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112 Cards in this Set
- Front
- Back
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Sheila is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. Following the initial assessment Sheila anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and function of drainage tubes. the client is in pain and will not be able to eat r drink until intestinal function returns. Sheila will have to establish priorities of care for which of the following situations? (Mark all that apply)
1. The family comes to visit the client 2. The client expresses concern about pain control 3. The client's vital signs change, showing a drop in blood pressure 4. The charge nurse approaches Sheila and requests a report at end of shift |
2, 3
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Shiela's client signals with her call light. Shiela enters the room and finds the drainage tube disconnected, the IV has 100 mL of fluid remaining, and the client has asked to be turned. Which of the following should Shiela perform first?
1. Reconnect the drainage tubing 2. Inspect te condition of the IV draining 3. Improve client' comfort 4. Go to the medication room and obtain the next IV fluid bag. |
1. Reconnect the drainage tubing
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In her nursing care plan, Sheila enters expected outcomes for her client. Which of the following expected outcomes are written correctly? (Choose all that apply)
1. Client will remain afebrile until discharge 2. IV site will be without phlebitis by the third postoperative day 3. Provide incentive sprometer for deep breathing every 2 hours |
1, 2
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Sheila set a time limit for her outcomes. The time frame serves to:
1. Indicate which outcome has priority 2. Indicate the time it takes to complete an intervention 3. Indicate how long Sheila is scheduled to care for the client 4. Indicate when the client is expected to respond in the desired manner |
4. Indicate when the client is expected to respond in the desired manner
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A client centered goal is a specific and measurable behavior or response that reflects a:
1. Physician's goal for the specific client 2. Client's response when compared to another client with a like problem 3. Client's desire for specified health care interventions 4. Client's highest possible level of wellness and independence in function |
4. Client's highest possible level of wellness and independence in function
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The nurse writes an expected outcome statement in measureable terms. An example of this is:
1. A client will be pain free 2. The client will have less pain 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take medication every 4 hours |
3. Client will report pain acuity less than 4 on a scale of 0-10.
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Sheila's client is experiencing nausea and abdominal distention postoperatively. Sheila initiates the interventions listed below. Which of the interventions are examples of independent interventions? (Choose all that apply)
1. Provide frequent mouth care 2. Maintain IV infusion at 100 mL/hr 3. Administer Compazine via rectal suppository 4. Consult with dietitian on initial foods to offer client 5. Control aversive odors or unpleasant visual stimulation that trigger nausea |
1, provide frequent mouth care
5, control aversive odors or unpleasant visual stimulation that trigger nausea |
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Collaborative interventions are therapies that requires:
1. nurse and client intervention 2. physician and nurse intervention 3. client and physician intervention 4. multiple health care professional |
4. multiple health care professionals
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When does implementation begin as the fourth step of the nursing process?
1. during the assesment phase 2. immediately, in some critical situations 3. after the care plan has been developed 4. after there is mutual goal setting between client/nurse |
3. after the care plan has been developed
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Mr. Switzer is a 34-year old client who had a surgical repair of an abdominal hernia this morning. At 12 noon the nurse records Mr. Switzer's vital signs on the recovery room flow sheet. The recording of vital signs is an example of:
1. psychomotor skill 2. indirect care measure 3. physical care technique 4. anticipating complications |
2. indirect care measure
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Before beginning insertion of a client's indwelling urinary catheter, the nurse considers the steps to take to avoid the possibility of breaking sterile technique, which could cause a urinary tract infection. This is an example of what type of decision making?
1. Identifying areas of assistance 2. Reviewing possible consequences of a nursing action 3. Reassesing the clinical situation to revise the care plan 4. Determining the probability of all consequences of the catheterization |
1. identifying areas of assistance
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Interdisciplinary care plans represent:
1. all nursing personnel havign input in the care plan 2. contributions of all disciplines caring for the client 3. the client's expressed wishes and advance directives 4. physicians and nurses working together to develop a plan of care |
2. Contributions of all disciplines caring for the client
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Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?
1. safety 2. nurse staffing 3. confidentiality 4. adequate pain relief |
1. safety
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In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?
