Module 1

Question 1

Which of the following methods of information exchange can occur without client authorization?

a. walking rounds that involve two nurses discussing an assigned client at the bedside in a private room
b. recording shift report on a device for all oncoming staff to access information about all clients on the unit
c. talking about a client’s information during a staff in service with all levels of unit staff present
d. providing an employer with confirmation that their employee is currently being treated in the facility

Answer 1

a. walking rounds that involve two nurses discussing an assigned client at the bedside in a private room

Question 2

A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Which of the following agencies should the nurse instruct the client to file the complaint?

a. Occupational Safety and Health Administration
b. The Joint Commission
c. Office for Civil Rights
d. Privacy and Civil Liberties Office

Answer 2

c. Office for Civil Rights

Question 3

A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client’s spouse is not present at the the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client’s surgery?

a. ask the facility’s privacy officer to witness the informed consent document
b. inform the client’s friends that are present about the surgery and obtain group consent
c. ask the nursing supervisor to provide implied emergency consent
d. inform the provider of the spouse’s contact information so consent can be obtained over the telephone

Answer 3

d. inform the provider of the spouse’s contact information so consent can be obtained over the telephone

Question 4

a nurse is teaching a newly licensed nurse about using a computer to document in a client’s health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

a. I should share my computer password with the nurse orienting me
b. I should remain aware of my surroundings when documenting in the computer
c. I can step away from the computer for a short time if i am logged on and no one is around
d. I can review the health records of other clients on the unit not assigned to me

Answer 4

b. I should remain aware of my surroundings when documenting in the computer

Question 5

which of the following actions should a nurse take after witnessing a breach of a client’s confidentiality in a provider’s office?

a. complete a health information privacy complaint form
b. anonymously notify the proper government agency
c. notify the client and ask them to complete a health information privacy complaint
d. inform the provider that a formal complaint will be submitted if another breech in committed

Answer 5

a. complete a health information privacy complaint form

Question 6

A nurse in a pediatrician’s office is speaking on the telephone with the guardian of a school age child who will become a new client at the office. The nurse should instruct the guardian to call the child’s previous providers office to request which of the following?

a. the guardian be allowed to take the child’s medical records and make photocopies for the new pediatricians office
b. the child’s original medical records be given to the new pediatricians office
c. a form authorizing release of copies of the child’s medical records to be signed by the guardian
d. a form authorizing of the release of the child’s medical records to be signed by the new pediatrician and sent back to the previous provider

Answer 6

c. a form authorizing release of copies of the child’s medical records to be signed by the guardian

Question 7

A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurse take to ensure the study complies with the HIPPA Privacy Rule?

a. contact the medical record department to obtain permission to access client’s charts
b. submit their proposal to the institutional review board for review and describe how they will de-identify client information
c. notify the clients who will be induces in the study to submit a written request if they choose not to participate
d. obtain permission from the risk management department to gain access to incident reports that were files due to client falls

Answer 7

b. submit their proposal to the institutional review board for review and describe how they will de-identify client information

Question 8

keeping promises and commitments to clients

Answer 8

fidelity

Question 9

providing impartial, fair, and equitable care to all clients

Answer 9

justice

Question 10

minimizing harm and practicing in a way that benefits the client

Answer 10

beneficence

Question 11

respecting the client’s right to make decisions about their care

Answer 11

autonomy

Question 12

providing truthful and accurate information to the client

Answer 12

veracity

Question 13

a nurse works in a small community hospital emergency department and receives a report from the EMS that they are on route with a pediatric client who has severe burns to the upper body and difficulty breathing. The nearest burn center is 75 miles away. Which of the following actions should the nurse and ED team take to adhere to EMTALA?

a. instruct EMS to reroute to the burn center instead of coming directly to the ED
b. ask EMS to confirm the client’s insurance status to determine if the client can be treated in the ED
c. attempt to stabilize the client in the ED before transport to the burn center
d. determine if a pediatric provider is available before accepting the client in the ED

Answer 13

c. attempt to stabilize the client in the ED before transport to the burn center

Question 14

in the video the charge nurse is informed that the client’s protected health information is displayed on a computer. which of the following actions should the nurse take first?

a. report the incident to the facilities privacy officer
b. talk with the clients nurse about the concern
c. log out of the client’s nurse from the computer
d. provide HIPPA training to the client’s nurse

Answer 14

c. log out of the client’s nurse from the computer

Question 15

the six ethical principles of the nursing profession

Answer 15

1. autonomy
2. beneficence
3. nonmaleficence
4. veracity
5. fidelity
6. justice

Question 16

the five professional values of nursing

Answer 16

1. altruism
2. human dignity
3. integrity
4. autonomy
5. social justice

Question 17

the process the nurse mist complete to identity, assess, and develop their own personal value system

