PN fundamentals 2023 with complete solution questions and answers

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if she does not use the urinal more carefully next time. Which of the following torts is the AP committing? Assault A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? False imprisonment A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? I plan to write that I don't want them to keep me on a breathing machine." A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) Make sure the surgeon obtained the client's consent. Witness the client's signature Zon the consent form. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? Report the observations to the When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? Place a mask on the client to limit the spread of micro-organisms into the surgical wound. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing sterile procedure. Which of the a touch without following objects can the nurse breaching sterile technique? (Select all that apply) The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply) Wash the hands with soap and water for at least 15 seconds. Use a clean paper towel to turn off hand faucets. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply) The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. The procedure is delayed 1 hr because the provider receives an emergency call. The nurse turns to speak to someone who enters through the door behind the nurse. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? Home health care Rehab facilities Skilled nursing facilities A nurse is explaining the various types of health care coverage. Which of the following health care financing mechanisms are federally funded? Medicare Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? Collaborating with providers to perform obesity screenings during routine office visits A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? Ensuring that health care providers comply with regulations A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (SATA) ICU Oncology treatment center Burn center Which clients should a nurse initiate a referral to a social worker A client with terminal cancer requests hospice care in home A client asks about community resources available for older adults A client requests an electric wheelchair for use after discharge Who should you refer a patient to see that has trouble with self feeding Occupational therapist Who can help a client understand medications and their effects? Provider Pharmacist RN A patient who has dysphagia should be referred to Speech-language pathologist CNAs can assist with Bathing Ambulation Toileting Vitals A patient refuses surgery for his blockages, his choice is an example of Autonomy Giving pain medicine to a client before ambulation is an example of Beneficence Organ donation requirements and qualifications ensures Justice A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence Nonmaleficence example of an ethical dilemma Family has conflicting feelings about initiation of enteral tube feedings What information should be included in the change of shift report Bone density scan scheduled for today What information should a nurse include when teaching about HIPPA Family members must provide a code communication should only be done at the nurses station client can request a copy of their medical record and a medical record maybe copy for transfer to another facility What are the legal requirements for documenting in a patient chart Documenting the date and time on all injuries and documenting objective data and leaving out opinions What incidents require completion of an incident report Medication error needle sticks omission of prescription Nurse nurse is receiving a phone order for morphine what actions are appropriate Repeat the details back to the provider Have another nurse listen to the telephone prescription Obtain the provider signature within 24 hours This task may be delegated to the system personnel Replace on a condom catheter on a client who has urinary incontinence Who should assess the patient immediately following back surgery with ambulation The RN What information should the nurse share with a P about a patient who is postop five days knee surgery The client ambulate's with his slippers on over his Antiembolic stockings Client uses a front wheeled walker when walking The patient had pain medication 30 minutes ago Which assignment should the LPN question Teaching a client who has asthma to use a metered dose inhaler What are some of the five rights of delegation Right supervision and evaluation right direction and communication right circumstances What should you do if a patient has not achieved pain management by the second day after surgery Reassess to determine reason for in adequate pain relief What are some examples of objective data What the nurse can see with her own eyes. Respiratory rate is 22 per minute with even a labored respirations Skin is pink warm and dry The assistive personnel reports the client walked with a limp Examples of interventions that do not require provider signature Showing a client progressive muscle Relaxation Perform daily bath after meals Reposition Klein every two hours to reduce pressure ulcer risk Which statement correctly identify as an appropriate steps in the planning of the nursing process I would determine the most important client problems that we should address A client 24 hour postop for repair of hernia He's tolerating clear liquids well and has active bowel sounds and is expressing desire for real food the nurse says she will call the surgeon to ask. What level level of critical thinking is this Basic The patient has a prescription for an anabiotic the nurse notices that this is listed in their allergies she calls the provider to prescribe something different she has demonstrated what critical thinking Responsibility Nurse nurse notices that a patient 24 hours postop for abdominal surgery has in adequate pain relief which of the following reinforces the suspicion The client is non-adherent to cough and deep breathing and dangling The client may have pain medication every 4 to 6 hours but only takes it every 6 to 7 Heart rate is 124 respiratory rate is 22 and temperature is 98.6 blood pressure is 156/80 The