Test Bank For Taylor’s Clinical Nursing Skills A Nursing Process Approach 5th Edition By P, Exams of Nursing

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Test Bank For Taylor’s Clinical Nursing Skills A

Nursing Process Approach 5th Edition By

Pamela Lynn

Television shows or movies that depict nurses as mean, cruel torturers, are reflective of which "image" of a nurse? - ANSWER ✔️ Battle-ax

One factor that prevents nursing from being described as a profession rather than as a "job" would be? - ANSWER ✔️ In general, the work of the nurse is determined by the healthcare facilities as employers.

Which organization is directly responsible for regulating the practice of nursing in each state? - ANSWER ✔️ the state board of nursing

Which healthcare provider dispenses medications and therapeutic solutions in hospitals, community pharmacies, and various health settings? - ANSWER ✔️ pharmacists

The most correct definition of critical thinking is - ANSWER ✔️ Purposeful, analytical thinking that results in a reasoned decision.

a nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence based practice. Which critical thinking attitude is the nurse demonstrating? - ANSWER ✔️ independent thinking

a patient has pitting pedal edema, crackles, and an elevated blood pressure. The nurse concludes that the patient has fluid volume excess. Which type of reasoning did the nurse use? - ANSWER ✔️ Inductive Reasoning. This means drawing a general conclusion from a pattern found in individual pieces of information.

The nurse incorporates Hispanic beliefs about "hot and cold" into her plan of care for her client. On which theorist is the nurse basing care? - ANSWER ✔️ Madeiline lieninger

A nurse researcher who intends to interview clients about the factors that influence their compliance with insulin therapy and summarize the data as themes is doing quantitative research. True or False? - ANSWER ✔️ False, it would be qualitative the data in this study would come from the experiences of clients living with diabetes as they relate that information to the nurse researcher.

College courses, such as microbiology and human growth and development, present content that is considered part of theoretical nursing knowledge. True or False? - ANSWER ✔️ True, because knowledge gained in these courses helps the nurse develop a more holistic and complete plan of patient care.

The student nurse is completed a research paper detailing the pros and cons of a medical ethical issue. This paper reflects which element of informatics? - ANSWER ✔️ Knowledge,

because a research paper consists of new knowledge about a topic that is created when one gathers and groups data.

In general, faxing client records between healthcare facilities prevents violation of HIPAA regulations. True or False - ANSWER ✔️ false

The nurse sits at the unit computer to begin her shift documentation for her client. She notes the previous user of the computer, the physical therapist, did not log off properly, the nurse should.... - ANSWER ✔️ complete the log off

You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to - ANSWER ✔️ continue for 15 seconds

To decontaminate your hands with an alcohol based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason for this is - ANSWER ✔️ Drying provides the full antiseptic effect Residual alcohol can easily stain clothing Excess gel could transfer to the patient slippery gel can make you drop supplies

standard precautions mandate - ANSWER ✔️ Disinfecting hands immediately after removing gloves

contact precautions would be mandated for a hospitalized patient diagnosed with - ANSWER ✔️ infectious diarrhea

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear? - ANSWER ✔️ Face Shield

which of the following is an advantage of using alcohol-based gel? - ANSWER ✔️ Its use takes time than washing with soap and water does.

Which product can affect permeability of gloves? - ANSWER ✔️ Petroleum-based hand lotion

After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? - ANSWER ✔️ gloves

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must - ANSWER ✔️ protect your eyes

A patient has a healthcare associated infection (HAI) This terminology means that the patient - ANSWER ✔️ acquired the infection while hospitalized

after assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil or grim on your hands. You - ANSWER ✔️ wash your hands with soap and water

which precaution should the nurse use when setting up a client's food tray? - ANSWER ✔️ Hand washing only

which precaution should the nurse use when giving a shot? - ANSWER ✔️ Standard

Which precaution should the nurse use when starting an IV for a client with a high fever and productive cough of unknown origin? - ANSWER ✔️ transmission based

The client has a reddened area around his intravenous site. It is tender to touch. Which type of infection is this? - ANSWER ✔️ localized

which type of drug-resistant infection most commonly impacts the gastrointestinal system? - ANSWER ✔️ Clostridium Difficile

which process in maintaining a clean environment includes the removal of pathogens using chemicals? - ANSWER ✔️ Disinfecting

Which example of personal protective equipment is unique to transmission-based precautions? - ANSWER ✔️ respirator mask

Which type of environment best protects a client who is immunosuppressed and at high risk for acquiring an infection? - ANSWER ✔️ Protective Isolation

a client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately? - ANSWER ✔️ Airborne

The client has developed kidney infection following a bladder infection from the urinary catheter. How would the nurse describe this? select all that apply - ANSWER ✔️ local, secondary, and healthcare-related

how should the nurse deliver the breakfast tray to the bedside of a client in airborne isolation? - ANSWER ✔️ apply respirator mask and gloves then place the tray on the clients nightstand.

