1The client with a PEG tube feeding complains of naseau and fullness. The most appropriate action by the nurse is to

call the physician and stop the feeding

When a client speaks a language that is different from the nurse’s language, what should the nurse do?

Use a certified medical interpreter

The nurse can best ensure that communication is understood by:

obtaining feedback from the patient that indicates accurate comprehension

6. Which of the following is an example of a sign?

Coarse crackles are heard upon auscultation over the right lower lung lobe

In order to safeguard patient information when using a computer, the nurse should:

log out of computer when finished using

What does the use of encouraging elaboration accomplish?

Helps the client fully describe concern or problem

A patient is having anxiety and is crying. The nurse decides to use imagery to calm the patient by:

ask the patient close her eyes and picture herself in her favorite place.

A pt’s cholesterol lab report sows as elevated high density lipoprotein (HDL) level this indicates..

his vessels are being cleansed of fatty deposits

The nurse properly documents the nursing diagnosis for a client with a BMI of 50 when they document

Imbalanced nutrition: more than body requirements

Why must a nurse be cautious when using humor as a complementary treatment?

It may be considered disrespectful by some

A student nurse finds out that one of the patients is a celebrity, the student reads the chart. The student

Violating the confidentiality of the patient’s record

While discharge teaching the client about vitamins and minerals the nurse correctly states (select all that apply)

Vitamin C aids in wound healing, Vitamin A deficiency can lead to night blindness

Which of the following demonstrates accuracy in documentation?

Client ambulated 100 feet while using walker at 1030

Which of the following is an example of a symptom?

The patient states that they have a throbbing headache

Which of the following best demonstrates the nurse giving clear and concise orders to the CNA?

Assist Mr. Z in room 112 to ambulate from their room to the nurses station

The student nurse is trying to determine if a task can be delegated to a CNA. The SN chooses correctly if they choose..

Assisting the client with obtaining a lunch menu

When communicating with the hearing impaired patient the nurse should (select all that apply)

Never speak directly into their ear, Face them directly, Get their attention first, before speaking, Give the patient time to respond to questions

A complete nursing diagnosis will contain (select all that apply)

The problem, Etiology, Defining characteristics

When helping the visually impaired client with their meal the nurse should

tell them where their food is using a clock as a reference.

1A client who practices Christian Science is refusing to take their scheduled meds. The nurse understands that

Christian Science do not normally seek traditional health care

The nurse properly teaches a PEG tube patient on self-administrating feedings at home when the nurse states

Do not push the feeding in with the syringe

A Native American pt.asks the nurse if his shaman can perform traditional healing rituals, the proper response is..

I will inform the physician and allow him to confer with your shaman

Which of the following is an example of adequate documentation?

Reports of dyspnea, 02 sat 88%, HR 120, prn inhaler given, 02 sats now 95%.

What does confidentiality with a patient’s medical records mean?

Only those caring for the patient can view the medical record

Which of the following tasks can be delegated to a CNA?

Assisting the client with repositioning every 2 hours

A client came to the ER with paleness and extreme fatigue. What should the nurse assess next?

The nurse should ask about their daily diet

Purposes of documentation includes (select all that apply)

Research and data collection, Evaluate staff performance, Provide evidence of care, Calculate insurance reimbursement

When assessing the client’s diet, the nurse should consider having the client do which of the following?

Have the client state their likes and dislikes, Write down their meals from the past few days, Inform the nurse of any religious considerations

Which of the following is an example of a properly written goal?