Answer 17

value clarification

Question 18

the two types of unintentional torts

Answer 18

1. malpractice

2. negligence

Question 19

the four types of intentional torts

Answer 19

1. invasion of privacy
2. defamation
3. assault
4. battery

Question 20

the two types of advance directives

Answer 20

1. living will

2. durable power of attorney

Question 21

the physical and mental exhaustion that can cause the nurse to be unable to function safely

Answer 21

nurse fatigue

Question 22

the process of documentation that is inaccurate, incomplete, or misleading

Answer 22

falsification of health records

Question 23

a nurse truthfully answers and clients questions about their laboratory results. the nurse is demonstrating which of the following ethical principles?

a. justice
b. nonmaleficence
c. fidelity
d. veracity

Answer 23

d. veracity

Question 24

a nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. which of the following is the provider violating?

a. the emergency medical treatment and labor act
b. the health insurance portability and accountability act
c. tort law
d. good Samaritan law

Answer 24

a. the emergency medical treatment and labor act

Question 25

a nurse is caring for a client who asks why they chose the nursing profession. the nurse states that it was because they wanted to heal others. the nurse is referring to which of the following professional values? a. integrity b. human dignity c. altruism d. social justice

Answer 25

c. altruism

Question 26

a nurse is teaching a newly licensed nurse about the professional values. the nurse should include that which of the following is an example of autonomy? a. a nurse provides the same quality of care for every client b. a nurse maintains client confidentiality c. a nurse admits they forgot to change a client's dressing d. a nurse respects a client's wish to discontinue a treatment

Answer 26

d. a nurse respects a client's wish to discontinue a treatment

Question 27

a nurse is providing privacy for a client who has incontinence. the nurse is demonstrating which of the following professional values? a. human dignity b. altruism c. social justice d. autonomy

Answer 27

a. human dignity

Question 28

a nurse is teaching a newly licensed nurse about ethical principles. the nurse should include that which of the following situations is an example of fidelity? a. a nurse involves a client in making decisions about their care b. a nurse implements fall precautions for a client who is at risk for falling c. a nurse tells the truth about forgetting to perform a procedure for a client d. a nurse keeps a promise to a client to not tell their family about their diagnosis

Answer 28

d. a nurse keeps a promise to a client to not tell their family about their diagnosis

Question 29

a nurse notifies their supervisor that they accidentally administered the wrong medication to a client. the nurse is demonstrating which of the following professional values? a. integrity b. human dignity c. altruism d. social justice

Answer 29

a. integrity

Question 30

a nurse is caring for a client who is alone and just received a serious diagnosis. the client asks the nurse is they can pray together and the nurse agrees. the nurse is demonstrating which of the following ethical principles? a. autonomy b. beneficence c. nonmaleficence d. justice

Answer 30

b. beneficence

Question 31

a nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. which of the following actions should the nurse take to provide the expected standard of care a. document the medication was not administered b. document that the client is not experiencing pain c. contact the provider to change the PRN prescription

Answer 31

a. document the medication was not administered

Question 32

a nurse suspects their coworker might be under the influence of a chemical substance. which of the following actions should the nurse take? a. counsel the coworker about the substance abuse b. report the coworker to the ethical committee at the facility c. ask the coworker how long they have been using substances d. tell the charge nurse that the coworker might be impaired

Answer 32

d. tell the charge nurse that the coworker might be impaired

Question 33

a nurse who has been working 12-hour shifts on a busy unit is experiencing nurse fatigue. which of the following effects can result from the nurse fatigue? a. increase in communication skills b. increase in effective clinical judgment c. increase in medication errors d. increase in productivity

Answer 33

c. increase in medication errors

Question 34

a nurse is caring for a client who is scheduled for surgery. before the client has signed the informed consent form, the client states, "I don't really understand what that doctor said. "which of the following actions should the nurse take? a. explain the procedure in detail to the client b. ask the provider to discuss the procedure with the client c. encourage the client to reread the consent form before signing d. tell the client that the surgeon will explain it to them in the operating room

Answer 34

b. ask the provider to discuss the procedure with the client

Question 35

a nurse is teaching a group of newly licensed nurse about the professional values. which of the following statements by a newly licensed nurse demonstrates understanding of social justice? a. health care should be a right for everyone b. all clients should have a private room in a health care facility c. i plan to volunteer at the local homeless shelter on my days off

Answer 35

a. health care should be a right for everyone

Question 36

a nurse is an emergency department is caring for four clients. which of the following clients requires mandatory reporting? a. an adolescent client who has a fractured tibia following a football game b. a young adult client who is positive for tuberculosis c. an older adult client who has dementia, a history of falls, and bruising on their knees d. a preschooler who has a frequent enuresis