1. following the prodcedural guideline for a dressing change 2. seeking necessary knowledge on the steps of the procedure 3. showing confidence in knowing which dressing materials to use 4. being sure that the dressing covers the entire wound completely |
3. showing confidence in knowing which dressing materials to use
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WHich steps do you follow when you are asked to perform a procedure with which you are unfamiliar? (Choose all that apply)
1. seek necessary knowledge 2. reassess the client's condition 3. collect all equipment necessary 4. have an experienced nurse available to assist 5. consider all possible consequences of the procedure |
1,2,3,4,5
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A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. after suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides water. Which of the following is an evauative measure used by the nurse?
1. Suctioning the airway 2. Sitting the client up in bed 3. Auscultating lung sounds 4. Asking client to describe what type of discomfort |
3. Auscultating lung sounds
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A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. after suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and proves a glass of water for the client. WHich of the following is an appropriate evaluative criterion used by the nurse?
1. Client drinks contents of water glass 2. Client's lungs are clear to auscultation in bases 3. Client reports abdominal pain on scale of 0-10. 4. Client's rate and depth of breathing are normal with head of bed elevated |
2, client's lungs are clear to auscultation in bases
4, client's rate and depth of breathing are normal with head of bed elevated |
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The evaluation process, which determines the effectiveness of nurisng care, includes five elements, one being interpreting findings. WHich of the following is an example of interpretation?
1. Evaluating the client's response to selected nursing interventions 2. Selecting an observable or measurable state or behavior that will reflect goal achievement 3. Matching the results of evaluative measures with expected outcomes to determine clients status |
3. Matching the results of evaluative...
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A goal specifies the expected behavior or response that indicates:
1. The specific nursing action was completed 2. the validation of the nurse's physical assessment 3. The nurse has made the correct nursing diagnosis 4. Resolution of a nursing diagnosis or maintenance of a healthy state |
4. Resolution of a nursing diagnosis or maintenance of a healthy state
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A client is recovering from surgery for removal of an ovarian tumor. It is one day after her surgery. Becasue she has an abdominal incision and dressing, the nurse has selected a nursing diagnosis for risk of infection. Which of the following is an appropriate goal statement for the diagnosis?
1. client will remain afebrile after discharge 2. Client's wound will remain free of infection by discharge 3. client will receive ordered antibiotic on time over next 3 days 4. client's abdominal incision will remain covered with a sterile dressing for 2 days |
2. client's wound will remain free of infection by discharge
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Unmet and partially met goals require the nurse to do which of the following? (Choose all that apply)
1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the client's response with that of another client |
1, redefine priorities
2, continue intervention |
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In the US, access to health care usually depends on a client's ability to pay for health care either through insurance or by paying cash. The client the nurse is caring for needs a liver transplant to survive. This client has been out of work for several moths and does not have insurance or enough cash. A discussion about the ethics of this situation would involve predominantly the principle of:
1. Accountability, b/c you as the nurse are accountable for the well-being of the client 2. Respect for autonomy, b/c this client's autonomy will be violated if he does o receive the liver transplant 3. Ethic of care, because the caring thing that the nurse could provide this client is resources for a liver transplant 4. Justice, b/c the first and greatest question in this situation is how to determine the just distribution of resources |
4. justice, b/c the first and greatest question in this situation is how to determine the just distribution of resources
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It may seem redundant that health care providers, including professional nurses, agree to "do no harm" to their clients. The point of this agreement is to reassure the public that in all ways the health care team will not only work to heal clients, they agree to do this in the least painful and harmful way possible. The principle that describes this agreement is called:
1. beneficence 2. accountability 3. nonmaleficence 4. respect for autonomy |
3. nonmalfience
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A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and for society, outwight the temoporary discomforts. this involves the principles of
1. fidelity 2. beneficence 3. nonmaleficence 4. respect for autonomy |
2. beneficence
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If a nurse assesses a client for pain and then offers to manage the pain, the principle that encourages the nurse to monitor the client's response to the plan is:
1. fidelity 2. beneficence 3. nonmaleficence 4. respect for autonomy |
1. fidelity
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Nurses agree to be advocates for their clients. Practice of advocacy calls for the nurse to:
1. seek out the nursing supervisor in conflicting situations 2. document all clinical changes in the medical record in a timely manner 3. work to understand the law as it applies to te client's clinical condition 4. assess the client's point of view and prepare to articulate this point of view |
4. assess the client's point of view..
