Nursing Confidentiality and Client Care: Best Practices and Scenarios, Exams of Nursing

Download Nursing Confidentiality and Client Care: Best Practices and Scenarios and more Exams Nursing in PDF only on Docsity! Fundamentals of Nursing Exam 1 Practice Questions and Answers A client is referred to a surgeon by the healthcare provider. After meeting the surgeon, the client decides to consult with a different surgeon about treatment options. The nurse supports the client's action, utilizing which ethical principle? 1.Beneficence 2.Veracity 3.Autonomy 4.Privacy - Correct answer 3. Autonomy A nurse forgets to administer a dose of a client's diuretic drug and the client experiences an episode of pulmonary edema. The nurse should consider that this error constitutes negligence because the situation contains which element? 1.Purposeful failure to perform a healthcare procedure 2.Unintentional failure to perform a healthcare procedure 3.Act of substituting a different medication for the one prescribed 4.Failure to follow a healthcare provider's prescription - Correct answer 2. unintentional failure to perform a healthcare procedure An individual falls and fractures a hip while walking down the street. A companion notices a nurse drive past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which reason? 1.The nurse had no duty to the individual. 2.The nurse did what most nurses would do in the same circumstance. 3.The nurse did not cause the client's injuries. 4.The nurse was off-duty at that time. - Correct answer 1. the nurse had no duty to the individual. A client asks why a diagnostic test has been prescribed and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle? 1.Nonmaleficence 2.Veracity 3.Beneficence 4.Fidelity - Correct answer 4. fidelity A client who takes warfarin is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode caused by interaction of these drugs. The legal nurse consultant interprets which necessary elements of malpractice are missing from this case? Select all that apply. 1.Breach of duty 2.Duty owed 3.Injury experienced 4.Causation between nurse's action and injury 5.Intent to cause harm or injury - Correct answer 2 & 5. - The nurse did not have a duty to the neighbor and was not in an employment capacity. - The nurse did not intend to cause injury or harm A client with cancer has decided to discontinue further treatment. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which ethical principle? 1.Justice 2.Fidelity 1."I am pretty sure that I am going to breastfeed my baby." 2."After feeding, I should put my baby on her tummy to prevent choking." 3."Solid foods are unnecessary during the baby's first 4-6 months." 4."I should wake my baby up every 3-4 hours for feeding." - Correct answer 2. After feeding, I should put my baby on her tummy to prevent choking 2.The result of a toddler's lead screening is 12 mg/dL. What would the nurse say to the mother at this time? 1."His lab values are just fine." 2."Have you noticed any blood in his stools?" 3."When were his last immunizations?" 4."Tell me about where you live." - Correct answer 4. tell me about where you live 3.A newborn is scheduled for discharge from the birthing center tomorrow. When teaching the new parents about car seats, which characteristics of infant restraint systems would the nurse include as essential for the newborn? Select all that apply. 1.Forward-facing 2.Rear-facing 3.In the back seat 4.In the front seat 5.Of a solid and neutral color - Correct answer 2 & 3. Rear-facing, in the back seat 4.Which snack would the nurse appropriately offer the hospitalized toddler? 1.Crackers 2.Peanuts 3.Grapes 4.Cereal bar - Correct answer 1. crackers What is the best method for the nurse to use to encourage the use of bicycle helmets by school-age children? 1.Advocate for legislation on helmet laws. 2.Teach parents to role-model helmet use while riding bicycles. 3.Verbally reprimand children who report not wearing helmets while riding. 4.Recommend the parents purchase stylish helmets to increase compliance. - Correct answer 2.Teach parents to role-model helmet use while riding bicycles. 6.A school nurse is planning a health class on accidents and injuries for high school students. Which topic is most important to include? 1.Occupational-related injuries at work 2.Motor vehicle-related injuries 3.Fall-related injuries 4.Injury due to residential fires - Correct answer 2.Motor vehicle- related injuries 7.The home health nurse is visiting an older adult client with diabetes mellitus. The nurse becomes concerned and implements safety education when which of the following occurs? 1.Neighbors bring a warm lunch to client 2.Children install air conditioners in kitchen and bedroom 3.Grandchildren place baskets of folded laundry by bedroom door 4.Client stores diabetic testing supplies on kitchen table - Correct answer 3.Grandchildren place baskets of folded laundry by bedroom door 8.The nurse preceptor observes the new RN administering medications. The preceptor concludes there is a risk for medication error when the new RN takes which action? 1.Answers a healthcare provider's page while passing medications 2.Uses military time for documentation 3.Asks for help with a dosage calculation 4.Does not give a medication that the client questions - Correct answer 1.Answers a healthcare provider's page while passing medications 9.The nurse would ask a client scheduled for a venogram about allergy to which substance before the procedure? 1.Peanuts 2.Iodine 3.Eggs 4.Meat tenderizer - Correct answer 2. iodine 10.Which of the following medication prescriptions should the nurse question? 1.Morphine sulfate 4 mg IV every 3-4 hours as needed for pain 2.Ceftriaxone IVPB every 8 hours 3.Furosemide 40 mg po daily 4.Metoprolol 50 mg po twice a day - Correct answer 2.Ceftriaxone IVPB every 8 hours there is no dosage 11.The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required? 