Week 2 Flashcards
1
Q
True or false… weight and height is generally measured and noted during the first interaction with the client
A
True
2
Q
True or false…. The head-to-toe approach involves a number of position changes required of the client.
A
False
3
Q
True or false ….. The Rivne test is an assessment technique for comparing air versus bone conduction of sound
A
True
4
Q
True or false….Prolonged “tenting” of the skin when assessing skin turbot indicated edema in the client
A
False
5
Q
True or false….The lub-dub sounds of the heart are called “S1 and S2”
A
True
6
Q
The method of ___________ involves striking or tapping part of the clients body with the fingertips to produce vibratory sounds.
A
Percussion
7
Q
________ are whistling or squeaking sounds heard in the lungs caused by air moving through a narrowed passage
A
Wheezes
8
Q
A skin _____ is an area that has been rubbed away by friction
A
Abrasion
9
Q
_________ is a sophisticated test of range of hearing that measures hearing acuity at various sound frequencies
A
Audiometry
10
Q
Bowel sounds are described as _____ if no sound is heard for two to five minutes
A
Absent
11
Q
True or false ….. objective data consists of information that only the client feels and can describe
A
False
12
Q
True or false… The nurse obtains database information beginning during admission interview and physical examination
A
True
13
Q
True or false …. NANDA international is the clearinghouse for proposals suggesting diagnoses that fall within the independent domain of nursing practice
A
True
14
Q
True or false….. planning is the way by which nurses determine whether a client has reached a goal
A
False
15
Q
True or false …… Concept mapping is a method of organizing information in a graphic or pictorial form
A
True
16
Q
__________ is the systematic collection of facts or data
A
Assessment
17
Q
A ______ assessment is information that provides more details about specific problems and expands the original data base
A
Focus
18
Q
A _______ results from analyzing the collected data and determining whether they suggest normal or abnormal findings
A
Diagnosis
19
Q
Setting and evaluating a ______ helps the nursing team know whether the nursing care has been appropriate for managing the clients nursing diagnosis and collaborative problems
A
Goal
20
Q
_________ means carrying out the plan of care
A
Implementation
21
Q
Which statement best describes clinical judgment?
A-clinical judgment applies to the process in which nurses make patient care decisions in the hospital
B- clinical judgment refers to interpretations and inferences that influence actions nurses use in clinical practice in all settings
C- clinical judgment denotes which nursing interventions qualify for individual payment
D- clinical judgement is reserved for nurses who have achieved a baccalaureate degree or higher.
A
B- clinical judgment refers to interpretations and inferences that influence actions nurses use in clinical practice in all settings
22
Q
_____________ is the thinking process by which a nurse reaches a clinical judgment.
A
Clinical reasoning
23
Q
Which of the following are true regarding the use of algorithms ( select all that apply)
A- algorithms are especially useful for beginning clinicians who lack experience
B- algorithms account for individualized patient needs
C- algorithms direct care in emergent situations that involve inter professional personnel.
D- algorithms encourage a wide exploration of treatment options
A
A and C
24
Q
Which reasoning process is most likely used by the novice or expert nurse who encounters an unfamiliar patient situation. A- analytic reasoning B- intuitive reasoning C- tacit reasoning D- interpretation
A
A. Analytic reasoning
25
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Through clinical reasoning patterns, data collection, and collaborating with colleagues, nurses develop an understanding of a particular clinical situation. Which term best describes this process?
A- responding
B- interpreting
C- interacting
D- assessing
```
B- interpreting
26
Which statement best describes the process of reflection in action? Reflection in action refers to:
A- the nurses understanding of patient responses to nursing actions while care is occurring
B- when the nurse reflects on a patient situation after the nursing actions are completed and the outcomes are known
C- when a nurse pursues further education to improve his or her ability to apply what has been learned regarding various nursing actions
D- the various types of reasoning nurses use when deciding which nursing actions to utilize in a given patient situation
A- the nurses understanding of patient responses to nursing actions while care is occurring
27
```
Which type of reasoning process is used when nurses make sense of patient situations through telling and interpreting stories?
A- intuitive reasoning
B- tacit reasoning
C- storytelling
D- narrative
```
D- narrative
28
Clinical judgement is required for every patient care activity and every nursing intervention
A- true
B- false
B- false
29
Which of the following are typically true regarding novice nurses?(select all that apply)
A- they rely more heavily on intuitive reasoning than experienced nurses
B- they tend to treat all pieces of patient data with similar importance
C- they have difficulty individualizing patient care
D- they rely on theoretical knowledge to make clinical judgements
E- they are more often proficient with providing holistic care
B
C
D
30
To improve clinical judgment which of these actions would be most beneficial for novice nurses?