nurse uses a electronica database for newly prescribed anti-tense medication before administration this is an example of which critical thinking step Knowledge A nurse performs a head to toe assessment for a patient who will have surgery next week what part of the critical thinking is this Discipline After performing an admission assessment for an older client what should the next priority of the nurse be Orient the patient to his room A nurse admitting a patient with a cute Coley cystitis to the MedSurg unit what actions are essential steps of the admission process Explain the roles of the other care members Began discharge planning Document the client wishes about organ donation Introduce the client to his roommate A client who had a stroke is about to be transferred to a rehab center what is the responsibility of the nurse Ensure the client has possession of his valuables confirm the rehab center has a room available at the time of transfer give verbal transfer report over the telephone complete a transfer form to for the receiving facility A patient preparing to be discharged after knee surgery, what information does the nurse include in the discharge summary Follow up care instructions for diet and medications contact information for the home healthcare agency During admission of a patient with dementia to long-term care facility what priority information should the nurse obtain from the family in regards to diet If the patient has any difficulty swallowing What action should the nurse take prevent falls in a nursing home call bell within reach provide nonskid footwear complete fall risk assessment What statement by the nurse requires further instruction for patient with seizures I will go to the nurses station for assistance The nurse observes smoke coming from the door of the nurses lounge what is her first action Remove nearby clients A nurse has a patient with history of falls what is her first priority Complete a fall risk assessment When assigning rooms to clients to prevent falls which of the following clients should the nurse assign closest to the nurses station An older client who was postop knee amputation What is the rationale for reporting infectious diseases such as SARS Planning and evaluating control prevention strategies Determine public health priorities ensure proper medical treatment monitoring for a common source outbreaks Patient presents with linear clusters of fluid filled vesicles with some crusting the nurse should identify this manifestation as what Herpes zoster The client reports severe sore throat pain when swallowing and swollen lymph nodes the patient is experiencing what stage of infection Illness What is the prodromal period? short period after incubation; early, mild symptoms What is the incubation period? the period between exposure to an infection and the appearance of the first symptoms What is convalescence? period of recovery systematic infection affects the entire body Symptoms or manifestations of a systemic infection Fever malice increase in pulse and respiratory rate What intervention should be made for patient being admitted with pertussis Wear a mask within 3 feet of the client place a surgical mask on the client when transporting wear a gown when performing care that might result in secretions A patient and older patient who describes having difficulty dealing with several issues which is most concerning I keep forgetting which medications I have taken during the day Patient has lost 9.9 pounds since his admission six months ago what instructions should the nurse give Eat foods that are easy to eat such as finger foods invite family members to eat meals with you exercise every day to increase appetite Which interventions should the nurse plan to teach to a group of older adults about health promotion and disease prevention Pneumococcal immunization yearly eye exam periodic mental health screening annual physical occult blood test Recommendations given to an older adult on how to improve nutritional status Increase protein to increase muscle mass increase calcium intake to prevent osteoporosis limit sodium intake to prevent Edema increase fiber to prevent constipation What are normal findings on an assessment of an older client related to aging Decreased height nail thickening decreased bladder capacity A nurse is planning care for patient with hyper natremia which of the following actions should the nurse anticipate including in the plan of care Infuse hypotonic IV fluids What is a risk factor for developing hypocalcemia Crohn's disease If a patient has a potassium level of 5.2 what should the nurse anticipate Initiating continuous cardiac monitoring because it indicates hyperkalemia which increases the risk of arrhythmia's A patient has a history of long-term use of glucocorticoids causing hypercalcemia what findings should the nurse anticipate Confusion bone pain nausea and vomiting When providing education for patient with severe hypomagnesemia what information should you provide Educate your patient on deep tendon reflexes that will need to be monitored The nurse is caring for a patient who has been sitting in a chair for one hour what is the greatest risk to the client Pressure ulcer When caring for postop patient what are interventions to reduce the risk of thrombus Apply elastic stockings assist the client to change position often A nurse is planning care for a patient who was on bedrest what intervention should she include Encourage the patient to perform antiembolic exercises every two hours A nurse is teaching a patient who has a new prescription for compression device what statement indicates an understanding by the client This thing will keep the blood pumping through my leg What instruction should the nurse include when teaching a client with left lower extremity weakness about using a cane Hold the cane on the right side keep two points of support on the floor after advancing the cane move the week and leg forward When caring for a patient with Enteral tube feedings due to dysphagia which of the following positions should the nurse use for safe care Semi Fowler's A client sitting in the chair I asked to return to bed what is the nurse is priority Determine if the client is able to help with the transfer A client with COPD understands the