FIN 6406 The Nursing process of Critical Thinking And Decision making

lOMoARcPSD| FIN 6406 The Nursing process of Critical Thinking And Decision making After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client’s plan of care. Which evaluation process supports the nurse’s decision? Answer s: a. Reviewing the effectiveness of previously initiated nursing interventions b. Recognizing that the client may be discharged from the hospital during this shift c. Using the knowledge that the client received a comprehensive health assessment d. Referring to the facility’s general plan of client care for the current shift • Question 2 At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are Answer s: a. Hidden. b. Subjective. c. Reported by the patient. . Measurable. • Question 3 While caring for a newly admitted client, the registered nurse (RN) gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests. Which step in the nursing process did this nurse complete? Answer s: a. Planning b. Implementa tion c. Evaluation d. Assessment • Question 4 The nurse is performing a shift assessment on a client. Which information should the nurse identify as objective data? Answer s: a. The client complains of feeling nauseated b. The client demonstrates facial grimacing c. The client complains of visual disturbances d. The client reports feelings of depression • Question 5 The LPN/LVN assists the RN in completing an admission history with a confused client. Which information should be identified as secondary information? Answer s: a. The client reports a history of chest pain. b. The client verbalizes anxiety about hospitalization. c. The client complains of chronic constipation. d. The client’s spouse reports experiencing marital issues. • Question 6 The nurse reviews problems identified for a client. Which problem should the nurse list as a priority? Answer s: a. Ambulates with a cane b. Is separated from the spouse c. Has irregular heart rhythm d. Is unable to use a new glucose meter • Question 7 A client has hyperactive bowel sounds, diarrhea, nausea, vomiting, and has lost five pounds over the last week. Which type of nursing diagnostic statement should be created for this client? Answer s: a. Wellnes s b. Three- part c. Syndro me d. Two- part • Question 8 A hospitalized client with diabetes is being treated for an infected diabetic foot wound. Which would be an appropriate short-term goal for this client? Answers: a. No further evidence of skin breakdown on the feet b. Wound is healed c. Demonstrates correct technique for self-injection of insulin d. Wears footwear in the home at all times Answer This is correct. Long-term goals are not expected to be met before the pat Feedback: time of discharge or transfer to another level of care. They may be met in Response This is correct. Long-term goals are not expected to be met before the pa Feedback: the time of discharge or transfer to another level of care. They may be m • Question 9 The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage caused by a back injury. Which type of intervention will be listed on the plan of care? Answer s: a. Dependen t b. Collaborati ve c. Direct d. Independe nt • Question 10 The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client? Answers: a. Provide 8 ounces enriched milkshake mid-morning and mid-afternoon b. Encourage fluids c. Avoid taking fluids while eating meals Answer Feedback: Response Feedback: d. Monitor intake and output and daily weights This is incorrect. Monitoring intake and output and daily weights are gene individualized for the client. Incorre ct. • Question 11 0 out of 1.11111 points A client has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care? Selected Answer: a. Uses nursing intervention (NIC) and outcome (NOC) statements Answers: a. Uses nursing intervention (NIC) and outcome (NOC) statements b. Coordinates nursing problems with medical diagnoses c. Care is based upon the day of hospitalization d. Provides areas for other disciplines to document interventions Answer This is incorrect. Computerized care plans utilize standardized taxonomy Feedback: Response Feedback: such as NIC and NOC. Incorre ct. • Question 12 0 out of 1.11111 points The nursing student is preparing a care plan for an assigned client. What should the nurse include that is least likely to be placed on an individualized plan of care for the same client? Selected Answer: a. Numbered day of hospitalization Answers: a. Numbered day of hospitalization b. Impact of laboratory data on selection of an intervention c. Consistent use of nursing taxonomy d. • Question 13 Generic nursing diagnoses based upon the primary health problem The nurse is preparing to instruct a client on how to change an ostomy appliance. What should be addressed prior to beginning this teaching session to ensure optimal learning occurs? Answer s: a. Turn off the television b. Address lower level needs c. Complete morning care d. Invite family to participate • Question 14 A nurse receives an order from the physician for an intravenous (IV) antibiotic to be administered to a patient who has experienced development of pneumonia. The nurse remembers that the patient has an allergy to another medication in the same family of antibiotics. The nurse should Answer s: a. Follow the physician’s orders and administer the IV. b. Call the laboratory for