Answer 36

b. a young adult client who is positive for tuberculosis

Question 37

a nurse is teaching a client about advance directives. which of the following client statements indicates an understanding of the teaching? a. i need to choose a family member as my health care surrogate b. once i sign my advance directive, i cannot change my decision c. my health care surrogate will make health care decisions for me if i am unstable d. i need to have an attorney present to complete my advance directives

Answer 37

c. my health care surrogate will make health care decisions for me if i am unstable

Question 38

a nurse is providing equal care to a group of clients who have varing economic statuses. which of the following ethical principles is the nurse demonstrating? a. fidelity b. autonomy c. justice d. veracity

Answer 38

c. justice

Question 39

a nurse is reviewing standards of care with a group of newly hired nurses. the nurse should include which of the following incidents as an example of a breach of standards of care? a. a nurse did not read back a verbal medication prescription to a provider b. a nurse did not return to a client's room with a promised blanket c. a nurse documents client care as soon as it is completed d. a nurse forgot to call a clients family after performing a procedure

Answer 39

a. a nurse did not read back a verbal medication prescription to a provider

Question 40

a nurse is teaching a newly licensed nurse about ethical principles. the nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles? a. veracity b. beneficence c. autonomy d. fidelity

Answer 40

c. autonomy

Question 41

which of the following is responsible for authorizing the practice of nursing? a. state board of nursing b. NCLEX c. American nurses association

Answer 41

a. state board of nursing

Question 42

which of the following is one of the foundations of the nursing profession? a. personal morals b. professional identity c. professional values

Answer 42

c. professional values

Question 43

which of the following resources provides guidance on the legal responsibilities of nurses to clients and society? a. nursing social policy statement b. code of ethics for nurses c. scope and standards of practice

Answer 43

b. code of ethics for nurses

Question 44

a nurse who displays a selfless concern for others is exhibiting which of the following? a. accountability b. altruism c. responsibility

Answer 44

b. altruism

Question 45

which of the following professional organizations provides specific guidance to licensed practical nurses? a. IPNRC - international parish nurse resource center b. NAPNES - national association for practical nurses education and services c. AACN - American association of critical care nurses

Answer 45

b. NAPNES - national association for practical nurses education and services

Question 46

which of the following professional associations advances the nursing profession by creating high standards for nursing practice? a. american nurses association b. national league for nursing c. american association of colleges of nursing

Answer 46

a. american nurses association

Question 47

a nurse is acting as a preceptor for a student studying the concept of autonomy. the nurse confirms the student's confirms the student's clear understanding o autonomy when the student describes it as which of the following? a. critical thinking b. team collaboration c. individual choice

Answer 47

c. individual choice

Question 48

which of the following actions demonstrates the professional concept of assertiveness? a. boldly sharing conflicting ideas b. using a team based approach c. feeling of strong self esteem

Answer 48

a. boldly sharing conflicting ideas

Question 49

which of the following situations is an example of horizontal violence? a. a nurse blames a peer for her error b. a provider openly scorns a charge nurse c. an assertiveness personnel is belittles by a nurse manager

Answer 49

a. a nurse blames a peer for her error

Question 50

a nurse educator is describing positive peer to peer interactions during a staff meeting. which of the following should he use to accurately describe coaching? a. helps overall care delivery b. has a defined time frame c. outlines clear initial goals

Answer 50

a. helps overall care delivery

Question 51

a nurse manager is developing an evaluation form for employees. which of the following description should be used to measure integrity? a. utilizes good decision making b. performs wound care successfully c. follows standard protocols

Answer 51

c. follows standard protocols

Question 52

which of the following relates to the concept of caring in professional nursing? a. straying from current values b. promoting role excellence c. reflecting historical evidence

Answer 52

b. promoting role excellence

Question 53

a nurse is compiling an orientation handout related to accountability and responsibility. which of the following should the nurse use to describe responsibilities? a. an internal obligation to others b. duty to report quality of work c. basic care needs of clients

Answer 53

c. basic care needs of clients

Question 54

a nurse is reviewing information related to balancing autonomy with boundaries. which of the following phrases should the nurse expect to find related to the concept of boundaries? a. allow for increased flexibility in caregiving b. impede design and delivery of safe care c. guided by state nurse practice act

Answer 54

c. guided by state nurse practice act

Question 55

nurses "five rights"

Answer 55

1. right task 2. right circumstance 3. right person 4. right direction and communication 5. right supervision

Question 56

which of the following professional association established the code of ethics, social policy statement, and scope and standards of practice? a. american association of colleges of nursing b. american nurses association c. national league for nursing