A- limit exposure to various clinical settings, thus avoiding confusion
B- analyze situations in which there are clear cut patient care solutions because this will assist with learning to recognize patterns
C- work closely with experienced nurses, paying attention to how clinical judgments are made
D- avoid examining their own nursing values, thus preventing bias.
B- analyze situations in which there are clear cut patient care solutions because this will assist with learning to recognize patterns
31
```
Conversing face to face, reading a newspaper, and texting via cell phone are examples of which category of communication?
A- linguistic
B- paralinguistic
C- meta communication
D- megacommunication
```
A- linguistic
32
Silence is a form of communication
A-true
B- false
A- true
33
```
A nurses scrub uniform is an example of which category of communication
A- linguistic
B- paralinguistic
C- meta communication
D- megacommunication
```
B- paralinguistic
34
The ultimate goal of communication is to create _________
Meaning
35
Which of the following are true regarding communication? (Select all that apply)
A- communication is an innate skill
B- communication occurs through a series of transmissions between a sender and receiver.
C- the relationship between the sender and receiver always affects the communication process
D- individuals typically show little change in their communication process through the lifespan
E- physical and mental health conditions impact the communication process.
B
C
E
36
Which statement best described the communication process?
A- the sender decodes a message, the message is transmitted, and the receiver encodes the message
B- the sender encodes a message and sends the message upon perceiving the message the receiver decides and interprets the message.
C- a message is transmitted and the sender and receiver both interpret the message and respond according to their individual perceptions of the content
D- the message is encoded by the sender and receiver, the message is sent via verbal and nonverbal cues, and finally the message is decoded and interpreted by both the sender and receiver.
B- the sender encodes a message and sends the message upon perceiving the message the receiver decides and interprets the message.
37
Communication competence in nursing means that communication is both ______ and ________
Effective and appropriate
38
Communication is cited as the leading cause of sentinel events
A- true
B- false
A- true
39
The institute of medicine recommends that nurses learn about the communication tool SBAR. What does SBAR stand for ??
Situation
Background
Assessment
And recommendation
40
The use of electronic health records as a communication tool is essential. What is the most significant Harris to using electronic health records.
A- the time it takes to bring up electronic health records in an emergency situation
B- the electronic health record is not considered to be legal documentation
C- the electronic health record is difficult to read and interpret
D- the potential for personal health care information to be accessed by those who do not have the right to access it.
D- the potential for personal health care information to be accessed by those who do not have the right to access it.
41
```
A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be go the highest priority keeping in mind the clients condition.
A- risk for activity intolerance
B- risk for ineffective coping
C- risk for infection
D- risk for imbalanced nutrition
```
C- risk for infection
42
```
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and e-cards the vital signs. Which data collected can be classified as subjective data.
A- blood pressure
B- nausea
C- heart rate
D- respiratory rate
```
B- nausea
43
A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan.
A- risk for impaired physical mobility due to surgery
B- ineffective denial related to poor coping mechanisms
C- disturbed body image related to the incision scar
D- risk of injury related to the surgical outcomes
C- disturbed body image related to the incision scar
44
A client who has undergone resection of the intestine is on a liquid diet with a nasogastric tube in place. He refuses the food tray with regular food that comes to his room and insists that a physician be called. The nurse insists that it is the right food and makes the silent take it. The client develops complications and requires another operation. How is negligence determined in this situation.
A- the nurse did not call the physician when the client asked.
B- the nurse did not realize the importance of the tube
C- the dietary department sent the wrong diet for the client
D- the nurse insisted the client have the solid food
B- the nurse did not realize the importance of the tube
45
```
A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the clients insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed?
A- libel
B- battery
C- assault
D- slander
```
D- slander… orally.
46
A nurse enters a clients room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?
A- the nurse documents a complete description of the happenings in the clients records.
B- the nurse makes a copy of the incident report and places it in the clients records
C- the nurse makes a copy of the incident report to give to the physician
D- the nurse mentions in the clients report that an incident report was complete
A- the nurse documents a complete description of the happenings in the clients records.
47
```
A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?
A- 1+ pitting edema
B- 2+ pitting edema
C- 3+ pitting edema
D- 5+ brawny edema
```
C- 3+ pitting edema
48
A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the clients bowel sounds as hypoactive.
A- if sounds occur 30 to 34 times a minute.
B- if sounds occur frequently
C- if sounds occur after a long interval
D- if no sound is heard for 3 - 5 minutes
C- if sounds occur after a long interval
49
The nurse is examining the anus of a client with a history of chronic constipation. What is indicative of chronic constipation?
A- presence of rectal fissures
B- area is more pigmented than adjacent skin
C- area is moist and hairless
D- presence of signs of trauma
A- presence of rectal fissures
50
True or false constitutional laws are enacted by federal, state, or local legislatures
False
51
True or false a misdemeanor is a serious criminal offense, such as murder, falsifying medical records, insurance fraud, and stealing narcotics
False
52
True or false
According to the Good Samaritan laws, legal immunity is provided to passerby who provides emergency first aid to victims of accidents.