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Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values, it may be possible to identify a philosophy of utilitarianism, which proposes that:
1. the value of something is determined by its usefulness to society 2. the value of people is determiend solely by leaders of the Unitarian Chuch 3. The decision to perform a liver transplant depends on a measure of the moral life that the client has lead so far |
1. the value of something is determiend by its usefulness to society
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The philosophy sometimes called the ethic of care suggests that ethical dilemmas can best be solved by attention to:
1. Clients 2. Relationships 3. Ethical principles 4. Code of ethics for nurses |
2. Relationships
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In most ethical dilemmas, the solution to the dilemma requires a negotiation among members of the health care team. The nurse's point of view is valuable because:
1. The principle of autonomy guides all participants to respect their own self-worth 2. Nurses have a legal licesne that encourages their presence during ethical discussions 3. Nurses develop a relationship to the client that is unique amog all professional health care providers 4. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care |
3. Nurses's develop a relationship to the client that is unique among all professional health...
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ethical dilemmas often arise over a conflict in opinion. Once the nurse has determined that the dilemma is ethical, a critical first step is negotiating the difference of opinion would be to:
1. Consult a professional ethicist to ensure that the steps of the process occur in full 2. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma 3. Ensure that the attending physician or health care pfovider has written an order for ethics consultation 4. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion |
2. Gather all relevant information regarding the clinical, social..
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The nurse notes that an advance directive is on the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow?
1. A living will allows an appointed persont o make helaht care deciison when the client is in an incapacitated state 2. A living will is involke only when the client has a terminal condition |
2, a living will is invoked only when the client has a terminal condition or is in a persistent vegetative state
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A nurse notes that the health care unit keeps a listing of the client names at the front desk in easy view for health care providers to more efficiently locate the client. The nurse knows that this action would be a violation of:
1. Mental Health Parity Act 2. Patient Self-Determination Act 3. Health Insurance Portability and Accountability Act 4. Emergency Medical Treatment and Active Labor Act |
3. Health Insurance Portability and Accountability Act
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Which statement represents actions that may result in an RN's receiving ether disciplinary action by the State Board or revocation of the nurse's professional liscence?
1. Taking or selling controlled substances 2. Assisting with physciian-assisted suicide 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order |
1. Taking/selling controlled substances
4. Applying physical restrints w/o a written physician's orders |
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The HIPPA 1996 act provides clients basic rights pertaining to their medical records. Which statemtn reflects a violation of HIPPA?
1. Discussion client conditions in the nursing report room 2. Allowing nursing studets to review client's charts before caring for clients to whom they are assigned 3. Posting daily nurisng care information along with the medicaiton condition of the client on a message board in the client's room |
3. Posting daily nursing care information on message board
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THe nurse must follow standards of care to avoid potential litigation ad suits of negligence. WHich of the following statements represents a potential nursing malpractice situation? (Mark all that apply)
1. Failure to make a nursing diagnosis 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for client monitoring 5. Failure to question a health care provider about appropriateness of a client order |
1,2,3,4,5
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Unmet and partially met goals require the nurse to do which of the following? (Choose all that apply)
1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the client's response with that of another client |
1, redefine priorities
2, continue intervention |
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In the US, access to health care usually depends on a client's ability to pay for health care either through insurance or by paying cash. The client the nurse is caring for needs a liver transplant to survive. This client has been out of work for several moths and does not have insurance or enough cash. A discussion about the ethics of this situation would involve predominantly the principle of:
1. Accountability, b/c you as the nurse are accountable for the well-being of the client 2. Respect for autonomy, b/c this client's autonomy will be violated if he does o receive the liver transplant 3. Ethic of care, because the caring thing that the nurse could provide this client is resources for a liver transplant 4. Justice, b/c the first and greatest question in this situation is how to determine the just distribution of resources |