Answer 56

b. american nurses association

Question 57

which of the following defines nurses scope of practice in each state? a. nurse practice acts b. american nursing association c. department of health and human services

Answer 57

a. nurse practice acts

Question 58

a nurse acting to accomplish goals in an effective manner with other people is fulfilling which of the following roles? a. change agent b. manager c. educator

Answer 58

b. manager

Question 59

participation in health policy development and the political process is a significant part of which of the following nursing roles? a. manager b. collaborator c. advocate

Answer 59

c. advocate

Question 60

a nurse is telling the truth, keeping promises, and doing no harm while caring for a client who is experiencing conflict with his family. which of the following is the nurse demonstrating? a. human client autonomy b. primary commitment to the client c. accountability for professional practice

Answer 60

b. primary commitment to the client

Question 61

which of the following makes it acceptable to report confidential client information if abuse, neglect, or exploitation is suspected? a. patient self determination act b. health insurance portability and accountability act c. Americans with disability act

Answer 61

b. health insurance portability and accountability act

Question 62

which of the following actions represents the professional value of altruism? a. a nurse mentoring a colleague in professional growth b. a nurse respecting a client's decision to refuse treatment c. a nurse encouraging a clinic to treat a homeless man who is unable to pay for his care

Answer 62

a. a nurse mentoring a colleague in professional growth

Question 63

which of the following is a characteristic of a mentor? a. formally assigned by the nurse manager b. assists protege in professional development c. orients new graduates to a specific work environment

Answer 63

b. assists protege in professional development

Question 64

a nurse is working as a member of an interprofessional team. which of the following actions should the nurse take? a. plan client care based on the nursing perspective b. separate client goals by discipline c. use assertive communication

Answer 64

c. use assertive communication

Question 65

according to patricia benner, a novice nurse demonstrates which of the following behaviors? a. intuition b. improved decision making c. inflexibility

Answer 65

c. inflexibility

Question 66

which of the following is a component of bioculturism? a. following a single value system b. evaluation of personal values c. development of professional identity

Answer 66

b. evaluation of personal values

Question 67

which of the following is a characteristic associated with kramer's honeymoon phase of reality? a. complacency b. excitement c. fear

Answer 67

b. excitement

Question 68

which of the following will assist the new graduate nurse with the development of knowledge and skills necessary for the nursing role? a. mentor b. collaborator c. preceptor

Answer 68

c. preceptor

Question 69

a mentor is assisting a new graduate nurse develop strategies to transition successfully from student to professional nurse. the mentor should intervene if the new nurse incorporates which of the following strategies? a. evaluates growth by comparing progress with peers b. actively participates in professional nursing association activities c. utilizes resources available through the employing facility

Answer 69

a. evaluates growth by comparing progress with peers

Question 70

a nurse is planning care for a client who is having difficulty swallowing food at a medium. which of the following interventions should the nurse include in the plan of care? a. place client in semi fowlers position while eating b. allow the client to rest for 15 min before eating c. tolt the clients head backwards when he swallows d. provide oral hygiene before a meal

Answer 70

d. provide oral hygiene before a meal

Question 71

a nurse is caring for a client who has crohns disease and is on a low residue diet. which of the following foods should the nurse provide the client as a snack? a. 1 cup of pasta b. 1 medium apple c. 1 cup steamed vegetables d. 1 cup of bran flakes

Answer 71

a. 1 cup of pasta

Question 72

a nurse is promoting independence at mealtime for a client who has vision impairment. which of the following interventions should the nurse implement? a. hand the client a fork with a piece of food placed on it b. place the client's napkin in his lap c. reference the face of a clock to indicate where the food is placed on the plate d. move the water jug before placing the food tray on the bedside table

Answer 72

c. reference the face of a clock to indicate where the food is placed on the plate

Question 73

a nurse is caring for a client who has been placed on a full liquid diet. which of the following foods should the nurse offer the client? a. cream of chicken soup b. scrambled eggs c. cottage cheese d. mashed potatoes and gravy

Answer 73

a. cream of chicken soup

Question 74

a nurse is assisting a client who is at risk for aspiration following a stroke with eating. which of the following actions should the nurse take? a. lay the client down flat on the bed 20 min after meals b. place 1 tbsp of food on the unaffected side of the clients mouth c. elevate the head of the clients bed to a 45 degree angle during meals d. palpate the clients throat while she is swallowing food

Answer 74

d. palpate the clients throat while she is swallowing food

Question 75

a nurse is reviewing a client's medication administration record. the nurse should identify that which of the following medications places the client at risk for dry mouth? a. digoxin b. gabapentin c. isosorbide dinitrate d. ranitidine

