QUESTION 1 1. A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality? A. writing 2. the client's name on the student's care plan B. discussing the medications with a unit nurse C. providing information to the physician about laboratory data D. providing the instructor with plans for care 2.22 points QUESTION 2 1. Which client outcomes are quantified, physiologic outcomes? Select all that apply. A. The 2. client's HbA1c is 7.4%. B. The C. The D. The E. The client axillary temperature reading of 37.0 Celsius. client describes manifestations of wound infection. client self-administers insulin subcutaneously. client's blood pressure is 118/74 mm/Hg. 2.22 points QUESTION 3 1. When planning nursing interventions, the registered nurse must review the etiology of the problem statement. The etiology is defined as: A. Identifies 2. problem factors causing undesirable response and preventing desired change B. Suggests patient goals to promote desired change C. Identifies patient strengths D. Identifies the unhealthy response preventing a desired change 2.22 points QUESTION 4 1. Which of the following is true of long-term care facilities? A. They 2. provide care to people of any age. B. They provide care only to older adults. C. They provide care only for people with dementia. D. They provide care for homeless adults. 2.22 points QUESTION 5 1. The wristband is an important safety component during the client's stay at a medical facility because it is one of two identifiers required by which group's national safety standards, to accurately identify a client during such activities as giving medication, IV fluids, and Blood? A. NANDA 2. B. The Kardex C. The Joint Commission D. HIPAA 2.22 points QUESTION 6 1. An expected client outcome is, "The client will remain free of infection by discharge." When evaluating the client's progress, the registered nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000/ μL (12 × 10 9/L), and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A. Goal 2. not met; white blood cell count elevated, presence of yellow-green discharge from wound. B. Client understands the signs and symptoms of infection. C. Goal partially met; client identified fever and presence of wound discharge. D. Goal partially met; client able to perform activities of daily living. 2.22 points QUESTION 7 1. Which question or statement would be an appropriate termination of the health history interview? A. "Perhaps 2. we can talk again sometime. Goodbye." B. "Well, I can't think of anything else to ask you right now." C. "I wish you could have remembered more about your illness." D. "Can you think of anything else you would like to tell me?" 2.22 points QUESTION 8 1. The nurse is admitting a client to the acute care facility. What actions by the nurse will assist in establishing an effective nurse-client relationship? Select all that apply A. setting 2. limits by clarifying the nurse's goals for the patient. B. anticipating the patient's anxiety and response to strangers. C. determining the patient's problems and expectations after discharge. D. make decisions for the client regarding care E. assisting family members with the transition to hospitalization. 2.22 points QUESTION 9 1. A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? A. "Client 2. has a history of recent abdominal pain." B. "Client reporting that her abdominal pain rated an 8, on a pain scale of 0 to 10." C. "Client is guarding her abdomen and occasionally moaning." D. "2 mg hydromorphone hydrochloride PO administered with good effect" 2.22 points QUESTION 10 1. A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The registered nurse then uses the data to update the client's plan of care. What are these actions considered? A. Initial 2. planning B. Ongoing planning C. Discharge planning D. Comprehensive planning 2.22 points QUESTION 11 1. A registered nurse in the emergency department is completing an emergency assessment for a teenager just admitted for serious injuries from a severe car crash. Which of the following is objective data? A. "I2.am so sick; I am about to throw up." B. "Unable to palpate femoral pulse in left leg." C. "Appears anxious and frightened." D. "My leg hurts so bad. I can't stand it." 2.22 points QUESTION 12 1. The registered nurse takes a cardiac patient's vital signs, and finds the pulse rate to be 120 beats/min. What would the registered nurse do next to interpret and analyze this pulse rate? A. Document 2. the pulse in the appropriate chart page. B. Compare the patient's pulse rate to the normal and standard pulse range. C. Ask another nurse to verify the pulse rate. D. Notify the patient's healthcare provider. 2.22 points QUESTION 13 1. What is the goal of nurses who provide home health care? A. helping 2. clients achieve maximum independence, promote health and prevent illness B. minimizing the manifestations of disease processes C. encouraging clients' dependence on family members D. collaborating with other health care providers and services 2.22 points QUESTION 14 1. Which are examples of breaches of client confidentiality? Select all that apply. A. A 2. nurse uses a computer to document the client's response to pain medication. B. A nurse shares her computer password with another nurse who was unable to log in to the system. C. A nurse updates the employer of a client, regarding the client's date of return to work. D. A nurse discusses information about a client with a co-worker in the elevator. E. A nurse checks the health record of a client they are caring for, to see who is the contact person for an emergency. 