Client will state a pain of 2/10 by the end of the day

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NU 136 Exam 3 #3

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Fundamentals of Nursing

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Questions 80

Answers

1
1The client with a PEG tube feeding complains of naseau and fullness. The most appropriate action by the nurse is to
call the physician and stop the feeding
change the feedings to a low calorie formula
lay the patient flat
slow the feeding to 20 mLs/hr
2
A patient is seen by an alternative medicine practitioner for menopausal symptoms. An effective herbal remedy is
echinacea
black cohosh
valerian
ma huang
3
The nurse administering a medication to a patient is performing
a dependent nursing action
a semi-dependent nursing action
an independent nursing action
an interdependent nursing action
4
When a client speaks a language that is different from the nurse’s language, what should the nurse do?
Use the patient’s family as translators
Ask siri for help
Use a certified medical interpreter
Ask Jose the CNA to help with translation
5
This complementary treatment is directed at disease prevention, lifestyle management, and a diet of natural foods
Naturopathic medicine
Ayurveda
Homeopathy
Aromatherapy
6
A Jewish client may ask for which type of diet during their stay in the hospital?
Vegetarian
Halal
Kosher
Medium steaks
7
Which commonly used herb is thought to decrease migraines and hay fever symptoms?
Butterbur
Ginkgo biloba
Ginseng
Cranberry
8
The nurse can best ensure that communication is understood by:
asking the family members whether the patient understands
checking for signs of hearing loss or aphasia before communicating
obtaining feedback from the patient that indicates accurate comprehension
speaking slowly and clearly
9
6. Which of the following is an example of a sign?
Coarse crackles are heard upon auscultation over the right lower lung lobe
The nurse made a conclusion based on observed data
Jesus took the wheel
The patient states that they are afraid of falling if they try to walk
10
In order to safeguard patient information when using a computer, the nurse should:
only use the computer located in the nurse’s station
use personal code words and abbreviations to disguise information
wait until the end of the shift and document all information at one time
log out of computer when finished using
11
What does the use of encouraging elaboration accomplish?
It shows readiness to help
Allows client to gather thoughts
Helps the client fully describe concern or problem
Sums up important parts of the conversation
12
When the patient complains of nausea and dizziness, the nurse recognizes these complaints as
objective
adjunct
medical
subjective
13
A nurse will arrive at a nursing diagnosis through the nursing process step of
research
assessment
evaluation
planning
14
Telling a client,”When you are stressed just find ways to relax.” Is which communication block?
Giving advice
Using cliches
Inattentive listening
Giving false reassurance
15
A patient is having anxiety and is crying. The nurse decides to use imagery to calm the patient by:
telling the patient to relax and to calm down.
ask the patient close her eyes and picture herself in her favorite place.
ask the patient do stretch exercises.
telling the patient strenuously focus on some image in the room.
16
A pt’s cholesterol lab report sows as elevated high density lipoprotein (HDL) level this indicates..
he is about to die
is developing atherosclerosis
his vessels are being cleansed of fatty deposits
he is at risk for hypertension
17
The nurse properly documents the nursing diagnosis for a client with a BMI of 50 when they document
Risk for Imbalanced nutrition: more than body requirements
Imbalanced nutrition: more than body requirements
Obesity related to increase in consumption of fatty foods
Imbalanced nutrition: less than body requirements
18
Which of the following is included in the nursing assessment?
The nurse assists the client with ambulation
Subjective and Objective Data
The nurse identified the reasons for an intervention to be carried out
A client centered goal that is realistic and attainable
19
A patient with B12 deficiency should increase their intake of
Sardines and clams
Rice and wheat
Kiwi and broccoli
Lentils and sweet potato
20
The nurse recognizes that the only plant source that contains all nine essential amino acids is
bean sprouts
soybeans
mushrooms
lima beans
21
Why must a nurse be cautious when using humor as a complementary treatment?
It may be considered disrespectful by some
Laughing can be loud and disturbing to other patients
It doesn’t work at all
Nurses are not funny people
22
When charting is organized in chronological order it is...
Source-oriented (Narrative)
Case management charting
