Fundamentals of Nursing Final Exam Test Bank 2024

Chap 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Correct Answer: 3 Question 2 While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 1 Question 3 During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic Correct Answer: 2 Question 4 Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Correct Answer: 3 Question 5 The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 3 Question 6 A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours Correct Answer: 4 Question 7 The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childbirth 2. Grandmother 3. Parents 4. Admitting physician Correct Answer: 3 Question 8 A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete, I need to ask these questions. 2. Youre right. Let me know if theres anything you need right now. 3. Ill be done shortly, just give me a few more minutes. 4. You shouldnt be upset. Were only doing our jobs. Correct Answer: 2 Question 9 The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing Correct Answer: 4 Question 10 A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-orkers discussing their clients conditions Correct Answer: 3 Question 11 A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator. Correct Answer: 3, 4, 5, 2, 1 Question 12 During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before? Correct Answer: 2 Question 13 The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on? Correct Answer: 1 Question 14 The nurse is assessing a client level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you? Correct Answer: 3 Question 15 A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview. Correct Answer: 1 Question 16 A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby. Correct Answer: 3 Question 17 A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Correct Answer: 2 Question 18 A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures. Correct Answer: 2 Question 19 The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, Im your nurse and Ill be taking care of you today. 2. Youre luckythere are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light. Correct Answer: 1 Question 20 The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. Im going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments youve had? 4. Is there anything youre worried about? Correct Answer: 1 Question 21 During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern Correct Answer: 4 Question 22 The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment Correct Answer: 3 Question 23 The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented. Correct Answer: 1, 2, 5 Question 24 The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Correct Answer: 3 Question 25 While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Correct Answer: 3 Question 26 Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Correct Answer: 1 Question 27 A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions Correct Answer: 1, 2, 4, 5 Question 28 The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position Correct Answer: 1, 4, 5 Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1.Identifying major problems or needs 2.Organizing data in the client’s family history 3.Establishing short-term and long-term goals 4.Administering an antibiotic Correct Answer: 1 Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1.Proposes hypotheses. 2.Generates desired outcomes. 3.Reviews results of laboratory tests. 4.Documents care. Correct Answer: 3 Which of the following elements is best categorized as secondary subjective data? 1.The nurse measures a weight loss of 10 pounds since the last clinic visit. 2.Spouse states the client has lost all appetite. 3.The nurse palpates edema in lower extremities. 4.Client states severe pain when walking up stairs. Correct Answer: 2 The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. “What did the doctor tell you about your diagnosis?” 2. “Are you worried about how the diagnosis will affect you in the future?” 3.“Tell me about your reactions to the diagnosis.” 4.“How is your family responding to the diagnosis?” Correct Answer: 3 The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1.Correlation of the data with other members of the health care team 2.Demonstration of cost-effective care 3.Utilization of creativity and intuition in creating a plan of care 4.Collection of all necessary information for a thorough appraisal Correct Answer: 4 Question 29 Nursing activities that represent the various characteristics of the nursing process includes the nurses: Standard Text: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care. Correct Answer: 1,2,3,4 Chap 12 Question 1 After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals interventions 3. The ones that focus on the clients primary illness 4. The ones that have standardized care available Correct Answer: 1 Question 2 A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Correct Answer: 3 Question 3 A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis Correct Answer: 1 Question 4 The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing Correct Answer: 4 Question 5 An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care? 1. The clients eyes are closed. 2. The clients skin is pale and mottled. 3. The clients spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up. Correct Answer: 2 Question 6 The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the schools activities. Correct Answer: 1 Question 7 The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher. Correct Answer: 3 Question 8 The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse wont have to spend time going over the pathology of the clients disease. Correct Answer: 1 Question 9 A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by clients report Correct Answer: 2 Question 10 A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions Correct Answer: 4 Question 11 The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth Correct Answer: 3 Question 12 The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors Correct Answer: 4 Question 13 After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns Correct Answer: 2 Question 14 After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily. Correct Answer: 3 Question 15 The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the clients problem, health risks, and strengths. Correct Answer: 4 Question 16 The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity Correct Answer: 3 Question 17 A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia Correct Answer: 1 Question 18 The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the clients room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the clients condition. Correct Answer: 2 Question 19 The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The clients clothes are soiled. 