True
53
True or false
An incident report is a written account of an unusual, potentially injurious event involving a client, employee or visitor
True
54
True or false
| Nomaleficence means “doing good” or acting for another’s benefit.
False
55
______ law refers to legislation that falls outside the realm of constitutional, statutory, and administrative law.
Common
56
______ torts are lawsuits in which the plaintiff charges that a defendant committed a deliberately aggressive act
Intentional
57
_______ is an ethical theory that prioritizes the final outcome of a situation
Teleology
58
______ refers to a competent persons right to make his or her choice without intimidation or influence
Autonomy
59
Free speech and privacy are examples of rights protected by _____ law
Constitutional
60
Which law protects fundamental rights and freedoms of U.S citizens.
Defines the duties and limitations of the executive, legislative, and judicial branches of government.
Protected the entire nation
Identified rights and privileges of U.S citizens
Constitutional laws.
61
Which law identifies local, state, or federal rules necessary for the publics welfare.
Statutory
62
Which law develops regulations by which to carry out the mission of public agency.
State boards of nursing, nurse licensure compacts
A) common law
B) statutory law
C) administrative law
D) civil law
Administrative law
63
Which law interprets legal issues based on previous court decisions in similar cases (legal precedents)
Based on the principle of stare decisis
Refers to litigation
Common law
64
Determines the nature of criminal acts that endanger all of society.
Identifies the differences in first- and second degree murder, manslaughter, etc..
Used to prosecute those who commit crimes.
Penal codes that protect all citizens from people who pose a threat to the public good.
Criminal law
65
Determines the circumstances and manner in which a person may be compensated for being the victim of another persons action or omission of an action.
Dereliction of duty, negligence.
Civil law
66
_________ act
A statute that legally defines the unique role of the nurse and differentiates it from that of other health care providers, such as physicians.
Nurse practice act
67
What is the board of nursing.
It’s a regulatory agency for managing the provisions of a states nurse practice act.
1- reviewing and approving nursing education programs in the state
2- establishing criteria for licensing nurses
3- overseeing procedures for nurse licensing examinations
4- issuing and transferring nursing licenses
5- investigating allegations against nurses licensed in that state
6- disciplining nurses who violate legal and ethical standards.
68
What is a serious criminal offense such as murder, falsifying medical records, insurance fraud, and stealing narcotics
A felony.
69
What is the difference between assault and battery?
Assault is an act in which bodily harm is threatened or attempted
Battery is unauthorized physical contact.
So assault is verbally threatening someone to do something to them and battery is ACTUALLY doing it.
70
What is a restraint
Device OR chemical that restricts movement!
| Know that it can be physical AND chemical.
71
What do you need to do before using a restraint?
Try alternative measures for protecting wandering clients.
Reduce the potential for a fall.
Ensure the patient does not jeopardize medical treatment by pulling out IV, G tube …
You need a medical order first.
72
Legislation that sets national standards for the security of health information, ensures that an individual’s electronic, paper, or oral health information is protected.
HIPPA.
| Health insurance portability and accountability act.
73
What’s the difference between slander and libel
Slander is orally
| Libel is written
74
Know some common nursing diagnosis for COPD, CHF, HIV, Parkinson’s disease and someone with surgery and someone who has abdominal pain.
Asthma, decreased cardiac output,
75
Know all about focused assessments
Information that provides more details about specific problems and expands the original database.
Generally repeated frequently or on a scheduled basis to determine trends in a clients condition and responses to therapeutic interventions.
76
Know the differences between subjective and objective data
Subjective data is information that only the client feels and can describe which is symptoms. Ex pain nausea depression fatigue anxiety
Objective is observable and measurable facts and are referred to as signs ex weight temperature skin color blood cell count vomiting bleeding.
77
Know that when we give a PRN As needed medication like NORCO we need to follow up with the patient to make sure that effective
78
Know ADPIE, and be able to give examples of each part
Assessment- collect data and organize data. The nurse collects patient health data.
Diagnosis- analyze data. Identify nursing diagnosis and collaborative problems. The nurse analyzes the assessment data to determine diagnoses.
Planning- prioritize problems. Identify measurable outcomes. Select nursing interventions. Document the plan of care.
Implementation- carry out the orders, document the nursing care and client responses.
Evaluation- monitor client outcomes, resolve, continue, and revise the current plan for care
79
Know about ROS or review of systems
Means assessing the client according to the functional systems of the body.
80
Know about short and long term goals
Short term goals are outcomes achievable in a few days to 1 week. NO LONGER THAN ONE WEEK. Client centered. Measurable. Realistic.
Long term goals are outcomes that take weeks or months to accomplish.
81
Know about level of consciousness and when to assess it
The glasgow coma scale. ?????
