CHAPTER 1 1. Which tasks would be appropriate for the nurse to delegate to unlicensed assistive personnel(UAP)? Standard Text: Select all that apply. 1. Taking vital signs 2. Measuring and recording intake and output 3. Postmortem care 4. Providing telephone advice 5. Weighing the client Correct Answer: 1,2,3,5 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 2: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 5: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Global Rationale: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of
practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19
2. Which procedure should the registered nurse delegate to unlicensed assistive personnel (UAP)? 1. Making a nursing diagnosis 2. Assisting a client to bedside commode 3. Performing assessments on client 4. Giving the client pain medication Correct Answer: 2 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis is not a task that can be delegated to the UAP. Rationale 2: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Assessment is not a task that can be delegated to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Administering pain medication is not an activity that can be delegated to the UAP. Global Rationale: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis, performing an assessment, and administering pain medications are activities that cannot be delegated to the UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care
QSEN Competencies: II.B.5.Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19 3. Which statement indicates that unlicensed assistive personnel (UAP) understand directions provided regarding client care? Standard Text: Select all that apply. 1. “I will bathe the client in room 402.” 2. “I am done with the assigned tasks for Mr. Wells.” 3. “I can give the medication for you.” 4. “I will note all orders.” 5. “I understand my assignment is to take and document the vital signs.” Correct Answer: 1,2,5 Rationale 1: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Rationale 2: Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation. Rationale 3: Medication administration cannot be delegated. Rationale 4: The UAP cannot note orders on the medical record. This activity must be done by the nurse. Rationale 5: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Global Rationale: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation. Medication administration cannot be delegated. The UAP cannot note orders on the medical record. This activity must be done by the nurse. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1. Apply leadership concepts, skills and decision making in the provision of high quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19 4. The nurse observing the unlicensed assistive personnel (UAP) using alcohol-based rubs for hand hygiene would recognize that further teaching is required when the UAP performs which act? 1. Rubs palm against palm when washing hands. 2. Applies a palmful of product into cupped hands. 3. Interlaces fingers palm to palm. 4. Dries hands with clean paper towel. Correct Answer: 4 Rationale 1: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 2: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 3: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 4: When using an alcohol-based hand rub, the hNanUdR sS shIoNuG ldTnBo.tCbO e dM ried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Global Rationale: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 5. The nurse is working in a day care center where there recently has been an outbreak of viral conjunctivitis. What should the nurse instruct the staff to stop the spread of this infection?
1. Require all children with conjunctivitis to stay home until there is a reduction in drainage. 2. Require all children with an infection to be on otic antibiotics for at least 24 hours prior to returning to school. 3. Isolate all children with conjunctivitis in the same room away from those who are not infected. 4. Perform hand hygiene after providing personal care for all children. Correct Answer: 4 Rationale 1: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to keep children away from the day care center. Rationale 2: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics. Rationale 3: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to isolate children with conjunctivitis. Rationale 4: The best way to reduce the spread of infection is through thorough hand hygiene. Global Rationale: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics, to isolate children with conjunctivitis, or to keep children away from the day care center. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use oNf U teR chSnIoNloGgT yB an.C dO staM ndardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18
6. For which situation should the nurse apply clean disposable gloves? 1. Providing denture care 2. Bathing a client 3. Applying antiemboli stockings 4. Assessing vital signs Correct Answer: 1
Rationale 1: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required. Rationale 2: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when bathing a client. Rationale 3: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when applying stockings. Rationale 4: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when assessing vital signs. Global Rationale: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required. In most instances, unless the client has an open wound, gloves would not be required when bathing a client, applying stockings, or assessing vital signs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 7. The nurse is caring for several clients during the shift. Which action demonstrates appropriate hand hygiene? 1. Putting on gloves 2. Washing hands with soap and water 3. Wiping hands off when entering room 4. Using the client’s soap on hands
Correct Answer: 2 Rationale 1: Putting on gloves does not demonstrate appropriate hand hygiene. Rationale 2: Washing hands with soap and water demonstrates appropriate hand hygiene. Rationale 3: Wiping hands off when entering the room does not demonstrate appropriate hand hygiene. Rationale 4: The use of the client’s soap on the hand is not appropriate when performing hand hygiene. Global Rationale: Washing hands with soap and water demonstrates appropriate hand hygiene. Putting on gloves and wiping hands off when entering the client’s room does not demonstrate appropriate hand hygiene. The use of the client’s soap on the hand is not appropriate when performing hand hygiene. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues, that invN olvUeRinSdIiN viG duTaB ls.,CfaOmM ilies, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 8. Which behavior indicates that the nurse is practicing as a professional? 1. Documenting that a client needs pain medication 2. Visiting with family of a client on another part of the care area 3. Telling a client to ask the next nurse for help getting out of bed 4. Directing unlicensed assistive personnel (UAP) to measure urine output Correct Answer: 4 Rationale 1: A professional nurse would assess the client’s pain level and provide medication. Documenting the need for pain medication does not demonstrate professionalism. Rationale 2: A professional nurse would not socialize with clients or family. Rationale 3: A professional nurse would meet the client’s needs at the time they are requested.