Focus charting
Problem-oriented
23
A student nurse finds out that one of the patients is a celebrity, the student reads the chart. The student
Doing appropriate research about nursing care plan
Is appropriately seeking knowledge during his clinical experience
Can read medical records as along as their work is completed
Violating the confidentiality of the patient’s record
24
While discharge teaching the client about vitamins and minerals the nurse correctly states (select all that apply)
You do not need iron supplements if you suffer from anemia
Vitamin K is not necessary for blood clotting
Vitamin C aids in wound healing
Vitamin A deficiency can lead to night blindness
25
Which of the following demonstrates accuracy in documentation?
Client ambulated 100 feet while using walker at 1030
Patient’s previous nurse refused to document vitals last shift
Physician called for medications
Patient did not sleep too well last night
26
Which of the following is an example of a symptom?
There is purplish black ecchymosis on the patient’s arm
The patient’s blood pressure is 165/100
By the end of the shift the patient has had 2500 mL’s of urine output
The patient states that they have a throbbing headache
27
Which of the following best demonstrates the nurse giving clear and concise orders to the CNA?
Assist Mr. Z in room 112 to ambulate from their room to the nurses station
Make sure to teach room 103 how to take their inhaler before leaving today
Ask the physician to clarify the medication order for Mr Radcliffe
I need you to take vital signs on the first 10 rooms
28
The student nurse is trying to determine if a task can be delegated to a CNA. The SN chooses correctly if they choose..
Checking the client’s wound for formation of granulation tissue
Ensuring the client understands proper hygiene care after being taught
Placing a sublingual tablet under the client’s tongue
Assisting the client with obtaining a lunch menu
29
When communicating with the hearing impaired patient the nurse should (select all that apply)
Never speak directly into their ear
Face them directly
Get their attention first, before speaking
Give the patient time to respond to questions
30
A complete nursing diagnosis will contain (select all that apply)
The problem
Etiology
Defining characteristics
Dependent nursing actions
31
The new nurse calls the MD and states,”Good morning doctor, I am nurse Ratchet...”. Which part of ISBARR is this?
Recommendation
Read back
Introduction
Situation
32
When helping the visually impaired client with their meal the nurse should
tell them where their food is using a clock as a reference.
teach them the type of foods they’re eating based on the food texture.
never track the patient’s weight in order to maintain their self-esteem.
be aware that this condition affects mainly men.
33
1A client who practices Christian Science is refusing to take their scheduled meds. The nurse understands that
they will have to ask again at a time more convenient for the patient
the patient is wanting to save on the visitation cost
Christian Science do not normally seek traditional health care
the physician needs to be notified stat
34
The nurse properly teaches a PEG tube patient on self-administrating feedings at home when the nurse states
Do not push the feeding in with the syringe
A feeding pump is not required for continuous feedings
Residual is checked every 6 hours
Flushing with water before and after feeds is not required
35
A Native American pt.asks the nurse if his shaman can perform traditional healing rituals, the proper response is..
I will inform the physician and allow him to confer with your shaman
I do not believe in those rituals therefore they cannot be performed here
I cannot allow you to do that. It may be more harmful to you if he does
It is against hospital policy to allow healing methods that are untested
36
Which of the following is an example of adequate documentation?
Pt states aching pain in right leg, morphine given.
Patient ambulated with little difficulty, will continue to monitor.
Reports of dyspnea, 02 sat 88%, HR 120, prn inhaler given, 02 sats now 95%.
The patient’s blood pressure is 145/90, physician notified.
37
Along with protein, what also helps with healing?
Phosphorus
Calcium
Vitamin C
Potassium
38
Which of the following vitamins will aid in hemoglobin and red blood cell synthesis? (select all apply)
Vitamin B12
Thiamine
Folic Acid
Retinol
39
The nurse states: “I think a breathing treatment would help with the pt’s SOB.” Is which part of SBAR?
Background
Assessment
Recommendation
Situation
40
What does confidentiality with a patient’s medical records mean?
All healthcare personnel can view any medical records at any time
Only those caring for the patient can view the medical record
As long as the person is a family member they can view the medical record