use of the orthopenic position when she states she will do what when she has difficulty breathing Sit on the side of her bed and rest her arms over pillows on top of her bedside table What are some ways for nurses to prevent injury request assistance when repositioning a patient avoid twisting your spine or bending at the waist Use smooth movements when lifting and moving clients What are some points to proper body mechanics The lower my center of gravity the more stability I have To broaden my base of support I should spread my feet apart when I lift an object I should hold it as close to my body as possible An adolescent client two days postop with a history of diabetes type one tolerating a regular diet has ambulated successfully requires pain medicine every 6 to 8 hours his incision is approximated and free of redness with scant serous drainage on the dressing the nurse should recognize that the client has which risk factors for impaired healing Impaired circulation impaired/suppressed immune system Patient patient five days postop from abdominal surgery and they provider suspects incision infection So he prescribes anabiotic's which findings should the nurse expect Increase in incisional pain fever and chills reddened wound edges A nurse educator is reviewing wound healing process with a group of nurses the educator should include information on the following alterations for wound healing my secondary intention select all that apply Stage III pressure ulcer open burn area A patient who had abdominal surgery 24 hours ago suddenly reports play pulling sensation and pain at the surgical incision site the nurse checked the wound and finds it is separated with viscera protruding what action should the nurse take Cover the area with Saline soaked sterile dressing's position the client supine with his hips and knees bent A nurse is caring for an older adult client who is at risk for developing pressure ulcers which of the following interventions should the nurse use to maintain the integrity of skin Keep the head of the bed elevated 30° have the client sit on a gel cushion with in a chair A nurse is delivering an Entersl feeding to a client who has an NG tube in place for intermittent feedings when the nurse pours water into the syringe after the formula drains the client asked the nurse why is the water necessary what should she say Water helps clear the tube so it doesn't get clogged A nurse is caring for a client who is receiving continuous ENTERAL feelings which of the following interventions is the highest priority when aspiration is suspected Stop the feeling The nurse is preparing to instill an ENTERAL feeding for a client who has an NG tube which of the following actions is The highest priority Verify the placement of the NG tube A nurse is caring for a client in a long-term care facility who was received an ENTER AL feedings which of the following actions should the nurse complete prior to administering the tube feeding select all that apply Auscultation bowel sounds Assist the client to an upright position test the pH of the gastric aspirate A nurse is preparing to insert an NG tube for a client who requires gastric decompression which of the following actions should the nurse before one before beginning the procedure Review a signal the client can use it feeling any distress lay a towel across the clients chest I'm nursing a providers office is evaluating a client reports losing control of your own whenever she calls last sneezes the client with lights a history of three vaginal births but no serious accidents or illness which of the following intervention should the nurse suggest for help in control or eliminate the clients imcotinence Decrease or avoid caffeine avoid drinking alcohol A client who has an indwelling catheter reports and need to urinate which of the following actions should the nurse take Check to see whether the catheter is patent. A nurse is caring for a client who has a prescription for 24 hour urine collection which of the following actions should the nurse take Discard the first void A nurse is reviewing factors that increase the risk of your new tract infections with a client who has recurrent UTIs which of the following factors should the nurse include Frequent sexual intercourse location of the new Reatha in relation to the anus frequent catheterization A nurse is preparing to initiate a bladder to re-training program for a client who has incontinence which of the following actions should the nurse take Have a client record urination times gradually increase the urination intervals remind the client to hold the year until the next scheduled urination time And nurse is assisting a client who has an acute respiratory infection that puts her at risk for hypoxemia which of the following findings are early indications that should alert the nurse the client is developing hypoxemia Restlessness tachypnea confusion pallor A provider is discharging a client who has a prescription for home oxygen therapy via a nasal cannula the client and family teach in by the nurse should include which of the following instructions select all that apply Check the position of the cannula frequently report any nasal stuffiness nausea or fatigue post no smoking signs in a prominent location A nurse is caring for a client who is having difficulty breathing the client is lying in bed and is already receive an oxygen therapy via nasal cannula which of the following interventions is the nurse is priority Assisted client to Fowler's position A nurse is preparing to perform in there tracheal suctioning for client the nurse should follow which of the following guidelines select all that apply Apply suction while withdrawing the catheter use a new catheter for each suctioning attempt limit total suctioning time to five minutes A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take one providing tracheostomy care Select all that apply Apply the oxygen source loosely if the SPO2 decreases during the procedure Use surgical asepsis to remove and clean the inner cannula clean the outer surfaces in a circular motion from the stoma site outward Non-breather mask allows higher levels of oxygen to be added to the air taken in by the patient Venturi mask an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered