Test 1 Flashcards by Abby Jackson

Which standard of practice would the nurse perform when evaluating a client’s pain after performing a back massage?

a.) evaluation
b.) consultation
c.) coordination of care
d.) outcomes identification

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Which statement made by the nurse requires correction when discussing RN licensure in the US with peers?

a.) “Candidates must pass the NCLEX-RN examination to become licensed in their state”
b.) “the scope of practice for RNs is found in each state’s Nurse Practice Act”
c.) “the examination for RN licensure is exactly the same in every state in the US”
d.) “passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice”

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Which points support nursing as a profession and not a job? SATA

a.) “A specific service is provided”
b.) “A basic liberal foundation and an advanced education are required”
c.) “Nursing has a theoretical body of knowledge leading to defined skills, abilities, norms.”
d.) “Members of a profession do not have any autonomy in decision-making and practice.”
e.) “The profession as a whole lacks a code of ethics for practice and simply follows the state rules and regulations.”

a, b, and c

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Which statement would the RN include in the teaching plan regarding the proficient stage of Benner’s five levels of proficiency?

a.) “work in the same clinical position for 2 to 3 years”
b.) “experience at some level with the situation”
c.) “ability to zero in on the problem and focus on managing care”
d.) “have more than 2 to 3 years of experience in the same clinical position”

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Which action would the nurse take for a client whose right radial pulse is weak and thready? SATA

a.) assessing all peripheral pulses
b.) assessing and comparing both radial pulses
c.) asking a second nurse to assess the client’s pulses
d.) assessing for edema or other issues that may be restricting peripheral blood flow
e.) observing for pallor/skin temp differences distal to the weak pulse

all of the above

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Which activity places a client at risk for hyperthermia?

a.) snowmobiling
b.) skiing in the winter
c.) hiking Alaskan mountains
d.) performing strenuous activity in high humidity

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The nurse is caring for her patients and is focused on managing their care as opposed to managing and performing skills. This nurse demonstrated which level of proficiency according to Benner?

a.) novice
b.) competent
c.) proficient
d.) expert

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The patient requires a routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse’s best option would be to take his temperature via which route?

a.) oral
b.) tympanic
c.) rectal
d.) axillary

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The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a spike in postoperative infections on this unit and categorizes this type of healthcare-associated infection as _____ infections.

a.) iatrogenic
b.) nosocomial
c.) endogenous
d.) exogenous

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In the diagnosis phase of the nursing process, which of the following is an example of health promotion?

a.) acute pain
b.) risk for infection
c.) readiness for enhanced parenting
d.) possible chronic low self-esteem

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A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

a.) to implement evidence-based practice
b.) to ensure the order follows hospital policy
c.) to be sure interventions are individualized
d.) to be sure the intervention is safe

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What is the purpose of evaluation in the nursing process?

a.) to direct future nursing interventions
b.) to formulate a dtatbase of nursing diagnoses
c.) to complete an intitial plan of care
d.) to transfer medical orders to the plan of care

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The first practicing nurse epidemiologist was

a.) Florence Nightingale
b.) Mildred Montag.
c.) Clara Barton
d.) Mary Agnes Snively

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The major difference between a baccalaureate degree nursing program and an associate’s degree nursing program is that the baccalaureate program includes studies in

a.) basic sciences and theoretical courses
b.) social sciences and humanities
c.) theoretical and clinical courses
d.) basic sciences and clinical courses

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The nurse spends time with a patient and family reviewing a dressing change procedure for the patient’s wounds. the patient’s spouse demonstrates how to change the dressing. The nurse is acting in which professional role?

a.) educator
b.) edvocate
c.) caregiver
d.) communicator

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A number of factors influence a patient’s personal preferences for hygiene. Because of this, it is important for the nurse to realize that

a.) no two individuals perform hygiene in the same manner
b.) it is important to standardize a patient’s hygienic practices
c.) hygiene care is always routine and expected
d.) hygiene is not the time to learn about patient needs

The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and needs a bath and foot care. When questioned about his hygiene habits, pt tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this pt, the nurse understands that

a.) personal preferences determine hygiene practices and are unchangeable
b.) patients who appear unkempt place little importance on hygiene practices
c.) the pt’s illness may require teaching new hygiene practices
d.) all culture value cleanliness with the same degree of importance

The nurse is caring for a pt who refuses “AM care”. When asked why, the pt tells the nurse that she always bathes in the evening. The nurse should

a.) defer bath until evening and pass on the information to the next shift
b.) tell the pt that she must bathe because that is “normal” routine
c.) explain to the pt the importance of maintaining morning hygiene practices
d.) cancel hygiene for the day and attempt again in the morning

