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

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

Which of the following should the nurse not include in the end of shift report?

The patient’s family is at the bedside

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

The nurse should ask about their daily diet

The client at high risk for hypertension should be taught which of the following?

Lower LDL levels will be good for your heart

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

Use a certified medical interpreter

When the patient says, “I get so anxious just lying here in this hospital bed”.

“It sounds like you’re having a tough time dealing with this situation.”

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

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

Defining characteristics, The problem, Etiology

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%.

Which of the following is an example of a symptom?

The patient states that they have a throbbing headache

Advantages of source-oriented or narrative charting include all of the following except that it:

Encourages documentation of normal and abnormal findings

A patient is leaving the hospital against medical advice (AMA) demands to have the medical record to take

“You will need to contact medical records after discharge o obtain a copy”

When prioritizing nursing diagnoses according to Maslows which of the following would the nurse address first?

Acute pain r/t injury of soft tissue aeb guarding, protective behavior

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

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

The client asks the nurse about alternative therapies that may help lower their BP and HR. The nurse correctly states

Relaxation therapy, Biofeedback therapy, Meditation

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

log out of computer when finished using

Which of the following demonstrates accuracy in documentation?

Client ambulated 100 feet while using walker at 1030

Purposes of documentation includes (select all that apply)

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

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

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

Assisting the client with repositioning every 2 hours

For unexpected complications that increases length of stay in a hospital, documentation by the nurse is likely to..

Justify insurance reimbursement for an extended hospital stay

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

An advantage of focus charting is (select all that apply)

It shortens documentation time, The focus is not limited to patient problems or nursing diagnoses, It’s compatible with the use of the nursing process

Decreasing intake of saturated fats reduces the risks of which of the following? (select all that apply)

Myocardial Infarction, Diabetes, Atherosclerosis and coronary artery disease

Which of the following is an advantage of narrative (source) charting?

It includes all aspects of the nursing process

When teaching about foods with high sodium content, the nurse tells the patient to avoid (select all that apply)

Cream of potato soup, Milk and milk products

Which of the following is an example of stereotyping another person?

The nursing student believes that all Japanese people watch anime

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

Determining if progress is made when comparing actual nursing outcomes to expected outcomes allows the nurse to

determine if revisions are needed

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

It may be considered disrespectful by some

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

Which of the following problems will have the highest priority?

A client being admitted with audible wheezes in bilateral upper lobes

Once the nursing plan has been initiated, the nursing care plan will:

change as the patient’s condition changes.

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Duplicate of NU136 Exam#3 Review

80 termsStudBud Administration

Fundamentals of Nursing

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Questions 80

Answers

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

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