Access to medical records are given only to other medical institutions
41
The LPN/LVN filling out the Jewish patient’s dietary menu for lunch would avoid ordering
meat and milk
milk and vegetables
meat and fish.
vegetables and fruit
42
This type of charting allows for documentation at the point of care but is costly and time consuming to implement
Focus charting
Case management charting
Problem-oriented
Computer charting
43
Which of the following tasks can be delegated to a CNA?
Reading the EKG stripes after obtaining an EKG on an MI patient
Cleaning the pins on a patient’s fixator
Preparing discharge teaching papers
Assisting the client with repositioning every 2 hours
44
Alternative meat products the nurse can offer to the patient with heart and cholesterol issues include (SATA)
grilled salmon
fried chicken and mashed potatoes
spare ribs
halibut
45
The nurse w/ a client on a PCA rechecks their pain at regular intervals. This is which phase of the nursing process?
Assess
Evaluation
Planning
Implementation
46
Saying,” I’ll just sit with you for a while”. Is an example of...
Seeking clarification
Offering of self
Reflection
Using general leads
47
A client came to the ER with paleness and extreme fatigue. What should the nurse assess next?
The client’s bowel habit needs to be observed
The nurse should ask about their daily diet
Whether their spouse or S.O will stay the night with them at the hospital
Medications they took during their last visit to the hospital
48
Documentation that only requires abnormal assessment findings to be recorded is known as which type of charting?
Problem-oriented charting
Narrative charting
Charting by exception
PIE charting
49
Purposes of documentation includes (select all that apply)
Research and data collection
Evaluate staff performance
Provide evidence of care
Calculate insurance reimbursement
50
When assessing the client’s diet, the nurse should consider having the client do which of the following?
Consider the client’s family’s meal plan
Have the client state their likes and dislikes
Write down their meals from the past few days
Inform the nurse of any religious considerations
51
Which of the following is an example of a properly written goal?
Client will state a pain of 2/10 by the end of the day
Client will have no wounds
All morning medications will be administered by 1015
The physician will order x-rays by tomorrow morning
52
A nurse enters a notation in a pt’s medical record but then discovers that the notion made was in the wrong chart
Follows agency policy for correcting the error
Blacks out the note to protect the confidentiality of the pt.
Removes the page on which the error is located
Pray that nobody finds out!
53
A patient who underwent surgery has an order to begin a clear liquid diet and can be offered
tea with milk
Jell O
fruit sherbet
cream soup
54
Determining if progress is made when comparing actual nursing outcomes to expected outcomes allows the nurse to
discharge the client quicker
save the facility money and cut down on waste
help the doctor determine the next steps medication plan
determine if revisions are needed
55
Advantages of source-oriented or narrative charting include all of the following except that it:
Includes aspects of all steps of the nursing process
Indicates the pt’s baseline condition for each shift
Encourages documentation of normal and abnormal findings
Gives info. On the pt’s condition and care in chronological order
56
Which of the following is an example of stereotyping another person?
The husband dominates all decision making and family choices
A person from Alabama says certain english phrases with a variation
A patient from Canada feels helpless and disoriented
The nursing student believes that all Japanese people watch anime
57
6. The method of computer-assisted charting:
speeds reimbursement for services
improves communication between departments
allows entries to be made at point of care
allows electronic records to be retrieved more quickly
58
A patient is leaving the hospital against medical advice (AMA) demands to have the medical record to take
“I will get it right now”
“The information in your medical record is confidential, so NO!”
“You will need to contact medical records after discharge o obtain a copy”
“Because you are leaving AMA, you can not have it ever”
59
A client is diagnosed with potassium deficiency, which foods should the client increase in their diet?
Figs
Green beans
Nuts
Beef liver
60
An advantage of focus charting is (select all that apply)
It shortens documentation time
It’s compatible with the use of the nursing process
The focus is not limited to patient problems or nursing diagnoses
Patient problems are never missed
61
When caring for a Muslim woman what must the nurse understand about their beliefs and values?
The nurse must respect her modesty
Her grandmother’s wishes is the final authority of the family
The woman is the head of the household
Prayer is not considered an integral part of Islam
62
Expected patient outcomes should meet which of the following criteria? (Select all that apply)
Realistic
Meets goals set by hospital management
Attainable
Have a defined timeline
63
Define charting by exception
Focus on deviations from norms
Centers on patient from a positive perspective
Narrative or story driven charting
Organizes patient illness on a time frame
64
Which of the following is an advantage of narrative (source) charting?
It saves time during the charting process
Abnormal findings are the only assessments that will be documented
Physicians prefer long and detailed nursing charting
It includes all aspects of the nursing process
65
After getting a telephone order from the physician the nurse should
Initiate the 5 rights of medication administration
Administer the medication
Call the pharmacy to confirm the order
Read back the order
66
The client asks the nurse about alternative therapies that may help lower their BP and HR. The nurse correctly states
Meditation
Relaxation therapy
Over-the-counter medications
Biofeedback therapy
67
With fat soluble vitamins the nurse understands that
consumption of too much fat soluble vitamins can lead to toxicity
those are the most important of all the vitamins
they have high caloric value
they are easily absorbed into the bloodstream
68
When prioritizing nursing diagnosis according to Maslows which of the following would the nurse address first?
Fall/injury risk
Imbalanced nutrition less than body requirements
Disturbed sleep pattern
Risk for social isolation
69
The nurse consults with a patient who is a vegan and stresses that this diet puts the patient at risk for
Iron deficiency
Osteoporosis
Scurvy
Diabetes
70
When the patient says, “I get so anxious just lying here in this hospital bed”.
“I know just what you’re going through.”
“It’s always darkest before the dawn. Hang in there; it will get better.”
“It sounds like you’re having a tough time dealing with this situation.”
“You sound pretty sorry for yourself. Why don’t you look at the positives?”
71
Decreasing intake of saturated fats reduces the risks of which of the following? (select all that apply)
Myocardial Infarction
Stroke
Diabetes
Atherosclerosis and coronary artery disease
72
When teaching about foods with high sodium content, the nurse tells the patient to avoid (select all that apply)
Milk and milk products
Tofu
Papaya
Cream of potato soup
73
The nurse states, “Everything will work out eventually” is an example of
Looking at alternatives
Using clichés
Clarifying
Giving advice
74
Which interventions will help with communicating with school-aged patients? (select all that apply)
Let the child play with the equipment
Use short sentence
Talk to them at eye level
Be thorough with all of your explanations
75
Which of the following should the nurse not include in the end of shift report?
The patient stated that the morphine IV relieves their pain
The patient’s family is at the bedside
The patient is scheduled for an MRI in at 1100
The patient’s physician is John Doe M.D
76
When prioritizing nursing diagnoses according to Maslows which of the following would the nurse address first?
Impaired physical mobility r/t fatigue aeb frequent daytime naps
Risk for infection aeb tissue injury
Deficient knowledge r/t unfamiliarity w/ condition aeb misconception of fx
Acute pain r/t injury of soft tissue aeb guarding, protective behavior
77
Which of the following problems will have the highest priority?
A client oozing blood from a laceration on the left forearm
A patient admitted with type 2 DM has a glucose level of 263
A client being admitted with audible wheezes in bilateral upper lobes
A client complaining of a pain level of 7/10
78
The client at high risk for hypertension should be taught which of the following?
Lower LDL levels will be good for your heart
Increasing saturated fats in the diet will help lower LDL levels
Decrease their intake of unsaturated fats
Keep their recommended fiber intake to only every other day
79
For unexpected complications that increases length of stay in a hospital, documentation by the nurse is likely to..
Be used against the nurse if a lawsuit results
Cause the primary care provider to get into trouble
Justify insurance reimbursement for an extended hospital stay
Be questioned by the nurses supervisor for time inefficiency
80
Once the nursing plan has been initiated, the nursing care plan will:
be given to the patient for final approval.
remain on the patient record to show progress.
change as the patient’s condition changes.
stay in place until all nursing goals have been met.

NU 136 Exam 3 #3 Flashcards | StudBud