Rationale 4: A professional nurse appropriately delegates tasks to UAP. Global Rationale: A professional nurse appropriately delegates tasks to UAP. A professional nurse would address a client’s pain management needs, avoid socializing with clients and families, and meet the client’s needs at the time they are requested. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: VIII. 2. Assume accountability for personal and professional behaviors NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Evaluation Learning Outcome: 1.1 Discuss what is meant by the concept “professional role of the nurse.” Page Number: 3 9. What actions should the nurse take to assist a client adapt to being hospitalized? Select all that apply. 1. Ensuring for the client’s comfort 2. Completing the admission assessment 3. Attempting to accommodate the client’s wishes 4. Communicating with the client as an individual 5. Accepting the client’s perception of the environment Correct Answer: 1, 3, 4, 5 Rationale 1: Ensuring for the client’s comfort is an action to assist a client adapt to being hospitalized. Rationale 2: Completing the admission assessment is not an approach to assist a client adapt to being hospitalized. Rationale 3: Attempting to accommodate the client’s wishes is an action to assist a client adapt to being hospitalized. Rationale 4: Communicating with the client as an individual is an action to assist a client adapt to being hospitalized. Rationale 5: Accepting the client’s perception of the environment is an action to assist a client adapt to being hospitalized.
Global Rationale: Actions to assist clients adapt to being hospitalized include ensuring for the client’s comfort, accommodating the client’s wishes if possible, communicating with the client as an individual, and accepting the client’s perception of the environment. Completing the admission assessment is not an approach to assist a client adapt to being hospitalized. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Implementation Learning Outcome: 1.7 List three ways you can assist the client to assume and adapt to the client role. Page Number: 4 10. Which document should the nurse refer to ensure safe care is being provided to a client? 1. Core measure sets 2. Nurse practice act 3. Joint Commission standards 4. National patient safety goals (NPSGs) Correct Answer: 4 Rationale 1: Core measure sets were created as a quality improvement tool. Rationale 2: Nurse Practice acts ensure the nurse practices in a safe and legal manner. Rationale 3: Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance. Rationale 4: NPSGs identify focus areas for client safety. Global Rationale: NPSGs identify focus areas for client safety. Core measure sets were created as a quality improvement tool. Nurse Practice acts ensure the nurse practices in a safe and legal manner. Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others
AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Planning Learning Outcome: 1.8 Describe Core Measures, the Joint Commission Standards, and National Patient Safety Goals and how they are developed and utilized in practice. Page Number: 5 11. The nurse is asked to perform a task that is beyond the scope of practice. What should the nurse use as a reason when refusing to complete the task? 1. “It is not a part of the National Patient Safety Goals.” 2. “The Joint Commission does not identify it as a nursing task.” 3. “It is not identified as permitted within the Nurse Practice Act.” 4. “The task can be delegated to unlicensed assistive personnel (UAP).” Correct Answer: 3 Rationale 1: The National Patient Safety Goals do not define nursing scope of practice. Rationale 2: The Joint Commission does not define nursing scope of practice. Rationale 3: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task. Rationale 4: Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Global Rationale: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task. The National Patient Safety Goals do not define nursing scope of practice. The Joint Commission does not define nursing scope of practice. Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Implementation Learning Outcome: 1.10 Discuss major sections of the Nurse Practice Act. Page Number: 5 12. For which reasons should a registered nurse contact the Board of Registered Nursing (BRN)? Select all that apply? 1. Renewing nursing license
2. Determining nursing standards 3. Identifying the date for a disciplinary hearing 4. Checking the dates for continuing education programs 5. Ascertaining when a nurse applicant became licensed Correct Answer: 1, 2, 3, 5 Rationale 1: A function of the BRN is to renew nursing licensure. Rationale 2: A function of the BRN is to determine nursing standards. Rationale 3: A function of the BRN is to investigate disciplinary actions. Rationale 4: The BRN is not responsible for continuing education programs. Rationale 5: A function of the BRN is to register nursing licenses. Global Rationale: Functions of the BRN include renewing nursing licensure, determining nursing standards, investigating disciplinary actions, and registering nursing licenses. The BRN is not responsible for continuing education programs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.12 State four functions of the Board of Registered Nursing. Page Number: 6 13. The nurse manager is contacting the Board of Registered Nursing (BRN) to report a staff member. Which action did the manager most likely observe the staff member perform? 1. Changing a client’s abdominal wound dressing 2. Instructed a client on self-administration of insulin 3. Assisting a client with ambulation to the bathroom 4. Informing a client to stop taking a prescribed medication Correct Answer: 4 Rationale 1: Changing an abdominal wound dressing is within the nurse’s scope of practice. Rationale 2: Medication teaching is within the nurse’s scope of practice.