4.Priority 4 (black tag) - Correct answer 2.Priority 2 (yellow tag) 18.The nurse should explain to the mother of a 10-month-old infant that a rear-facing car safety seat should continue to be used until the child exceeds the weight limit or is months of age - Correct answer 24 months, or 2 years 19.The nurse is treating a client who continues to return to a violent relationship saying, "There is nothing I can do." What is the nurse's best response? 1."You do have some choices; let's sit together and explore them." 2."If you return you are at risk for further abuse." 3."Here is the number of the crisis hotline." 4."Do you have family or friends who can help?" - Correct answer 1."You do have some choices; let's sit together and explore them." 20.The nurse is assessing a school-age child. Which finding by the nurse may indicate physical neglect? 1.Not following instructions well 2.Boisterous activity 3.Stealing or hoarding food 4.Sudden onset of enuresis - Correct answer 3.Stealing or hoarding food 21.The nurse admits a female client to the emergency department who arrives with a black eye and reports of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical workup was negative. The nurse should assess the client for which priority problems? Select all that apply. 1.Premenstrual syndrome 2.Physical or sexual abuse 3.Irritable bowel syndrome 4.Self-destructive potential 5.Migraine headache - Correct answer 2 & 4. Physical or sexual abuse, and self-destructive potential what is the chain of infection? - Correct answer 1. etiologic agent (microorganism) 2. reservoir (source) 3. portal of exit from reservoir 4. method of transportation 5. portal of entry to the susceptible host 6. susceptible host what Is the most effective way to prevent spread of microorganisms? - Correct answer Hand hygiene What does PPE consist of? - Correct answer Gloves, gown, mask, eye protection During a nursing assessment, the client states he is 70 years old and has a history of staphylococcus infections, increased intraocular pressure, and blurred vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts? 1. History of staphylococcus infections 2. Increased intraocular pressure 3. Stated age of client 4. Long duration of blurred vision - Correct answer 3. age of the client A 92-year-old client who is very hard of hearing is hospitalized. Which action by the nurse is appropriate when conducting the admission interview and assessment of the client? 1. Use a cotton swab to clean cerumen in the client's ear before the interview. 2. Speak louder into the client's ear determined to have better hearing. 3. Maintain normal pitch of the voice and face the client during the interview. 4. Put new batteries in the hearing aid to ensure proper functioning. - Correct answer 3. Maintain normal pitch of the voice and face the client during the interview. A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply. 1. Remove equipment from the room. 2. Explain procedures and routines to the client upon admission. 3. Provide a clock and calendar in the client's room. 4. Maintain a balance of activity and rest periods. 5. Maintain constant conversation when in the client's room. - Correct answer 3. Provide a clock and calendar in the client's room. 4. Maintain a balance of activity and rest periods. The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure? 1.Moderately stretch the bandage and wrap it from distal extremity to proximal. 2. Wrap the extremity loosely enough to insert two fingers beneath the bandage. 3. Maintain a tight stretch with each wrap of the bandage. 4. Start proximal to the injury site and work distally. - Correct answer 1. Moderately stretch the bandage and wrap it from distal extremity to proximal. All of the following clients visit the emergency room during one shift. For which clients should the nurse expect the healthcare provider to prescribe an antibiotic? Select all that apply. Uses the swing-to gait Uses axillary crutches Bears weight on the armpits Replaces rubber tips on the crutches - Correct answer Bears weight on the armpits A male client sustained numerous types of wounds when he lost control of his motorcycle and was thrown onto the pavement. The client asks the nurse which wounds will heal best. The nurse's reply is based on analysis that which type of wound would generally be least likely to scar? A wound that heals by primary intention A wound that heals by secondary intention A wound that becomes infected A wound to an extremity - Correct answer A wound that heals by primary intention A postoperative client tells the nurse that he developed dehiscence after his last surgery and wants to make sure it doesn't happen this time. Which nursing intervention should the nurse implement that would be most effective in preventing dehiscence in a postoperative client? Helping the client lose weight Preventing vomiting Administering antibiotics Keeping the wound dry - Correct answer Preventing vomiting An older adult client's postoperative abdominal wound is still healing weeks after the surgery. The client asks the clinic nurse why the wound is healing so slowly. Which factors should the nurse identify that negatively affect healing in older adults? Select all that apply. Vascular changes Nutritional status Decreased activity Keloid formation Nutrient absorption - Correct answer Vascular changes Nutritional status Nutrient absorption A client admitted to the hospital for gallbladder surgery is diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively? Unusual muscle weakness Mental confusion Delayed wound healing Ataxia upon ambulating - Correct answer Delayed wound healing The nurse is assessing a client with a mobility problem to determine an appropriate assistance device. The client's lower extremities have no paralysis, but are very weak. Upper-body strength is also reduced. The nurse should suggest which device for this client? Cane Four-wheeled walker Canadian or elbow extension crutch Lofstrand crutch - Correct answer Four-wheeled walker The nurse is evaluating a client using a cane. Which