82
Know the difference between the weber and rinne test
Weber test- an assessment technique for determining equality or disparity of bone conducted sound
Rinne test is an assessment technique for comparing air versus bone conduction of sound.
83
What’s the normal hearing acuity level?
0-25
84
Some common skin color variations and possible causes
Pallor- pale- anemia, blood loss
Red- erythema- superficial burns, local inflammation
Pink- flushed- fever, hypertension
Yellow- jaundice- liver or kidney disease
85
What are some common skin lesions.
Macule- flat, round, colored, no palpable area ex freckles
Paulette- elevated, palpable, solid ex wart
Vesicle- elevated, round, filled with serum ex blister
Wheal- elevated, irregular border, no free fluid ex hives
Pustule- elevated, raised border, filled with pus ex boil
Nodule- elevated, solid mass, deeper and firmer than papule ex enlarged lymph nodes
Cyst- encapsulated, round, fluid filled or solid mass beneath the skin ex tissue growth
86
Know about conducting a mental assessment
A mental status assessment is a technique for determining the level of a clients cognitive functioning.
For clients who were previously unconscious
Clients who were recently resuscitated.
Clients with periods of confusion.
Clients with head injuries.
Clients who overdosed on drugs.
Clients with histories of chronic alcoholism.
Clients with psychiatric diagnoses. E
87
Know the clinical definitions of hyperactive, hypoactive and absent bowel sounds
Hyperactive is frequent
Hypoactive is if they occur after long intervals of silence
Absent is if no sound is heard for 2 to 5 minutes.
88
Know the definition of a normal breath sound and know how describe the breath sounds
```
Normal sounds are s1 and s2 lub dub
Normal :
Tracheal are loud and coarse
Bronchial sounds are harsh and loud
Bronchovesicular are medium range sounds
Vesicular are soft, rustling quality.
```
89
Know about inspection of the anus and rectum
Should appear intact but more pigmented than adjacent skin, it should be moist and hairless. External hemorrhoids (saccular protrusions filled with blood) may extend beyond the external sphincter muscle. There may be rectal fissures.
90
Differences between unintentional torts and intentional torts
Intentional torts are lawsuits in which a plaintiff charges that a defendant committed a deliberately aggressive act. Ex: assault, battery, invasion of privacy.
Unintentional tort results in an injury, though the person responsible did not mean to cause harm. Ex allegations and mal practice.
91
What’s the difference between negligence and malpractice
Negligence is harm that results because a person did not act reasonably
Malpractice is professional negligence, which differs from simple negligence. Holds professionals to a higher standard.
92
What is the Good Samaritan law?
Provide legal immunity to passersby who provide emergency first aid to victims of accidents.
93
What is statute of limitations
Designated time within which a person can file a lawsuit.
94
What’s the difference between teleology and deontology
Teleology is ethical decision making based on final outcomes also known as utilitarianism
Deontology is ethical decision making based on duty or moral obligations.
95
Differences between beneficence and nonmaleficence
Beneficence means doing good
| Nonmaleficence means doing no harm
96
What is autonomy
A competent persons right to make his or her own choices without intimidation or influences.
97
What is veracity
Means the duty to be honest and avoid deceiving or misleading a client
98
What is fidelity
Being faithful to work related commitments and obligations
99
What is justice
Mandates that clients be treated impartially without discrimination according to age, gender, race, religion, weight ….
100
What is whistle blowing
Reporting incompetent or unethical practice, calls attention to unsafe or potentially harmful situations.
101
A client is brought to the Emergency Department in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis in the client?
Ineffective Breathing Pattern
Impaired Gas Exchange
Impaired Spontaneous Ventilation
Ineffective Airway Clearance
Impaired spontaneous ventilation
102
The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?
Comfort the client and family.
Provide more information about diabetes.
Ask the client whether anyone else in the client's family also has diabetes.
Test the client's blood glucose levels.
Comfort the client and family
103
Which action should the nurse perform during the planning phase of the nursing process?
Assess the client's overall health.
Analyze the client's response to medicines.
Identify the client's health-related problems.
Identify measurable goals or outcomes.
Identify measurable goals or outcomes
104
The nurse is assisting with the creation of a care plan for a client experiencing pain from kidney stones. What is an appropriate intervention for this client?
Reports a history of kidney stones and the last one was 6 months ago.
The client will be free of pain within 24 hours after admission.
Administer ketorolac 30 mg IV now and every 6 hours.
The client has a pain level of 9 on a scale of 0 to 10.
Administer Kerouac 30 mg IV now and every 6 hours
105
A community health nurse has been working with an older adult client who lives alone and who receives regular wound care for a chronic, diabetic foot ulcer. What action by the nurse most clearly demonstrates the implementation phase of the nursing process?
arranging an alternative time for a subsequent home visit in order to accommodate the client's schedule
asking the client about dietary changes that the nurse recommended during a previous visit
teaching the client to maintain asepsis while applying a prescribed topical ointment
taking a swab of the wound bed in order to have it tested for culture and sensitivity
Teaching the client to maintain asepsis while applying a prescribed topical ointment
106
Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?