In which situation would standard precautions be adequate? select all that apply - ANSWER ✔️ while assisting a client with oral care, while ambulating a client after a procedure, and while inserting an intravenous catheter.

The nurse notices a blood pressure cuff in the clients room with spots of dried blood on it. What should be the nurse next action? - ANSWER ✔️ disinfect it with a chemical cleaner

The nurse is assessing a client with a high fever and chills. What should be included in the assessment? select all that apply - ANSWER ✔️ Risk for compromised, immune system, abnormal white blood cell count, drainage from wounds, history of fevers

which objects are at greatest risk for infection transfer in the healthcare environment? select all that apply - ANSWER ✔️ Healthcare workers, artificial fingernails, vital sign equipment

a client is asking the nurse how he contracted a multidrug- resistant microorganism in his foot wound. What factors likely contributed? select all that apply. - ANSWER ✔️ previous use of antibiotics, advanced age, chronic illness

The nurse is teaching a group of elementary students about infection prevention. Which factors should be included in the discussion? Select all that apply - ANSWER ✔️ importance of washing hands, regular physical activity, getting an annual influenza immunization, and sleeping 6 to 9 hours at night.

The nurse needs an IV pole to begin a new medication for a client. There is a pole in another client's room that is not in use. What should be the nurse's next action? - ANSWER ✔️ disinfect the pole and begin using

which process in maintaining a clean environment includes the removal of pathogens using chemicals? - ANSWER ✔️ disinfecting

which example of protective equipment is unique to transmission based precautions? - ANSWER ✔️ respirator mask

the nurse is caring for an older adult at risk for falls. What should be included in the plan of care? Select all that apply - ANSWER

✔️ provide nonskid footwear, keep call light within reach, clear floor of obstacles, keep bed wheels locked.

what should be the nurse's first action when there's a fire in the patients room? - ANSWER ✔️ relocate the client away from the fire.

a nurse is a new employee in a facility learning about the joint commission patient safety goals. What is included within these goals? - ANSWER ✔️ elimination of never events

As Carol enters the home she visually scans the room. What is concerning? - ANSWER ✔️ several throw rugs, space heater on the floor, open medication bottles, smoke detector hanging open in the kitchen

as the nurse caring for William gives him an injection of pain medication, he accidentally sticks himself. What measure should the nurse should have taken? - ANSWER ✔️ using a needle with a needle guard, not recapping needles, placing syringe and needles directly into sharp container when used, confirming that the sharp container isn't filled, and not-hand passing sharps from one person to another.

a nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are the actions the nurse can take when caring for this client? Select all that apply - ANSWER ✔️ Repeat fall risk assessment every 8 hours, place call light within reach, identify medications that increase falling risk.

a nursing unit is receiving report for five clients being newly admitted. which client is at the highest risk for injury and best place close to the nurse's station? - ANSWER ✔️ an 87 year old patient who is confused

which statements by a nurse are correct when preventing needlesticks and blood exposure? - ANSWER ✔️ i always place my used needles into a puncture proof labeled container, i confirm that the sharps container is not overfilled before placing the syringe inside, I only recap with a needle guard when available.

The nurse knows that falls most often occur in hospitals and long term care facilities during which time frames? - ANSWER ✔️ weekends, nights, and holidays

The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? - ANSWER ✔️ apply a lift belt, get additional help, clear area of obstacles.