assessment made by the nurse would indicate that the client is using the cane appropriately? Client holds the cane with the hand on the stronger side. Client holds the cane with the hand on the affected side. Client moves the cane and the affected leg together. The cane tip is made of aluminum to prevent slippage. - Correct answer Client holds the cane with the hand on the stronger side. A client is at risk for developing a pressure injury and is placed on a repositioning regimen. The client does not like to lie on his side and complains about the need to turn. Which explanations by the nurse may enhance compliance? Select all that apply. "Turning helps maintain skin integrity by alternating areas of pressure." "Excess pressure interferes with skin absorption of vitamin D." "Changing positions will promote circulation and prevent contractures." "Changing position helps prevent skin breakdown that could ultimately lead to infection." "A repositioning schedule is a standard part of hospital policy." - Correct answer "Turning helps maintain skin integrity by alternating areas of pressure." "Changing positions will promote circulation and prevent contractures." "Changing position helps prevent skin breakdown that could ultimately lead to infection." The nurse is changing the abdominal dressing of a client who is 4 days postoperative. The nurse notes a moderate amount of serosanguineous drainage, wound edges not approximated, and puffy tissue protruding through the wound. What condition should the nurse suspect from theses manifestations? Hemorrhage Normal healing by primary intention Normal healing by secondary intention Evisceration - Correct answer Evisceration The nurse needs to conduct an admission interview with a 74- year-old client who is hearing impaired. What should the nurse do to enhance the client's ability to hear? Select all that apply. Position self to be within the client's line of vision Dim the lights in the room Overarticulate words Reevaluate status every 3 to 5 minutes until the code team arrives. - Correct answer Depress the sternum at least 5 cm (2 in.) during cardiac compressions. The nurse who is doing the documentation during a code blue on an adult client observes an unlicensed assistive person (UAP) doing CPR. The nurse concludes the UAP is using correct procedure after noting that the UAP is depressing the sternum at least how many inches? - Correct answer 2 inches The nurse is performing cardiopulmonary resuscitation (CPR) on a 10-month-old infant. The nurse times the rate of compressions to achieve a minimum of how many compressions per minute - Correct answer 100 A nurse witnesses an adult male collapse at the airport and an automated external defibrillator (AED) is brought to the scene. The nurse should perform which actions in using the device? Press the electrodes down firmly because the client has a hairy chest. Instruct another person at the scene to keep the airway open during delivery of the electric shock. Initiate CPR after 5 minutes if the AED has not restored a perfusing cardiac rhythm. Quickly wipe up the spilled coffee under the victim's chest before using the AED. - Correct answer Quickly wipe up the spilled coffee under the victim's chest before using the AED. A nurse is eating in a restaurant when a woman who is 8 months pregnant at the next table begins to choke. Which hand placement should the nurse use to perform the abdominal-thrust maneuver? Midsternum Lower sternum Midway between umbilicus and xiphoid process Midway between umbilicus and symphysis pubis - Correct answer Midsternum The long-term care nurse has been called to the aid of a resident who has become unconscious after choking in the dining room. After positioning the client on the back, which action should the nurse take next? Attempt to ventilate the client. Begin cardiopulmonary resuscitation, starting with chest compressions. Perform five abdominal thrusts. Perform five chest thrusts. - Correct answer Begin cardiopulmonary resuscitation, starting with chest compressions. A nurse enters an adult client's room and says, "Good morning!" while doing initial shift rounds after receiving report. The client does not respond. Put the nurse's actions in order of priority. Call for someone to announce a code blue. Check for a carotid pulse. Gently shake the client's shoulder and ask, "Are you okay?" Begin chest compressions. - Correct answer Gently shake the client's shoulder and ask, "Are you okay?" Call for someone to announce a code blue. Check for a carotid pulse. Begin chest compressions. what are the interrelated roles of nurses? - Correct answer - caregiver -communicator -teacher/educator -counselor -leader -researcher -advocate -collaborator what are the QSEN competencies? - Correct answer -patient centered care -teamwork and collaboration -quality improvement -safety -EBP -informatics What is the nurse practice act? - Correct answer - Define legal scope of nursing practice - Create a state board of nursing to make and enforce rules and regulations - Define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - Establish criteria for the education and licensure of nurses what are the 6 human dimensions - Correct answer Physical, Emotional, Sociocultural, Spiritual, Environmental, and Intellectual What is an example of a nursing activity that promotes secondary prevention as a level of preventive care? A. Conducting a smoking cessation class B. Performing a blood pressure screening at a local mall C. Performing range-of-motion exercises on a bedridden patient D. Promoting safer sex practices in school settings - Correct answer B. Performing a blood pressure screening at a local mall Maslows hierarchy of human needs- List from highest level needs to lowest level needs - Correct answer self-actualization, self esteem, love and belonging, safety and security, physiologic Which patient need has the highest priority? A patient who needs to ambulate to prevent DVT A patient who is in isolation and feels lonely