Answer 75

b. gabapentin

Question 76

a nurse is assessing a client's oral cavity and observes an accumulation of foul matter. which of the following findings should the nurse document? a. tartar b. sordes c. periodontal disease d. xerostomia

Answer 76

b. sordes

Question 77

a nurse is teaching a family member of a client who is unconscientious how to provide oral care for the client. the nurse should identify which of the following statements as an indication that the family member understands the teaching? a. i will use mineral oil to keep her lips moist b. i will cleanse her guns with a lemon glycerin swab c. i will use my fingers to keep her mouth open d. i will rinse her mouth with an alcohol free mouth wash

Answer 77

d. i will rinse her mouth with an alcohol free mouth wash

Question 78

a nurse is assessing a client who is receiving chemotherapy and reports pain and burning in his mouth. the nurse notes red and inflamed oral mucosa. which of the following should the nurse document? a. stomatitis b. halitosis c. gingivitis d. glossitis

Answer 78

a. stomatitis

Question 79

a nurse is caring for a client who is unconscious and requires oral hygiene. the nurse should place the client in which of the following positions? a. dorsal recumbent b. lateral c. prone d. Trendelenburg

Answer 79

b. lateral

Question 80

a nurse is preparing an educational program for a group of staff nurses about transmission precautions. which of the following instructions should the nurse include? a. a nurse should use airborne precautions when caring for a client who has tuberculosis b. a nurse should use contact precautions when caring for a client following stem cell transplant c. a nurse should use a protective environment when caring for a client who has streptococcal pharyngitis

Answer 80

a. a nurse should use airborne precautions when caring for a client who has tuberculosis

Question 81

a nurse is preparing to exit the isolation room of a client who has disseminated varicella zoster virus which requires airborne precautions. which of the following actions should the nurse take? a. keep the client's door open to prevent a feeling of loneliness b. remove the first glove b grasping the lower portion of the glove with the opposite hand and pulling it off inside out c. remove the mask by holding the front of the mask with one hand while trying to untie the top and bottom ties with the other hand d. fold the contaminated side outward when removing the gown

Answer 81

b. remove the first glove b grasping the lower portion of the glove with the opposite hand and pulling it off inside out

Question 82

a nurse is evaluating an assistive personnel's understanding of isolation precautions. which of the following actions by the AP indicates an understanding of isolation precautions? a. covering her uniform with a client hospital gown when emptying the bed pan for a client who has clostridium difficile infection b. wearing cleaning gloves when providing a back massage for a client who is post operative following an appendectomy c. using separate urinary measuring container to empty a clients urinary catheter drainage bag d. holding her hands higher than her elbows when performing hand hygiene at the beginning of the shift

Answer 82

c. using separate urinary measuring container to empty a clients urinary catheter drainage bag

Question 83

a nurse in full PPE is preparing to leave the room of a client who is in isolation. which of the following PPE should the nurse remove first? a. face shield b. gloves c. gown d. mask

Answer 83

b. gloves

Question 84

a nurse is contributing to the plan of care for a client who has a wound infection and requires contact precautions. which of the following actions should the nurse include in the plan of care? a. remove the isolation gown before leaving the clients room after providing direct care to the client b. place the client in a room with a negative airflow pressure of at least six exchanges pre hour c. limit the visitation of family members to 30 min per day d. instruct the client to remain in bed

Answer 84

a. remove the isolation gown before leaving the clients room after providing direct care to the client

Question 85

a nurse is caring for a client who has a health care associated infection. which of the following describes an exogenous HAI? a. a salmonella infection that occurs after eating contaminated food b. an infection that occurs during a therapeutic procedure c. a yeast infection that occurs while receiving broad spectrum antibiotics d. a urinary tract infection that occurs after a sterile catheter insertions

Answer 85

a. a salmonella infection that occurs after eating contaminated food

Question 86

what should the nurse do to maintain standard precautions? a. rinse gloves that become visibly soiled during use b. use an antimicrobial soap for routine handwashing c. disinfect hands immediately after washing hands d. keep gloves on when touching environmental surfaces

Answer 86

c. disinfect hands immediately after washing hands

Question 87

a nurse is caring for a client who has mycoplasma pneumoniae. the client has been placed on droplet precautions. which of the following actions should the nurse take when caring for the client? a. wear a respirator b. protect the eyes c. put on clean gloves d. wear shoe covers

Answer 87

b. protect the eyes

Question 88

a nurse is about to irrigate a clients open wound. besides gloves which of the following PPE should the nurse wear? a. a sterile gown b. goggles c. a face shield d. an N95 respirator