In which situation would standard precautions be adequate? - ANSWER ✔️ while assisting a client with oral care, while ambulating a client after a procedure, while inserting an intravenous catheter

The nurse is teaching a group of parents of toddlers about safety. What should be included in the presentation? - ANSWER ✔️ encourage child to sleep on his/ or her back at night, keep the

telephone number of the poison control center accessible, have self-closing, locking swimming pool gates, cut food into small bite size pieces.

which are considered "never events"? select all that apply - ANSWER ✔️ hypoglycemic episode after insulin administration, sponge left in a client after a hysterectomy, and blood clot in the lungs after an orthopedic surgery

The nurse gathers equipment for the insertion of a Foley catheter, obtains a verbal consent from the client, and follows the agency's procedure to complete the task. - ANSWER ✔️ not critical thinking

The nurse discovers abnormal findings when performing a physical assessment. She reviews the electronic health record, comparing the findings, and calls the healthcare provider with the contrasting information. The nurse practitioner then gives new medication orders. - ANSWER ✔️ critical thinking

The student explores the client's health record, reads the history and physical examination, and records the information on the nursing care plan. - ANSWER ✔️ not critical thinking

The nurse recognizes that the client has crackles in the lower lung fields from an accumulation of fluid. He further explores the patient's weight, intake and output, and medication list before documenting the findings - ANSWER ✔️ critical thinking

The unlicensed assistive personnel reports to the nurse that the blood pressure for a client is very low. The nurse reports the information to the next shift. - ANSWER ✔️ not critical thinking

Without assistance, a student ambulates a client in the hallway who recently returned from surgery. - ANSWER ✔️ not critical thinking

A nurse decides to place the intravenous catheter into the client's left arm because he is right handed. - ANSWER ✔️ critical thinking

The nurse delivers the first dose of a new blood pressure medicine that the client has not taken previously. She assesses the blood pressure before delivery of the medication and 1 hour afterward. Prior to the second dosage, the patient's blood pressure is very low and the nurse decides to hold the medication. - ANSWER ✔️ critical thinking

A client tells the nurse that the hospital food is "terrible." The nurse asks what foods the client would prefer based on his cultural customs. She then contacts the dietary department to determine whether adjustments can be made. After the next meal, the nurse asks the client whether the food has improved. - ANSWER ✔️ critical thinking

Which of the following exemplify critical thinking? Select all that apply. Following a step-by-step procedure

Collecting data and recording findings Decision making following data evaluation Accounting for patient considerations Always delivering medications as ordered - ANSWER ✔️ decision making following data evaluation, accounting for patient considerations

The steps of critical thinking include which of the following? - ANSWER ✔️ explore, identify, and analyze

Which of the following describe the decision-making process of a nurse? - ANSWER ✔️ Complex maze of alternatives

How can a student develop critical-thinking skills? Select all that apply. Play "what if?" multiple times a day. Question each test item, asking why it was incorrect. Study with a peer to compare class notes. Complete all of the questions at the end of the book chapter. Come to class daily. - ANSWER ✔️ play "what if?" multiply times a day; question each test item, asking why it was incorrect.

The nurse completes the critical-thinking process but the client's care outcome has been only partially met. What should be the nurse's next action? - ANSWER ✔️ reevaluate the plan to determine whether it was realistic.

The nurse Is completing a head to toe assessment on her client at the beginning of the shift for the hospital unit. Which type of assessment is the nurse completing? - ANSWER ✔️ Ongoing

When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should a. Explain to the client how weight gain occurs b. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. Instruct the UAP to re-weigh the client in 2 hours - ANSWER ✔️ B. check the calibration and reweigh the client.

A client acuity level has decreased after hip replacement surgery. The client has been receiving opioid analgesia and has decreased fluid intake. Which type of diagnosis will the nurse choose? - ANSWER ✔️ Risk

Identify the long-term goal. A. Client pulse oxygenation level will be greater than 92% on room air by tomorrow. B. Client will administer his own insulin using correct technique by discharge. C. Client's pressure ulcer will who presence of granulation tissue in 30 days. D. Client's urine output will be 400mL per 8 hr shift within 72 hr - ANSWER ✔️ C

Identify the client outcome/goal that is written correctly. A. The clients urine output will be adequate by the end of the shift

B. The clients pneumonia will be resolved as evidence by clear breath sounds bilaterally by discharge C. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow D. The client will drink more fluids than he did yesterday by 7:00pm today. - ANSWER ✔️ c

The Nurse reviews care needs for a group of clients. Which task is inappropriate to assign to nursing assistive personnel. - ANSWER ✔️ Make sure a client takes his pills after his meal.

