Exam 1 Review Flashcards
Which organization defines nursing with a framework that clarifies what nursing involves and the responsibilities of the nurse as a professional?
American Nursing Association (ANA)
a legal and regulatory body that is created by, and applicable in, each individual state. It establishes common definitions, rules, and regulations to guide the practice of a licensed nurse and thereby promote quality of care and safety when caring for a client?
A Nurse Practice Act
The _______ Scope of Nursing Practice provides the nurse with a clear definition of the complex and dynamic role of the nurse and the expectations of the nurse in that role
ANA’s
The _______ standards of Nursing Practice are explanatory statements that describe a competent level of care and professionalism that all nurses should achieve.
ANA’s
Which of the following are Florence Nightingale’s contributions that are still used today…
A. Documentation
B. Hand hygiene
C. Evidence-based practice
D. Data collection
E. American Red Cross
A, B, C, D
A patient has measles. Which type of precaution would they be on?
Airborne
A patient has varicella. Which type of precaution would they be on?
Airborne
A cancer patient has a CBC done which shows a very weak immune system. Which precaution would they be on?
Neutropenic
A patient has meningitis. Which precaution would they be on?
Droplet
A patient comes in feeling sick, has a temperature and we need to run tests, but none of the results are back yet. Which precaution would you use?
Standard
A patient tests positive for C. diff and you need to put a precaution sign on the door. Which precaution would you use?
Contact precautions
What PPE would you use for contact precaution patients?
Gloves and Gown
What PPE would you use for droplet precautions?
mask
What PPE would you use for airborne precautions?
gown, gloves, N95
For which adult client should the nurse make follow-up observations and monitor the vital signs closely?
A. Resting morning BP is 128/78mm Hg, whereas the afternoon BP is 122/76 mm Hg
B. Oral temp is 97.9 in AM and 99.8 in evening
C. Heart rate is 76 beats/min before eating and 88 bpm after eating
D. Respiratory rate is 16 breaths per min when standing and 18 breaths/min lying down
A. Because both blood pressures are higher and the resting rate was even higher than afternoon blood pressure.
If a test question refers to a nurse following up, which step of the nursing process is this?
Evaluation
If someone is eating it could make their HR go up or down?
Up
When a question asks what the ‘best action’ is what part of the nursing process is it referring to?
Intervention
What do we expect a temperature to do in the afternoon? Go up or down?
Go up
If a respiratory rate goes from 16 breaths/min when standing to 18 breaths/min when lying down is that an expected change or not?
Yes, it is an expected change
What is an antipyretic?
Medication used to reduce fever
A client’s vital signs 4 hours ago: oral temperature 101.4, HR 110 beats/min, RR 26 breaths/min, and BP 124/78 mm Hg. The temp is now 99.4 - based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find?
1. 16
2. 18
3. 20
4. 22
18 - for every degree the temperature falls the respiratory rate should fall 4 beats
For every degree a temperature drops, the respiration rates drop how many beats per minute?
4
The nurse is planning to initiate a research project that involves adult patients as participants. The nurse accepts moral and legal responsibility to protect research participants from physical or emotional harm. Which mechanism will the nurse utilize for participant protection?
IRB - The institutional review board at the research facility.
The nurse makes the following entry regarding the patient’s outcome, goal not met. “Patient’s pain remained the same after administering Acetaminophen.” What should the nurse do next?
Goal not met - create a new intervention
‘Goal not met’ in a question is referring to which part of the nursing process?
Evaluation
The nurse is using contact precautions to change the soiled bed sheets of a client with C. diff. In the process, the nurses right glove and skin on a finger are torn. After removing soiled gloves what action is priority?
A. Hold pressure to stop bleeding
B. Use bleach wipes to clean hands
C. Wash hands with soap and water
D. Cleanse hands using alcohol-based hand rub
C
With C. diff should you use soap and water or alcohol based cleanser for your hands after changing patient?
Soap and water
When heart rate increases does the respiratory rate increase or decrease?
Increase
What is diaphoresis?
Sweating
Would you expect temperature to decrease after diaphoresis? Y/N
Yes
A nurse is assisting a UAP about caring for a patient who has a low platelet count from chemo. Which of the instructions is the priority for measuring vital signs for this client?
A. Do not take the client’s temp rectal
B. Count the client’s radial pulse for 30 seconds and multiply by 2
C. Do not let the client know that you are counting their respirations
D. Let the client rest for 5 minutes before taking BP
A
If a patient has a low platelet count why wouldn’t you want to take rectal temperature?
