Fundamentals Skills Exam 2 Questions and Verified Answers Latest 2024 Update

Exam 2 Fundamentals Cultural Assimilation – process that occurs when a minority group, living as part of a dominant group with a culture, loses the cultural characteristics that made it different Cultural Blindness – the process of ignoring differences in people and proceeding as though the differences do not exist Cultural Diversity – (1) coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit; (2) diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location Cultural Imposition – tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group Cultural Respect – enables nurses to deliver services that are respectful of a responsive to the health beliefs, practices, and cultural and linguistic needs pf diverse patients; critical to reducing health disparities and improving access to high quality health care Culture – sum of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group Culture Conflict – situation that occurs when people become of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values Culture Shock – those feelings, usually negative, a person experiences when placed in a different culture Ethnicity – sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns Ethnocentrism – belief that one’s own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one’s cultural norms as the standard to evaluate others’ beliefs Linguistic Competence – ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter. Personal Space – external environment surrounding a person that is regarded as being part of that person Race – division of human beings based on distinct physical characteristics Stereotyping – assigning characteristics to a group of people without considering specific individuality Subculture – group of people with different interests or goals than the primary culture Transcultural Nursing – providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society Accreditation – process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education Assault – threat or an attempt to make bodily contact with another person without that person’s permission Battery – assault that is carried out Certification – process by which a person who has met certain criteria established by a nongovernmental association is granted recognition Common Law – law resulting from court decisions that is then followed when other cases involving similar circumstances and facts arise; common law is as binding as civil law Credentialing – general term that refers to ways in which professional competence is maintained Crime – offense against people or property; the act is considered to be against the government, referred to in a lawsuits as “the people,” and the accused is prosecuted by the state Defamation of Character – an intentional tort in which one party makes derogatory remarks about another that diminishes the other party’s reputation; slander is oral defamation of character; libel is written defamation of character Defendant – the one being accused of a crime or tort Expert Witness – nurse who explains to the judge and jury what happened based on the patient’s record and who offers an opinion as the whether the nursing care met acceptable standards of practice Fact Witness – nurse has knowledge of the actual incident prompting a legal case, bases testimony on firsthand knowledge of the incident, not on assumptions Felony – (1) crime punishable by imprisonment in a state or federal penitentiary for more than 1 year; (2) crime of greater offense than a misdemeanor Fraud – willful and purposeful misrepresentation that could case, or has caused, loss or harm ro people or property Incident Report – a report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor Law – rule of conduct established and enforced by the government of a society Liability – legal responsibility for one’s acts (and failure to act); includes responsibility for financial restitution of harms resulting from negligent acts Licensure – to be given a license to practice nursing in a state or province after successfully meeting requirements Litigation – process of lawsuit Malpractice – act of negligence as applied to a professional person such as a physician, nurse, or dentist Misdemeanor – crime of lesser offense than a felony and punishable by fines, imprisonment (usually for less than 1 year). Or both Negligence – performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do Plaintif – person or government bringing a lawsuit against another Root Cause Analysis – deep investigation into a sentinel event to determine why the event to determine why the event occurred, and exploring the circumstances that led to it to determine where improvements can be made Sentinel Event – an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Statutory Law – law enacted by a legislative body Tort – wrong committed by a person against another person or that person’s property Whistle-blowing – term generally used to refer to employees who report their employer’s violation of the law to appropriate lay enforcement agencies outside the employers’ facilities Blended Competencies – the set of intellectual, interpersonal, technical, and ethical/legal capabilities needed to practice professional nursing Caring – moral imperative that guides nursing praxis (education, practice, and research); action and competencies that aim toward the good and welfare of others Clinical Judgement – refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes Clinical Reasoning – a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking Concept Mapping – instructional strategy that requires learners to identify, graphically display, and link key concepts Creative Thinking – a process involving imagination, intuition, and spontaneity – factors that underpin the art of nursing Critical Thinking – thought that is disciplined, comprehensive, based on intellectual standards, and as a result, well-reasoned; a systematic way to form and shape one’s thinking that functions purposefully and exactingly Critical Thinking Indicators – evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Decision Making – purposeful, goal-directed effort applied in a systemic way to make a choice among alternatives Intuitive Problem Solving – direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible Nursing Process – five-step systemic method for giving patient care; involves assessing, diagnosing, planning, implementing, evaluating Person-centered