Self-Care Deficit
Impaired Memory
Impaired Physical Mobility
Risk for Injury
Risk for injury
107
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?
focused assessment
comprehensive assessment
database assessment
functional assessment
Functional assessment
108
A nurse is educating a client about care to be taken in the treatment of nephrotic syndrome. The client expresses that the teachings are of no use, because the disease is not curable. What nursing diagnosis should the nurse write with regard to the client's concern?
Impaired Comfort
Disturbed Body Image
Ineffective Coping
Risk for Powerlessness
Risk for powerlessness
109
A client is post-operative day six following total hip replacement. When reviewing the client's plan of care, the nurse reads the following goal: "The client will transfer from the bed to the commode with one-person assistance." However, the nurse is aware that the client has been ambulating with a walker for the past two days and is now able to climb stairs. How should the nurse follow up this observation?
Assess the client's ability to transfer from the bed to a commode.
Revise the plan of care in light of the client's increased mobility.
Create a new plan of care that is more relevant to the client's present condition.
Collaborate with the client's physician and the physical therapist.
Revise the plan of care in light of the clients increased mobility
110
An older adult client suffered a stroke a short time ago and has experienced dysphagia (difficulty swallowing) consequent to neurological damage. The nurse has thus identified the nursing diagnosis of Risk for Imbalanced Nutrition: Less than Body Requirements. What action should the nurse first take after identifying this diagnosis?
Arrange for nutritional supplements to be provided for the client.
Specify a calorie count to be recorded after each meal.
Educate the client's family about actions they can take to enhance the client's nutritional intake.
Liaise with nurses and members of other health disciplines to create a plan for promoting the client's nutrition.
Liaise with nurses and members of other health disciplines to create a plan for promoting the client's nutrition.
111
The nurse is obtaining data from a client newly admitted into the acute care unit with severe pain in the left upper quadrant. Which data will the nurse document as subjective data?
Pupils equal and reactive to light and accommodation
Reports pain of 8 on a scale of 0 to 10
Blood pressure of 140/82 mm Hg
Hypoactive bowel sounds
Reports pain of 8 on a scale of 0 to 10
112
A hospital nurse is reviewing a client's plan of care at the beginning of a shift. One of the client's problems is denoted as a collaborative problem. The nurse should recognize what unique characteristic of this problem?
The problem affects more than one organ system.
The problem requires interventions by physicians as well as nurses.
The problem will need to be addressed by every nurse who provides care for this client.
The problem existed prior to the client's admission to the hospital.
The problem requires interventions by physicians as well as nurses.
113
The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?
involving the client with all the steps of the process in care development
ensuring the client is informed after decisions are made with care delivery
implementing the standard plan of care for all clients with diabetes mellitus
requiring the client to evaluate the plan of care after implementation
Involving the client with all the steps of the process in care development
114
A nurse has encouraged a bedridden hospital client to perform deep breathing and coughing exercises each hour to prevent respiratory complications. After performing this intervention, the nurse should:
obtain an order for bronchodilators from the client's physician.
assess the client's lungs to determine the effectiveness of the intervention.
ask the client's family to observe the client's performance of the exercises.
ensure that the client expresses an understanding of the etiology of pneumonia.
Assess the clients lungs to determine the effectiveness of the intervention
115
Which is the purpose of a focused assessment?
Suggests possible problems
Provides breadth for future comparisons
Gives a comprehensive volume of data
Adds depth to existing information
Adds depth to existing information
116
A client, who is scheduled for coronary angioplasty, is concerned if the procedure is safe. Which nursing diagnosis relates most directly to this client's condition?
Anxiety related to fear of death during surgery
Fear related to potential risk and surgical outcomes
Ineffective Coping related to anxiety and fear of surgery
Knowledge Deficit: treatment regimen related to surgical outcomes
Fear related to potential risk and surgical outcomes
117
The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply.
Transferring accountability and responsibility for the client to the UAP
Being available for questions from the UAP
Giving a report on the client to the UAP and answering questions
Confirming that the UAP has successfully passed this skill competency
Confirming that the UAP has repeatedly completed similar tasks
Being available for questions from the UAP,
Giving a report on the client to the UAP and answering questions,
Confirming that the UAP has successfully passed this skill competency,
Confirming that the UAP has repeatedly completed similar tasks
118
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the client's atenolol to 12.5 mg daily. However, since the physician is late for another visit, the physician requests that the nurse write down the order and sign it. What should be the appropriate nursing action in this situation?
The nurse should implement the order and monitor the client closely.
