Exam #2

Question 1

A nurse enters the clients room and finds the client on the floor after the nurse has insured the client safety which of the following actions. Should the nurse take
A. contact for management about the occurrence
B.Request another nurse to complete the occurrence report
C.Notify the client provider about the occurrence
D.Document the completion of an occurrence report in the medical record

Answer 1

C.

Question 2

Charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of sentinel even?
A client had surgery and died from sepsis
A client fell out of the bed and fractured their hip
A client was almost given client medication
A client has prescribed the medication they were allergic to, but the prescription was canceled before the medication was given

Answer 2

A client had surgery and died from sepsis

Question 3

Client is scheduled for a procedure which of the following action. Should the nurse take during the time?
Ask the client to read their notification bracelet
verify that the surgical side has been marked
ask the client to state the surgery being performed
ask the client to point the surgical site
use two acceptable client identifiers

Answer 3

verify that the surgical side has been marked
ask the client to state the surgery being performed

ask the client to point the surgical site

use two acceptable client identifiers

Question 4

A nurse is reviewing a client medical record which of the following following findings. Should the nurse identify as a fall risk
Hyperthyroidism
Multiple sclerosis
Hyperlipidemia
Inguinal Hernia

Answer 4

Multiple sclerosis this is a physical disorder that can place the client at risk for falls due to problems with mobility. Other physical disorders that can contribute to our visual impairment, recent surgery and stroke.

Question 5

A nurses snow coming from the central supply room which of the following actions to the nurse take first
Wrap clients in blankets

Walk to a safe surface

Close all the doors

Stay close to the ground

Answer 5

Close all the doors

Question 6

A nurse is preparing a client for a procedure. Which of the following is unacceptable intent fire to use identify the client.
Room number

Medical condition

Home address

Telephone number

Answer 6

Telephone number

Question 7

Our nurse is caring for client who is experiencing suicidal thoughts which of the following action should the nurse take?

Encourage visitors to bring items to client

Remove objects from the clients room

Place the client 12 on hour observation

Encourage visitors for the client anytime

Answer 7

Remove harmful objects from the clients room
The nurse should complete our environmental checklist of the clients room to the client could use to cause to have removed

Question 8

T/F: Always have 4 rails up for safety

Answer 8

No that will be known as a restraint 3 is the limit

Question 9

Physical considerations for adults

Answer 9

-Teach about how stress impacts
lifestyle and health(cig smoker= change for a fidget spinner (lol)
-Counsel about unsafe health
habits
-Counsel about domestic
violence
-Prevent accidents
-Orient
-Maintain vehicles
-Scheduled eye exams
-Noise kept at minimum
-Promote safe home
environment
-Use medication organizers ( very important , confused patients). will need this type of help)

Question 10

What do we do when our patient falls

Answer 10

DONT MOVE PATIENT

ask them if anything hurts or causes discomfort (assess them)

AFTER
-complete an incident report so this can be prevented in the future

-describe circumstances, detail clients response to incident and the treatment
this does not go to the medical record

Question 11

before you leave the room you should check for?

Answer 11

at least on bed rail is down
lock bed
non slip socks

Question 12

DAME stands for ?

Answer 12

This is to assess risk for falls in older adults

Question 13

DAME: D

Answer 13

Drugs and ETOH use( a scientific way to reference alcohol)

Question 14

DAME: A

Answer 14

Age-related physiological status

Question 15

DAME: M

Answer 15

Medical Problems

Question 16

DAME: E

Answer 16

Environment

Question 17

Plans to bring a person experiencing domestic abuse to safety: Things we need to know before we can help

Answer 17

A place to stay
-An escape route
-Person to call in crisis/time to leave
-Signal to neighbor to call for help
-Keys for house and car
-Secure copies of important papers
-Packed bag with necessities like clothing and medication
-Important addresses, phone numbers, contact info

Question 18

Rescue
RACE: R

Answer 18

Rescue:

Question 19

RACE: A

Answer 19

Activate: call 911 , pull the alarm, alarm personall

Question 20

RACE: C

Answer 20

Confine: shut all doors

Question 21

RACE:E

Answer 21

Evacuate: take client to safety . help people closer to the fire first

Question 22

List of things that can happen with restraints

Answer 22

Increased possibility of serious injury due to
fall
-Skin breakdown
-Contractures
-Incontinence
-Depression
-Delirium
-Anxiety
-Aspiration and respiratory difficulties
-Death

Question 23

Alternatives to restraints

Answer 23

-assessment
-bed alarms
-cameras
-have someone occupy and sit next to them
-involve family
-distracting( agitated? get them off the focus. puzzle, remain calm)
Place furniture to limit area

Question 24

Safety is Maslow’s ___?

