Gathering Data
What is considered a primary source of data?
A) the client is observed grimacing when attempting to brush her hair w/ her left arm
B) Mother states "she told me that her shoulder is sore every morning"
A) the client is observed grimacing when attempting to brush her hair w/ her left arm
Which of the following would not be considered a secondary prevention behavior in regard to health promotion?
A. Screening for lead exposure.
B. Exercising 30 minutes daily
C. Performing a monthly self-breast exam
D. Receiving an annual tuberculosis screening for work
B. Exercising 30 minutes daily Rationale: Secondary prevention consists of following guidelines for screening for diseases that are easily treated if found early or for detecting return of a disease.
A nurse is discussing HIPPA Privacy Rule with nurses during new employee orientation. Which of the following info should the nurse NOT include?
A. A single electronic records password is provided for nurses on the same unit.
B. Family members should provide a code prior to receiving client health info.
C. Communication of client info can occur at the nurses' station.
D. A client can request a copy of her medical record.
A. A single electronic records password is provided for nurses on the same unit.
The nurse can best ensures that communication is understood by:
A. Speaking slowly and clearly in the patient's native language.
B. Asking the family members whether the patient understands.
C. Obtaining feedback from the patient that indicates accurate comprehension.
D. Checking for signs of hearing loss or aphasia before communicating.
C. Obtaining feedback from the patient that indicates accurate comprehension. Rationale: Good communication requires active listening (focusing on what is being said), timely feedback (return of information and how it was interpreted), and validation of assumptions about nonverbal cues.
A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse plan to delegate to an assistive personnel (AP)?
A. Verifying a client’s ability to walk safely
B. Assisting a client with feeding
C. Evaluating changes to a client's pressure ulcer
D. Teaching a client how to self-administer insulin
B. Assisting a client with feeding
A nursing is caring for a client who presents to an urgent care with a laceration on his forearm. Which of the following activities is an example of primary prevention?
A) Suturing the client’s wound
B) Applying a sterile dressing
C) Administering a tetanus immunization
D) Teaching the client about follow-up care
C) Administering a tetanus immunization Answer Rationale: Primary prevention is true prevention of the manifestations of illness through health promotion and disease prevention. This level of prevention includes immunizations because they provide protection against specific infections and diseases.
A nurse is completing a client’s history and physical examination. Which information should the nurse consider subjective data?
A. Blood pressure
B. Cyanosis
C. Nausea
D. Petechiae
C. Nausea
A nurse witnesses an adult who is experiencing a cardiac arrest while at the grocery store. The nurse performs CPR. Which of the following criteria is necessary for the Good Samaritan law to provide civil immunity for the nurse?
A) The nurse has basic life support certification.
B) The nurse has a license to practice nursing in the state where the event occurred.
C) The nurse remains with the client when traveling to the hospital in an ambulance.
D) The nurse does not cause any harm to the client.
Correct 1) The nurse has basic life support certification. Answer Rationale: Good Samaritan laws provide civil immunity to a nurse when she performs emergency care for which she has the qualifications. If the nurse has basic life support certification, she has the qualifications to perform CPR in this emergency situation.
INCORRECT 2) The nurse has a license to practice nursing in the state where the event occurred. Answer Rationale: The Good Samaritan law will provide civil immunity for a nurse even if she does not have a license to practice in the state of the occurrence.
INCORRECT 3) The nurse remains with the client when traveling to the hospital in an ambulance. Answer Rationale: In order for the Good Samaritan law to protect the nurse, she is only legally responsible for the client’s care until she is able to transfer the care to another qualified health provider. Therefore, it is not necessary for the nurse to travel with the client in the ambulance, as other health care providers can assume care.
INCORRECT 4) The nurse does not cause any harm to the client. Answer Rationale: The Good Samaritan law will provide civil immunity if the nurse caused harm as long as she acted within her scope of practice and level of expertise.
The nurse can best ensures that communication is understood by:
A. Speaking slowly and clearly in the patient's native language.
B. Asking the family members whether the patient understands.
C. Obtaining feedback from the patient that indicates accurate comprehension.
D. Checking for signs of hearing loss or aphasia before communicating.
C. Obtaining feedback from the patient that indicates accurate comprehension. Rationale: Good communication requires active listening (focusing on what is being said), timely feedback (return of information and how it was interpreted), and validation of assumptions about nonverbal cues.