The bowel could be easily perforated causing bleeding with an already low platelet (clotting) issue.
The nurse caring for a post surgical pt obtains an oral temp of 102F. The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? (Select all that apply)
A. Obtained oral temp of 102F
B. Called the surgeon to obtain the order
C. Administered acetaminophen 650mg orally
D. Administered aspirin 650 mg orally
E. Obtained rectal temp of 102F
A, B, C
TIP: For select all questions
-DON’T try to make the answer options make sense together
-DO ask if each option is true/false
:)
What is the first level of Maslow’s hierarchy of needs that must be met before you can move upward?
Physiologic Level
What is included in Maslow’s physiologic level that must be met?
Sex, food, water, air, shelter, sleep, air
What is one factor that will take over all other levels of Maslow’s hierarchy and won’t allow a person to climb the heirarchy?
Pain
What tasks can you delegate to a UAP?
bathe, hygiene, vital signs if not the first time, ambulate, feed (unless stroke pt)
What are four things the nurse can’t delegate to anyone else?
T.A.P.E
Teach, assess, plan, evaluate
What are the five stages of Benner’s Novice to Expert theory?
Novice, Advanced beginner, competent, proficient, expert
How long does it take to go from being a novice to competent nurse?
2-3 years
Why do we do the nursing process?
To gain critical thinking skills
If a nurse is very task oriented, doesn’t have a good nurse intuition they are a _____ nurse.
Novice
When writing goals and following SMART. What does ‘SMART’ stand for?
specific, measurable, attainable, realistic, timely
What are the steps of the nursing process in order?
ADPIE: Assess, Diagnose, Plan, Implementation, Evaluation
When writing goals and following KISS - what does ‘KISS’ stand for?
keep it simple specific
A nursing home is trying to see how happy the patients are with their new weekly food menu by getting opinions from patients. Would this be quantitative or qualitiative?
Qualitative
A hospital is tracking UTIs in patients that had catheters. Would this be quantitative or qualitative data?
Quantitative
Interviewing a patient that comes into the ED is which part of the nursing process?
Assessment
A patient is having a hard time breathing - the nurse tries to reposition the patient. Which type of intervention is this?
Independent intervention
A patient is having a hard time breathing, the nurse tries to reposition but feels they need orders for oxygen. They ask the doctor for orders. This is what type of intervention?
Dependent intervention
A patient comes back from surgery after having a skin graft and needs to have their wound assessed. The nurse performs this assessment. Which type of care? Indirect or Direct
Direct care
What does the State Board of Nursing do?
They make the nursing laws regarding each state.
What does the ANA do?
Create guidelines based on what the board of nurses has stated.
What does JCO do?
They set guidelines for patient safety. (Scanning armbands, two forms or identification, protecting patient rights)
What does NLN (National League of Nurses) do?
Sets guidelines, mostly for education of nurses.
If you are a nurse and you have an order for something that doesn’t seem quite right, do you do it?
No - be an assertive nurse - question it
What characteristics should you have as a nurse?
be a leader, advocate, be accountable
Which precaution would require a patient to be in a negative pressure room?
Airborne precaution
TIP: Know the appropriate way to don and doff PPE
:-)
An increase in heart rate and decrease in blood pressure are consistent with?
Fluid volume deficit
A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precaution?
1. Client with rubella
2. Client who has measles
3. Client who has hepatitis A
4. Client who has Rocky Mountain spotted fever
Client who has rubella
PIMP (surgical mask & eye protection) patient placed in a single room: P (pertussis) I (influenza) M (meningitis) P (pneumonia)
droplet precautions
MTV on air M (measles, mumps, & rubella) TB (tuberculosis) V (varicella) turn on room air
airborne precautions
TAPE
teaching, assessment, planning, education
what precautions should a patient be placed on if they have rubella?
airborne
what precautions should a patient be placed on if they have measles?
airborne
what precautions should a patient be placed on if they have mumps?
airborne
A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the new nurse indicates an understanding of the teaching?
A. Radial pulse regular 68/min
B. BP 148/72 mm Hg
C. Temp 36 degrees
D. SpO2 95%
A - the nurse documented location where it was taken and if it was regular or irregular.
A nurse is providing care to a client. Prior to exiting the client’s room, the nurse ensures the client’s bed is locked and their call light is within reach. Which of the following QSEN competencies is the nurse demonstrating?
Safety
A nurse is obtaining an oxygen saturation on a client. Which action should the nurse take?