Answer 24

2nd level

Question 25

A nurse is preparing a poster presentation about communicating with clients. Which of the following strategies should the nurse include to enhance communication?
(Select All that Apply.)

-Interrupt a client when they are verbalizing feelings of worthlessness.
-Convey empathy for a client who voices painful emotions.
-Show respect for a client who is making decisions about treatment.
-Speak to a client using clear and simple words and phrases.
-Cross both arms across the chest when speaking with an angry client.

Answer 25

—Show respect for a client who is making decisions about treatment is correct. The nurse should include that showing respect for a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.

—Convey empathy for a client who voices painful emotions is correct. The nurse should include that conveying empathy for a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.

Interrupt a client when they are verbalizing feelings of worthlessness is incorrect. The nurse should include that interrupting a client is a nontherapeutic action that can inhibit effective communication. The nurse should avoid interrupting the client and actively listen while they speak.

—Speak to a client using clear and simple words and phrases is correct. The nurse should include that using simple, clear language with a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.

Cross both arms across the chest when speaking with an angry client is incorrect. The nurse should identify that crossing the arms across the chest is a nonverbal action that can inhibit effective communication. The nurse should keep their arms and legs uncrossed and make eye contact with the client.

Question 26

A nurse is teaching a class about the steps of critical thinking. The nurse should include that interpreting data is included in which of the following steps?
Creativity
Analysis
Questioning
Intuition

Answer 26

INCORRECT
Creativity is a critical thinking skill that involves applying knowledge and skills to try different approaches to planning and implementing care. The steps of critical thinking include questioning, synthesis, interpretation, analysis, inference, inductive and deductive reasoning, intuition, application, and creativity.

Analysis
CORRECT
My Answer
Analysis is a critical thinking step that involves interpreting data to determine client problems and formulate a plan of care. The other critical thinking steps include questioning, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.

Questioning
INCORRECT
Questioning is a critical thinking skill that involves using the scientific method to determine client problems. The steps of critical thinking include questioning, synthesis, interpretation, analysis, inference, inductive and deductive reasoning, intuition, application, and creativity.

Intuition
INCORRECT
Intuition is a critical thinking skill that involves using knowledge and instinct about the client and the situation to recognize that something is not right. The steps of critical thinking include questioning, synthesis, interpretation, analysis, inference, inductive and deductive reasoning, intuition, application, and creativity.

Question 27

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

Answer 27

INCORRECT
The nurse should plan to provide the client with a text copy of the discharge instructions. However, Braille is a specific text intended for clients who have a significant visual loss and are familiar with the tactile symbols

Repeat any phrases that the client misunderstands.
INCORRECT
My Answer
The nurse should rephrase instructions that the client misunderstands and speak slowly, in different volume levels

Guide the client away from background noise.
CORRECT
The nurse should plan to take measure to ensure a quiet environment when communicating with a client who has hearing loss. Background noise can be distracting and interfere with a client’s comprehension of the spoken words.

Stand next to the client when speaking.
INCORRECT
The nurse should plan to position themselves face-to-face when speaking with a client who has hearing loss. This enables the client to utilize lip-reading to increase their comprehension.

Question 28

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance?

Bureaucratic leader
Situational leader
Laissez-faire leader
Transformational leader

Answer 28

CORRECT
Bureaucratic leaders are rule-based. They are not open to creativity and strictly enforce the rules to maintain compliance.

Situational leader
INCORRECT
My Answer
Situational leaders look at each situation quickly and adjust strategies based on the circumstances. These leaders communicate, problem-solve, organize, and prepare with their employees to accomplish tasks and improve overall efficiency.

Laissez-faire leader
INCORRECT
Laissez-faire leaders provide minimal direction and allow staff members the freedom to work independently.

Transformational leader
INCORRECT
Transformational leaders establish a common mission and vision. They encourage empowerment in employees to elevate their level of performance.

Question 29

A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Administer oral PRN pain medication to a client who has arthritis.
Teach the use of an incentive spirometer to a postoperative client.
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Obtain a daily weight on a client who has heart failure.

Answer 29

The nurse should not delegate the task of administering oral PRN pain medication to a client to an AP. This task is beyond the range of function of an AP. The nurse can delegate this task to a PN or another RN.

Teach the use of an incentive spirometer to a postoperative client.
INCORRECT
The nurse should not delegate the task of teaching the use of an incentive spirometer to a postoperative client. The task of teaching is beyond the range of function of an AP and a PN. The nurse should delegate this task to another RN.

Irrigate and perform a dressing change for a client who has a pressure injury wound.
INCORRECT
The nurse should not delegate the task of irrigating and performing a dressing change for a pressure injury wound. This task is beyond the range of function of an AP. The nurse should delegate this task to a PN or another RN.