2.22 points QUESTION 15 1. A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A. Tell 2. the client to ask the visitors to leave the room. B. Ask the visitors to leave the room. C. Ask the client if visitors should remain in the room. D. Wait until the visitors leave to begin the procedure. 2.22 points QUESTION 16 1. Registered Nurses who are employed in home health care services have a variety of responsibilities. Which of the following is one of those responsibilities? A. Maintain 2. a clean home environment. B. Advise clients on financial matters. C. Provide all care and services. D. Collaborate with other care providers. 2.22 points QUESTION 17 1. A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? A. low 2. priority B. no priority C. high priority D. medium priority 2.22 points QUESTION 18 1. The registered nurse should utilize I-SBAR-R communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation? A. When 2. preparing to discharge the client home B. When reporting to a client's family member or significant other C. When documenting the care that was provided to a client whose condition recently deteriorated D. When transferring a client from the emergency department to the acute care unit 2.22 points QUESTION 19 1. A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A. Take 2. the client's vital signs after ambulation. B. Ask another student to help with ambulation. C. Delay ambulation until the following shift. D. Ask the client's wife to assist with ambulation. 2.22 points QUESTION 20 1. A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths? A. Nothing; 2. this observation is not important. B. Nurturing is a strength for developing infants. C. The mother is just behaving as all mothers do. D. A baby is not capable of having strengths. 2.22 points QUESTION 21 1. A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a 'cue' to a nursing diagnosis for this problem? A. "I2.get out of breath when I walk a few steps." B. "I often have diarrhea after I eat spicy foods." C. "I just feel so bad about myself these days." D. "My skin is so dry I just can't keep from scratching." 2.22 points QUESTION 22 1. A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A. "Everyone 2. who ages has bowel problems." B. "Do you take anything to help your constipation?" C. "Why don't you use a laxative every night?" D. "Do you have a family history of chest problems?" 2.22 points QUESTION 23 1. What is the nurse's best defense if a client alleges nursing negligence? A. Client's 2. electronic medical record (EMR) B. Testimony of expert witnesses C. Client's family D. Testimony of other nurses 2.22 points QUESTION 24 1. What is the rationale for conducting patient discharge planning? A. to2.provide a means of documenting nursing care B. to enlist family members in providing home care C. to ensure the best possible care in the acute care setting D. to ensure client and family needs are met consistently 2.22 points QUESTION 25 1. A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A. Implement 2. a change. B. Assess the change. C. Discover or identify the problem. D. Plan a strategy. 2.22 points QUESTION 26 1. A registered nurse is working at a walk-in health care setting, provides technical services (e.g., administering medications), determines the priority of client care needs, and provides client teaching on all aspects of care. Which of the following terms best describes this type of health care setting ? A. Physician's 2. office B. Hospital C. Ambulatory center D. Long-term care 2.22 points QUESTION 27 1. The registered nurse notes that the client's blood glucose level has increased and is planning to notify the primary health care provider by telephone. Which technique would be most appropriate for the registered nurse to use when communicating with the primary health care provider? A. POMR 2. B. ISBAR C. EMAR D. SOAP 2.22 points QUESTION 28 1. A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A. Frequency 2. of home visits to be made B. Friendliness of the client and family C. Safety of the immediate environment D. Number of rooms in the house 2.22 points QUESTION 29 1. An older adult woman has total care of her husband, the husband suffers from debilitative pain from rheumatoid arthritis. The couple voices concern over the pain and stress associated with the condition. What type of care might the nurse suggest to help the couple? A. Palliative 2. care B. Primary care C. Respite care D. Bereavement care 2.22 points QUESTION 30 1. A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which action would be most appropriate for the nurse to do? A. Completely 2. erase or delete the erroneous entry if possible. B. Strike out the entry with a single line, place initials next to it, and write the correct entry. C. Black