clarification. c. Notify the physician of the potential for the patient to have a reaction to the ordered antibiotic. d. Retest the patient for allergies. • Question 15 While caring for a patient who is complaining of abdominal pain, the nurse determines that the top priority is to manage the patient’s pain with medication. This step in the nursing process is called Answer s: a. Implementat ion. b. Planning. c. Diagnosis. d. Assessment. • Question 16 A nurse is caring for a patient who has a broken leg. When the patient complains of pain, the nurse administers additional pain medication. When the nurse medicates the patient, he or she is performing a step in the nursing process that is called Answer s: a. Planning. b. Implementat ion. c. Evaluation. d. Assessment. • Question 17 A nurse is caring for a patient with asthma who is having difficulty breathing. The nurse notifies the respiratory therapist, who administers treatment. After the treatment, the nurse reflects on the results to determine whether the goal of relief has been accomplished. When the nurse determines whether the goal has been met, he or she is performing a step in the nursing process called Answer s: a. Implementat ion. b. Planning. c. Evaluation. d. Diagnosis. • Question 18 A nurse is performing a shift assessment on a patient. While collecting objective and subjective data, the nurse identifies as objective data that Answer s: a. The patient reports feelings of depression. b. The patient demonstrates facial grimacing. c. The patient complains of feeling nauseated. d. The patient complains of visual disturbances. • Question 19 While performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that Answer s: a. The patient’s spouse reports the patient has difficulty sleeping. b. The patient’s caregiver complains of feeling overwhelmed. c. The patient reports a history of chronic obstructive pulmonary disease. d. The patient’s daughter appears anxious about the patient’s hospitalization. • Question 20 The health-care team member responsible for performing a patient assessment and formulating nursing diagnoses is Answer s: a. The licensed practical nurse (LPN). b. The registered nurse (RN). c. The medical doctor (MD). d. The unlicensed assistive personnel (UAP). • Question 21 A licensed practical nurse (LPN) has formulated four nursing diagnoses for her patient. The priority nursing diagnosis would be Answer s: a. Altered nutrition. b. Chronic low self- esteem. c. Risk for infection. d. Ineffective airway clearance. • Question 22 A nursing instructor explains that a complete nursing diagnosis may be a one-part, two-part, or three-part statement. Three-part statements are often called PES statements, which stands for Answer s: a. Pathogen, etymology, and symptoms. b. Problem, etiology, and signs and symptoms. c. Problems, evaluations, and solutions. d. Prognoses, examination, and solution. • Question 23 A nurse assesses a patient’s urine and notices that it is dark yellow, concentrated, and lower in volume than normal. The nurse decides to put the patient on intake and output measurement because the patient has a risk for imbalanced fluid volume. This is an example of a(n) Answer s: a. Dependent intervention. b. Independent intervention. c. Collaborative intervention. d. Indirect intervention. • Question 24 A nursing instructor is explaining the initial steps of most nursing interventions. The instructor recognizes that additional explanation is required when a student nurse states: Answer s: a. “You should always carry out the physician’s order as quickly as possible without question.” b. “You should always think critically about the order to make sure the patient’s condition has not changed in such a way that the order might no longer be appropriate.” c. “You should always check the chart to be certain of a physician’s or other health-care provider’s order.” d. “You should always explain the procedure to the patient using words the patient understands.” • Question 25 The nurse discovers a client lying on the floor. Which should the nurse write when completing an incident report? Answer s: a. “Found client lying face down on the floor beside the bed.” b. “Client accidentally fell out of bed onto the floor.” c. “Client fell out of bed onto the floor.” d. “Heard client fall from the bed to the floor.” • Question 26 While documenting in a client’s chart, the nurse realizes that it is the wrong chart. What should the nurse do? Answer s: a. Write over the incorrect letters. b. Use correction tape to blank out the mistaken entry. c. Use correction fluid to blank out the mistaken entry. d. Write “mistaken entry” and place initials just above incorrect entry. • Question 27 The nursing instructor is reviewing the different types of charting methods with the class. Which should the instructor explain for the acronym SOAPIER? Answer s: a. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results b. Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision c. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision d. Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision • Question 28 A health-care organization is considering focus charting. Which categories are commonly documented using this approach? Answer s: a. Subjective, objective, assessment, plan b. Abnormal findings and checklist c. Problem, intervention, evaluation d. Data, action, response • Question 29 The nurse uses a cheat sheet to jot down pertinent client data while providing care. What should the nurse do with the sheet after documenting all client care? Answer s: a. Shred the paper. b. Keep the paper for use the next day. c. Throw it in the trash. d. Give the paper to the next nurse during hand off communication. • Question 30 A health-care facility uses narrative charting. What should the nurse remember when following this documentation approach? Answer s: a. It focuses on data, action, and response. b. It tells the client’s story. c. It is the least time-consuming documentation method. d. It is the least thorough documentation method. • Question 31 A client received a dose of intravenous pain medication before change of shift. After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest. Who is most liable for this situation? Answer s: a. The health-care provider who prescribed the medication b. The nurse who gave the first dose of medication c. The nurse who gave the second dose of medication d. The person who called the nurse away before documenting the medication • Question 32 A nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states: Answer s: a. “The purpose of written documentation is to serve as a record of accountability for accreditation.” b. “The purpose of written documentation is to serve as a record of accountability for quality assurance.” c. “The purpose of written documentation is to serve as a legal record for the health-care provider only.” d. “The purpose of written documentation is to communicate pertinent data to the health-care team.” • Question 33 A nurse is aware that the best method to ensure documentation accuracy is to consistently chart Answer s: a. At the completion of each shift. b. Immediately after care is provided. c. Immediately before providing care. d. Within 4 hours of providing care. • Question 34 A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is: Answer s: a. “Average intake of clear liquid diet noted.” b. “Patient swallowing clear liquids normally.” c. “No complaints of nausea while on clear liquid diet.” d. “Patient tolerates the clear liquid diet well.” • Question 35 While bathing a patient, a nurse recognizes that the personal space- distance zone that he or she is in when physically touching the patient is Selected Answer: b. Social- consultative. Answers: a. Intimate. b. Social- consultative. c. Casual- personal. d. Public. • Question 36 When interacting with patients, a nurse demonstrates a willingness to communicate by Answer s: a. Standing over seated patients. b. Folding arms while talking to patients. c. Slumping while talking to patients. d. Leaning slightly forward toward patients. • Question 37 When a nurse educates a patient about his medications, the patient tells the nurse that he should go back to nursing school because he does not know very much about medications. The style of communication that the patient is demonstrating is Answer s: a. Aggressi ve. b. Passive. c. Assertive . d. Avoidant. • Question 38 A nursing instructor teaches a class of student nurses that the most effective communication style for nurses to practice is Answer s: a. Passive. b. Avoidant. c. Aggressi ve. d. Assertive . • Question 39 A nurse is caring for a patient who has end-stage renal disease and will require dialysis three times per week. The patient states, “I’m upset that I didn’t visit all the places I’d like to see. Now that I’m on dialysis, I won’t be able to.” The most therapeutic response by the nurse is: Answer s: a. “You are upset that it’s too late to visit places that you would like to see?” b. “Don’t worry. You can still visit all of the places that you would like to see.” c. “There are many people who feel exactly the same as you do.” d. “I think you should visit the places you would like to see before it’s too late.” • Question 40 A nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if she should choose to have surgery. The nurse’s most therapeutic response is: Answer s: a. “Tell me what you know about the surgery.” b. “If I were you, I would definitely have the surgery.” c. “Don’t worry. You will be fine if you don’t have surgery.” d. “I would never decide against having surgery.” • Question 41 A nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient’s primary health-care provider. This type of communication is called Answer s: a. Upward. b. Downwar d. c. Horizont al. d. Bilateral. • Question 42 A nurse observes a student nurse caring for a hearing-impaired patient. The nurse will intervene if the student nurse Answer s: a. Positions himself or herself in front of the patient when speaking. b. Speaks clearly without shouting. c. Speaks directly to the patient’s interpreter. d. Turns down the radio volume when speaking to the patient. • Question 43 A nurse is caring for a patient who was admitted to the hospital for a cerebrovascular accident (CVA) resulting in difficulty understanding speech. The nurse recognizes that the patient is experiencing Answer s: a. Expressive aphasia. b. Expressive dysphagia. c. Receptive aphasia. d. Receptive dysphagia. • Question 44 For nurses to be able to give care to patients, they must quickly establish a trusting relationship with them. Nurses can establish a trusting relationship with their patients by Answer s: a. Conveying