Answer 88

c. a face shield

Question 89

which of the following products can affect the permeability of latex gloves? a. antimicrobial soap and water b. alcohol based antiseptic gel c. petroleum based hand lotion d. water based hand lotion

Answer 89

c. petroleum based hand lotion

Question 90

a nurse is washing their hands with soap and water prior to repositioning a client in bed. during the handwashing procedure, it is important to take which of the following actions? a. make sure the water is hot b. wash for at least 20 seconds c. use a liquid soap preparation d. remove rings and watches first

Answer 90

b. wash for at least 20 seconds

Question 91

contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? a. hepatitis B b. measles c. meningitis d. infectious diarrhea

Answer 91

d. infectious diarrhea

Question 92

a nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include? a. lean on the crutches to support your body weight when standing b. fully extend your arms when holding onto the hand grips c. hold the crutches on your unaffected side when preparing to sit in a chair d. hold the crutches 9 in in front of and to the side of each foot

Answer 92

c. hold the crutches on your unaffected side when preparing to sit in a chair

Question 93

a nurse stands facing a client to demonstrate active range of motion exercises. which of the following actions should the nurse take to demonstrate hyperextension of the hip? a. move their leg behind their body b. move their leg forward and up c. move their leg medially toward their other leg d. turn their foot and leg away from their other leg

Answer 93

a. move their leg behind their body

Question 94

a nurse is assisting with the ambulation of a client who becomes light headed and begins to fall. which of the following actions should the nurse take? a. wrap both arms around the clients arms and shoulders b. move both feel together when the client begins to fall c. protect the client's extremities while lowering them to the ground d. extend one leg and allow the client to slide down the leg to the floor

Answer 94

d. extend one leg and allow the client to slide down the leg to the floor

Question 95

a nurse is caring for a client who has a prescription for knee length antembolic stockings. which of the following actions should the nurse take? a. place the stocking on the client after the client ambulates to the restroom b. ensure the client's toes are visible after placing the stockings on the client c. after applying the stockings, place two fingers between the clients leg and stocking to check the fit d. measure the clients calf circumference and leg length from heel to toe

Answer 95

d. measure the clients calf circumference and leg length from heel to toe

Question 96

a nurse is caring for a client who has been hospitalized and is performing active range of motion exercises. which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? a. abducting the arm so that it lies next to the clients side b. flexing the shoulder by raising the arm from a side position to a 180 degree angle c. abducting the arm to a 90 degree angle from the side of the body d. circumduction the shoulder in a 180 degree half circle

Answer 96

b. flexing the shoulder by raising the arm from a side position to a 180 degree angle

Question 97

a nurse is preparing to transfer a client who has left sided weakness from the bed to the chair. which of the following actions by the nurse demonstrates correct transfer technique? a. positioning the chair slightly behind the nurse so that the seat faces the clients bed b. placing the clients left leg in front of the right leg just prior to the transfer c. aligning the nurses knees with the clients knees just before the transfer d. grasping the client under the axillae to assist them to their feet

Answer 97

c. aligning the nurses knees with the clients knees just before the transfer

Question 98

a nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a client from the bed to the chair. for which of the following actions by the AP should the nurse intervene? a. places a removable cover over the sling b. leaves the beg in the lowest position throughout the procedure c. locks the hydraulic valve before attaching the sling to the lift d. raises the head of the bed to a sitting position just before the transfer

Answer 98

b. leaves the beg in the lowest position throughout the procedure

Question 99

a nurse is a long term care facility is caring for a client who is on bed rest and requires frequent linen changes. which of the following should the nurse identify as the priority rationale for frequent linen changes? a. moisture from excessive diaphoresis can cause skin breakdown b. moisture of the sheets can cause discomfort to the client c. it provides an opportunity to frequently evaluate the skin on the clients back d. it provides an opportunity to turn the client from side to side to facilitate clearing potential fluid from the lungs

Answer 99

a. moisture from excessive diaphoresis can cause skin breakdown

Question 100

a nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. which of the following statements by the newly licensed nurse indicated an understanding of the teaching? a. ill swab the clients mouth with lemon glycerin swabs b. ill swab the clients mouth with mouthwash c. ill swab the clients mouth with chlorhexidine d. ill swab the clients lips with a very small amount of mineral oil

Answer 100

c. ill swab the clients mouth with chlorhexidine

Question 101

a nurse is planning morning hygiene care for postoperative client. which of the following actions should the nurse take? a. inform the client when morning hygiene care is provided at the hospital b. schedule the clients morning hygiene care at the same time as their roommate c. ask the client in what order they typically perform their morning routine d. plan to provide care before the next scheduled dose of pain medication

