Unit II: Professional Standards in Nursing

Question 1

Which teaching method is MOST EFFECTIVE when providing instruction to members of special populations?
A. Teach-back
B. Video Instructions
C. Written Materials
D. Verbal Explanation

Answer 1

A

RATIONALE: When providing education to members of special populations, return explanation and demonstration (teach back) are of particular important to ensure safety and mutual understanding.

Question 2

Which is MOST APPROPRIATE when communicating with a transgender person?
A. Using preferred pronouns
B. Using their first name to address them
C. Using pronouns associated with birth sex
D. Anticipating the client’s needs and making suggestions

Answer 2

A

RATIONALE: The nurse needs to address the client with the name and pronouns that the client prefers, and the first name may not necessarily be preferred.

Question 3

The nurse is volunteering with an outreach program to provide basic health care for homeless people. which finding, if noted, must be addressed FIRST?
A. Blood pressure 154/72 mm Hg
B. Visual acuity of 20/200 in both eyes
C. Random blood glucose level of 206 mg/dl
D. Complains of pain associated with numbness and tingling in both feet

Answer 3

D

RATIONALE: The nurse needs to address the complaints of pain and numbness and tingling in both feet first with this population. if the client perceives value to the service provided and his or her complaint is addressed, they will be more likely to return for follow up care.

Question 4

The nurse completing the admission assessment of a client encounter may require more time to complete?
A. The history
B. The physical assessment
C. The nursing plan of care
D. The readmission risk assessment

Answer 4

A

RATIONALE: intellectually disabled clients tend to have difficulty trying to remember their medical history. it may be necessary for the nurse to take more time to ask questions in a variety of different ways when collecting the history data.

Question 5

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond?
A. “Health care is very limited in the prison setting”
B. “Living in a prison isn’t different than living at home”
C. “Living in prison can predispose a person to different health conditions”
D. “Living in prison is similar to living in a condominium complex or dormitory”

Answer 5

C

RATIONALE: The environment of a prison can predispose a person to different health conditions, such as TB, STIs, or other infectious diseases.

Question 6

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and SOB. Which physical assessment findings, if noted by the nurse, warrant a NEED FOR A FOLLOWUP?
A. Reddened sclera of the eyes
B. Dry Flaking noted on the scalp
C. A reddish-purple mark on the neck
D. A scaly rash noted on the elbows and knees

Answer 6

C

RATIONALE: The client in this question must be screened for abuse. Battered women experience bruises or broken bones. Mental health problems can also arise.

Question 7

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in the population? (select all that apply)
A. Asthma
B. Claustrophobia
C. Sleep Problems
D. Bipolar Disease
E. Aggressive Behaviours
F. ADHD

Answer 7

C,D,E,F

RATIONALE: Foster children are at risk for a variety of health conditions, including attention deficit/hyperactivity disorder, aggressive behaviour, anxiety disorder, bipolar disorder, depression, mood disorder, PTSD, reactive detachment disorder, sleep problems, and personality disorders.

Question 8

The nurse assisting in planning care for a military veteran must PRIORITIZE nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?
A. Hypertension
B. Hyperlipidemia
C. Substance Abuse Disorder
D. PTSD

Answer 8

D

RATIONALE: PTSD is extremely common in this population. Identifying and treating mental health problems assists in mitigating suicide risk. Use screening tools may also help identifying this.

Question 9

The nurse caring for a refugee considers which health care need a PRIORITY for this client?
A. Access to housing
B. Access to clean water
C. Access to transportation
D. Access to mental health care services

Answer 9

D

RATIONALE: Mental health problems are the primary issue for this population as a result of difficult events. Although all other option are important for all clients, they do not address this specific needs of this special population.

Question 10

Which action by the nurse will BEST facilitate adherence to the treatment regimen for a client with a chronic illness?
A. Arranging for home health care
B. Focusing on managing a single illness at a time
C. Communicating with one provider only to avoid confusion for the client
D. Allowing the client to teach a support person about their treatment regimen

Answer 10

A

Question 11

Which identifies accurate nursing documentation notions? Select all that apply
A. The client slept through the night
B. Abdominal wounds dressing is dry and intact without drainage.
C. The client seemed angry when awakened for vital sign measurements
D. The client appears to become anxious when it is time for respiratory measurements
E. The clients left lower medial leg would is 3 cm in length without redness, drainage, or edema

Answer 11

A,B,E

RATIONALE: Factual documents contains descriptive and objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. Vague terms such as ‘seemed’ or ‘appears’ are no acceptable because it seems as the nurse is taking an opinion

Question 12

The LPN enters a clients room and finds the client laying on the bathroom floor. The LPN calls the RN, who checks the client throughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervision and primary health care provider (PHCP) are notified of the incident. Which is the NEXT nursing action regarding the incident?
A. Place the incident report in the clients chart
B. Make a copy of the incident report for the PHCP
C. Document a complete entry in the clients record concerning the incident
D. Document in the client’s record that an incident report has been completed.

