Flashcards in Test 1 Deck (413)
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect, compassion, client education, and empowerment. By assessing the effect of the clients culture on health care,
this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client
and family to the room is an important safety measure, but not directly related to demonstrating client-centered
A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should
call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. The primary care provider should be
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
frequently, but the priority is getting the rapid care to the client.
A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband
Each action could be important for the client or family to perform. However, encouraging the client to be
active in his or her health care as a partner is the most critical. The other actions are very limited in scope and
do not provide the broad protection that being active and involved does.
A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the
student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to
guard the clients safety.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is
the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for. b. Keep the doctors phone number by the telephone. c. Make sure all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up
campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their
medications and why they take them. This will help prevent medication errors.
Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a
signature on the consent form, assessing if the client still has questions is vital, because without full
information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
A student nurse asks the faculty to explain best practices when communicating with a person from the
lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is
a. Avoid embarrassing the client by asking questions. b. Dont make assumptions about their health needs. c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population
Many members of the LGBTQ community have faced discrimination from health care providers and may be
reluctant to seek health care. The nurse should never make assumptions about the needs of members of this
population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any
health care need is more likely to answer honestly.
A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that
is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for
a. A: I would like you to order a different pain medication. b. B: This client has allergies to morphine and codeine. c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds. d. S: This client had a vaginal hysterectomy 2 days ago.
SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the
on-call physician might order. Situation describes what is happening right now that must be communicated; the
clients surgery 2 days ago would be considered background. Assessment would include an analysis of the
clients problem; asking for a different pain medication is a recommendation. Recommendation is a statement
of what is needed or what outcome is desired; this information about the surgeons preference might be better
placed in background.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous
readings, and the clients mental status has changed. What action by the nurse would most likely have
prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to
report them right away. An experienced UAP should know how to take vital signs and the nurse should not
have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are
within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the
nurse did not provide adequate instruction to the UAP.
A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital
there. What advice by the nurse is best?
a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school.
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a
focus on safety. Nurse-client ratios differ by unit type and change over time. New technology doesnt
necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, but
safety is most important.
A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?
a. All staff nurses are required to participate in quality improvement here.
b. Even being new, you can implement activities designed to improve care.
c. Its easy to identify what indicators should be used to measure quality.
d. You should ask to be assigned to the research and quality committee.
The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly
licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how
that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not
be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the
nurse information about how to implement QI in daily practice.
. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best
demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
e. Shows the nursing care plans to other disciplines
ANS: A, B, C, D
Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a
team with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively
involving them or collaborating with them.
A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of
competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency
according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality?
(Select all that apply.)
a. Collaborating with an interdisciplinary team
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
ANS: A, B, D, E
The IOM report lists five broad core competencies that all health care providers should practice. These include
collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused
care, using informatics in client care, and using quality improvement in client care.
The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all
a. Cost-saving measures
b. Nurses expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the clients values and preferences, and the nurses expertise when
planning care. It does not include cost-saving measures.
A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.)
a. Attend hand-off rounds to coach and mentor.
b. Conduct audits of staff using a new template.
c. Create a template of topics to include in report.
d. Encourage staff to ask questions during hand-off.
e. Give raises based on compliance with reporting.
ANS: A, B, C, D
A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE
stands for standardize critical information, hardwire within your system, allow opportunities to ask questions,
reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manager
opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is
hardwiring within the system. Encouraging staff to ask questions and think critically about the information is
allowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff is
resistive and other measures have failed, but this is not part of the SHARE model.
A nurse working with older adults in the community plans programming to improve morale and emotional
health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
All activities would be beneficial for the older population in the community. However, failure in performing
ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program
designed to maintain and/or improve physical functioning would best address this need.
A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the client.
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and
constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these
problems exist. The other assessments are important, but will not yield information specific to the clients food
preferences as they relate to constipation.
A nursing faculty member working with students explains that the fastest growing subset of the older
population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old
The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99
years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of
age; and the elite old are over 100 years of age.
A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
a. Cut some sodium out of your diet.
b. Dehydration can cause incontinence.
c. Have something to drink every 1 to 2 hours.
d. Take your diuretic in the morning.
Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy
is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some
sodium from the diet will not address this issue. Although dehydration can cause incontinence from the
irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing
the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.
A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the
client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole wheat bread
Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.
A home health care nurse is planning an exercise program with an older client who lives at home
independently but whose mobility issues prevent much activity outside the home. Which exercise regimen
would be most beneficial to this adult?
a. Building strength and flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase
functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain
independence longer. The other plans are good but will not specifically maintain the clients functional abilities.
An older adult recently retired and reports being depressed and lonely. What information should the nurse
assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adults life
d. Usual leisure time activities
Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the
role that work played in the clients life. The other factors can be assessed as well, but this circumstance is
commonly seen in the older population.
A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping?
a. I have had the same best friend for decades.
b. I think I am coping very well on my own.
c. My kids come to see me every weekend.
d. Oh, I have lots of friends at the senior center
Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope
A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete
steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe
on the steps?
a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.
As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of
where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase
awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an
alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not
help if the client is unaware of where the foot is on the step.
An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
Medication side effects and adverse effects are common in the older population. Something as simple as a new
antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new
medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once
more is known about the clients condition.
An older adult client takes medication three times a day and becomes confused about which medication
should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those
are for old people. What action by the nurse would be most helpful?
a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.
Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening
meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if
the person doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list
might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder
is always with the medication.
An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the
nurse would be most helpful in preventing falls in this client?
a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed.
Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in
a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce
the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the
client in bed are considered restraints and should not be used in that fashion.
An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The
client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which
medication should he or she suggest in place of the morphine?
a. Cyclobenzaprine (Flexeril)
b. Hydromorphone hydrochloride (Dilaudid)
c. Ketorolac (Toradol)
d. Meperidine (Demerol)
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers
list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse
should suggest hydromorphone hydrochloride.
A nurse admits an older client from a home environment where she lives with her adult son and daughterin-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the
nurse is most appropriate?
a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can
then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult
Protective Services is notified in the community setting.