that they are confident and competent when providing care. b. Communicating that they are approachable and ready to listen. c. Communicating empathy to their patients. d. All of the above. • Question 45 A nurse is caring for a patient from Germany. The nurse must keep in mind to respect the comfort levels of people from different cultures regarding Answer s: a. Touch. b. Body position. c. Personal space. d. Both 1. and 3. • Question 46 The nurse is discussing health with a client. What should the nurse explain about health being measured on a continuum scale? Answer s: a. It measures only the physical aspects of health. b. It proves that health is constant and rarely fluctuates. c. It would be more accurate if mental and emotional aspects could be measured. d. The higher the measurement is, the better one’s health is. • Question 47 An older client with a chronic illness lives alone, has a fixed income, and often cannot afford required medications. In which quadrant on Dunn’s wellness grid should the nurse categorize this client? Answer s: a. High-level wellness in a favorable environment. b. Emergent high-level wellness in an unfavorable environment. c. Protected poor health in a favorable environment. d. Poor health in an unfavorable environment. • Question 48 A client being seen in the clinic reports having pain on the right side of the abdomen. In which phase of illness is this client? Answer s: a. Symptom atic b. Prodromal c. Dependen cy d. Seeking help • Question 49 A client reports not remembering anything before or after a motor vehicle crash, but the police report indicates black marks on the road caused by the car tires. How should the nurse respond? Answer s: a. “Your fight-or-flight response pumps adrenaline into your system, which enhances your ability to react quickly.” b. “When scared, the parasympathetic system stimulates the fight- or-flight response.” c. “Cortisol, a natural hormone, ceases production and, as a result, we are able to respond quickly in an emergency.” d. “The sympathetic nervous system blocks your endocrine glands, resulting in additional hormones enabling a quick response.” • Question 50 The nurse provides a client with a label from an ice cream container and asks specific questions about the information on the label. What is the nurse assessing in this client? Answer s: a. Nutritional intake b. Health literacy c. Ability to hear d. Ability to read • Question 51 A client seeks medical attention for a sore throat, nasal congestion, and productive cough. For which type of illness should this client receive care? Answer s: a. Chronic b. Exacerbat ion c. Acute d. Prodromal • Question 52 A patient being seen in the clinic tells a nurse, “The pain is in my right side.” The patient’s phase of illness is Answer s: a. Prodromal. b. Dependen cy. c. Symptoma tic. d. Seeking help. • Question 53 A nurse educator explains to student nurses that according to Selye, the general adaptation syndrome (GAS) is Answer s: a. A theory explaining the body’s attempt to adjust to stress. b. What prevents the threat to health when there is long-term stress. c. Validated by how many people are struggling with terminal illnesses, such as cancer. d. An explanation of how the body’s response to stress prevents death. • Question 54 A patient at the clinic is complaining to a nurse that she has no specific symptoms, but that her body aches, she is fatigued, and she just does not feel good. This patient’s phase of illness is the Answer s: a. Prodromal phase. b. Seeking help phase. c. Dependency phase. d. Symptomatic phase. • Question 55 A patient who has been sexually abused continues to describe the situation as if it happened to a friend instead. This patient is presenting the defense mechanism of Answer s: a. Repression. b. Regression. c. Rationalizati on. d. Dissociation . • Question 56 When questioned about the automobile accident that brought him into the hospital, the patient began to cry loudly. The patient then proceeded to curl up in a ball on the bed and suck his thumb. This patient is presenting the defense mechanism of Answer a. s: Sublimatio n. b. Avoidance. c. Displacem ent. d. Regression . • Question 57 A nurse thoughtfully plans care that will be provided to the patients assigned to him or her. To provide culturally competent nursing care, the nurse will Answer s: a. Openly discuss his or her thoughts and beliefs about the patient’s culture. b. Deliver appropriate care that is not discriminating to any race, sex, or ethnic group. c. Show respect for each individual for whom he or she provides care. d. Become familiar with any facet of the patient’s culture that may have an impact on his or her care. • Question 58 In preparation for contributing to a patient’s plan of care, a nurse will assess a patient’s rituals, values, customs, and beliefs. The nurse is assessing the patient’s Answer s: a. Culture . b. Heritag e. c. Ethnicit y. d. Race. • Question 59 A nurse takes into account the patient’s culture when providing care. The nurse knows that which of the following patients would have the most difficulty increasing protein in their diet? Answer s: a. A Mexican patient b. A Jewish patient c. An Asian patient d. A Hindu patient • Question 60 A nurse may fail to provide spiritual care for a patient if Answer s: a. The nurse’s religious background differs greatly from that