Answer 12

C

RATIONALE: The incident report is confidential and privileged information, and it would no be copied, placed in a chart, or have any reference made to it in the client’s record. The incident Report is not a substitute for a complete entry in the clients record concerning the incident

Question 13

An unconscious client bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the clients life. With regard to informed consent for the surgical procedure, what is the BEST action?
A. Call the nursing supervisor to initiate a court order for the surgical procedure
B. Try calling the clients spouse to obtain telephone consent before the procedure
C. Ask the friend who accompanied the client to the emergency department to sign the form
D. Transform the client to the operating department immediately without obtaining an informed consent

Answer 13

D

RATIONALE: There are two situations where an adults consent is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death. the second is when the client waves the rights to get informed consent.

Question 14

The nurse arrives at work and is told to report (float) to the paediatric unit for the day because the unit is understaffed and needs additional nurses too care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate action?
A. Call the hospital lawyer
B. Call the nursing supervisor
C. Refuse to float to the pediatric unit
D. Report to the pediatric unit and identify tasks that can be safely performed

Answer 14

D

RATIONALE: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can drive a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse would identify potential areas of harm to the client and only perform tasked that he or she is trained and experienced in

Question 15

The nurse enters a clients room and notes that the clients lawyer is present and the client is preparing a living will. The living will requires that the client’s signature is witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?
A. Decline to sign the will
B. Sign the will as a witness to the signature only
C. Call the hospital lawyer before signing the will
D. Sign the will, clearly identifying credentials and employment agency

Answer 15

A

RATIONALE: Living wills are required to be in writing and signed by the client. The clients signature either must be witnessed by specific individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care

Question 16

The nurse finds the client lying on the floor. The nurse calls the RN who checks the client and then calls the nursing supervisor and the PHCP to inform them of the occurrence. The nurse completes the incident report for what purpose?
A. Providing clients with necessary stabilizing treatments
B. A method of promoting quality care and risk management
C. Determining the effectiveness of interventions in relation to outcomes
D. The appropriate Method of reporting to local state, and federal agencies

Answer 16

B

RATIONALE: Proper documentation of unusual occurrences, incidents and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present

Question 17

The nurse observes that a client receives pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action?
A. Report the information to the police
B. Call the impaired nurse organization
C. Talk with the nurse who gave the medication
D. Report the information to the nursing supervisior

Answer 17

D

RATIONALE: Nurse practice act require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision.

Question 18

A client has died, and the nurse asks a family member abbot the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action at this time?
A. Show acceptance of feelings
B. Provide information needs for decision making
C. Suggest a referral to a mental health professional
D. Remain with the family member without discussing funeral arrangements

Answer 18

D

RATIONALE: The family member is exhibiting the first stage of grief (denial) and the nurse would remain with the family member.

Question 19

A nurse lawyer provides an education session to the nursing staff regarding client rights with an emphasis on invasion of these rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the staff nurse, indicates an understanding of a violation of this client’s rights?
A. Threatening to place a client in restraints
B. Performing a surgical procedure without consent
C. Taking photographs of the client without consent
D. Telling the client that he or she cannot leave the hospital

Answer 19

C

RATIONALE: Invasion of privacy takes place when an individuals private affairs are intruded on unreasonably. Threatening to place a client in restraints is assault. Performing a surgical procedure without consent is an example of battery. Not allowing the patient to leave the hospital is false imprisonment

Question 20

An older women is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the clients arms and buttocks. The nurse asks the client how the bruises were sustained. The client although reluctant, tells the nurse in confidence that her daughter frequency hits her if she gets in the way. Which is the appropriate nursing response?
A. “I have a legal obligation to report this type of abuse”
B. “I promise I won’t tell anyone, but lets see what we can do about this”
C. “Lets talk about ways that will prevent your daughter from hitting you”
D.” This should not be happening. If it happens again, you must call the emergency department”

Answer 20

A

RATIONALE: Confidential issues are not to be discussed with non medical personnel or with the clients family or friends with there clients permission. Clients would be assured that information is kept confidential unless it places the nurse under legal obligation. The nurse must report situations related to the child, older adult abuse, and other types of abuse.

Question 21

The nurse is recording a nursing hands-off (end of shift) report for a client. Which information needs to be included?
A. as needed medications given that shift
B. Normal vital signs that have been the same since admission
C. All of the tests and treatments the client has had since admission
D. Total number of scheduled medications that the client received on that shift

Question 22

The nurse is planning the client assignments for the day. Which is the MOST APPROPRIATE assignment for the assistive personnel(AP)?
A. A client who requires wound irrigation
B. A client who requiring frequent ambulation
C. A client who is receiving continuous tube feeding
D. A client who requires frequent VS after a cardiac catheterization

Answer 22

B

RATIONALE: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case the best assignment for the AP would be to care for the client who requires frequent ambulation.

Question 23

The nurse employed in a long term care facility is planning the client assignments for the shift. Which client would the nurse assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)?
A. A client who requires a 24-hour urine collection
B.A client who requires twice-daily dressing changes
C. A client with DM who requires daily insulin and the reinforcement of dietary measures
D. A client who has been placed on a bowel management program and requires rectal suppositories and daily enema

Answer 23

A

RATIONALE: The nurse must determine the appropriate assignment on the basis of the skills of the staff member and the needs of the client. The assignment of the tasks needs to be implemented on the basis of the job description of the individual, individuals level of competence, and state law

Question 24

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check FIRST?
A. A client in skeletal traction
B. A client who is dependent on a ventilator
C. A postoperative client preparing for discharge
D. A client admitted during the previous shift with a diagnosis of gastroenteritis

Answer 24

B

RATIONALE: The airway is always the priority and the nurse first checks the person on the ventilator

Question 25

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving at the ED. The nurse would assign PRIORITY to which client?
A. A client complaining of muscle ache, headache, and malaise
B. A client who twisted their ankle when they fell in-line skating
C. A client with minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

Answer 25

D

RATIONALE: In the emergency department, triage involves classifying client according to their need for care, and it includes establishing priority of cares, this type of illness, severity of the problem, and the resources available to govern the process.

Question 26

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a NEED for further teaching? Select all that apply.
A. “An event is termed a mass casualty when it overwhelms local medial capabilities”
B.”Mass casualty events do not require an increase in the number of staff that are needed”
C. “A mass casualty event occurs only within the health care facility and could endanger staff”
D. “Mass casualty events may require at the collaboration of many local agencies
E. “Mass casualty event occurs if a fight between visitor occurs in the emergency department

Answer 26

B,C,E

RATIONALE: Mass causality events (disasters) whelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crisis. May occur outside or inside the health care facility

Question 27

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. Which of the following describes the team-based model of nursing practice?
A. A task approach method is used to provide care to clients
B. Managed care concepts and tools that are used when providing care
C. Nursing staff are led by the nurse when providing care to a group of clients
D. A single registered nurse is responsible for providing nursing care to a group of clients

Answer 27

C

RATIONALE: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing, option 2 identifies component nursing and option 4 identifies primary nursing

Question 28

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?
A. Autocratic
B. Situational
C. Democratic
D. Laissez-faire

Answer 28

A

RATIONALE: Autocratic leadership is an approach which the leader retains all authority and is primarily concerned with task accomplishment

Question 29

The nurse has delegated several nursing tasks to staff members. Which is the nurse’s PRIMARY responsibility after the delegation of tasks?
A. Document that the tasks was completed
B. Assign the tasks that were not completed to the next nursing shift
C. Allow each staff member er to make judgements when performing the tasks
D. Perform follow up with each staff member regarding the performance and outcome of the task

Answer 29

D

RATIONALE: The ultimate responsibility lies with the person who delegated it. Therefore, it is the nurses primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task.

Question 30

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from FIRST?
A. A client scheduled for a chest x-ray
B. a client requiring daily dressing changes
C. A postoperative client preparing for discharge
D. A client receiving oxygen who is having difficulty breathing

Answer 30

D

RATIONALE: The airway is always a priority and the nurse would attend to the client who has been experiencing an airway problem first