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the pt’s temp is 96.8F (36C), whereas at 4 PM the preceding day, it was 98.6F (37C). What should the nurse do?

a.) call the physician immediately to report a possible infection
b.) realize that this is a normal temperature variation
c.) provide another blanket to conserve body temperature
d.) provide medication to lower the temperature further

When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as

a.) pyrexia
b.) the plateau phase
c.) the set point
d.) becoming afebrile

The nurse is caring for an elderly pt and notes that his temp is 96.8F (36C). The nurse understands that this pt is

a.) suffering from hypothermia
b.) expressing a normal temperature
c.) hyperthermic relative to his age
d.) demonstrating the increased metabolism that accompanies aging

The pt is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the pt’s ____ pulse.

a.) radial
b.) brachial
c.) posterior tibial
d.) carotid

The pt’s blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of

a.) 140
b.) 60
c.) 80
d.) 200

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

a.) completes a comprehensive database
b.) identifies pertinent nursing diagnoses
c.) intervenes based on pt goals and priorities of care
d.) determines whether outcomes have been achieved

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from her subjective data that a.) the pt can now perform the dressing changes herself b.) the pt can begin retaking all her previous medications c.) the pt is apprehensive about discharge d.) surgery was not successful

The nurse is attempting to prompt the pt to elaborate on her complaints of daytime fatigue. Which question should the nurse ask? a.) "Is there anything that you are stressed about right now?" b.) "What reasons do you think are contributing to your fatigue?" c.) "What are your normal work hours?" d.) "Are you sleeping 8 hours a night?"

A RN administers pain medication to a pt suffering from fractures ribs. What type of nursing intervention is the nurse implementing? a.) collaborative b.) independent c.) interdependent d.) dependent

Which intervention is most appropriate for the pt problem, Impaired verbal communication due to loss of facial motor control and decreased sensation? a.) obtain an interpreter for the patient asap b.) assist the pt in performing swallowing exercises each shift c.) ask the family to provide a sitter to remain with the patient at all times d.) provide the pt with a writing board each shift

Which of the following is a nursing intervention? a.) the pt will ambulate in the hallway twice this shift using crutches correctly b.) impaired physical mobility related to the inability to bear weight on right leg c.) provide assistance while the pt walks in the hallway twice this shift with crutches d.) the pt is unable to bear weight on right lower extremity

The nurse is caring for a pt who requires a complex dressing change. While in the pt's room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing? a.) assess the pt's readiness for the procedure b.) gathers and organizes needed supplies c.) decides on goals and outcomes for the pt d.) calls for assistance from another nursing staff member

A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate? a.) "during evaluation, you determine whether all nursing interventions where completed' b.) "during evaluation, you determine when to downsize staffing on nursing units." c.) "nurses use evaluation to determine the effectiveness of nursing care." d.) "evaluation eliminates unnecessary paperwork and care planning."

The nurse is caring for a pt who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated. What is the nurse's next action? a.) wait and change the dressing at 1800 as ordered b.) revise the plan of care and change the dressing now c.) reassess the dressing and the wound in 1 hour d.) discontinue the plan of care

A pt is admitted to a medical unit for a home-acquired pressure ulcer. The pt has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as a.) restraints b.) poor hygiene c.) foley catheter bag d.) improper positioning

The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is to a.) encourage preschool children to eat a nutritious diet b.) encourage parents to provide a multivitamin to the children c.) clean the toys every afternoon before putting them away d.) wash their hands between each interaction with children

You are caring for a pt who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should a.) start antibiotics b.) notify the physician c.) document the findings and reassess in 2 hours d.) place the pt on isolation precautions

The nurse is admitting a pt with an infectious disease process. What question would be appropriate for a nurse to ask this pt? a.) "do you have a chronic disease, and how long have you had it?" b.) "do you have any children living in the home?" c.) "what is your marital status--single, married or divorced?" d.) "do you have any cultural or religious beliefs that will influence your care?"

The nurse is providing an education session to an adult community group about the effects of smoking. Which of the following is the most important point to be included in the educational session? a.) smoke from tobacco products slings to your clothing and hair b.) smoking affects the cilia lining the upper airways in the lungs c.) smoking tobacco products can be very expensive d.) smoking can affect the color of the pt's fingernails

The nurse is caring for a group of medical-surgical pts. The pt most at risk for developing an infection is the pt who a.) is in observation for chest pain b.) is recovering from a right total hip arthroplasty c.) has been admitted with dehydration d.) has been admitted for stabilization or atrial fibrillation