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test 1 102
test 1 102
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1
A nurse is working at a community clinic servicing families with young children. What is a priority intervention ?
setting up parenting classes
providing alcohol/drug information
screening for congenital defects
providing sex education
2
the client identifies 3 strategies for minimizing leakage of ileostomy bag. This is an example of:
a physiologic outcome
a cognitive outcome
an affective outcome
a psychomotor outcome
3
When assessing the firmness of a client’s abdomen, the nurse should use which assessment ?
auscultation
palption
pulsation
percussion
4
the nursing staff on unit uses peer review to improve professional performance. Who performs the review?
nurses
visitors
clients
unit manager
5
Nurse is caring for 10yo child with seizure. What variable would alter the nurses plan for educating the client/family?
the client has a sister who has been treated for seizure disorder for 3yrs
the parents verbalize acceptance of the need to closely monitor their child
the parents have comprehensive insurance coverage for medical care
the client expresses desire to learn how to manage taking medications
6
nurse is talking about diabetes to clients family-to promote the heath of family members what info should the nurse tell
risk factors for and prevention of diabetes
the cellular metabolism of glucose
the severity of the client’s disease
medications used to treat diabetes mellitus
7
A community is defined as a social group that may or may not share common geographic boundaries yet interact because of?
common political beliefs
common interests
common school districts
common economic interests
8
A nurse created a care plan for an obese patient with altered health maintenance. What outcome is most appropriate?
the client will exercise 30 minutes everyday
create an exercise plan that is realistic and valued
the client i’ll only eat three meals per day
the client will exclude meat from their diet
9
A nurse would take responsibility and refrain from delegating which task to a UPA?
older adult with pneumonia who is being discharged to son’s home tomorrow
a client with a high fever receiving intravenous fluids, antibiotics and o2
an adult client who is being treated for kidney stones
middle aged client who is ambulating in the hall 3 days after surgery
10
the nurse notified several clients with heart failure are being readmitted within 2 weeks of discharge
performance improvement: implementing change
performance improvement: assessing the change
performance improvement: discovering a problem
performance improvement: planning a strategy using indicators
11
new patient of Chinese descent admitted for abdominal surgery. Which step should nurse prioritize during the assessment?
ask the client if they would like the door left open or closed
explain the nurse will need to touch the client during assessment
concentrate on a focused assessment of the abdomen only
discuss various goals before the assessment is complete
12
client has pulse oximetry and they require pharyngeal suctioning. Who should the nurse avoid delegating this task to ?
licensed practical/vocational nurse
senior student in nursing school who is present for clinical
unlicensed personnel who is in nursing school
registered nurse
13
why are quality-assurance programs important in nursing?
they enable nursing to be accountable for the quality of care
they allow increased retention in qualified nurses
they facilitate increased enrollment in educational programs
they specify how resources are used or not used
14
a nurse administers anti hypertensive meds for client with uncontrolled hypertension. what indicates outcome is been met
client reports no headache
clients lipids are within range
client is normotensive
client is drowsy after lunch
15
Which theory describes, explains, predicts, and controls outcomes in nursing practice?
nursing theory
developmental theory
adaptation theory
systems theory
16
The nurse is preparing discharge teaching for a diabetic client. Which information is the least important to include?
way to pay for hospitalization and outpatient care
appropriate use of a glucometer
meal planning
community resources
17
A client tells a nurse, “I feel like you ignored me today” In response to the statement the nurse should:
sit at the bedside and allow the client to explain the statement
apologize and say this behavior will not happen again
smile at the client and explain to them how busy you’ve been today
ignore the client and continue to empty their urinary catheter
18
A nurse is applying Tanner’s clinical judgment model for patient care. Which action is the first step in this process?
Build trust and rapport
Come up with a hypothesis
Noticing the significance aspects of the client’s condition
Reflection
19
A clients physiatrist, therapist & nurse are in a conference. the nurse is demonstrating the values of what organization
National Board of Nursing
National League for Nursing
Interaprofessional Education Collaborative
20
A client has a condition the nurse isn’t familiar with. What is the best source for information on this condition?
Consult with the client
The nursing and medical literature
Check the clients chart
Consults with the healthcare provider
21
A nurse is discussing cataract treatment w/ client. Which statement by nurse would be most therapeutic?
“Why don’t you try laser surgery?”
“Have you ever thought of laser surgery?”
“My grandfather also benefited from laser surgery.”
“You should try last surgery!”
22
A nursing student’s parents are both healthcare providers. The nursing instruction may feel the student has…
socialization in health care
attitudes that will be hard to change
a predetermined career plan
experience in healthcare
23
The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts teaching in what way?
gives instructions in multiple different ways
uses medical terminology to make the client feel smarter
uses video, diagrams, and pictures, rather than focusing on verbal teaching
provides general teaching instead of specific teaching
24
A nude is aware that which problem may occur in a single-parent family at a greater level than other types of families?
knowledge on child safely
conflict among family members
incidence of child abuse
increased financial concerns
25
Who was the first Nursing theorist who conceptualized nursing in terms of manipulation the environment?
Sister Callista Roy
Florence Nightgale
Lydia Hall
Dorothea Orem
26
A nurse is planning education a client on their new diagnosis of asthma. What diagnosis would be the most appropriate?
