A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client paper record. Which action would be most appropriate for the nurse to do?
Strike out the entry with a single line, place initials next to it, and write the correct entry.
Which task can the nurse safely delegate to unlicensed assistive personnel (UAP)?
documentation of client's intake and output on a flow sheet
The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?
intradermal
When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed?
invasion of privacy
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family.
A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching?
keeping medications in clearly labeled containers
A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse?
negligence
A nurse is caring for a client who is in acute respiratory distress from pneumonia but refuses to stay for treatment. It is the nurse's responsibility to:
notify the health care provider, discuss the outcomes of the client's decision, and have the client sign a release form.
A client is scheduled for surgery at 8 a.m.(0800). While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?
notifying the surgeon that the client hasn't signed the consent form
A group of nurses working in a long-term care facility fails to keep the opioid medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the:
nurses' licenses.
The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)?
obtaining a wound culture during a dressing change
The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:
orthostatic hypotension
A registered nurse should assign a nursing assistant to care for a client with inflammatory bowel disease who:
requires assistance with ambulation.
A nurse is overheard in the hospital cafeteria making false, derogatory comments about a client. The nurse is guilty of:
slander.
What is the primary purpose of standards of nursing practice?
to ensure knowledgeable, safe, comprehensive nursing care
A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?
tort
The nurse is preparing to give a vaccination to an infant. At which site should the nurse plan to administer the injection?
vastus lateralis
Nurses must maintain the privacy of clients. Which example is a breach in privacy and would pose an ethical problem?
Taking a picture of a client with the nurse's cell phone
Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)?
The LPN/LVN should work under the supervision of an RN.
What governing body has the authority to revoke or suspend a nurse's license?
The State Board of Nurse Examiners
Which best exemplifies malpractice?
The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.
The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?
Use night-lights in bedrooms and bathrooms
A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?
Verbally report the finding immediately to the client's health care provider.
The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?
Wait with the client until the medications are taken.
A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client's confidentiality when the client makes which statement?
When I get out of here, I'm going to kill my neighbor."
Which is an open-ended question?
Why did the health care provider prescribe this medication for you?"
A registered nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which client's care will the nurse safely delegate to the UAP?
a client diagnosed with renal calculi who is encouraged to ambulate four times daily
To which client would the nurse be most likely to administer a PRN medication?
a client who is reporting pain near the surgical site
After a client falls out of bed, the nurse completes:
a safety event report (incident report).
A client is seen in the emergency department and reports left arm pain, fatigue, palpitations, and shortness of breath. Which condition would the nurse suspect?
acute coronary syndrome
A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?
administering bedside blood glucose testing
A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:
an audiologist.
Which medication administration task will the registered nurse (RN) appropriately delegate to a licensed practical nurse (LPN)?
antibiotic piggyback via peripheral IV
The nurse is caring for multiple clients on a medical-surgical floor. Which task may the nurse delegate to unlicensed assistive personnel (UAP)?
assisting a client 3 days post-op to ambulate in the hallway
Which nursing care task is acceptable for a registered nurse to delegate to the unlicensed assistive personnel (UAP)?
assisting a client with ambulation
The nurse is delegating tasks to the unlicensed assistive personnel (UAP) prior to beginning the shift on the acute care unit. Which task is appropriate to delegate to the UAP?
assisting an older adult client with using the bedside commode
It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to
avoid aspiration.
While at lunch, a nurse sitting alone heard other nurses at a nearby table talking about a client they did not like. When the group asked the solo nurse for their thought, the solo nurse politely refused to join in the conversation. What value was the solo nurse demonstrating?
basic respect for human dignity
When the nurse researcher informs the participant that the participant's identity will not be linked with the information that is collected, the researcher is ensuring the participant's:
confidentiality.
A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take?
consult with the charge nurse before performing the procedure.
A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent?
cultural beliefs
Which preoperative task can the nurse delegate to the UAP (unlicensed assistive personnel)?
Assisting the client to the bathroom before surgery
A nurse has been named as a defendant in a lawsuit. With whom should the nurse discuss the case?
Attorney
A nurse manager makes all of the decisions for staff activities. What type of leadership is demonstrated by this action?
Autocratic
The nurse is caring for a client who is scheduled to receive a local anesthetic. The nurse understands that vital signs should be monitored at what point?
Before, during, and after the procedure
Which nursing pioneer established the Red Cross in the United States in 1882?
Clara Barton
A client is brought to the emergency room (ER) in an unconscious state and emergency surgery is needed. No family members are present, and the client does not have identification. What action by the nurse is the priority regarding consent for treatment?
Clearly document level of consciousness (LOC) and health status on the client's chart.
Which management function involves a team effort to achieve patient care outcomes?
Collaboration
The primary aim of the Healthy People 2030 initiative is:
health promotion.
When administering immunizations, the nurse is engaged in:
illness prevention.
The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first?
Administer a dose of digoxin that is two hours behind schedule.
A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication?
Administer the medication in the neonate's vastus lateralis with a 25-gauge needle.
Which organization is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice?
American Nurses Association (ANA)
Which action constitutes battery?
An older adult client refuses an intramuscular injection, but the nurse administers it.
The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 191/110 mm Hg on a client. Which is the nurse's priority action?
Assess the client and re-evaluate the vital signs.
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?
Assess the client to determine the cause of the pain.
The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?
Assess the need for assistance with ambulation.
The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include?
Place all household cleaners out of reach
The nurse has administered preanesthetic medication. What action should the nurse take next?
Place the client on bed rest with the side rails up.
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?
Placing the client in a bed with a bed alarm
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?
Reassess the client to determine the effectiveness of the interventions.
A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse?
Redressing lacerations on the wrists of a client who attempted suicide.
The registered nurse (RN) wants to delegate a task to an unlicensed assistive personnel (UAP) but is unsure if the task can be delegated. What is the best resource for the RN to use in determining if the task is appropriate?
The nurse practice act or facility's policy and procedures
A health care facility determined that a nurse employed on a medical unit was documenting care that was not being given, and subsequently reported the action to the State Board of Nursing. How might this affect the nurse's license to practice nursing?
The nurse's license may be revoked or suspended.
While working in an institution that uses computer documentation, the nurse understands the need to log out of the computer if it is not in use. Following this procedure is necessary because of what ethical problem in nursing?
The right of confidentiality is essential to protect each client's private information.
The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task?
The stability of the client's condition, potential for harm, and complexity of the activity
The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?
They must take a licensure exam.
A nurse tells a client that the nurse will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?
Trust
The nurse is reading an order that indicates that a drug is to be given to a client "q4h." How will the nurse administer the medication?
every 4 hours