Care – model of patient care based on a background of experience, knowledge, and skill that makes expert decision making possible Quality and Safety Education for Nurses (QSEN) – stands for Quality and Safety Education for Nurses, a project for preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve that quality and safety of the health care systems within which they work Reflective Practice – occurs when the caregiver has a profound awareness of self, and one’s own biases, prejudgments, prejudices, and assumptions, and understands how these may affect the therapeutic relationship Scientific Problem Solving – systemic problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation resulting in conclusion or revision of the study Standards for Critical Thinking – clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair Therapeutic Relationship – relationship between the caregiver and patient that is focused on prompting or restoring health and well-being of the patient Thoughtful Practice – the care of a patient by a clinician who utilizes clinical reasoning and reflective practice to guide thoughtful actions and person-centered processes of care Trial-and-error problem solving – method of problem solving that involves testing any number of solutions until one is found that works for that problem Bedside Report – standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family Change-of-shift Report – communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped Charting by exception (CBE) – shorthand method for documenting patient data that are based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes Confer – to consult with someone to exchange ideas or to seek information, advice, or instructions Consultation – process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution Critical/collaborative pathway – case management plan that is detailed, standardized plan of care developed for a patient population with a designed diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions Discharge Summary – description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals Documentation – written, legal record of all pertinent interventions with the patient – assessments, diagnosis, plans, interventions, and evaluations Electronic Health Record (EHR) – digital version of a patient’s chart that may contain the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results Flow Sheet – graphic record of abbreviated aspects of the patient’s condition (e.g., vital signs, routine aspects of care) Focus Charting – a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses data (D), action (A), response (R) format Graphic Record – form used to record specific patient variables Handof – a nurse’s report to another nurse or health care provider about a patient’s status and progress Health Information Exchange (HIE) – an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information ISBAR communication – a process for effective handoff communication among health care professionals about a patient’s condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read Back Minimum data set – a standard established by health care institutions that specifies the information that mist be collected from every patient Narrative Notes – progress notes written by nurses in a source-oriented record Occurrence Charting – documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay Outcome and Assessment Information Set (OASIS) – assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided Patient Record – a complication of a patient’s health information; the patient record is the only permanent legal document that details the nurse’s interactions with the patient PIE Charting – documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem(P) – interaction(I) – evaluation (E) – format, and evaluated each shift Problem-oriented medical record (POMR) – documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes Progress note – any of a variety of methods of notes that relate how a patient is processing toward expected outcomes Purposeful Rounding – proactive, systemic, nurse driven, evidence-based intervention that helps nurses anticipate and address patient needs Read-back – a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted Referral – process of sending or guiding someone to another source for assistance SOAP format – method of charting narrative progress notes: organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P) Source-oriented record – documentation system in which each health care group record data on its own separate form Variance Charting- documentation method in case management when a patient fails to meet an expected outcome or when a planned intervention is not implemented that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate; typically used for variances that affect quality, coast, or length of stay; also called occurrence charting Variance Report – tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report Analytics – discovery, interpretation, and communication of meaningful patterns in data Big Data – accumulation of data from various sources, combines with new technologies that allow for the transformation of data to information Clinical Information System (CIS) – computer-based system designed for collecting, storing, manipulating, and making available clinical information important to the health care delivery process Data Visualization – presentation of data in a pictorial or graphical format Genomics – (1) study of the structure and interactions of all genes in the human body, including their interactions with each other as well as the environment; (2) emerging discipline in which genomic information about a person is used in their clinical care (e.g., for diagnostic or therapeutic decision making) Health Information Technology (IT) – standard and agreed upon terms used in an electronic health record to improve data trending and sharing Interoperability – ability of a systemic to exchange electronic health information with and use electronic health information with and use electronic health information from other systems without special effort on the part of the user Meaningful Use – the use of certified electronic health information with and use electronic health information from other systems without special effort on the part of the user Nurse Informatics/Nursing Informatics (NI) – specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice Optimization – strategies to improve processes, maximize effective use, reduce errors, reduce costs, eliminate workflow inefficiencies, improve end-user skills and satisfaction with the system Patient Portal – web-based tool with secure access that allows patients to communicate with and receive information from their health care providers Pharmacogenomics – use of information about a person’s genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that person Predictive Analytics – variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events Standard Terminology – standard and agreed upon terms used in an electronic health record to improve data trending and sharing Systemic Development Lifecycle (SDLC) – development cycle for an information technology system that includes the following phases: 1. Analyze and plan. 2. Design. 