Nursing Practices and Documentation Quiz

<p>A nurse asks a nurse from another unit to assist with documentation for a client. (C)</p> Signup and view all the answers

<p>Gently shake the container of medication prior to administration. (D)</p> Signup and view all the answers

<p>Compare prescriptions with medications the client received while at the facility. (D)</p> Signup and view all the answers

<p>What could I have done to deserve this illness? (C)</p> Signup and view all the answers

<p>Rapid heart rate (D)</p> Signup and view all the answers

<p>Assess the client for orthostatic hypotension. (C)</p> Signup and view all the answers

<p>Initiate droplet precautions. (B), Request a prescription for an antipyretic medication. (C), Wear a mask within 1 m (3 feet) of the client. (E), Request a prescription for an antibiotic medication. (F)</p> Signup and view all the answers

<p>8 oz of ice chips (D)</p> Signup and view all the answers

<p>A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. (A)</p> Signup and view all the answers

<p>Auscultate lung sounds. (A)</p> Signup and view all the answers

<p>Skin blanching (A)</p> Signup and view all the answers

<p>A client who has asthma (C)</p> Signup and view all the answers

<p>The caregiver insists on remaining in the room. (D)</p> Signup and view all the answers

<p>Arrange food in a consistent pattern on the client's plate. (C)</p> Signup and view all the answers

<p>Client 3 (A), Client 4 (B)</p> Signup and view all the answers

<p>0.3 mg (A)</p> Signup and view all the answers

<p>You should have a fecal occult blood test every year. (C)</p> Signup and view all the answers

<p>Breath sounds (B)</p> Signup and view all the answers

The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

The nurse should gently shake the liquid medication to ensure that the medication is mixed.

When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection.

The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

Skin blanching, edema, and coolness at the IV site indicate infiltration.

Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia.

The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures.

It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure.

The client is describing the quality of the pain, which is how the pain feels in the client's own words.

The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition.

The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old.

Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma.

Echinacea is taken to promote immunity and reduce the risk of infection.

The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

Practice sessions require psychomotor skills when learning.

A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding.

According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.

To descend stairs, the client should first shift his body weight to his right, unaffected leg.

The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection.

Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia.

The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures.

It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure.

The client is describing the quality of the pain, which is how the pain feels in the client's own words.

Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition.

The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma.

Echinacea is taken to promote immunity and reduce the risk of infection.

Practice sessions require psychomotor skills when learning.

The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding.

According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.

To descend stairs, the client should first shift his body weight to his right, unaffected leg.