Rationale 3: Providing direct client care is within the nurse’s scope of practice. Rationale 4: Practicing medicine without a license is an action that is identified as misconduct. Global Rationale: Practicing medicine without a license is an action that is identified as misconduct. Changing a dressing, providing medication teaching, and providing direct client care are all within the nurse’s scope of practice. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Assessment Learning Outcome: 1.13 Discuss four grounds for licensure revocation for professional misconduct. Page Number: 7 14. What action should the nurse take to ensure the safe adNmUinRisStrIaNtiG onToBf.pCrO esM cribed medications to a client? Select all that apply. 1. Validating the healthcare provider’s order 2. Checking two forms of client identification 3. Leaving a client’s medications at the bedside 4. Returning a mislabeled medication to the Pharmacy 5. Deciding to report a medication error later in the shift Correct Answer: 1, 2, 4 Rationale 1: Nurses must not administer any drug without a specific healthcare provider’s order. Rationale 2: Nurses must check two forms of client identification before administering medications. Rationale 3: Nurses must never leave prepared medicines unattended. Rationale 4: Nurses must send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling. Rationale 5: Nurses must always report errors immediately. Global Rationale: Nurses must not administer any drug without a specific healthcare provider’s
order; check two forms of client identification before administering medications; and send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling. Nurses must never leave prepared medicines unattended and always report errors immediately. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.14 Explain the legal issues of drug administration. Page Number: 7 15. A client asks for a copy of the medical record to take home upon discharge. What action should the nurse take regarding this request? 1. Prepare the requested documentation 2. Tell the client that the record belongs to the hospital 3. Explain to the client that the record cannot be provided 4. Ask the health care provider if the medical record can be provided Correct Answer: 1 Rationale 1: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record. Rationale 2: The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. Rationale 3: The record can be provided. Rationale 4: The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client. Global Rationale: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record. The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. The record can be provided. The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care
QSEN Competencies: VI. C. 3. Protect confidentiality of protected health information in electronic health records AACN Essential Competencies: VIII. 10. Protect patient privacy and confidentiality of patient records and other privileged communications NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.15 Discuss the role of HIPAA in health care. Page Number: 8 16. What should the nurse include when reviewing the Patient Care Partnership brochure with a newly admitted client? 1. Visiting hours 2. Times for meals 3. Help with billing claims 4. How to avoid paying for medications Correct Answer: 3 Rationale 1: Visiting hours is not a part of the Patient Care Partnership brochure. Rationale 2: Times for meals are not a part of the Patient Care Partnership brochure. Rationale 3: Help with billing claims is a part of the PatienNt U CR arS e IPNarG tnTeB rs.hCipObM rochure. Rationale 4: How to avoid paying for medications is not a part of the Patient Care Partnership brochure. Global Rationale: Help with billing claims is a part of the Patient Care Partnership brochure. Visiting hours, times for meals and avoiding paying for medications are not a part of the Patient Care Partnership brochure. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 2. Value own and others' contributions to outcomes of care in local care settings AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.16 Describe what is meant by clients’ rights and the Patient Care Partnership brochure Page Number: 9