out the erroneous entry with a dark pen or marker. D. Use a highlighter to mark the incorrect entry and place initials next to it. 2.22 points QUESTION 31 1. A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a registered nurse measure achievement of an outcome for this plan? A. Laboratory 2. data B. Physical assessment C. Health history D. Client statements 2.22 points QUESTION 32 1. Which example of patient care is 'not' the responsibility of the registered nurse? A. Tailoring 2. treatment and medication regimens for each patient B. Promoting safety and preventing harm, detecting and controlling risk of injury C. Confirming a medical diagnosis D. Monitoring for changes in health status 2.22 points QUESTION 33 1. Of the following data, what type of priority measurable signs would be collected during a physical assessment? A. Foods 2. eaten that cause nausea B. Type, amount, and duration of pain C. Possible specific allergies resulting in itching D. Color, moisture, and temperature of the skin 2.22 points QUESTION 34 1. At what point during hospital-based care does planning for discharge begin? A. Upon 2. admission to the hospital B. Immediately before discharge C. After the client is settled in a room D. After leaving the hospital 2.22 points QUESTION 35 1. What activity is carried out during the implementing step of the nursing process? A. Mutual 2. goals are established and desired client outcomes are determined. B. Planned nursing actions (interventions) are carried out. C. Desired outcomes are evaluated and, if necessary, the plan is modified. D. Assessments are made to identify human responses to health problems. 2.22 points QUESTION 36 1. A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean? A. Nothing, 2. the nurse's honesty will not be questioned. B. In the eyes of the law, if it is not documented, it was not done. C. The physician will verify that the nurse carried out the order. D. The nurse can add the documentation after the client goes home. 2.22 points QUESTION 37 1. Ordered is Heparin 7,500 units SQ QD Pharmacy sends Heparin 10,000 units/mL. How many mL do you administer for one dose? A. 0.25mL 2. B. 7.5mL C. 0.75mL D. 1mL 2.32 points QUESTION 38 1. A physician orders Solu-medrol 6mg IV push STAT time one now. Pharmacy delivers Solu-medrol 24mg in 10mL vial. How many mL do you administer for one dose? A. 1.5mL B. 0.25mL C. 3.5mL D. 2.5mL 2.22 points QUESTION 39 1. Which outcome is correctly written? A. On 2. discharge, client will be able to list five symptoms of infection. B. On discharge, client will be free of infection. C. During home care, nurse will not observe symptoms of infection. D. Abdominal incision will show no signs of infection. 2.22 points QUESTION 40 1. Which open-ended question or statement would be appropriate in eliciting further information when conducting a health history interview? A. "If2.I were you, I would not wait to get help next time." B. "Are you feeling better now than you did during the night?" C. "Tell me more about what caused your pain." D. "Why didn't you go to the doctor when you began to have this pain?" 2.22 points QUESTION 41 1. The client's expected outcome is "The client will maintain intact skin integrity by discharge." Which measure is best in evaluating the outcome? A. Pressure-relieving 2. mattress on the bed B. Percent intake of a diet high in protein by discharge C. The client's ability to reposition self in bed D. Condition of the skin over bony prominences 2.22 points QUESTION 42 1. Upon evaluation of the client's current plan of care, the registered nurse determines that the expected outcomes have all been achieved. Based upon this response, the registered nurse will: A. reevaluate 2. the plan of care. B. terminate the plan of care. C. continue the plan of care. D. modify the plan of care. 2.22 points QUESTION 43 1. A man is scheduled for hospital outpatient surgery. He tells the nurse, "I don't know what that word, outpatient, means." How would the nurse respond? A. "You 2. will have surgery and go home that same day." B. "It means the surgeon will come to your home to do the surgery." C. "Why would you ask such a question? Don't worry about it." D. "It means you will have surgery in the hospital and stay for 2 days." 2.22 points QUESTION 44 1. A client is considering transfer into an extended-care facility. What services can the nurse educate the client about that will be provided in this setting? Select all that apply. A. Nonmedical 2. care for chronic illness B. 23 hour observational stay C. Assistance with activities of daily living D. Assistance for mental disability E. Immediate care after a major surgical procedure 2.22 points QUESTION 45 1. A registered nurse is preparing to discharge a patient from an acute care facility. Which action must be performed by the nurse upon discharge of this patient ? A. Writing 2. discharge orders for the patient release B. Writing any orders for future home visits that may be necessary for the patient C. Sending the patient's records to the health care provider D. Coordinating future care for the patient 2.22 points Click Save and Submit to save and submit. Click Save All Answers to save all answers.