of his or her patient. b. The nurse notifies a clergyman, with the patient’s consent, to provide spiritual care. c. The nurse believes that a patient’s illness is caused by his or her lack of religious practice. d. The nurse does not understand the relationship between mind, body, and spirit. • Question 61 While a nurse is trying to complete the morning care for a female patient, she tells the nurse that she does not want anyone else in the room while her spiritual advisor is visiting. The nurse will Answer s: a. Tell the patient that he or she will leave the room if the spiritual advisor visits. b. Ask the patient when the spiritual advisor plans to visit and schedule her care around it. c. Assure the patient that once her bath is done, she may see her spiritual advisor. d. Suggest that she ask her spiritual advisor to visit later because there are several more patients who need to be cared for as well. • Question 62 A male patient in dire need of medical assistance has refused treatment, stating it is against his religion. A nurse correctly identifies and documents the patient’s refusals of treatment because he is a Answer s: a. Latter Day Saint. b. Seventh Day Adventist. c. Buddhist. d. Christian Scientist. • Question 63 A charge nurse will take into consideration when making nursing assignments that a 62-year-old Muslim woman will Answer s: a. Be assigned a female nurse. b. Require more care than other patients. c. Require yogurt and sweets be provided at every meal. d. Need a nurse who has an understanding of astrology. • Question 64 A nurse is caring for a Jewish patient with strong cultural beliefs. The nurse must intervene when food services brings him Answer s: a. Chicken breast. b. Fish fillet. c. Bacon and eggs. d. Steak. • Question 65 An instructor explains that a nurse must provide care to the patient and show respect for and incorporate the patient’s specific cultural beliefs and values into his or her care. This idea is known as Answer s: a. Cultural sensitivity. b. Morality. c. Cultural awareness. d. Diversity. • Question 66 A client makes an appointment at the health clinic to receive an annual influenza vaccination. Which health belief is this client demonstrating? Answer s: a. Religious based b. Holistic c. Folk healing d. Biomedical • Question 67 A client from a non-English speaking culture is dying. Which should the nurse do to ensure that this client receives culturally specific care? Answer s: a. Ask the chaplain to see the client. b. Provide towels and a clean gown for the family to bathe the body. c. Ask if there are any specific cultural interventions at this time. d. Suggest the family leave. • Question 68 A client from a non-English speaking culture becomes visibly upset when the phlebotomist arrives to draw a blood sample, and he changes clothes to leave the hospital. What should the nurse do at this time? Answer s: a. Help the client get dressed and obtain a wheelchair to escort them to the exit. b. Find an interpreter to help with communication. c. Provide the paperwork for the client to sign before leaving the hospital. d. Call the health-care provider to stop the client from leaving. • Question 69 A nurse instructs a postpartum client who wishes to breastfeed to gently touch the newborn’s cheek that is closest to the breast to cause the baby to turn toward the breast and open the mouth to find milk. Which reflex is the nurse describing the client to elicit? Answer s: a. Sucking reflex b. Rooting reflex c. Moro reflex d. Babinski reflex • Question 70 Which statement is inappropriate for the nurse to say prior to administering an intramuscular analgesic medication to a school-age child? Answer s: a. “This will only hurt for a little while.” b. “This medication will help take your pain away.” c. “My injections don’t hurt.” d. “This will feel like a prick and will hurt a little.” • Question 71 Which action is best from the nurse when providing care to a toddler who throws a “temper tantrum” during a well-child visit? Answer s: a. Meeting the needs and wants of the toddler immediately b. Offering the toddler some ice cream as a reward for calming down c. Removing the toddler to a quiet place away from the situation d. Scolding the toddler in a stern tone of voice • Question 72 The nurse observes an infant picking up items and immediately placing the items in the mouth. When documenting this observation, the nurse identifies that the infant is encouraging cognitive development through which concept? Answer s: a. Egocentric experiences b. Formal operational thinking c. Concrete operational thought d. Sensorimotor experiences • Question 73 Children in preschool often learn from pretending, role-playing, and exploring the identities of adults in various positions, such as nurses, doctors, teachers, police officers, firefighters, and others who serve as role models. A nurse identifies this as an example of which type of behavior? Answer s: a. Cognitive development b. Psychosocial development c. Physical development d. Moral development • Question 74 During adolescence, girls develop breasts and boys develop facial hair. The nurse documents these findings as a normal stage of which type of development? Answer s: a. Physical b. Psychosoc ial c. Moral d. Cognitive • Question 75 The nurse provides care to an older adult client who displays a fearful attitude