Obtain a daily weight on a client who has heart failure.
CORRECT
The nurse should delegate the task of obtaining a daily weight on a client to an AP. This task is within the range of function of an AP.

Question 30

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders identifies common values to empower employees?

Answer 30

INCORRECT
Bureaucratic leaders are rule-based. They are not open to creativity and strictly enforce the rules to maintain compliance.

Transactional leader
INCORRECT
Transactional leaders use rewards or punishments to encourage compliance for an established goal. They communicate specific expectations, focusing on tasks and completion of short-term goals.

Transformational leader
CORRECT
My Answer
Transformational leaders establish a common mission and vision. They encourage empowerment in employees to elevate their level of performance.

Laissez-faire leader
INCORRECT
Laissez-faire leaders provide minimal direction and allow staff members the freedom to work independently.

Question 31

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following techniques should the nurse include when discussing therapeutic communication?

Offering personal opinions
Providing passive responses
Using silence
Offering sympathy

Answer 31

INCORRECT
Offering personal opinions is a nontherapeutic communication technique. This technique inhibits problem solving and can take away the client’s decision-making.

Providing passive responses
INCORRECT
Providing passive responses is a nontherapeutic communication technique. Passive responses aim to avoid conflict or difficult conversations. Passivity is often a reflection of sadness, fear, powerlessness, or depression.

Using silence
CORRECT
My Answer
The use of silence is a therapeutic communication technique. Silence gives the nurse and client time to think, sort out feelings, and reflect on what has already been said. It also demonstrates the nurse’s willingness to be patient and allow the client the time needed to formulate thoughts or make decisions. Silence can be especially therapeutic when a client is grieving.

Offering sympathy
INCORRECT
Offering sympathy is a nontherapeutic communication technique. Sympathy occurs when a nurse takes on a client’s problem as their own, leading to feelings of pity or sorrow for the client.

Question 32

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

Answer 32

INCORRECT
My Answer
Right documentation is one of the rights of medication administration, not delegation.

Right room
INCORRECT
Right room is not one of the rights of delegation.

Right time
INCORRECT
Right time is one of the rights of medication administration, not delegation.

Right communication
CORRECT
Right communication is one of the five rights of delegation. The nurse should be sure to communicate clearly and provide sufficient directions when delegating tasks.

Question 33

Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision?

Concept mapping
Critical thinking
Clinical judgement
Clinical reasoning

Answer 33

INCORRECT
Concept mapping uses a chart or diagram to compare existing nursing knowledge to new information to plan client care.

Critical thinking
INCORRECT
My Answer
Critical thinking is the foundation of clinical decision making and aligns with the nursing process. A nurse uses critical thinking to make clinical decisions.

Clinical judgement
CORRECT
The clinical judgement model is designed to be used by nurses to think critically and make decisions based on evidence-based practice.

Clinical reasoning
INCORRECT
Clinical reasoning is used by nurses to analyze and interpret data pertaining to a particular clinical situation and make decisions based on that information.

Question 34

The nurse has entered a client’s home and has observed that the client’s respiratory rate is elevated and that the client is exhaling audibly. Based on these cues, the nurse suspects that the client is either anxious or hypoxic. Which step of the Clinical Judgment Measurement Model (CJMM) has the nurse just applied?

diagnosing
prioritizing hypotheses
taking action
providing explanations

Answer 34

INCORRECT
The CJMM does not include steps of “diagnosing” or “providing explanations.”

prioritizing hypotheses
CORRECT
The Clinical Judgment Measurement Model (CJMM) proceeds from identification and analysis of cues (data and assessment results) to prioritizing hypotheses, or considering potential explanations.

taking action
INCORRECT
My Answer
Taking action involves providing interventions, and occurs later than prioritizing hypotheses.

providing explanations
INCORRECT
The CJMM does not include steps of “diagnosing” or “providing explanations.”

Question 35

A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

Assessing a client who just returned from surgery.
Obtaining a blood pressure for a client who is to be discharged later in the day.
Teaching a client who is preoperative how to use an incentive spirometer.
Providing tracheostomy care for a client.

Answer 35

INCORRECT
It is beyond the scope of an AP to assess a client. This task cannot be delegated.

Obtaining a blood pressure for a client who is to be discharged later in the day.
CORRECT
My Answer
It is within the scope of an AP to obtain a blood pressure on a client who is stable. The nurse should delegate this task to the AP.

Teaching a client who is preoperative how to use an incentive spirometer.
INCORRECT
It is beyond the scope of an AP to provide teaching for a client. This task cannot be delegated.