17. A client refuses to complete an advance directive because he is not “ready to die.” What should the nurse respond to this statement? 1. “It’s best to be safe than sorry.” 2. “You are right – it is more appropriate for someone who has a terminal illness.” 3. “That’s fine. I’ll just document that you refuse to decide your medical treatment.” 4. “It is a document that allows you to make legal decisions about how you wish to receive future medical treatment.” Correct Answer: 4 Rationale 1: Saying that it is better to be safe than sorry does not explain the purpose of an advance directive. Rationale 2: Advance directives are appropriate for all clients and not just those with a terminal illness. Rationale 3: The client did not refuse to decide medical treatment. Rationale 4: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. Global Rationale: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. Saying that it is better to be safe than sorry does not explain the purpose of an advanceNdU irR ecStiIvN e.GATdB va.C n cOe M directives are appropriate for all clients and not just those with a terminal illness. The client did not refuse to decide medical treatment. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.17 Explain what is meant by advance directives Page Number: 10
CHAPTER 2 1. The nurse is planning care for a newly admitted client. Which behavior indicates that the nurse is using critical thinking? 1. Recalls a similar client situation 2. Asks the healthcare provider for suggestions 3. Looks at a care plan written for another client 4. Expects the oncoming nurse to complete the care plan Correct Answer: 1 Rationale 1: An important aspect of critical thinking is the ability to use reflection and language properly. Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation. Rationale 2: Asking a healthcare provider for suggestions when planning client care does not exemplify critical thinking. Rationale 3: Looking at a care plan written for another client does not exemplify critical thinking. Rationale 4: Expecting the oncoming nurse to complete the care plan does not exemplify critical thinking Global Rationale: An important aspect of critical thinking is the ability to use reflection and language properly. Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation. Asking a healthcare provider for suggestions, looking at a care plan written for another client; and expecting the oncoming nurse to complete the care plan do not exemplify critical thinking. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1 Define the term critical thinking. Page Number: 23
2. The nurse is assigned to care for a newly admitted client. Which approach should be used to address the client’s responses to the illness? 1. Best practices 2. Nursing process 3. Critical thinking 4. Evidence-based practice Correct Answer: 2 Rationale 1: Best practice is a generic or general phrase for a process of infusing nursing practice with research-based knowledge. Rationale 2: The nursing process is used to diagnose and treat human responses to health and illness. Rationale 3: Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion. Rationale 4: Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making. Global Rationale: The nursing process is used to diagnose and treat human responses to health and illness. Best practice is a generic or gNeUnReSraINl G phTrBa.sCeOfM or a process of infusing nursing practice with research-based knowledge. Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion. Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2 Define the term nursing process. Page Number: 24 3. The nurse is reviewing care provided to a client. Which behavior indicates that the nurse is using critical thinking? 1. Administers prescribed medications 2. Studies the results of diagnostic tests
3. Individually analyzes client problems 4. Documents responses to care provided Correct Answer: 3 Rationale 1: Administering prescribed medications is an action and would not be conducted when reviewing care. Rationale 2: Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process. Rationale 3: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care. Rationale 4: Documentation is an action that would not be completed when reviewing care provided to a client. Global Rationale: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care. Administering prescribed medications is an action and would not be conducted when reviewing care. Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process. Documentation is an action that would not be completed when reviewing care provided to a client. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3 Explain how critical thinking is used in each step of the nursing process. Page Number: 24 4. After receiving morning report the nurse categorizes an assigned client’s care according to priority needs. How does this behavior support the nursing process? 1. Organizes and structures care 2. Emphasizes client preferences 3. Follows Maslow’s hierarchy of needs 4. Considers time needs for each nursing action Correct Answer: 1