The nurse should discuss the order with a pharmacist.
The nurse should inform the client of the change in medication.
The nurse should ask the physician to come back and write the order.
The nurse should ask the physician to come back and write the order
119
A nurse witnesses a 50-year-old woman go into cardiac arrest while traveling in a train and attempts to resuscitate her. In spite of the nurse's efforts, the woman dies, and the family members file a suit against the nurse. Which of the following statements about Good Samaritan laws is applicable here?
The Good Samaritan law will likely protect the nurse because she acted in the woman's best interests.
The Good Samaritan law will protect the nurse if she was negligent in her action.
The Good Samaritan law is not applicable to nurses and health professionals.
The Good Samaritan law will protect the nurse from any lawsuit filed by family members.
The Good Samaritan law will likely protect the nurse because she acts in the women’s best interests.
120
A nurse has become aware of a conflict between a client's children, one of whom wants to withhold the client's recent cancer diagnosis from her in the belief that the client would "give up hope" if she became aware of her condition. Which response to this situation most clearly represents a deontological perspective?
Precedents from similar cases in the past should guide the nurse's decision-making.
The wishes of the majority of the client's children should be respected.
The advantages and disadvantages of withholding this information should be weighed carefully.
The morality of the withholding information from a client is the primary concern.
The morality of the withholding information from a client is the primary concern
121
While at a coworker's house, a nurse discusses with the coworker a client whom the nurse suspects of physically abusing the client's child. The next day, the client is moved to another nursing unit after a surgical procedure and comes under the care of the coworker, who is also a nurse. The coworker confronts the client about the alleged physical abuse. The client is shocked and angered by the accusation and denies it categorically. What would be the charge if the client were to file a suit?
The second nurse could be charged with libel.
No charges are valid because both nurses are involved in the client's care.
No charges are valid because the revelation took place during off-duty hours and off-site.
The first nurse could be charged with slander.
The first nurse could be charged with slander
122
Recent staffing shortages on a hospital unit have resulted in unlicensed care providers being assigned to duties that are beyond their scope of practice. This has resulted in a number of near misses involving client safety. How should a nurse best respond to this trend in care?
Remind the unlicensed care providers of their appropriate scope of practice.
Make the appropriate hospital authorities aware of this practice.
Take on an increased client assignment during shifts.
Inform clients' family members of the risk that this poses to clients.
Make the appropriate hospital authorities aware of this practice
123
The nurse is caring for a client on a postsurgical unit. At change of shift, the nurse will have completed documentation for this client that includes which components? Select all that apply.
The nurse's subjective opinion of the client's current status
All documented entries have been co-signed by a second health care provider
The written documentation is clear and easily read and understood.
Evidence of including the client's opinion is present in the documentation
Each entry is complete at the time the nursing actions were carried out
The written documentation is clear and easily read and understood
Each entry is complete at the time the nursing actions were carried out.
124
The nurse is performing nursing care for clients at the health care facility. Which event by the nurse indicates that battery has occurred with the client?
Discussing the client's condition with a friend of the family
Taking the client's photograph without consent
Performing a surgical procedure without getting consent
Telling the client that the client may not leave the hospital
Performing a surgical procedure without getting consent.
125
A nurse has been assigned to the ICU by a supervisor because of a number of sick calls. However, the nurse is not highly experienced in providing intensive nursing care. What would be the most appropriate action by the nurse?
to report to the nurse in charge for duty but explain the nurse's practice limitations
to refuse to go to the ICU and keep working in the previously assigned unit
to call the lawyer and seek advice regarding the sudden change
to report to the ICU and take leave on the pretext of some illness
To report to the nurse in charge for duty but explain the nurses practice limitations.
126
A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime?
misdemeanor
tort
felony
negligence
Felony- a serious criminal offense
127
A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?
Notify the family.
Obtain a medical order.
Get written consent.
Sedate the client.
Obtain a medical order
128
A public health nurse is involved in planning a community outreach program for a large assisted living community. Due to the aging population within the community, the program will offer hypertension screening and management. This decision is based on which principle?
utilitarianism
autonomy
nonmaleficence
veracity
Utilitarianism also known as teleology which is an ethical theory that prioritizes the final outcomes of a situation.
129
A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?
The nurse informs the family about the living will.
The nurse confirms that the client's family has signed the consent form.
The nurse confirms that the client has signed the consent form.
The nurse informs the family about advance directives.
The nurse confirms that the clients family has signed the consent form
130
An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?
Asking the LPN/LVN to teach a new diabetic client how to administer insulin
Delegating oral medication administration to the LPN/LVN
Obtaining vital signs on a newly admitted client
Calling the health care provider about abnormal lab results
Asking the LVN to teach a new diabetic client how to administer insulin
131
Which nursing action demonstrates the principle of fidelity?