Choose a finger with a capillary refill less than 2 sec
An infection control nurse is teaching a class about transmission of infectious agents. The nurse should include that which of the following diseases is transmitted via airborne transmission?
Select all that apply
A. Varicella
B. C. diff
C. Rubella
D. Staphylococcus aureus
E. Tuberculosis
A, C, E
Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision?
A. Critical Thinking
B. Clinical Reasoning
C. Concept Mapping
D. Clinical Judgement
D
A nurse wants to become more involved in nursing on a national level. Which of the following organization should the nurse join?
A. American Nursing Association
B. National Student Nurses Association
C. National League for Nursing
D. National Academy of Medicine
A
During which of the following situations should a nurse wear eye protection?
A. Providing hygiene care to a client who is HIV positive
B. Emptying urinary drainage bag for a client who has pneumonia
C. Irrigating a client’s abdominal wound
D. Transporting cerebrospinal fluid specimen to the lab
E. Suctioning a client’s tracheostomy tube
C and E
A nurse is discussing the effect of low health literacy with a group of community members. Which of the following statements should the nurse include?
A. “Clients who have low health literacy have lower mortality rates than others”
B. “Low health literacy leads to an increase in preventative services.”
C. “Low health literacy leads to increased use of emergency services.”
C
Which precaution should the nurse use when setting up a client’s food tray?
-Transmission-based
-Handwashing only
-Standard
Handwashing Only
Which precaution should the nurse use when starting an IV for a client with a high fever and productive couch of unknown origin?
-Handwashing only
-Standard
-Transmission-based
Transmission-based
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?
A. I will begin 48 hours before the client’s discharge
B. I will begin once the client’s discharge order is written
C. I will begin upon the client’s admission to the facility
D. I will begin once the client’s insurance company approves discharge coverage
C
A nurse is teaching a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients?
A. A client who has hemorrhoids
B. A client who had recent oral surgery
C. A client who breaths through the mouth
D. A client who is drinking ice water
E. A client who has a coagulation disorder
A, E
A nurse in a long-term care facility has assigned a task to an assistive personnel. The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?
A. I feel you are being inconsiderate of the other team members
B. I have to let the director of nursing know about this situation
C. I need to talk to you about the unit policies regarding client assignments
C
A patient has tuberculosis. What PPE should be worn when entering the room?
N-95 mask
What precaution would require a negative pressure room?
Airborne precautions
With which precaution would you mask when within 3 ft of the patient?
Droplet
Which precaution requires for the door to be kept closed?
Airborne
A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 10. Which of the following findings should the nurse expect?
A. Hypertension
B. Decreased respiratory rate
C. Hypoglycemia
D. Bradycardia
C.
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
1. Tell the client that it is unlikely that he has bone cancer
2. Ask the client why he thinks his pain isn’t a result of hiking
3. Suggest genetic testing so the client can understand his risks
4. Explain that the provider will see him and determine a course of action
- This illustrates the therapeutic communication technique of focusing the client on the usual course of action that must proceed drawing any conclusions about the cause of a client’s pain.
A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
A. Dizziness
B. Hypoglycemia
C. Temp of 39 degrees
D. History of cigarette smoking
A. Bradycardia can cause dizziness due to decreased perfusion to the brain
A nurse is caring for a client who has MRSA in an abdominal would. The nurse enters the room to check the client’s pulse. Which of the following actions should the nurse take?
A. Wear an N-95 respirator
B. Wear sterile gloves
C. Wear clean gloves
D. Wear protective eyewear
C. Clean gloves
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
A. Planning
B. Implementation
C. Evaluation
D. Assessment
A
A nurse is assessing a client who has an oral temperature of 102.2F. Which of the following findings should the nurse expect?
A. Respiratory rate 10/min
B. Dilated pupils
C. Heart rate 108/min
D. Decreased peripheral pulses
C. Heart rate of 108/min
A heart rate is greater than the normal 60-100 bpm. A fever causes an increase in metabolic demands and an increased heart rate.
ABC
airway, breathing, & circulation
Implementation step of the Nursing Process
How the nurse carries out nursing actions
Evaluation step of the of the Nursing Process
Determining whether patient goals have been achieved and interventions have been successful
Evaluation step of the of the Nursing Process
Determining whether patient goals have been achieved and interventions have been successful
If a patient experiences a fall, is the event documented on an incident report?
NO, this is not part of the health record and is a separate document
SBAR
(documentation)
situation, background, assessment, & recommendation
Informatics
managing and processing information necessary to make decisions