6. The client has obvious body odor. Correct Answer: 1, 2, 5, 6 Question 20 The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis Correct Answer: 3 Question 21 The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordons health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location Correct Answer: 2, 3, 4, 6 Question 22 The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely Correct Answer: 1,3,4,6 Question 23 The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDAs Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting. Correct Answer: 3 Question 24 The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety Correct Answer: 1,5 Question 25 A nursing diagnosis that was written according to the PES format model would include: Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips Correct Answer: 1,4 Chap 13 Question 1 A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this clients care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this clients care 4. The client and the clients support system Correct Answer: 3 Question 2 A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 4 Question 3 A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this clients care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 3 Question 4 The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? SAP 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Correct Answer: 2, 3 Question 5 The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual Correct Answer: 2 Question 6 A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order Correct Answer: 4 Question 7 According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the clients home. 2. Assist the client in finding an alternative plan for the achieving the therapys outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility. Correct Answer: 2 Question 8 A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Correct Answer: 1 Question 9 The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours. Correct Answer: 4 Question 10 The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan Correct Answer: 3 Question 11 The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone. Correct Answer: 2 Question 12 The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain Correct Answer: 4 Question 13 One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Correct Answer: 1 Question 14 A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily. Correct Answer: 3 Question 15 The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily. Correct Answer: 2 Question 16 A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client Correct Answer: 2 Question 17 The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowlers position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat. Correct Answer: 3 Question 18 The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? Standard Text: Select all that apply. 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment. 6. Plans are standardized and generalized for all clients. Correct Answer: 1, 2, 3, 4, 5 Question 19 The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Standard Text: Select all that apply. 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurses time 4. To eliminate care disparities among clients 5. To minimize health care costs Correct Answer: 2, 3 Question 20 The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? Standard Text: Select all that apply. 1. Congruent with the clients values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the clients age Correct Answer: 1, 2, 4, 5 Question 21 The nurse is reviewing a clients plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Standard Text: Select all that apply. 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors. Correct Answer: 1, 2, 3, 4 Question 22 The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? Standard Text: Select all that apply. 1. I can look up interventions according to the nursing diagnosis that Ive selected. 2. The interventions connected to a diagnosis are appropriate for any client with that diagnosis. 3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions. 4. Care plans are best written when the interventions are broad and flexible. 5. I find NIC interventions a really good place to start when Im working on client interventions. Correct Answer: 1, 3, 5 Question 23 The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse? Standard Text: Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem. Correct Answer: 3, 4 After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1.Initial 2.Ongoing 3.Discharge 4.Strategic Correct Answer: 4 The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care Correct Answer: 1 The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The cli-ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1.Pain 2.Nausea 3.Constipation 4.Potential for wound infection Correct Answer: 2 The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated goal/outcome? The client will 1. Turn in bed q2h. 2. Report the importance of applying lotion to skin daily. 3.Have intact skin during hospitalization. 4.Use a pressure-reducing mattress. Correct Answer: 3 The care plan includes a nursing intervention “4/2/15 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? 1.Action verb 2.Content 3.Time 4.None Correct Answer: 3 The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed. 2. The nurse chooses from a list of interventions. 3. They are much shorter than nurse-authored care plans. 4.They have been approved by accrediting agencies Correct Answer: 2 Which of the following is likely to occur if a goal statement is poorly written? 1. There is no standard against which to compare outcomes. 2. The nursing diagnoses cannot be prioritized. 3. Only dependent nursing interventions can be used. 4. It is difficult to determine which nursing interventions can be delegated Correct Answer: 1 When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse’s and the client’s value Correct Answer: 4 Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be “doing,” not just “monitoring Correct Answer: 1 Chap 14 Question 1 The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive Correct Answer: 4 Question 2 A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic Correct Answer: 1 Question 3 The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic Correct Answer: 2 Question 4 The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? SAP 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions Correct Answer: 2, 4, 5 Question 5 Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurses need for assistance 3. Supervising delegated care 4. Reassessing the client Correct Answer: 4 Question 6 The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods Correct Answer: 3 Question 7 During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care. Correct Answer: 4 Question 8 On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one. Correct Answer: 1 Question 9 A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physicians orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for. Correct Answer: 2 Question 10 The nurse is providing care to an assigned client. Which action indicates that the nurse supports the clients respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the clients needs 4. Presenting information to the clients family about the clients condition Correct Answer: 1 Question 11 The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurses efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next clients medications and treatments. Correct Answer: 3 Question 12 The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used. Correct Answer: 4 Question 13 The nurse notes that a client has the outcome goal Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which client statement should the nurse use to evaluate this goal? 1. Im getting really sleepy from that medication. I think Ill take a nap. 2. My pain is a 4. 3. I still have some pain. 4. Will the pain ever go away? Correct Answer: 2 Question 14 A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by weeks end. 4. Goal incomplete, client not able to positively state anything about rehab. Correct Answer: 3 Question 15 A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day. Correct Answer: 1 Question 16 A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped. Correct Answer: 2 Question 17 A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough. Correct Answer: 3 Question 18 A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis? 