3. Test. 4. Train. 5. Implement. 6. Maintain and 7. Evaluate Telecare – technologies that provide for patient safety and independence at home, such as health and fitness apps, sensors and tools that connect the patients with caregivers, digital medication reminder systems, and early warning and detection technologies Telemedicine – use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners Usability – extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use Asphyxiation – stoppage of breathing or the lack of air reaching the lungs; synonym for suffocation Bioterrorism – the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic Bullying – negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility Chemical Emergency – event caused by the release of a chemical compound that has the potential for harming people’s health Culture of Safety – organizational environment where “core values and behaviors resulting from a collective and sustained commitment by organizational leadership, management, and workers emphasize safety over competing goals” Cyber Terror – the use of high-tech means to disable or delete critical electronic infrastructure data or information Disaster – an emergency event of greater magnitude that requires the response of people outside the involved community Elder abuse – intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult: includes physical abuse, sexual abuse/contact, emotional/psychological abuse, neglect, and financial abuse/exploitation Intimate Partner Violence (IPV) – domestic violence or battering between two people in a close relationship Nuclear Terrorism – intentional dispersal of radioactive material into the environment for the purpose of causing injury and death Poison Control Center – facility that handles poison exposure and provides poison prevention teaching to the general population Restraint – device used to limit movement or immobilize a patient Safety Event Report – documentation describing any injury or potential for injury suffered by a patient in a health care facility Sentinel Event – an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Active Exercise – joint movement activated by the person Atrophy – decrease in the size of a body structure Contractures – permanently contacted state of muscle Ergonomics – practice of designing equipment and work tasks to conform to the capability of the worker and providing a means for adjusting the work environment and work practices to prevent injuries Flaccidity – decreased muscle tone; synonym for hypotonicity Footdrop – complication resulting from extended plantar flexion Isokinetic Exercise – exercise involving muscle contractions with resistance varying at a constant rate Isometric exercise – exercise in which muscle tension occurs without a significant change in muscle length Isotonic Exercise – movement in which muscles shorten (contact) and move Orthopedics – the correction or prevention of disorders of body structures used in locomotion Paralysis – absence of strength secondary to nervous impairment Paresis – impaired muscle strength or weakness Passive Exercise – manual or mechanical means of moving the joints Patient Care Ergonomics – practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care Range of Motion – complete extent of movement of which a joint is normally capable Spasticity – increased muscle tone Tonus – normal, partially steady of muscle contraction Chapter 3 ATI A nurse is caring for a client for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client’s choice is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence - Rationale: in this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others’ opinions of what is “best” for them A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this client’s choice is an example of which of the following? a. Fidelity b. Autonomy c. Justice d. Beneficence - Rationale: beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that the aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence o Rationale: justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. A nurse questions a medication prescription as too extreme considering 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 o Nonmaleficence is a commitment to do no harm. In this situation could harm the client. By questioning it, the nurse is demonstrating this ethical principle A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of chemical impairment b. a nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints c. a family has conflicting feelings about the initiation of enteral tube feedings for their father, who if terminally ill d. a client who is terminally ill hesitates to name their partner on their durable power of attorney form o Rationale: making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve. The decision will have a profound effect on the situation and on the client Chapter 4 ATI A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? a. Assault b. Battery c. False imprisonment d. Invasion of privacy - Rationale: By threatening the client, the AP is committing assault . The AP's threats could make the client fearful and apprehensive A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which if the following type of tort is the nurse about to commit? a. Assault b. False imprisonment c. Negligence d. Breach of confidentiality - Rationale: Administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor considered to receiving the sedative 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 "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a. "I'd rather have my brother make decisions for me, but I know it has to be my wife." b. "I know they won't go ahead with the surgery unless I prepare these forms." c. "I plan to write that I don't want them to keep me on a breathing machine." d. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - Rationale: The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises 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) a. Make sure the surgeon obtained the client's consent b. Witness the client's signature on the consent form c. Explain the client's signature on the consent form d. describe the consequences of choosing not to have the surgery e. tell the client about alternatives to having the surgery - Rationale: a. It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that the client understands the information the surgeon gave them b. It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. The nurse also should verify that the client understands the information the surgeon has provided 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, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? a. Alert the American Nurses Association b. Fill out an incident report c. Report the observations to the nurse manager on the unit d. Leave the nurse alone to sleep - Rationale: any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager Chapter 5 ATI A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record - Rationale: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit An nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following info should the nurse include? (select all) a. A single electronic records password is provided for nurses on the same unit b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurse's station d. A client can request a copy of her medical record e. A nurse my photocopy a client's medical record for transfer to another facility. - Rationale: b. the HIPPA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code c. the HIPPA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot hear it. A unit nurses' station is considered a private and secure location d. The HIPPA Privacy Rule states that clients have a right to read and obtain a copy of their medical record e. The HIPPA Privacy Rule states that nurses can only photocopy a client's medical record if it is to be used for transfer to another facility or provider A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (select all) a. Cover errors with correction fluid, and write in the correct info. b. Put the date and time on all the entries. c. Document objective data, leaving out opinions. d. Use as many abbreviations as possible. e. Wait until the end of shift to document. - Rationale: b. The day and time confirm the recording of the correct sequence of events c. Documentation must be factual, descriptive, and objective, without opinions or criticism A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (select all) a. Medication error b. Needlestick c. Conflict with provider and nursing staff d. Omission of prescription e. Complaint from a client's family member - Rationale: a. Complete an incident report regarding a medication error b. Complete an incident report regarding a needlestick d. Complete an incident report following an omission of a prescription A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all) a. Repeat the details of the prescription back to the provider. b. Have another nurse listen to the telephone prescription c. Obtain the provider's signature on the prescription within 24 hr. d. Decline the verbal prescription because is not an emergency situation. e. Tell the charge nurse that the provider has prescribed morphine by telephone. - Rationale: a. The nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation b. Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication Chapter 7 ATI By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? a. Reassess the client to determine the reasons for unsatisfactory pain relief. b. See whether the pain lessens during the next 24 hr. c. Change the plan to ensure that the client achieves adequate pain relief. d. Teach the client about the plan of care for managing his pain. - Rationale: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care. A charge nurse is observing a new licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation - Rationale: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply). a. Respiratory rate of 22/min with even, unlabored respirations b. "I can only walk three blocks before my legs start to hurt." c. Pain level 3 on a scale of 0 to 10 d. Skin pink, warm, and dry e. Urine output of 300 mL/8 hr f. Dressing clean, dry, and intact - Rationale: Objective data includes information the nurse measures (vital signs), includes information the nurse observes (skin appearance), includes information from the observations of others (family and staff). A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) a. Writing a prescription for morphine sulfate as needed for pain. b. Inserting a nasogastric (Ng) tube to relieve gastric distention. c. Showing a client how to use progressive muscle relaxation. d. Performing a daily bath after the evening meal. e. Repositioning a client every 2 hr to reduce pressure ulcer risk - Rationale: Showing a client how to use progressive muscle relaxation is an appropriate nurse- initiated intervention for stress relief. Unless there is a contraindication {of a condition or circumstance} suggest or indicate {a particular technique or drug} should not be be used in the case in question) for a specific client, use this technique with clients without a provider's prescription. Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription. Repositioning a client every 2 hr is an appropriate nurse- initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider's prescription. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address." b. "I will review the past medical history on the client's record to get more information." c. "I will go carry out the new prescriptions from the provider." d. "I will ask the client if his nausea has resolved." - Rationale: Prioritize the client's problems during the planning step of the nursing process. Review the client's history during the assessment/ data collection step of the nursing process. Implement nurse- and provider- initiated actions during the intervention step of the nursing process. Gather information about whether the client's problems have been resolved during the evaluation step of the nursing process. Chapter 8 ATI A nurse is caring for a client who is 24 hr post-op following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? a. Basic b. Commitment c. Complex d. Integrity - Rationale: At the basic level, thinking is concrete and based on a set of rules such as obtaining the prescription for diet progression. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? a. Fairness b. Responsibility c. Risk taking d. Creativity - Rationale: The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies ensures safety. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply) a. finds a mentor b. use a journal to write about the outcomes of clinical judgement c. review articles about evidence-based practice d. limit consultation with other professionals involved in a client's care e. make quick decisions when unsure about a client's needs - Rationale: Learning from the experience of peers can improve critical thinking. Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking. Improving knowledge by learning new information about evidence-based practice improves the nurse's ability to think critically A nurse is caring for a client who has a new prescription for antihypertensive meds. Prior to administering the med, the nurse uses an electronic database to gather information about the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the med info? a. Knowledge b. Experience c. Intuition d. Competence - Rationale: By using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. Confidence b. Perseverance c. Integrity d. Discipline - Rationale: Discipline includes using a systematic approach to thinking. Using a head-to-toe approach ensures the nurse is thorough and calculated in getting information about the client's physical status Chapter 12 ATI A nurse is caring for a client who fell at the nursing home. The client is oriented to person, place and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? a. place a belt restraint on the client when they are sitting on the bedside commode b. Keep the bed in its lowest position with all side rails up c. Make sure that the client's call light is within reach d. Provide the client with nonskid footwear e. Complete a fall-risk assessment - Rationale: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. Nonskid footwear keeps the client from slipping. A fall-risk assessment serves as the basis for a plan of care that can then individualize for the client. A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a. "I will place the client on their side." b. "I will go to the nurses' station for assistance." c. "I will note the time that the seizure begins." d. "I will prepare to insert an airway." - Rationale: During a seizure, stay with the client and use the call light to summon assistance A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is priority? a. Extinguish the fire b. Activate the fire alarm c. Move clients who are nearby d. Close all open doors on the unit - Rationale: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? a. Complete a fall-risk assessment b. Educate the client and family about fall risks c. Eliminate safety hazards from the client's environment d. Make sure the client uses assistive aids in their possession - Rationale: The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? a. Open the windows in the client's room to allow smoke to escape b. Obtain a class C fire extinguisher to extinguish the fire c. Remove all electrical equipment from the client's room d. Place wet towels along the base of the door to the client's room - Rationale: Place wet towels along the base of the door to the client's room to contain with fire and smoke in the room Chapter 13 ATI A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) a. Family members who smoke must be at least 10 ft from the client when oxygen is in use. b. Nail polish should not be used near a client who is receiving oxygen. c. A "No Smoking" sign should be placed on the front door. d. Cotton bedding and clothing should be replaced with items made from wool. e. A fire extinguisher should be readily available in the home - Rationale: Remind the client to not use nail polish or other flammable materials in the home. Have the client place a "No Smoking" sign near the front door, and possibly on the client's bedroom door. Remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heatstroke will have which of the following? a. Hypotension b. Bradycardia c. Clammy skin d. Bradypnea - Rationale: Hypotension is a manifestation of heat stroke A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? a. "I will set my water heater at 130° F." b. "Once my baby can sit up, he should be safe in the bathtub." c. "I will place my baby on his stomach to sleep." d. "Once my infant starts to push up, I will remove the mobile from over the crib." - Rationale: The guardian should plan to remove crib toys (mobiles) from over the bed as soon as the infant begins to push up so the infant begins to push up so the infant is unable to touch them A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? a. Carbon monoxide has a distinct odor. b. Water heaters should be inspected every 5 years. c. The lungs are damaged from carbon monoxide inhalation. d. Carbon monoxide binds with hemoglobin in the body. - Rationale: Warn the client that carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) a. Most food poisoning is caused by a virus. b. Immunocompromised individuals are at risk for complications from food poisoning c. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. d. Healthy individuals usually recover from the illness in a few weeks. e. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning. - Rationale: Warn the client that very young, very old, immunocompromised, and pregnant individuals are at risk for complications from food poisoning. Include that clients who are at high risk should follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products. Include interventions to prevent food poisoning (performing proper hand hygiene, cooking meat and fish to the correct temperature, handling raw and fresh food separately to avoid cross-contamination, and refrigerating perishable items.) Chapter 14 ATI A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? a. Supine b. Semi-fowler’s c. Semi-prone d. Trendelenburg - Rationale: In the semi-Fowler's position, the client lies supine with the head of the bed elevated 15 to 45 degrees (typically 30 degrees). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? a. Obtain a walker for the client to use to transfer back to bed. b. Call for additional personnel to assist with the transfer. c. Use a transfer belt and assist the client to bed. d. Assess the client's ability to help with the transfer. - Rationale: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers and then proceed with a safe transfer. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? a. "lie on my back with my head and shoulders elevated on a pillow." b. "lie flat on my stomach with my head to one side." c. "sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." d. "lie on my side with my weight on my hips and shoulder with my arms flexed in front of me." - Rationale: This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.) a. Request assistance when repositioning a client. b. Avoid twisting the spine or bending at the waist. c. Keep the knees slightly lower than the hips when sitting for long periods of time. d. Use smooth movements when lifting and moving clients. e. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles. - Rationale: To reduce the risk of injury, at least two staff members should reposition clients. Twisting the spine or bending at the waist (flexion) increases the risk for injury. Using smooth movements instead of sudden or jerky muscle movements helps prevent injury. A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply) a. "My line of gravity should fall outside my base of support." b. "The lower my center of gravity, the more stability I have." c. "To broaden my base of support, I should spread my feet apart." d. "When I lift an object, I should hold it as close to my body as possible." e. "When pulling an object, I should move my front foot forward." - Rationale: Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. Spreading the feet apart increases and widens the base of support. Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability. Chapter 15 ATI A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? a. a client who received crush injuries to the chest & abdomen and is expected to die. b. a client who has a 4 inch laceration to the head c. a client who has a partial thickness and full thickness burns to his face, neck and chest d. a client who has a fractured fibula and fibula - Rationale: A client who has burns to the face, neck, and chest is at risk for airway obstruction and requires immediate intervention for survival. Using the survival approach to client care, the nurse should give priority to this client (Emergent (Immediate) Category: Class II) A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? select all the apply a. open doors to the client rooms b. place blankets over clients who are confined to bed c. move beds away from windows d. draw shades & close drapes e. instruct ambulatory clients in the halls to return to their rooms - Rationale: Place blankets over clients to protect them from shattering glass or flying debris. Move all beds away from windows to protect clients from shattering glass or flying debris. Draw shades and close drapes to protect clients against shattering glass. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water b. Wash the affected area with antibacterial soap c. Brush the chemical of the skin & clothing d. Leave the clothing in place until emergency personnel arrive - Rationale: Use a brush to remove the chemical off the skin and clothing A Security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? a. I will get the caller of the pone as soon as possible so I can alert the staff b. I will begin evacuating clients using the elevator c. I will not ask any questions & just let the caller talk d. I will listen for background noise - Rationale: In order to identify the location of the caller, listen for background noises (church bells, train whistles, or other distinguishing noises.) A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (select all that apply) a. A Client who is dehydrated & receiving IV fluid & electrolytes b. A client who has a nasogastric tube to treat a small bowel obstruction c. A client who is scheduled for elective surgery d. A client who has chronic hypertension & blood pressure 135/85 mm Hg e. A client who has acute appendicitis and is scheduled for an appendectomy - Rationale: Identify a client who is scheduled elective surgery is stable and should recommend for discharge. A blood pressure 135/85 mm Hg is within the reference range for prehypertension. Identify this client as stable and should recommend for discharge Chapter 40 ATI A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? a. Decreased subcutaneous fat b. Muscular atrophy c. Pressure injury d. Fecal impaction - Rationale: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a. Instruct the client not to perform the Valsalva maneuver. b. Apply elastic stockings c. Review laboratory values for total protein level. d. Please pillows under the client's knees and lower extremities. e. Assist the client to change position often. - Rationale: Elastic stockings promote venous return and prevent thrombus formation. Frequent position changes prevents venous stasis. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a. Encourage the client to perform antiembolic exercises every 2 hr. b. Instruct the client to cough and deep breath every 4 hr. c. Restrict the client's fluid intake. d. Reposition the client every 4 hr. - Rationale: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of atelectasis A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a. "This device will keep me from getting sores on my skin." b. "This thing will keep the blood pumping through my leg." c. "With this thing on, my leg muscles won't get weak." d. "This device is going to keep my joints in good shape." - Rationale: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation A nurse is instructing a client, who has an injury of the left lower extremity, about the use of the cane. Which of the following instructions should the nurse include? (Select all that apply.) a. Hold the cane on the right side. b. Keep two points of support on the floor. c. Please the cane 38 cm (15 in) in front of the feet before advancing. d. After advancing the cane, move the weaker leg forward. e. Advance the stronger leg so that it aligns evenly with the cane. - Rationale: The client should hold the cane on the uninjured side to provide support for the injured left leg. The client should keep two points of support on the ground at all times for stability. The client should advance the weaker leg first, followed by the stronger leg.