4. justice, b/c the first and greatest question in this situation is how to determine the just distribution of resources
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It may seem redundant that health care providers, including professional nurses, agree to "do no harm" to their clients. The point of this agreement is to reassure the public that in all ways the health care team will not only work to heal clients, they agree to do this in the least painful and harmful way possible. The principle that describes this agreement is called:
1. beneficence 2. accountability 3. nonmaleficence 4. respect for autonomy |
3. nonmalfience
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A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and for society, outwight the temoporary discomforts. this involves the principles of
1. fidelity 2. beneficence 3. nonmaleficence 4. respect for autonomy |
2. beneficence
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If a nurse assesses a client for pain and then offers to manage the pain, the principle that encourages the nurse to monitor the client's response to the plan is:
1. fidelity 2. beneficence 3. nonmaleficence 4. respect for autonomy |
1. fidelity
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Nurses agree to be advocates for their clients. Practice of advocacy calls for the nurse to:
1. seek out the nursing supervisor in conflicting situations 2. document all clinical changes in the medical record in a timely manner 3. work to understand the law as it applies to te client's clinical condition 4. assess the client's point of view and prepare to articulate this point of view |
4. assess the client's point of view..
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Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values, it may be possible to identify a philosophy of utilitarianism, which proposes that:
1. the value of something is determined by its usefulness to society 2. the value of people is determiend solely by leaders of the Unitarian Chuch 3. The decision to perform a liver transplant depends on a measure of the moral life that the client has lead so far |
1. the value of something is determiend by its usefulness to society
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The philosophy sometimes called the ethic of care suggests that ethical dilemmas can best be solved by attention to:
1. Clients 2. Relationships 3. Ethical principles 4. Code of ethics for nurses |
2. Relationships
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In most ethical dilemmas, the solution to the dilemma requires a negotiation among members of the health care team. The nurse's point of view is valuable because:
1. The principle of autonomy guides all participants to respect their own self-worth 2. Nurses have a legal licesne that encourages their presence during ethical discussions 3. Nurses develop a relationship to the client that is unique amog all professional health care providers 4. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care |
3. Nurses's develop a relationship to the client that is unique among all professional health...
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ethical dilemmas often arise over a conflict in opinion. Once the nurse has determined that the dilemma is ethical, a critical first step is negotiating the difference of opinion would be to:
1. Consult a professional ethicist to ensure that the steps of the process occur in full 2. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma 3. Ensure that the attending physician or health care pfovider has written an order for ethics consultation 4. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion |
2. Gather all relevant information regarding the clinical, social..
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A nurse works on a cardiac unit. She is taking care of a client who recently had coronary bypass surgery. Which of the following represent legal sources of standards of care nurses use to deliver safe health care? (choose all that apply)
1. information provided by the head nurse 2. Policiies and procedures of the employing hospital 3. Nurse Practice Act of the State the nurse is working in 4. Regualtions identified by in the Joint Commission's manual 5. The American Nurses Association standards of nursing practice |
2, 3, 4, 5
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A nurse is sued for failure to monitor a client appropriately. Which statement sare correct about professional negligence lawsuits? (Choose all that apply)
1. The nurse represents the plaintiff 2. The defendant must prove injury, damage, or loss 3. The person filing the lawsuit has the burden of proof 4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury |
3,4
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WHen the nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the nurse's employing institution's insurance does not cover the nurse, the nurse would probably be covered by:
1. The nurse's automobile insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence 4. The Patient Care Partnership, which may grant immunity from suit if the injured party consents |
3
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Even thought he nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the
1. Client 2. PHysician 3. Nursing student 4. Supervising nurse |
2
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The legal definition of death that facilitates organ donation is cessation of:
1. Pulse 2. Respiration 3. Function of entire brain 4. Cirulatory and respiratory functions |
3
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The nurse notes that an advance directive is on the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow?
1. A living will allows an appointed persont o make helaht care deciison when the client is in an incapacitated state 2. A living will is involke only when the client has a terminal condition |
2, a living will is invoked only when the client has a terminal condition or is in a persistent vegetative state
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A nurse notes that the health care unit keeps a listing of the client names at the front desk in easy view for health care providers to more efficiently locate the client. The nurse knows that this action would be a violation of:
1. Mental Health Parity Act 2. Patient Self-Determination Act 3. Health Insurance Portability and Accountability Act 4. Emergency Medical Treatment and Active Labor Act |
3. Health Insurance Portability and Accountability Act
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Which statement represents actions that may result in an RN's receiving ether disciplinary action by the State Board or revocation of the nurse's professional liscence?
1. Taking or selling controlled substances 2. Assisting with physciian-assisted suicide 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order |
1. Taking/selling controlled substances
4. Applying physical restrints w/o a written physician's orders |
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The HIPPA 1996 act provides clients basic rights pertaining to their medical records. Which statemtn reflects a violation of HIPPA?
1. Discussion client conditions in the nursing report room 2. Allowing nursing studets to review client's charts before caring for clients to whom they are assigned 3. Posting daily nurisng care information along with the medicaiton condition of the client on a message board in the client's room |
3. Posting daily nursing care information on message board
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THe nurse must follow standards of care to avoid potential litigation ad suits of negligence. WHich of the following statements represents a potential nursing malpractice situation? (Mark all that apply)
1. Failure to make a nursing diagnosis 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for client monitoring 5. Failure to question a health care provider about appropriateness of a client order |
1,2,3,4,5
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A client tells the nurse, "I have stomach cramps and feel nauseous." THis is an example of what kind of data?
1. Objective 2. Historical 3. Subjective 4. Assessment |
3. Subjective
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As you enter the client's room, you notice he is anxious to say something. He quickly states, "I do not nknow what is going on; I cannot get an explanation from my doctor about the results of my test. I want something done about this." Which of the following is most appropriate documentaiton of the client's emotional status?
1. The client has a defiant attitude 2. The client is demanding and complains frequently 3. THe client stated "he felt frustrated by the lack of information he has received regarding his diagnostic tests" |
3.
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A primary benefit of HIPPA regulations is to:
1. Allow access of the medical record to all hospital staff 2. Limit what information must be documented in the client's record 3. Provide clients with greater control over personal health care information 4. Enable health care institutions to release any client-related information with a general client authorization |
3 provide clients w...
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Clients frequently request copies of their medical records. The nurse understands:
1. Only the families may read the records 2. They have the right to read those records 3. They are not allowed to read those records 4. Only health care workers may have access to the records |
2
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Accurate entries are an important characteristic of good documentation. Which of the following charting entres is most accurate in the way it is written?
1. Client up, out of bed, walked down hallway with assistance, tolerated well 2. Client up, out of bed, walked 50 feet, and back down hallway, tolerated well 3. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise |
3
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What does SOAP stand for?
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S- subjective
O- objective A - assessment P - plan |
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On the nursing unit at Stevens Health Center a nurse is able to access a client's medical record and review the education that nurses provided the client during an initial hospitalization and three subsequent clinic visits. This type of record system is an example of:
1. Information technology 2. Electronic health record 3. Personal health information 4. Administrative information system |
2. electronic health record
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You practice using nursing's code of ethics for profsional RNs. This code:
1. Improves self-health care 2. PRotects the client from harm 3. Ensures identical care to all clients 4. Defines the principles by which nurses provide care to their clients |
4
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Lacey Conrad has developed wheeizng and shortness of breath. The physician orders a medicated nebulizer treatment ow and in 4 hours. WHich standard of care are you performing?
1. Planning 2. Evaluation 3. Assessment 4. Implementation |
4. Implementation
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A nurse works on a cardiac unit. She is taking care of a client who recently had coronary bypass surgery. Which of the following represent legal sources of standards of care nurses use to deliver safe health care? (choose all that apply)
1. information provided by the head nurse 2. Policiies and procedures of the employing hospital 3. Nurse Practice Act of the State the nurse is working in 4. Regualtions identified by in the Joint Commission's manual 5. The American Nurses Association standards of nursing practice |
2, 3, 4, 5
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A nurse is sued for failure to monitor a client appropriately. Which statement sare correct about professional negligence lawsuits? (Choose all that apply)
1. The nurse represents the plaintiff 2. The defendant must prove injury, damage, or loss 3. The person filing the lawsuit has the burden of proof 4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury |
3,4
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WHen the nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the nurse's employing institution's insurance does not cover the nurse, the nurse would probably be covered by:
1. The nurse's automobile insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence 4. The Patient Care Partnership, which may grant immunity from suit if the injured party consents |
3
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Even thought he nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the
1. Client 2. PHysician 3. Nursing student 4. Supervising nurse |
2
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The legal definition of death that facilitates organ donation is cessation of:
1. Pulse 2. Respiration 3. Function of entire brain 4. Cirulatory and respiratory functions |
3
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The nurse notes that an advance directive is on the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow?
1. A living will allows an appointed persont o make helaht care deciison when the client is in an incapacitated state 2. A living will is involke only when the client has a terminal condition |
2, a living will is invoked only when the client has a terminal condition or is in a persistent vegetative state
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A nurse notes that the health care unit keeps a listing of the client names at the front desk in easy view for health care providers to more efficiently locate the client. The nurse knows that this action would be a violation of:
1. Mental Health Parity Act 2. Patient Self-Determination Act 3. Health Insurance Portability and Accountability Act 4. Emergency Medical Treatment and Active Labor Act |
3. Health Insurance Portability and Accountability Act
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Which statement represents actions that may result in an RN's receiving ether disciplinary action by the State Board or revocation of the nurse's professional liscence?
1. Taking or selling controlled substances 2. Assisting with physciian-assisted suicide 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order |
1. Taking/selling controlled substances
4. Applying physical restrints w/o a written physician's orders |
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The HIPPA 1996 act provides clients basic rights pertaining to their medical records. Which statemtn reflects a violation of HIPPA?
1. Discussion client conditions in the nursing report room 2. Allowing nursing studets to review client's charts before caring for clients to whom they are assigned 3. Posting daily nurisng care information along with the medicaiton condition of the client on a message board in the client's room |
3. Posting daily nursing care information on message board
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THe nurse must follow standards of care to avoid potential litigation ad suits of negligence. WHich of the following statements represents a potential nursing malpractice situation? (Mark all that apply)
1. Failure to make a nursing diagnosis 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for client monitoring 5. Failure to question a health care provider about appropriateness of a client order |
1,2,3,4,5
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A manager is reviewing the nurses' notes in a client's medical record. She finds the following entry, "CLient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions should the manager give to the staff nurse who entered the note?
1. Avoid rushing when charting an entry 2. Use correction fluid to remove the entry 3. Draw a ginle line through the statement and initial it 4. Enter only objective and factual information about the client |
4. Enter only objective/factual information
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A client tells the nurse, "I have stomach cramps and feel nauseous." THis is an example of what kind of data?
1. Objective 2. Historical 3. Subjective 4. Assessment |
3. Subjective
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As you enter the client's room, you notice he is anxious to say something. He quickly states, "I do not nknow what is going on; I cannot get an explanation from my doctor about the results of my test. I want something done about this." Which of the following is most appropriate documentaiton of the client's emotional status?
1. The client has a defiant attitude 2. The client is demanding and complains frequently 3. THe client stated "he felt frustrated by the lack of information he has received regarding his diagnostic tests" |
3.
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A primary benefit of HIPPA regulations is to:
1. Allow access of the medical record to all hospital staff 2. Limit what information must be documented in the client's record 3. Provide clients with greater control over personal health care information 4. Enable health care institutions to release any client-related information with a general client authorization |
3 provide clients w...
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Clients frequently request copies of their medical records. The nurse understands:
1. Only the families may read the records 2. They have the right to read those records 3. They are not allowed to read those records 4. Only health care workers may have access to the records |
2
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Accurate entries are an important characteristic of good documentation. Which of the following charting entres is most accurate in the way it is written?
1. Client up, out of bed, walked down hallway with assistance, tolerated well 2. Client up, out of bed, walked 50 feet, and back down hallway, tolerated well 3. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise |
3
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What does SOAP stand for?
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S- subjective
O- objective A - assessment P - plan |
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On the nursing unit at Stevens Health Center a nurse is able to access a client's medical record and review the education that nurses provided the client during an initial hospitalization and three subsequent clinic visits. This type of record system is an example of:
1. Information technology 2. Electronic health record 3. Personal health information 4. Administrative information system |
2. electronic health record
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You practice using nursing's code of ethics for profsional RNs. This code:
1. Improves self-health care 2. PRotects the client from harm 3. Ensures identical care to all clients 4. Defines the principles by which nurses provide care to their clients |
4
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Lacey Conrad has developed wheeizng and shortness of breath. The physician orders a medicated nebulizer treatment ow and in 4 hours. WHich standard of care are you performing?
1. Planning 2. Evaluation 3. Assessment 4. Implementation |
4. Implementation
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Evidence-based practice is defined as:
1. Nursing care based on tradition 2. Scholarly inquiry of nursing and biomedical research 3. A problem-solving approach to clinical practice based on best practices 4. Quality nursing care provided in an efficient and economically sound manner |
3. Problem-solving approach q
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contemporary nursing requires that the nurse possess knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples?
1. Providing bedside care 2. Autonomy and accountability 3. following health care provider orders 4. Increased emphasis on health promotion and illness prevention |
4. Increased emphasis on health promotion and illness prevention
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Advanced practice nurses generally:
1. Function independently 2. Function as unit directors 3. Work in acute care |
1. Function independently
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Which of the following is the biggest consumer of health care?
1. Hospitals 2. Businesses 3. Federal governemnt 5. Private insurance companies |
3 federal government
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WHich of the following was most significant in influencing competition in health care costs?
1. Medicare and Medicaid 2. Diagnosis-related groups 3. Managed care organizations 4. Prospective payment system |
4. prospective payment system
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A nurse is working in an acute care hospital that uses a case management model. Which of the following activities should the nurse communicate with the case manager?
1. Manageent of a client transfer to the x-ray department 2. Coordination of a client transfer to the step-down rehabilitation center 3. Obtaining permission to bring in special food to a client by the family 4. Follow-up after a client's discharge to evaluate whether needs have been met |
2,4
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which of the following clients need to be in an extended care facility with skilled nursing?
1. A client who had a stroke, can talk, and has lost bowel and bladder control 2. A severely brain injured client on a ventilator with intravenous medications 3. A client with Alxheimer's disease who is abusive, combative, and a threat to self and others |
2,4
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Which of the following statements is true about evidence-based practice? (select all that apply). Evidence based pracitce:
1. is based only on the results of research 2. assists nurses with meeting standards of practice 3. helps nurses solve dilemmas in the clinical setting 4. requires nurses to review and critique research and practice findings |
1,2
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Which of the following are population-based interventions for HTN? (mark all that apply)
1. Obtaining a medication prescription and follow-up appointment 2. Identfying the prevalence of HTn by age, race, and sex 3. Discovering the subpopulation with the highest rate of untreated HTN |
2,3
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A client is receiving health care by a health care provider who is a salaried employee. Which type of managed care organization (MCO) does the client belong to? (select all that apply)
1. Staff model 2. Group model 3. Network model 4. Independent practice association |
1
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The overall goal of Healthy People 2010 is to:
1. Assess the health care needs of individuals, families, or communities 2. Develop and implement public health policies and improve access to care 3. Gather information on incident rates of certain diseases and social problems 4. Increase life expectancy and quality of life and to eliminate health disparities |
4. Increase life expectancy...
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Community health nursing is a nursing approach that merges knowledge from which of the following professional nursing theories?
1. Population sciences 2. Public health sciences 3. Mental health sciences 4. Environmental sciences |
1, 2
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You are caring for a Bosnian community. You identify that the children are undervaccinated and the community is unaware of resources. As you assess the community, you determine that there is a helath clinic within a 5 mile radius. You meet with communty leaders and explain the need for immunizations, the location of the clinic, and the process of accessing healthcare resources. which fo the following practices are you providing?