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis. Correct Answer: 4 Question 19 A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase. Correct Answer: 2 Question 20 The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome Correct Answer: 2, 4, 5 Question 21 A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome Correct Answer: 2 Question 22 A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome Correct Answer: 3 Question 23 A nursing units records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit Correct Answer: 1 Question 24 The nurse reviews clients records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective Correct Answer: 4 Question 25 The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care Correct Answer: 4 Question 26 The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention Correct Answer: 2, 4, 5 Question 27 After implementing interventions and reassessing the clients response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Correct Answer: 1, 2, 3, 4 Question 28 The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the clients needs 2. Selecting the appropriate nursing diagnosis related to the clients needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase Correct Answer: 1, 2, 3, 4 Question 29 The nurse notes that assessment data indicate a change in a clients condition. What should the nurse ask before changing this clients plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan? Correct Answer: 2, 3, 4 Question 30 The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan Correct Answer: 1, 2, 3, 4 Question 31 A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication Correct Answer: 1, 2 Chap 15 Question 1 A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as its his record. How should the nurse respond to this clients request? 1. Youll have to ask your doctor for permission to do that. 2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records. 3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have to worry about those details. 4. Theres a new law that protects your records, so youre not going to be able to have access to them. Correct Answer: 2 Question 2 After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. Confidentiality and privacy laws dont apply to students. 2. Most students review so many records and charts that they could not possibly remember details from any one of them. 3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. 4. As long as the clinical instructor is in the area, accessing client records is part of the education process. Correct Answer: 3 Question 3 The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the units information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets Correct Answer: 1, 3, 5 Question 4 A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The clients record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake. Correct Answer: 1 Question 5 When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the clients chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting Correct Answer: 1 Question 6 The nurse makes chronological entries in a clients chart that include documentation about the routine care provided, assessment findings, and client problems during a 12hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care Correct Answer: 3 Question 7 The nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Correct Answer: 3 Question 8 A client has specific cultural needs that affect the plan of care. In which part of the clients problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Correct Answer: 2 Question 9 The client states: I really dont want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning Correct Answer: 1 Question 10 The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes Correct Answer: 2 Question 11 The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception Correct Answer: 4 Question 12 The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report. Correct Answer: 3 Question 13 A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation Correct Answer: 2 Question 14 A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex Correct Answer: 1 Question 15 Before providing care, the nurse reviews the clients pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The clients medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex Correct Answer: 4 Question 16 The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM Correct Answer: 1 Question 17 A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex Correct Answer: 1 Question 18 When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed, but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to clients call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. Correct Answer: 3 Question 19 After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart. 4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it. Correct Answer: 4 Question 20 The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly. Correct Answer: 2, 3, 5, 6 Question 21 Type: MCSA The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, this information would be included in the section identified as: 1. Data (D). 2. Action (A). 3. Response (R). 4. Planning (P). Correct Answer: 3 Question 22 Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal and ethical standards is shown when: Standard Text: Select all that apply. 1. Charting the clients response to pain medication taken. 2. Describing the client as appearing to be comfortable. 3. Leaving sufficient charting space for the previous shift to chart client teaching. 4. Documenting that the client reports, Im so afraid of tomorrows surgery. 5. Making a late entry regarding a clients request for pain medication. Correct Answer: 1,4,5 Question 23 The nurse shows an understanding of the importance of avoiding potentially confusing abbreviations when: Standard Text: Select all that apply. 1. Documenting vital signs as TPR. 2. Charting that the drsg was dry and intact. 3. Transcribing a verbal order as Carbamazepine 12 mg/ml IV push daily. 4. Documenting Client consistently requesting IM MS for pain well before prescribed time. 5. Charting, Client to be ambulated q.i.d. Correct Answer: 1,2,5 Chap 26 Question 1 A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity Correct Answer: 3 Question 2 The nurse observes during a dressing change that the clients wound has become infected. When asked by the client how the wound looks, the nurse says it looks fine but the nurses facial expression doesnt support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity Correct Answer: 1 Question 3 A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The clients spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. I know youre worried about your loved one. Im sure this is a difficult situation for you. Do you have any questions right now? 2. Your spouses heart stopped. All these people are here to help get it started. 3. Your spouses physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now. 4. Is there someone you would like to call? Im sure this is a scary situation and you may feel more comfortable if someone were with you during this time. Correct Answer: 2 Question 4 The nurse enters a clients room and finds that the telephone is lying in the clients lap, tissues are wadded up on the bed, and the clients eyes are red and watery. What is the best response by the nurse? 1. Can I hang that phone up for you? 2. Well, its a beautiful day outside. Lets open the blinds. 3. Has your doctor been in to talk to you yet? 4. You look upset. Is there anything youd like to talk about? Correct Answer: 4 Question 5 A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. If you look better, you might feel better. 2. Taking a shower might wash away some of that gloom and doom. 3. This is a positive sign. Ill be right back with your supplies. 4. Your spouse will be glad to see that youre feeling better. Correct Answer: 3 Question 6 A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the childs parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the childs doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions. Correct Answer: 2 Question 7 A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public Correct Answer: 3 Question 8 A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distan