NURS 322 Exam 1 || All Accurately Answered.
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the client's basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room correct answers ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
culture, respect compassion, client education, and empowerment. By assessing the effect of the
client's culture on health care, this nurse is practicing client-focused care. Providing for basic
needs does not demonstrate this competence. Simply telling the client about all upcoming tests is
not providing empowering education. Orienting the client and family to the room is an important
safety measure, but not directly related to demonstrating client-centered care.
A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes. correct answers ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant
change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and
pain are particularly significant. Documentation is vital, but the nurse must do more than
document. The primary care provider should be notified, but this is not the priority over calling
the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting
the rapid care to the client.
,A nurse is orienting a new client and family to the inpatient unit. What information does the
nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband. correct answers ANS: A
Each action could be important for the client or family to perform. However, encouraging the
client to be active in his or her health care as a partner is the most critical. The other actions are
very limited in scope and do not provide the broad protection that being active and involved
does.
A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor
advises the student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care correct answers ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the
priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000
Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes.
Every nurse has the responsibility to guard the clients safety.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
explain is the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
,d. Write down the name of each caregiver who comes in the room. correct answers ANS: A
Medication errors are the most common type of health care mistake. The Joint Commissions
Speak Up campaign encourages clients to help ensure their safety. One recommendation is for
clients to know all their medications and why they take them. This will help prevent medication
errors.
Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients correct answers ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the
nurse obtains a signature on the consent form, assessing if the client still has questions is vital,
because without full information the client cannot practice autonomy. Giving accurate
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
client fairly is providing social justice.
A student nurse asks the faculty to explain best practices when communicating with a person
from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What
answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population. correct answers ANS: B
Many members of the LGBTQ community have faced discrimination from health care providers
and may be reluctant to seek health care. The nurse should never make assumptions about the
needs of members of this population. Rather, respectful questions are appropriate. If approached
with sensitivity, the client with any health care need is more likely to answer honestly.
, A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has
pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the
SBAR format for communication?
a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago. correct answers ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation,
Background, Assessment, and Recommendation. Appropriate background information includes
allergies to medications the on-call physician might order. Situation describes what is happening
right now that must be communicated; the clients surgery 2 days ago would be considered
background. Assessment would include an analysis of the clients problem; asking for a different
pain medication is a recommendation. Recommendation is a statement of what is needed or what
outcome is desired; this information about the surgeons preference might be better placed in
background.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed
assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much
higher than previous readings, and the clients mental status has changed. What action by the
nurse would most likely have prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task correct answers ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and
following up on delegated tasks. The nurse should either have asked the UAP about the vital
signs or instructed the UAP to report them right away. An experienced UAP should know how to
take vital signs and the nurse should not have to assess this at this point. Double-checking the
work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP
and are permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the UAP.
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the client's basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room correct answers ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
culture, respect compassion, client education, and empowerment. By assessing the effect of the
client's culture on health care, this nurse is practicing client-focused care. Providing for basic
needs does not demonstrate this competence. Simply telling the client about all upcoming tests is
not providing empowering education. Orienting the client and family to the room is an important
safety measure, but not directly related to demonstrating client-centered care.
A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes. correct answers ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant
change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and
pain are particularly significant. Documentation is vital, but the nurse must do more than
document. The primary care provider should be notified, but this is not the priority over calling
the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting
the rapid care to the client.
,A nurse is orienting a new client and family to the inpatient unit. What information does the
nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband. correct answers ANS: A
Each action could be important for the client or family to perform. However, encouraging the
client to be active in his or her health care as a partner is the most critical. The other actions are
very limited in scope and do not provide the broad protection that being active and involved
does.
A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor
advises the student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care correct answers ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the
priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000
Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes.
Every nurse has the responsibility to guard the clients safety.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
explain is the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
,d. Write down the name of each caregiver who comes in the room. correct answers ANS: A
Medication errors are the most common type of health care mistake. The Joint Commissions
Speak Up campaign encourages clients to help ensure their safety. One recommendation is for
clients to know all their medications and why they take them. This will help prevent medication
errors.
Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients correct answers ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the
nurse obtains a signature on the consent form, assessing if the client still has questions is vital,
because without full information the client cannot practice autonomy. Giving accurate
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
client fairly is providing social justice.
A student nurse asks the faculty to explain best practices when communicating with a person
from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What
answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population. correct answers ANS: B
Many members of the LGBTQ community have faced discrimination from health care providers
and may be reluctant to seek health care. The nurse should never make assumptions about the
needs of members of this population. Rather, respectful questions are appropriate. If approached
with sensitivity, the client with any health care need is more likely to answer honestly.
, A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has
pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the
SBAR format for communication?
a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago. correct answers ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation,
Background, Assessment, and Recommendation. Appropriate background information includes
allergies to medications the on-call physician might order. Situation describes what is happening
right now that must be communicated; the clients surgery 2 days ago would be considered
background. Assessment would include an analysis of the clients problem; asking for a different
pain medication is a recommendation. Recommendation is a statement of what is needed or what
outcome is desired; this information about the surgeons preference might be better placed in
background.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed
assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much
higher than previous readings, and the clients mental status has changed. What action by the
nurse would most likely have prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task correct answers ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and
following up on delegated tasks. The nurse should either have asked the UAP about the vital
signs or instructed the UAP to report them right away. An experienced UAP should know how to
take vital signs and the nurse should not have to assess this at this point. Double-checking the
work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP
and are permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the UAP.