1. Education about community resoruces 2. Teaching the community about illnesses 3. Promoting autonomy in decision making 4. Improving the health care of the community's children |
1,2,3,4
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Vulnerable populations of clients are those who are more likely to develop health problems as a result of:
1. choric diseases, homelessness, poverty 2. lack of transportation, dependence on others for care, and homelessness 3. excess risks, limits in access to health care services, and dependency on others for care |
3. excess risks, limits in access to health care services, and dependency on others for care
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WHich of the following are major health care problems commonly affecting older adults?
1. substance abse 2. confusional state 3. financial limitations 4. acute and chronic physical illnesses |
4. acute and chronic ...
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The local health department received information frot he CDC that the flu was expected to be very contagious this season. You are asked to set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention?
1. Tertiary prevention 2. Primary prevention 3. Nursing intervention 4. Secondary intervention |
2. primary intervention
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The local school has an increasing number of adolescent parents, and you work iwth the school district to design and teach classes about infant care, child safety, and time management. These are examples of which nursing role?
1. Educator 2. Advocate 3. Consultant |
1. Educator
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You are practicing in an occupational health setting. There are a large number of employees who smoke, adn you design an employee assistance program for smoking cessation. This is an example of which nursing role?
1. Educator 2. Counselor 3. Collaborator 4. Case manager |
2. Counselor
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In your community clinic you care for Lisa, a 40 year old woman who takes insulin to manage her diabetes. She is having increased difficulty in managing her disease, and you want her to try a new insulin pump to help her control the disease. Which of the following change factors increase the likelihood that she will accept this new insulin pump? mark all that apply.
1. lisa tries the isulin pump on a limited basis 2. lisa views use of the insulin pump as a simpler way to control her blood sugars 3. the insulin pump is compatible with lsa's existing needs, values and past experiences 4. lisa percives the insulin pump as more advantageous than other alternatives of insulin administration |
1,2,3,4
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What are the three elements that are included in a community assessment?
1. environment, families, social sys 2. people, neighborhood, social sys 3. structure or locale, people, social sys 4. health care sys, geographic boundaries, and people |
3. structure or locale, people, and social sys
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Of the five caring processes, which describes "knowing" the client?
1. anticipaitng the client's cultural preferenc 2. gathering task-oriented information during assessment 3 establishing an enhanced understanding of the client's needs |
3. establishing an enhanced understanding of the client's needs
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Helping a new mother through the birthing experience demonstrates which of the five caring behaviors?
1. Knowing 2. Enabling 3. Doing for 4. Being with |
2. Enabling
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Mr. Kline is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the bible with Jada, his nurse, and she recommends a favorite Bible verse. Another nurse tells Jada that there is no place in nursing for spiritual caring. Jada replies:
1. Spiritual care should be left to a professional 2. You are corrrect, religion is a personal choice 3. Spiritual, mind, and body connections can affect health |
3. spiritual, mind, and body...
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A number of strategies have potential for creating work environments that enable nurses to demonstrate more caring behaviors. Some of these include:
1. Increasing working hours 2. Increasing monetary gain 3. Flexibility, autonomy, and improved staffing |
3. Flexibility...
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A nurse demonstrates caring by helping family members:
1. Become active participants in care 2. Provide activities of daily living 3. Remove themselves from personal care |
1. Become active..
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Listening is not only "taking in" what a client say; it also includes:
1. Incorporating the views of the physician 2. Correcting any errors in the client's understanding 3. Injecting the nurse's personal views and statements 4. Interpreting and understanding what a client means |
4. interpreting and understanding what a client means
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Presence involves a person-to-person encounter that:
1. Enables clients to care for self 2. Provides personal care to a client 3. Conveys a closeness and sense of caring |
3. Conveys closeness
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Client's perceptions are importat b/c health care:
1. Always acts in the best interest of the client 2. Is placing greater emphasis on client satisfaction 3. Is carefully watched and regulated by the federal government |
2. Is placing greater emphasis on client satisfaction
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