Answer 101

c. ask the client in what order they typically perform their morning routine

Question 102

a nurse is preparing to provide oral care for a client who is NPO. the client tells the nurse i don't need oral care because i haven't eaten anything. which of the following responses should the nurse take? a. since you are not eating we can wait and do it before bedtime b. oral care is still important even though you are not eating c. ill give you a sip of water to swish around in your mouth then you can spit it out d. we will wait until your family gets here to help

Answer 102

b. oral care is still important even though you are not eating

Question 103

a nurse is observing an assistive personnel make a clients bed while the client is out of the room. which of the following actions indicates an understanding of the procedure? a. the AP records the tasks when it is completed b. the AP wears sterile gloves while making the bed c. the AP changes the clients pillowcase d. the AP reuses the clients clean blanket and spread

Answer 103

d. the AP reuses the clients clean blanket and spread

Question 104

a nurse is performing a complete bed bath for a client. which of the following actions should the nurse take? a. raise the room temperature b. completely remove the linens c. add soap to the water in the basin before beginning the bath d. . bathe one side of the body at a time

Answer 104

a. raise the room temperature

Question 105

a nurse is assisting a client with personal hygiene care. which of the following actions should the nurse take to reduce the risk of infection? a. massage the reddened areas of the clients skin b. wash eyes from the outer canthus to the inner canthus c. wash the client from the shoulder down to the fingertips with smoothed, short strokes d. clean the least soiled areas prior to cleaning the most soiled areas

Answer 105

d. clean the least soiled areas prior to cleaning the most soiled areas

Question 106

a nurse is caring for a client who has refused to have a biopsy. the client states, "I don't need the biopsy. I wouldn't do anything about it anyways if it is cancer." the nurse replies "you don't want the biopsy because you would not seek treatment if it as cancer. is that correct?" which of the following therapeutic communication techniques is the nurse using? a. affirmation b. open ended question c. reflection d. restating

Answer 106

d. restating

Question 107

A nurse asks a client how he learns best. The client states, " I think I learn the best when I can discuss the information with a group of people. "This indicates that the client has a preference for which of the following learning styles?

Answer 107

Auditory

Question 108

A nurse is preparing to a teach a client how to ambulate with crutches and is determining the client's readiness to learn. Which of the following factors should the nurse include in this assessment?

Answer 108

The client's cognitive ability, the client's physical needs, the client's level of motivation, the client's developmental stage

Question 109

A nurse is teaching a client who has a new diagnosis of diabetes mellitus type 1. Which of the following questions by the nurse addresses the client's affective domain?

Answer 109

"How do you feel diabetes will affect your lifestyle?" One of the focuses of the affective domain is the client's feelings.

Question 110

A nurse is preparing an educational lecture for bariatric client. Which of the following should the nurse take into consideration when developing the lecture?

Answer 110

Audiovisuals are an important component of the lecture format in order to engage the audience, the content should apply to all lecture participants

Question 111

A nurse is preparing an adult client's teaching plan and gathering information about the client's culture. Which of the following client statements helps the nurse understand the client's social organization?

Answer 111

"My mother needs to be present for any teaching." The client's comment, indication a matriarchal family structure, is a component of cultural social organization.

Question 112

A nurse is evaluating a client's ability to self-administer insulin. Which of the following behaviors is reflective of the mechanism level of psychomotor domain?

Answer 112

The client demonstrates confidence in a performing an insulin injection. The psychomotor domain consists of seven levels of behavior. The mechanism level refers to the client's ability to perform a skill with confidence.

Question 113

A nurse is caring for a client who has a new prescription for digoxin (Lanoxin). Which of the following should the nurse first teach the client?

Answer 113

"Your provider is prescribing medication to strengthen your heart's contraction." Knowledge is the first level of cognitive behavior. Identifying the purpose of the medication is an example of providing basic knowledge information is the first thing the nurse should teach.

Question 114

Which of the following should the nurse take into consideration when selecting an environment to provide client education?

Answer 114

Noise level, size of space, lighting, and temperature.

Question 115

A nurse is preparing a toddler for surgery. Which of the following s appropriate for the nurse to take into consideration when developed the teaching plan?

Answer 115

Toddlers depend on their senses to learn. Toddlers are in the sensorimotor cognitive stage, which means that they learn from their senses.

Question 116

A client with Alzheimer disease in a nursing home is more compliant in following directions for dressing and feeding with one nurse than with other staff members. This phenomenon is best explained by - the Therapeutic Model of Interaction. - aggression. - empathy. - the Health Belief Model.

Answer 116

the Therapeutic Model of Inteaction

Question 117

Chronic illness may be characterized by periods of remission. Remission is best defined as: - the presence of a disease with the absence of symptoms. - a pathologic change in the structure of function of the body or mind. - the reappearance of symptoms of a disease. - the response of a person to a disease.