Rationale 1: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings. Rationale 2: Client preferences may or may not coincide with care priorities. Rationale 3: Maslow’s hierarchy of needs may or may not coincide with care priorities. Rationale 4: The time needed for nursing actions may or may not coincide with care priorities. Global Rationale: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings. Client preferences, Maslow’s hierarchy of needs, and time to complete nursing actions may or may not coincide with care priorities. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4 Describe how the nursing process relates to nursing. Page Number: 24 5. The nurse collects data slowly and methodically from a new client. Why is the nurse using this approach during this phase of the nursing process? 1. Ensures accuracy of data 2. Identifies client outcomes 3. Establishes a rapport with the client 4. Highlights the importance of the therapeutic relationship Correct Answer: 1 Rationale 1: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained. Rationale 2: Client outcomes are not identified during the assessment phase. Rationale 3: Client rapport does become established during the assessment phase however this is not the reason for the nurse to collect data slowly and methodically.
Rationale 4: The therapeutic relationship is important however this is not the reason for the nurse to collect data slowly and methodically. Global Rationale: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained. Client outcomes are not identified during the assessment phase. Client rapport and the therapeutic relationship are important however these are not reasons for the nurse to collect data slowly and methodically. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.5 Discuss the term assessment, and describe how it influences the nursing process. Page Number: 24 6. The nurse is preparing to assess a client new to the out-patient care environment. Which actions should the nurse expect to complNeU teRdSuINriG nTgBth.CisOM phase of the nursing process? Select all that apply. 1. Complete a client interview 2. Conduct a physical examination 3. Analyze test results and findings 4. Categorize data into meaningful patterns 5. Identify pertinent family health history issues Correct Answer: 1, 2, 3, 5 Rationale 1: A client interview is a part of the assessment. Rationale 2: A physical examination is a part of the assessment. Rationale 3: Analyzing test results and findings is a part of the assessment. Rationale 4: Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process. Rationale 5: Identifying pertinent family health history issues is a part of the assessment. Global Rationale: Client interview, physical examination, analysis and findings of diagnostic tests, and family health history issues are all parts of the assessment phase of the nursing process.
Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.6 List the components of the assessment step. Page Number: 24 7. After completing an assessment the nurse analyzes all data collected. What is the significance of the nurse performing this analysis? 1. Confirms observations 2. Identifies client outcomes 3. Establishes a foundation for the client’s care 4. Prioritizes interventions according to client needs Correct Answer: 3 Rationale 1: Confirming observations occurs during the assessment phase. Rationale 2: Identifying client outcomes occurs during the planning phase. Rationale 3: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care. Rationale 4: Prioritizing interventions occurs during the implementation phase. Global Rationale: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care. Confirming observations occurs during the assessment phase. Identifying client outcomes occurs during the planning phase. Prioritizing interventions occurs during the implementation phase. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.7 Describe the primary purpose of the analysis phase of the nursing process. Page Number: 25 8. The instructor is preparing a lecture on the nursing process. Which statement should the instructor use that best describes nursing diagnosis? 1. It is an educated judgment about a client’s potential or actual health problems 2. It refers to the priority nursing actions or interventions performed to accomplish a specified goal 3. It involves the careful acquisition and interpretation and use of information to reach a conclusion 4. It is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation Correct Answer: 1 Rationale 1: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client. Rationale 2: The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to accNoUmRpSlIiNshGTaBs.pCeOcM ified goal. Rationale 3: Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion. Rationale 4: Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation. Global Rationale: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client. The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to accomplish a specified goal. Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion. Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic. 4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds. Correct Answer: 3 Rationale 1: The client's respiratory rate is unknown, so it cannot be described as tachypneic. Rationale 2: Bradycardia is a slow heart rate, and the client's pulse is unknown. Rationale 3: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. Rationale 4: Korotkoff’s sounds are heard when measuring blood pressure. Global Rationale: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's respiratory rate is unknown, so it cannot be described as tachypneic. Bradycardia is a slow heart rate, and the client's pulse is unknown. Korotkoff’s sounds are heard when measuring blood pressure. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.1 Identify the cardinal signs that reflect the body’s physiologic status. Page Number: p. 261 3. The nurse is informed during shift report that a client has a wide pulse pressure, is hypertensive, and has a pulse deficit. When the nurse enters the client's room, which assessments should the nurse perform in order to confirm this report? 1. Blood pressure and apical pulse assessments 2. Blood pressure and radial pulse assessment 3. Blood pressure and respiratory rate assessment
4. Blood pressure and radial-apical pulse assessment Correct Answer: 4 Rationale 1: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure. Rationale 2: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure. Rationale 3: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure. Rationale 4: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure. Global Rationale: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be assessed by measuring blood pressure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research NLN Competencies: Knowledge and Science: Knowledge; Relationships between knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Discuss the pulse, and indicate how it is an index of heart rate and rhythm. Page Number: pp. 259, 261 4. When the nurse delegates measurement of vital signs to unlicensed assistive personnel (UAP), which are the nurse's responsibilities? Standard Text: Select all that apply. 1. Assessment of vital sign readings obtained by UAP 2. Assessment of the UAP’s skills in measuring vital signs
3. Determination that the vital signs were obtained correctly 4. Follow up on vital sign measurements that are abnormal or unexpected 5. Observe the UAP as vital signs are being measured Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should review and assess all vital sign readings. Rationale 2: The nurse should determine that the UAP is competent to perform any task delegated. Rationale 3: The nurse should assess the UAP's competence while performing the task. Rationale 4: If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading. Rationale 5: The nurse does not need to follow the UAP around once judged to be competent. Global Rationale: Although the nurse can delegate the performance of tasks, the responsibility for those tasks is not delegated, and rests with the nurse. The nurse should review and assess all vital signs. The nurse should determine that the UAP is competent to perform any task delegated URSINGTB.COM and should assess the UAP's competenceNw hile performing the task. If the UAP reports an unusual reading, the nurse should recheck the vital sign to determine that it is accurate before treating or responding to the reading. The nurse does not need to follow the UAP around once judged to be competent. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Practice; Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.15 Discuss conditions when vital signs may be delegated and when they would not be delegated. Page Number: p. 293 5. The nurse delegates the measurement of vital signs on three clients to unlicensed assistive personnel (UAP). The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed. Which is the priority action by the nurse?
1. Commend the UAP for following the proper procedure. 2. Inform the charge nurse that the UAP does not know how to measure blood pressures. 3. Yell at the UAP and tell her she is incompetent. 4. Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart, and demonstrate correct technique. Correct Answer: 4 Rationale 1: The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading. Rationale 2: Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice. Rationale 3: Yelling at a team member is never correct, and would be highly unprofessional. Rationale 4: The nurse is responsible for teaching the UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it. Global Rationale: The nurse is responsiNbUleRfSoIN r tGeTaBch.CinOgMthe UAP how to measure vital signs properly in a professional manner. Demonstrating proper technique is far more effective than just discussing it. The nurse would not commend the UAP for proper technique, because blood pressure measurement performed with the artery lower than the heart will give a false reading. Telling the charge nurse transfers the responsibility held by the nurse delegating the procedure to another team member, and would not be the best choice. Yelling at a team member is never correct, and would be highly unprofessional. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for client outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork: Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.15 Discuss conditions when vital signs may be delegated and when they would not be delegated. Page Number: p. 286 6. The nurse is preparing to measure a client’s temperature. Which factors could influence this measurement?
Standard Text: Select all that apply. 1. Smoking 2. Eating or drinking 3. Exercise 4. Perfusion 5. Time of day Correct Answer: 1, 2, 3, 5 Rationale 1: If the client has smoked a cigarette, the nurse should wait 15–30 minutes before measuring temperature because of the heat created in the oral cavity by the inhaled smoke. Rationale 2: Eating or drinking will alter temperature readings, and the nurse should postpone temperature assessment 15–30 minutes after intake. Rationale 3: The client who is exercising will have a slight elevation in temperature due to the heat produced by the muscles. NGTB.COM Rationale 4: Perfusion does not impact oNrUaR l tSeIm perature readings, because the sublingual area is a very vascular area that is not greatly impacted by reduced peripheral perfusion.
Rationale 5: Temperature readings have been shown to be lower in the morning than in the evening. Global Rationale: If the client has smoked a cigarette, the nurse should wait 15–30 minutes before measuring temperature because of the heat created in the oral cavity by the inhaled smoke. Eating or drinking will alter temperature readings, and the nurse should postpone temperature assessment 15–30 minutes after intake. The client who is exercising will have a slight elevation in temperature due to the heat produced by the muscles. Perfusion does not impact oral temperature readings, because the sublingual area is a very vascular area that is not greatly impacted by reduced peripheral perfusion. Temperature readings have been shown to be lower in the morning than in the evening. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based
transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.5 Differentiate between the oral, rectal, axillary, and tympanic methods of taking temperature. Page Number: pp. 266, 271 7. The nurse is caring for a client with a fever of 101.8°F oral. Which other vital signs should the nurse anticipate would be affected? Standard Text: Select all that apply. 1. Pulse rate 2. Respiratory rate 3. Diastolic blood pressure 4. Systolic blood pressure 5. Oxygen saturation Correct Answer: 1, 2 Rationale 1: Pulse rate will increase with fever. Rationale 2: Respiratory rate will increase with fever. Rationale 3: Blood pressure is usually not significantly impacted by fever. Rationale 4: Blood pressure is usually not significantly impacted by fever. Rationale 5: The client's oxygen saturation might remain normal with a fever unless his respiratory status is compromised, and then the increased demand for oxygen could cause a drop in oxygen saturation. Global Rationale: Pulse and respiratory rate will increase with fever. Blood pressure is usually not significantly impacted by fever. The client's oxygen saturation might remain normal with a fever unless his respiratory status is compromised, and then the increased demand for oxygen could cause a drop in oxygen saturation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health
and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.18 Discuss conditions when respiratory rate would be elevated or decreased. Page Number: p. 258 8. A client's blood pressure us144/82 which is higher than the usual baseline which has been normal. For what factors should the nurse assess the client based on the current blood pressure reading? Standard Text: Select all that apply. 1. Diet 2. Medication history 3. Activity 4. History of recent symptoms of hypertension 5. Recent stress factors the client has expNeUriReSnIcNeGdTB.COM Correct Answer: 1, 2, 3, 5 Rationale 1: The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. Rationale 2: The nurse should assess the client's medication history as this can impact blood pressure. Rationale 3: The nurse should assess the client's activity as this can impact blood pressure. Rationale 4: There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. Rationale 5: The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure. Global Rationale: The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.13 Identify four of the seven factors that affect blood pressure. Page Number: p. 2921 9. The nurse is reviewing a client's vital signs from birth to age 10. Which changes should the nurse expect to find? 1. Reduction in temperature, increase in heart rate, decrease in respiratory rate, and increase in blood pressure 2. Reduction in oxygen saturation, decreased heart and respiratory rate, and decreased blood pressure 3. Reduced heart and respiratory rate andNU inRcSreINasGeTdBb.CloOoMd pressure 4. Decreased temperature, reduced heart and respiratory rate, and increased blood pressure Correct Answer: 3 Rationale 1: Temperature will not normally change throughout childhood. Heart rate should decrease. Rationale 2: Blood pressure should increase through childhood. Oxygen saturation will not normally change throughout childhood. Rationale 3: The nurse would expect to see a reduced heart and respiratory rate, and an increase in blood pressure from birth through childhood. Rationale 4: Temperature will not normally change throughout childhood. Heart rate and respiratory rate will decrease. Global Rationale: The nurse would expect to see a reduced heart and respiratory rate, and an increase in blood pressure from birth through childhood. Temperature will not normally change throughout childhood. Heart rate should decrease. Blood pressure should increase through childhood. Oxygen saturation will not normally change throughout childhood. Temperature will not normally change throughout childhood. Heart rate and respiratory rate will decrease.