toward the nurse when care is provided. The client has multiple unexplained bruises, and several old fractures appear on the x-ray that were never treated. Which does the nurse suspect based on the current data? Answer s: a. The client may have been injured on the job. b. The client may have dementia. c. The client may have been abused by a caregiver. d. The client may be suffering from poor balance. • Question 76 The nurse provides care to a toddler-aged client who is hospitalized. Which intervention does the nurse implement to promote the toddler’s autonomy? Answer s: a. Asking the child to choose between chocolate or vanilla pudding b. Telling the parent to dress the child c. Chastising the child because the shoes are on the wrong feet d. Playing peek-a-boo with the child • Question 77 The psychoanalyst who theorized that psychosocial development occurs throughout one’s life in distinct stages is Answer s: a. Lawrence Kohlberg. b. Erik Erikson. c. James Fowler. d. Jean Piaget. • Question 78 When performing a physical assessment on a neonate, a nurse notes a triangular-shaped soft area that is not yet fused together toward the back of the top of the head. The nurse should Answer s: a. Document this as a normal assessment finding. b. Notify the health-care provider. c. Document this as an abnormal assessment finding. d. Assess the neonate’s vital signs. • Question 79 Which of the following is the infancy stage according to Erikson’s psychosocial stages of development? Answer s: a. Autonomy vs. shame and doubt b. Identity vs. role confusion c. Trust vs. mistrust d. Integrity vs. Dispair • Question 80 The nurse reviews outcome statements with a new colleague. Which information about outcome statements should the new nurse identify as being appropriate? Select all that apply. Answer s: a. “An outcome statement should be a realistic, specific action.” b. “An outcome statement is an action that is measurable and can be evaluated.” c. “An outcome statement should be an action the client is unable to perform.” d. “An outcome statement should be a specific action to be taken by the nurse.” e. “An outcome statement has a definite time frame for completion of the action.” • Question 81 The nurse reviews a care plan prepared for a client. Which are indirect nursing interventions in this plan of care? Select all that apply. Answer a. s: Bathing a client b. Administering pain medication c. Documenting a client’s bath d. Listening to a client’s complaints e. Informing the physician about a client’s pain • Question 82 The nurse is preparing to care for a client. Which action should be completed before implementing any identified interventions? Select all that apply. Answer s: a. Maintain privacy b. Explain the procedure c. Gather equipment and supplies d. Document the procedure completed e. Check the health-care provider’s order • Question 83 The nursing instructor is reviewing documentation with a group of students. Which should the instructor include as the purpose of written documentation? Select all that apply. Answer s: a. Communicate pertinent data to the health-care team b. Serve as a record of accountability for accreditation c. Serve as a legal record for the health-care provider only d. Serve as a record of accountability for quality assurance and reimbursement purposes e. Provide a permanent record of medical and nursing diagnoses • Question 84 Information about the Health Insurance Portability and Accountability Act (HIPAA) is being prepared for a group of new nurses to review during orientation. Which should be emphasized about this act? Select all that apply. Answer s: a. HIPAA guarantees a client the right to view and obtain a copy of his or her medical record. b. HIPAA guarantees a client the right to take the original medical chart. c. HIPAA asks a client to specify who can obtain personal health data. d. HIPAA ensures the right of a client to amend personal health information. e. HIPAA requires hospitals to disclose the way in which a client’s health data will be used. • Question 85 When performing an admission assessment, a nurse assesses a patient’s verbal communication. The nurse recognizes that verbal communication includes which of the following? Select all that apply. Answer a. s: The patient’s tense posture b. The patient’s written words c. The patient’s facial grimacing d. The patient’s vocalization of pain e. The patient’s disheveled appearance • Question 86 A nurse demonstrates active listening when doing which of the following? Select all that apply. Answer a. s: Ignoring nonverbal cues b. Tuning out intrusions and distractions c. Using all of the senses to interpret verbal messages d. Using all of the senses to interpret nonverbal messages e. Paying attention to both what the speaker is saying and not saying • Question 87 The nurse plans to reinforce education for an adolescent client. Which topics does the nurse include during the session? Select all that apply. Answer s: a. Firearms b. Water safety c. Birth control d. Internet safety e. Sexually transmitted infections • Question 88 1500ml D5W with 40mEq KCL/L has been ordered to run over 12 hours. Set calibration is 20gtt/ml. Calculate the flow rate in gtt/min. Answe r: 42 gtt/min • Question 89 Ordered: Aspirin 600mg Available: Aspirin 5 gr tablet Give: tab(s) Answe r: 2 • Question 90 15 mL = oz. Selected 0. Answer: 5