Witnessing a client signature on an informed consent
Treating an uninsured client in the emergency department
Filing an incident report after making a medication error
Administering a vaccination
Filing an incident report after making a medication error
132
A client is received in a postoperative nursing unit after undergoing abdominal surgery. During this time the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?
battery
misdemeanor
felony
tort
Tort
133
A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. The nurse helps the client to get up, makes him comfortable, and then informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?
to provide information to local, state, and federal agencies
to provide a method of deciding the nurse's fault in the incident
to evaluate quality care and potential risks for injury to the client
to evaluate the immediate care provided by the nurse to the client
To evaluate quality care and potential risks for injury to the client.
134
A nurse has applied soft wrist restraints to a client following endotracheal intubation. Documentation of which information is essential when using restraints on a client? Select all that apply.
0.9 normal saline infusing intravenously at 100 mL/hr
Chest physiotherapy completed
Family presence at the bedside
Findings from patient assessment, performed every 2 hours
Foley catheter draining clear yellow urine
0.9 normal saline infusing intravenously at 100 mL/hr,
Findings from patient assessment, performed every 2 hours,
Foley catheter draining clear yellow urine
135
A nurse is caring for a client with a complete spinal cord injury that has caused paraplegia. The client is very distraught and asks the nurse, "Are they sure, even with therapy, I will never walk again?" Which statement made by the nurse demonstrates veracity?
"It is too soon to tell. There is always a possibility you will regain movement in your legs."
"You have a complete injury, which results in a total loss of movement and sensation below the level of injury."
"I see you are upset; I can ask your physician to stop by and explain your injury in more detail."
"Sometimes with physical therapy, a person may notice some improvement with movement."
You have a complete injury, which results in a total loss of movement and sensation below the level of injury
136
Following a neonatal death, a maternity nurse has become named in a malpractice suit. When evaluating the nurse's actions, the court will compare the nurse's actions to:
the practice norms of nurses in similar circumstances.
the judge's or jury's expectations of the nurse.
the actions of a reasonable citizen.
the ethical principle of autonomy.
The practice norms of nurses in similar circumstances
137
A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?
The nurse should let the client go because the nurse cannot do anything.
The nurse should warn the client that the client cannot come to the hospital again.
The nurse should call and inform the nursing supervisor of the situation.
The nurse should have the client restrained and call the physician.
The nurse should call and inform the nursing supervisor of the situation
138
A nurse is conducting a head-to-toe assessment of a client who is being treated in the hospital for liver disease. When assessing the client's mental status, what question should the nurse ask the client?
"Can you tell me what the month and the year is right now?"
"Would you say that you are alert, drowsy, or somewhere in between this morning?"
"If a fire broke out on the hospital unit, what action would you take?"
"Can you describe your mood for me this morning?"
Can you tell me what the month and the year is right now
139
The nurse on a geriatric care unit is completing assessments of four clients. Which client is most likely to exhibit edema?
a 76-year-old man who is receiving treatment for a head injury and arm fracture suffered in a fall
a 90-year-old man who will require surgery because of an enlarged prostate gland
an 81-year-old woman who has been admitted with chronic heart failure
an 80-year-old woman who was admitted with a foot ulcer that is attributable to diabetes
An 81 year old woman has been admitted with chronic heart failure
140
During assessment of the lower extremities, the nurse notes that the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4-mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?
1+ pitting edema noted on bilateral lower extremities
bilateral lower extremities within normal limits
brawny edema noted over bilateral lower extremities
2+ pitting edema noted on bilateral lower extremities
2+ pitting edema noted on bilateral lower extremities
141
While assessing the characteristics of the skin of the client, the nurse observes a mouth slit at the aperture of the mouth. The nurse documents this finding as a fissure. What is a fissure?
a mark left on the skin by the healing of a wound or lesion
a crack in the skin, especially in or near a mucous membrane
an area of the skin that has been rubbed away by friction
an open, crater-like area on the skin
A crack in the skin, especially in or near a mucous membrane.
142
A nurse has assessed a client's respiratory system and made the following entry in the client's medical record: "Crackles auscultated to lower lungs fields bilaterally." This abnormal assessment finding indicates:
accumulation of carbon dioxide in the alveoli.
movement of air through a narrow passage.
the presence of fluid in the alveoli.
hypoventilation
The presence of fluid in the alveoli
143
A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response?
"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."
"Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"
"Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s."
"Your physician will decide when it is best for you to begin having mammograms based on your family history."
According to the American and Canadian cancer societies, your first mammogram should be done at the age 40 and then yearly after that
144
A nurse is preparing to complete a physical assessment on an older adult client with a history of emphysema. What is the nurse's most appropriate action?
Dim the lights to avoid eye strain.
Begin with auscultation of the lungs.
Lie the client supine on the exam table.
Assist the client to a sitting position.