The nurse enters a patient’s room who is complaining of severe chest pain. Which independent nursing action is most appropriate?
A. Provide the patient with emergency pain medication
B. Apply oxygen and advance the flow rate to the maximum setting
C. Raise the head of the bed and reposition the patient
D. Delegate to the assistive personnel to take vital signs and notify the treating physician
C. Raise the head of the bed and reposition the patient Rationale: An independent nursing action does not require a primary care provider’s order, but it does require critical thinking and clinical judgment.
What is the purpose of proper documentation in the electronic medical record?
A. "Documentation provides a communication tool for the health care team."
B. "Documentation facilitates reimbursement from the local government."
C. "Documentation provides information for a client audit."
D. "Documentation enables providers to monitor the nurse."
A. "Documentation provides a communication tool for the health care team." Rationale: Nurses document to communicate clients’ data to the health care team. Nurses document so that the facility receives reimbursement from the federal government, not local government. Nurses document to provide information for a nursing audit, not a client audit, to verify that nurses are adhering to nursing and client care standards. Nurses document to enable providers to monitor clients’ care and progress, not to monitor nurses.
The order in which the nursing process is approached is:
A. planning, assessment, implementation, nursing diagnosis, evaluation.
B. nursing diagnosis, evaluation, assessment, implementation, planning.
C. assessment, nursing diagnosis, planning, implementation, evaluation.
D. evaluation, nursing diagnosis, planning, implementation, assessment.
C. assessment, nursing diagnosis, planning, implementation, evaluation. Rationale: The five components of the nursing process are assessment (data collection), nursing diagnosis, planning, implementation, and evaluation.
A nurse is obtaining informed consent from a client who is scheduled for a total hip arthroplasty. Which if the following statements should the nurse include?
A) "Your provider will discuss other treatment options."
B) "Your partner will need to witness you sign the consent form."
C) "The charge nurse will review risks of the procedure."
D) "Once you sign the consent form, you cannot refuse treatment." Answer Rationale: The client can refuse treatment at any time.
Correct A) "Your provider will discuss other treatment options." Answer Rationale: The nurse should instruct the client that is the provider’s responsibility to discuss and explain the procedure and other treatment options available.
INCORRECT 2) "Your partner will need to witness you sign the consent form." Answer Rationale: The consent form does not need to be witnessed by the client’s partner.
INCORRECT 3) "The charge nurse will review risks of the procedure." Answer Rationale: The provider should review the risks of the procedure with the client.
INCORRECT 4) "Once you sign the consent form, you cannot refuse treatment." Answer Rationale: The client can refuse treatment at any time.
A nurse is observing a client’s nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
A. Nonverbal communication conveys less truth than what the client states verbally.
B. The client’s sociocultural background influences nonverbal communication.
C. Nonverbal communication is a poor reflection of what the client feels.
D. The client enacts nonverbal communication consciously.
B. The client’s sociocultural background influences nonverbal communication. Rationale:Sociocultural background has a major influence on what a client’s nonverbal behavior means.
A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?
A. Providing a central line dressing change
B. Evaluating pain relief after administering pain medication
C. Collecting intake and output
D. Selecting a menu for a low-sodium diet
C. Collecting intake and output
A nurse is collecting data for a newly admitted client. Which of the following actions should the nurse take next?
A. Reviewing the provider's prescriptions
B. Ordering an appropriate meal tray
C. Documenting the client's allergies in the electronic medical record
D. Requesting that an assistive personnel obtain admission weight
C. Documenting the client's allergies in the electronic medical record Rationale: The first action the nurse should take using the nursing process is to collect data from the client and then document these findings within the electronic medical record. This will allow for continuity of care in the case that another nurse or provider needs to perform care for this client. If information such as current medications, past medical history, laboratory test, allergies, and consent forms are missing from the documentation, sound clinical decisions might not be made.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
A. Crackles Rationale: Crackles are a series of explosive, high-pitched sounds the nurse hears just before the end of inspiration. The sound is similar to that of rolling hair between the fingers just behind the ear.