Answer 117

the presence of disease with the absence of symptoms

Question 118

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon? - Morbidity - Risk factor - Exacerbation - Infection

Answer 118

exacerbation

Question 119

An older adult patient has been recently diagnosed with vascular dementia. Because the client lives alone and has poorly controlled hypertension, the client has begun to receive home healthcare. This new aspect of the client's care is characteristic of which stage of illness? - Assuming a dependent role - Experiencing the symptoms - Assuming the sick role - Achieving recovery and rehabilitation

Answer 119

Assuming a dependent role

Question 120

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model? - Factors that predispose a person to infectious diseases - How people interact with their environments - What people believe to be true about their health - How health is a constantly changing state

Answer 120

What people interact with their environment

Question 121

The nurse is caring for a client admitted to the hospital with pneumonia and associated pleuritic chest pain. Which would be a priority when creating the nursing care plan? - Monitoring fluid intake and output. - Effective infection control measures. - Effective pain management. - Monitoring airway clearance.

Answer 121

-Monitoring airway clearance.

Question 122

Which model is most useful in examining the cause of disease in an individual, based upon external factors? - The Agent-Host-Environment Model - The High-Level Wellness Model - The Health Belief Model - The Health-Illness Continuum

Answer 122

-The Agent-Host-Environment Model

Question 123

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease? - It takes a long time to cure. - It is a sequela of acute illness. - It has a gradual onset and lasts for a long time. - It persists for a long time.

Answer 123

-It has a gradual onset and lasts for a long time.

Question 124

A community health nurse arranges for a dental checkup camp for the local children in the school district. Which of the following would most likely be the nurse's goal for this health camp? - Reversal of self-care deficit - Illness prevention - Health promotion - High-level wellness

Answer 124

Health promotion

Question 125

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model? - Health belief model - Clinical model - Holistic health model - High-level wellness model

Answer 125

-Health belief model

Question 126

The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of? - Tertiary - Medical - Primary - Secondary

Answer 126

-Primary

Question 127

Which is an example of tertiary health promotion? - Water treatment - Pap tests - Family counseling - Rehabilitation

Answer 127

-Rehabilitation

Question 128

What have the models of health promotion and illness prevention been used for? - To define a medical framework for the care of the disabled. - To create a forum for improving rehabilitative care. - To help health care providers understand health-related behaviors. - To formulate care plans for the disabled population.

Answer 128

-To help health care providers understand health-related behaviors.

Question 129

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept? - Focus on what can no longer be. - Focus on why the client has the illness. - Focus on what is possible. - Focus on the altered functioning.

Answer 129

-Focus on what is possible.

Question 130

A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client's circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions? - Sociocultural and intellectual - Physical and emotional - Environmental and spiritual - Emotional and environmental

Answer 130

-Sociocultural and intellectual

Question 131

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? - Secondary prevention - Residual prevention - Tertiary prevention - Primary prevention

Answer 131

-Tertiary prevention

Question 132

A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness? - New symptoms occur at this time. - Symptoms are not experienced. - The disease is no longer present. - The symptoms of the illness reappear.

Answer 132

Symptoms are not experienced

Question 133

The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as: - health belief model. - agent-host-environment. - illness. - high-level wellness.

Answer 133

High-level Wellness

Question 134

What level of prevention is represented by educating a group of clients on breast self-examination? - Secondary prevention - Primary prevention - Educational prevention - Tertiary prevention

Answer 134

Primary prevention

Question 135

The client is admitted with a gastrointestinal bleed. The physician ordered a colonoscopy. Which level of care encompasses this procedure? -Quanternary -Primary -Secondary -Tertiary Secondary

Answer 135

Secondary

Question 136

To be an effective change agent for wellness, the nurse must: -lead a sedentary lifestyle. -consume a diet low in fat. -skip breakfast to reduce calories. -drink caffeinated beverages. Consume a diet low in fat

Answer 136

Consume a diet low in fat

Question 137

A client enjoys eating high-calorie carbohydrate meals, but understands her blood sugar can increase sharply, ultimately causing the feeling of butterflies in her stomach as her blood sugar decreases. This is considered: - health promotion. - illness prevention. - self-concept. - a holistic approach.

Answer 137

Self-concept

Question 138

Why are health promotion and illness prevention a key responsibility of nurses? - Chronic illnesses are the leading health problem in the world. - Chronic illnesses can cause pain and suffering. - People do not like to be sick and feel bad. - Treatment of chronic illnesses is very expensive.

Answer 138

Chronic illnesses are the leading health problem in the world