Risk: Client is having difficulty dealing with the diagnosis
knowledge deficit: medications related to new medical diagnosis
Noncompliance: not will to learn about medication or diagnosis
Ineffective airway clearance: due to asthma
27
Which component of a record describes the client’s responses to what has been done and revisions to the initial plan?
plan of care
data base
problem list
progress notes
28
client admitted 2 days after surgery & the nurse hears refinished lung sounds in posterior base. what is the best action
reassess in 4 hours and document findings
provide oral pain meds before ambulation
encourage hourly use of the incentive spirometer
promote oral fluid intake between meals
29
The nurse is going to teach a client recovering from abdominal surgery. when is the most appropriate time to teach?
when the meal tray arrives
As the client is sitting quietly reading a book
immediately before discharge
at the time of pain medication administration
30
A client with sepsis- The nurse updates care plan based on improvements in client’s condition. This is an example of?
initial planning
discharge planning
outcome planning
ongoing planning
31
Information is collected for analysis in both quantitative and qualitative research. What is this information called?
Data
verbal interviews
nursing theory
patient rating
32
The 2nd step in implementation of EBP includes systematic review. To complete review of the literature the nurse must?
begin recommendation for best practice
ask questions bout a clinical practice
summarize findings from multiple studies that are related to nursing case
preform meta-analysis
33
A nurse makes a diagnosis of constipation for a client who reports not defecting in the bathroom but has no other info
the nurse is interpreting data
the nurse is exhibiting inconsistent cues
the nurse is exhibiting premature closure
the nurse is exhibiting clustering of cues
34
Which is the primary reason for a nurse collecting data continuously on a client ?
the clients health status can change quickly
reimbursement hospital required
so that you have lots of documentation on the client
it makes the client feel like you want to spend time with them
35
Client states, “My grandma always told me beans will make my muscles grow” This information is known as?
authoritative knowledge
traditional knowledge
scientific knowledge
philosophy
36
Which scenario is an example of a time lapse reassessment ?
assess a client found on the floor before calling emergency assessment
assess the client based on their specific diagnosis
assess new resident in the long-term care facility
nurse assess to see how a client is doing with strategies practiced before
37
what is a focus of medical research rather than nursing research?
drug metabolism
health appraisal
promotion of recovery
prevention of trauma
38
which guideline should the nurse follow when including interventions in a plan of care?
date the nursing intervention when written and whenplan of care is reviewed
make sure intervention doesn’t describe the action the nurse should preform
make sure health care provider approves and signs nursing intervention
make sure the nursing interventions are unrelated to the original outcomes
39
This documented in a clients health record: Client c/o severe HA upon waking: Which interpretation is most accurate?
the client has a history of severe complaints in the morning
the client is coughing and experiencing severe heartburn in the morning
the client reports waking up this morning the severe headache
the client has symptoms in the morning associate with a heart attack
40
What nursing care behavior by the nurse will help build the clients trust in the nurse?
Nurse tells client to ask the oncoming nurse after shift change
Nurse answers the clients questions while documenting
Nurse answers questions, uses a gentle voice, and keeps eye contact
Nurse tells the client not to worry and that everything will be fine
41
Client tells nurse “My mind is made up, I can’t do this anymore” What is the best action by the nurse for plan of care?
tell another nurse about this clients statement
document that the depression has resolved
add the nursing diagnosis: Risk for self harm
encourage the client to join a therapy group
42
Which observation during nursing assessment of a client supports the documentation of low health literacy?
client had complete health forms
client can provide coherent health history
client exhibits compliance with mediation regimen
the client avoids health screenings and seeks care at local ED
43
Quoting statements made by the client will help in maintaining what type of assessment data?
reimbursement
organization
subjectivity
objectivity
44
Health care provider is in a hurry to leave and tells the nurse to give 2mg morphine q4h prn. What should the nurse do?
write the order in the clients record
inform the health care provider that a written order is needed
add the new order to the medication administration record
call the pharmacy to have the order entered in the electronic record
45
Nurse has 16y/o p admitted for threatened suicide. What info is essential in determining coping function of family ?
the child’s physical well being
family’s financial status
the size of the family
family patterns of communication
46
Within the model of experiential learning, what outcome indicates the nurse achieving the stage of transformation?
the nurse integrates experience and reflection into new forms of practice
the nurses work results in practice improvements
the nurse understands the influence on others
the nurse has increased awareness of ethics
47
A client with end stage COPD has “activity intolerance” Which expected outcome most directly demonstrates resolution?
client will alternate rest periods with exercise throughout the day
client will use oxygen by nasal cannula when short of breath
client will consistently perform pulmonary exercise
client will increase protein intake in small frequent meals
48
A nurse is communicating the plan of care to a client who is cognitively impaired. What action will they NOT take?
give a lengthy detailed explanation of the care that will be given
maintain eye contact
shoe patience with the client/ give them time to respond
keep communication simple and concrete
49
what is the order of critical thinking in the nursing process to client care?
ideas, interpret evidence, client perception, detect bias, predict results
detect bias, clients perception, interpret evidence, ideas, predict results
ideas, interpret evidence, client perception, detect bias, predict results
ideas, interpret evidence, detect bias, client perception, detect bias
50
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?
small bowel obstruction
ulcerative colitis
irritable bowel syndrome
bowel incontinence
51
Which statement by the client would leads the nurse to make a nursing diagnosis of a care giver role strain?
we go on daily walks every afternoon
i still have time to do important things for myself
i just don’t have time to take a shower
i feel great but wish that i could get more sleep
52
priority setting is based on info obtained during reassessment. All factors contribute to priority setting except ?
time and resources
feedback from the family
finances of the client
the client’s condition
53
A home care nurse discussed with a client when visits will occur and how long they will last.
this relationship is established in the termination phase
this relationship is established in the working phase
this relationship is established in the evaluation phase
this relationship is established in the orientation phase
54
Which statement best conveys the role of intuition in nurse problem solving?
intuition is dependent on if a nurse has the special “gift”
intuition can be used as a a replacement for logical problem solving
intuition can be used in place of scientific problem solving
intuition can be clinically useful adjunct to logical problem solving