Providing tracheostomy care for a client.
INCORRECT
It is beyond the scope of an AP to provide tracheostomy care for a client. This task cannot be delegated.

Question 36

A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first?

A client who reports their IV pump is beeping.
A client who is postoperative and is reporting nausea.
A client who is requesting a bedpan.
A client who reports they have fallen while ambulating.

Answer 36

INCORRECT
Using the urgent vs. nonurgent priority framework, there is another client the nurse should attend to first. The nurse can delegate the task of assisting this client to another nurse.

A client who is postoperative and is reporting nausea.
INCORRECT
My Answer
Using the urgent vs. nonurgent priority framework, there is another client the nurse should attend to first. The nurse can delegate the task of assisting this client to another nurse.

A client who is requesting a bedpan.
INCORRECT
Using the urgent vs. nonurgent priority framework, there is another client the nurse should attend to first. The nurse can delegate the task of assisting this client to an assistive personnel.

A client who reports they have fallen while ambulating.
CORRECT
Using the urgent vs. nonurgent priority framework, the nurse should first assist the client who has fallen on the floor. The client will need to be assisted back to bed and assessed to determine if they have sustained an injury. Following this, the nurse should obtain vital signs and notify the provider of the incident. An incident report of the event will be required.

Question 37

A nurse is assessing an older adult client with mobility issues in the home and notes the following:

Multiple throw rugs on the floors from the living room to the kitchen.
Several extension cords running across the floor in the client’s path to the restroom.
Bags of old circulars and junk mail scattered about the living room.
Limited lighting in hallway from the door to the main living space.
The nurse determines that the client’s risk for falling is increased. The nurse is demonstrating which concept?

reflection
cognitive load
responding
situational awareness

Question 38

What is leadership style??

Answer 38

In nursing, this is only good with emergencies because individually a person will lead on their own and think and do on their own

Question 39

what are the critical thinking steps?

Answer 39

critical thinking steps include questioning, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.

Question 40

What is Laissez faire?

Answer 40

Hand-off leadership style.
Let people make their own decisions
low productivity and leads to frustration

no leadership happening

Question 41

Transactional

Answer 41

reward for task being done

Question 42

Transformational

Answer 42

IDEAL leadership
Promotes teamwork and shared decision making

Question 43

Bureaucratic

Answer 43

strict!

Question 44

differentiate complementary health approaches and integrative health from allopathic/conventional medicine.

Answer 44

Complementary health approaches and integrative health focus on holistic, patient-centered methods and blending diverse therapies, while allopathic medicine relies on conventional, science-based treatments and pharmaceuticals.

Question 45

Compare and contrast the beliefs about about the origin of disease and ways to promote health of each of the three main categories of complementary health approaches.

Answer 45

Compare and contrast the beliefs about about the origin of disease and ways to promote health of each of the three main categories of complementary health approaches.

Question 46

A sputum specimen report from the laboratory states, “Contamination with typical oral flora.” Which
interpretation is correct?
A. Bacteria in the mouth are growing in the lungs.
B. The normal flora has become pathogenic.
C. The patient has a pulmonary infection.
D. The sputum from the lungs has mixed with bacteria in the mouth.

Answer 46

D. The sputum from the lungs has mixed with bacteria in the mouth.
Contamination with typical oral flora suggests that the sputum sample is mixed with bacteria from the mouth, not necessarily indicating an infection.

Question 47

describe ways in which nurses can use selected complementary health approaches for self care and health promotion.

Answer 47

Nurses can use complementary health approaches for self-care and health promotion by practicing techniques such as mindfulness, yoga, and herbal remedies to manage stress, improve overall well-being, and enhance their physical and mental health.

Question 48

A college student is seen in the campus health center with a sore throat. Examination of the throat reveals
redness and swelling but no sign of infection. Which of the following is an accurate description of the
inflammatory process?
A. A granuloma will develop if the inflammation is unresolved.
B. The student is not at risk for the development of an infection.
C. There is an influx of leukocytes to the throat.
D. Scarring will result from phagocytic action.

Answer 48

C

Question 49

When caring for a patient who is receiving morphine, it is most important that the nurse regularly
assess for which of the following?
A. respiratory depression
B. hyperactive bowel sounds
C. frequent urination
D. insomnia

Answer 49

A

Question 50

A man has an order for morphine sulfate 2 mg intravenously every 2 hours following a cholecystectomy.
The patient has a history of IV drug abuse. He reports that his pain is 7 out of 10 (with 10 being the
worst) and requests the morphine every hour. What is the nurse’s appropriate response?
A. to instruct him about possible adverse effects
B. to tell him that you can administer the drug only every 2 hours
C. to use distraction techniques to help him forget his pain
D. to notify the surgeon of his request

Answer 50

b