B. Rhonchi Rationale: Rhonchi are continuous rumbling, snoring, or rattling sounds.
C. Stridor Rationale:Stridor is a harsh, shrill inspiratory sound.
D. Wheezes Rationale: Wheezes are continuous, high-pitched squeaking or whistling sounds, first evident on expiration, but possibly evident on inspiration as the airway
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (select all)
A. Medication error
B. Needlestick
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Complaint from a client's family member
A. Medication error
B. Needlestick
D. Omission of prescription
A nurse using active listening techniques would:
A. Use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.
B. Avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned
C. Anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence.
D. Ask probing questions to direct the conversation and obtain the information needed as efficiently as possible.
A. Use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard. Rationale: Nonverbal cues that indicate active listening are leaning forward, focusing on the speaker’s face, nodding slightly to indicate the message is being heard, and maintaining an open body posture
A nurse is assigning tasks for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)
A. Providing postmortem care to a client who has just passed away
B. Suctioning a client's newly inserted tracheostomy
C. Transferring a client to radiology for x-rays
D. Performing a simple dressing change on a client's arm
E. Instructing a client about the use of a spirometer
A. Providing postmortem care to a client who has just passed away
C. Transferring a client to radiology for x-rays
D. Performing a simple dressing change on a client's arm
A nurse is documenting in a client's medical record. Which of the following abbreviations are acceptable for the nurse to use? (Select all that apply.)
A. MSO4
B. bid
C. 30 mL
D. .2 mg
E. Q.D
B. bid
C. 30 mL
Rationale: MSO4 is incorrect. This abbreviation is unauthorized because it can be confused with other medications such as morphine sulfate and magnesium sulfate. The Joint Commission expects that medication names will be written out.bid is correct. This abbreviation is acceptable. It is not included in the "do not use" list.30 mL is correct. This abbreviation is acceptable. It is not included in the "do not use" list. It is acceptable for the nurse to write "ml" or "milliliters". However, "mL" is preferred. The nurse should not use "cc" because this can be mistaken for units (U). The abbreviation "cc" is on the "do not use" list..2 mg is incorrect. Doses less than 1.0 should have a leading zero (0.2 mg) and doses should not have trailing zeros (2.0 mg) because of the potential for dosage errors. If the decimal point is missed (e.g. giving 2 mg instead of 0.2 mg, and giving 20 mg rather than 2.0 mg) the client is at risk.Q.D. is incorrect. This abbreviation is listed on The Joint Commission's "do not use" list. This abbreviation is intended to mean "every day". It is unauthorized because it can be confused with Q.O.D., which is intended to mean "every other day". The Joint Commission expects the prescriber to write "daily."
What does the nurse do during assessment? Select all that apply.
A. validate
B. interpret
C. cluster data
D. create goals
A. validate
B. interpret
C. cluster data
A nurse is reinforcing teaching with a newly licensed nurse about ethical principles when providing client care. Which of the following situations should the nurse use as an example of negligence?
A) A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning. The nurse reports the findings to the provider in the early afternoon.
B) A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to the client without his knowledge.
C) A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent her from leaving.
D) A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells him she will apply wrist restraints if he does not stop eating the chips.
Correct A) A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning. The nurse reports the findings to the provider in the early afternoon. Answer Rationale: Negligence is conduct that does not show due care. It can be an act of omission, which is the failure to perform an act that a reasonable prudent person, under similar circumstances, would do. A reasonably prudent nurse would notify the provider of this neurovascular finding immediately.
INCORRECT B) A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to the client without his knowledge. Answer Rationale: This action violates the ethical principle of veracity and also has elements of battery.
INCORRECT C) A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent her from leaving. Answer Rationale: This is an example of false imprisonment and also has elements of battery.
INCORRECT D) A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells him she will apply wrist restraints if he does not stop eating the chips. Answer Rationale: This is an example of assault.
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)
A) "I isolate myself in my room for a few hours when things get overwhelming."
B) "I tense and release my muscles, starting with my feet."
C) "I think about being on my favorite beach vacation."
D) "I call a friend who makes me smile and laugh."
Incorrect 1) "I isolate myself in my room for a few hours when things get overwhelming."
Correct 2) "I tense and release my muscles, starting with my feet."
Correct 3) "I think about being on my favorite beach vacation."
Correct 4) "I call a friend who makes me smile and laugh."
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
A. Bathe a client who had an amputation 2 days ago.
B. Assist a client to ambulate using a gait belt.
C. Review a low-sodium diet for a client who has hypertension.
D. Explain oral hygiene to a client receiving chemotherapy.
E. Feeding a client who had a stroke 3 months ago.
A. Bathe a client who had an amputation 2 days ago.
B. Assist a client to ambulate using a gait belt.
E. Feeding a client who had a stroke 3 months ago.