Assist the client to a sitting position
145
A nurse conducting physical assessment for a client is using the percussion technique. What is the purpose of using this technique?
to check the skin temperature and moisture
to assess the sounds from the heart, lungs, and abdomen
to assess the mobility of normal tissues and unusual masses
to determine the location, size, and density of underlying structures
To determine the location, size, and density of underlying structures
146
After completing a comprehensive head-to-toe assessment of a client, the nurse has documented the presence of decreased skin turgor. This assessment finding is suggestive of what health problem?
electrolyte imbalance
allergic reaction
dehydration
skin infection
Dehydration
147
A nursing student is having difficulty hearing and interpreting sounds during the auscultation phase of chest assessment. What should this student do to improve the ability to discern between different sounds during auscultation?
Practice auscultating on as many healthy and ill individuals as possible.
Review the anatomy, physiology, and pathophysiology involved in respiratory diseases.
Have a colleague listen simultaneously with a different stethoscope.
Perform a thorough percussion assessment prior to auscultating.
Practice auscultating on as many healthy and ill individuals as possible.
148
A nurse is beginning a physical exam on a child who is admitted to the pediatric unit with suspected meningococcal meningitis. What is the nurse's priority action?
Begin with assessment of vital signs.
Allow the child to examine the instruments.
Gather and sterilize equipment.
Perform hand hygiene and apply personal protective equipment.
Perform hand hygiene and apply personal protective equipment
149
The nurse conducting a physical assessment can encourage the client to be honest and open in identifying the health problem by:
explaining the assessment technique before performing it.
explaining that all information will be kept confidential.
explaining how the assessment will be conducted.
offering the client an opportunity to ask questions.
Explaining that all information will be kept confidential
150
Arrange the answers into the correct order.
A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed. All options must be used.
Auscultate the thorax.
Position the client supine and drape appropriately.
Inspect the skin of thorax and abdomen.
Palpate the thorax.
Auscultate the abdomen.
Palpate the abdomen
1) Position the client supine and drape appropriately.
2) Inspect the skin of thorax and abdomen.
3) Palpate the thorax.
4) Auscultate the thorax.
5) Auscultate the abdomen.
6) Palpate the abdomen.
151
A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?
on the center of the head
on the mastoid area
near the ear canal
behind the client's head
On the mastoid area
152
A nurse is caring for a client with respiratory disorders. How would the nurse be able to distinguish tracheal sounds from the other sounds in the lungs when listening to lung sounds?
The sounds are shorter on inspiration than expiration, with a pause between them.
The sounds are medium-range sounds of equal length, with no noticeable pause.
The sounds are equal in length and are separated by a brief pause.
The sounds are soft and rustling, longer on inspiration than expiration, with no pause between them.
The sounds are equal in length and are separated by a brief pause
153
A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?
Palpate the abdomen before auscultating.
Assist the client to a sitting position.
Uncover the client to expose the chest and abdomen.
Warm the diaphragm of the stethoscope.
Warm the diaphragm of the stethoscope
154
A client has arrived in the emergency department by ambulance and is reporting shortness of breath. After placing the client on oxygen and contacting the physician, which is the priority action of the nurse?
percussing the thorax bilaterally
transporting the client for a chest x-ray
taking vital signs
auscultating anterior and posterior lung sounds
Auscultating anterior and posterior lung sounds
155
During the assessment of a client, the nurse places a paper towel on the weighing scale before the client stands barefoot on it. What is the purpose of this intervention by the nurse?
to overcome chances of zero error in the equipment
to reduce contact with microorganisms on the equipment
to ensure that the weight obtained is accurate
to provide a rough approximation of the gross body weight
To reduce contact with microorganisms on the equipment
156
When assessing the sounds of a client's lungs, the nurse asks the client to breathe in and out through an open mouth, deeply but slowly. How does this intervention help in the assessment?
It reduces sound from air turbulence and prevents hyperventilation.
It facilitates hearing sounds in the upper and lower lobes.
It ensures that characteristics during each phase of ventilation are heard.
It helps to clear the air passages and open the alveoli.
It reduces sound from air turbulence and prevents hyperventilation
157
A client is brought to the health care center in a semi-conscious state following a suicide attempt. The nurse is assisting the physician in resuscitating the client. The client's skin appears to be bluish. What should the nurse document as the cause for this coloration?
low tissue oxygenation
trauma to soft tissue
carbon monoxide poisoning
anemia due to blood loss
Low tissue oxygenation
158
The nurse is preparing to conduct a health interview with a client who is hearing impaired. Which considerations will the nurse make for the alteration in the client's hearing? Select all that apply.
Determine if hearing aids are required
Ensure any open windows are closed
Turn on soft music in the background
Dim the lighting in the interview space
Sit directly in front of the client
Determine if hearing aids are required
Ensure any open windows are closed
Sit directly in front of the client