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Compare normal heart rate range for adults and children. Page Number: p. 260 10. A client who plays professional football reports having no symptoms and has the following vital signs: 98.6°F; 48; 10; 88/54. Which action by the nurse is the priority? 1. Notify the health care provider. 2. Encourage fluids. 3. Document the client's vital signs and continue the history. 4. Place client in the Trendelenburg position. Correct Answer: 3 Rationale 1: There would be no need to intervene for this client. Rationale 2: This client is not dehydrated. Rationale 3: Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. Rationale 4: The Trendelenburg position is not indicated for this client. Global Rationale: Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client. This client is not dehydrated. The Trendelenburg position is not indicated for this client. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance
Client Need Sub: QSEN Competencies: I.B.3. Provide client-centered care with sensitivity and respect for the diversity of human experience AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment: Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.18 Discuss conditions when respiratory rate would be elevated or decreased. Page Number: p. 278 11. The nurse is assessing a client's peripheral pulses. For what should the nurse assess for? Standard Text: Select all that apply. 1. Bilaterality 2. Regularity 3. Strength 4. Rate 5. Arrhythmia Correct Answer: 1, 2, 3, 4 Rationale 1: When assessing peripheral pulses, the nurse assesses for bilaterality. Rationale 2: When assessing peripheral pulses, the nurse assesses for regularity. Rationale 3: When assessing peripheral pulses, the nurse assesses for strength. Rationale 4: When assessing peripheral pulses, the nurse assesses for rate. Rationale 5: The nurse could not determine if there is an arrhythmia without the use of an ECG. Global Rationale: When assessing peripheral pulses, the nurse assesses for bilaterality, regularity, strength, and rate. The nurse could not determine if there is an arrhythmia without the use of an ECG. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub:
QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.16 Demonstrate the proper techniques for obtaining peripheral pulses. Page Number: p. 276 12. The nurse is unable to palpate a client’s pedal pulse even though the foot is pink and warm. Which action by the nurse is the most appropriate? 1. Apply a warm soak to the foot. 2. Notify the health care provider that the client has lost circulation to the foot. 3. Elevate the foot. 4. Auscultate the pulse using an ultrasound Doppler. Correct Answer: 4 Rationale 1: The nurse would not applyNaUwRaSrIm ecause there is the potential for reduced NGsToBa.kC,ObM sensation if pulses are not palpable, which could result in a burn. Rationale 2: There is no need to notify the health care provider. Rationale 3: Elevating the foot would reduce blood flow, making the pulse more difficult to palpate. Rationale 4: If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler. Global Rationale: If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler. The nurse would not apply a warm soak, because there is the potential for reduced sensation if pulses are not palpable, which could result in a burn. There is no need to notify the health care provider, and elevating the foot would reduce blood flow, making the pulse more difficult to palpate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Quality and Safety: Knowledge; Current best practices
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.16 Demonstrate the proper techniques for obtaining peripheral pulses. Page Number: p. 277 13. A newborn is admitted to the nursery after delivery. Which site should the nurse use to measure this infant’s temperature? 1. Axillae 2. Temporal artery 3. Tympanic membrane 4. Oral cavity Correct Answer: 1 Rationale 1: It is appropriate to monitor an infant’s temperature using the axillae. Rationale 2: The temporal artery is not an appropriate site to assess an infant’s temperature. Rationale 3: The tympanic membrane is not an appropriate site to assess an infant’s temperature. Rationale 4: The oral cavity is not an appropriate site to assess an infant’s temperature. Global Rationale: It is appropriate to monitor an infant’s temperature using the axillae. It is not appropriate to use the temporal artery, the tympanic membrane, or the oral cavity to assess an infant’s temperature. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5 Differentiate between the oral, rectal, axillary, and tympanic methods of taking temperature. Page Number: p. 268 14. The nurse demonstrating proper placement of the stethoscope when assessing the apical pulse. Where should the diaphragm be placed?