What are the raw, unprocessed numbers, symbols, or words that have no meaning without context called in nursing informatics? - ANSWER ✔️ Data

The nurse is mentoring a new nursing employee in an acute care facility. The new employee needs to access a patient's electronic health record (EHR) to retrieve laboratory results, but has not yet received a computer password. What action should the preceptor take? - ANSWER ✔️ Notify your supervisor that the new employee needs a new password

The nurse receives an electronic order for a new medication, then collects and administers it. Which technology device will be used during this process to prevent error? - ANSWER ✔️ Bar code medication scanning

The nurse walks past a computer workstation in the hallway that is logged in to an active client record showing on the screen.

Knowing that patient privacy is a priority, what should the nurse do to best protect the client information showing on the screen? - ANSWER ✔️ log out of the system and close the client record

Madeline is a senior nursing student taking a course in nursing informatics. She hasn't heard of this subject before and is eager to begin the class.Madeline's first assignment in the course is to write a paper about the factors that make up informatics. What should be included for discussion? Select all that apply. Knowledge Data Wisdom Information Processing - ANSWER ✔️ Knowledge Data Wisdom Information

Madeline is comfortable with computers, e-mailing, texting, web conferencing, and social networking. In the course she learns about telehealth, which fascinates her. She thinks about her grandfather, a war veteran with medical conditions that are not closely monitored because of his rural environment and the 2- hour drive to his physician's office in the city. How might telehealth help Madeline's grandfather? Select all that apply. 's grandfather? By providing recording and monitoring of vital signs using equipment in the home By providing transportation to and from the office in the city

By allowing the clinic's doctors to perform remote physical assessments By maintaining regular visits with the healthcare provider via computer and telephone from home By allowing the healthcare provider to visit the home - ANSWER ✔️ By providing recording and monitoring of vital signs using equipment in the home By allowing the clinic's doctors to perform remote physical assessments By maintaining regular visits with the healthcare provider via computer and telephone from home

Madeline is preparing for her first exam. She meets with her study group and they have a discussion about what constitutes evidence-based practice. Which would be the best example? - ANSWER ✔️ Review of a peer-reviewed journal article on decreasing the incidence of healthcare-acquired infections

Madeline visits her grandfather over spring break and shares what she is learning in her informatics class. He says, "I don't understand this computer generation! I don't see what good could possibly come from having so many electronics in healthcare; it seems so impersonal." How should Madeline reply? Select all that apply. - ANSWER ✔️ Technology is helpful to guide care, but human caring is still important." Computers have been proved to prevent errors by healthcare workers Think of them as safety features to save lives, like those that cars have."

Madeline graduated from her nursing program and is excited to begin her new job at the hospital. One of her orientation days includes an 8-hour training session with the electronic health record (EHR) system. During the training, Madeline learns that sometimes computerization can increase the risk of errors in healthcare. This was not emphasized in her senior informatics course. What are some ways this can happen? Select all that apply. Computerized physician order entry increases the risk of error. Documentation can lack details of the client situation. Employees override the system to save time. Copy-and-paste errors can lead to mistakes. Use of smart technologies confirms correct dosing. - ANSWER ✔️ Documentation can lack details of the client situation. Employees override the system to save time. copy-and-paste errors can lead to mistakes

During Madeline's training, she learns that there are legal and ethical implications to the use of EHRs. What choices can she make to prevent getting into trouble? Select all that apply. Change her password often View the screens that pertain to the care of her patient, and not those of others Use complex passwords Share information only with immediate family of the client Never allow someone else to chart using her login - ANSWER ✔️ Change her password often View the screens that pertain to the care of her patient, and not those of others Use complex passwords

Never allow someone else to chart using her login

Madeline is becoming more comfortable in her new RN position. She asks her charge nurse about the relationship between infection and central line care. Her charge nurse encourages Madeline to do some evidence-based research on the topic and present it at the next staff meeting. How should Madeline begin the research process? Select all that apply. Ask her peers what they think. Identify the information. Formulate a precise definition of the problem. Conduct a computer search. Look in her nursing school textbooks for information. - ANSWER ✔️ Identify the information. Formulate a precise definition of the problem. Conduct a computer search.

While performing research at the hospital's library, Madeline asks the librarian for clarification about what makes a journal scholarly. Which definitions are best? Select all that apply. A well-known publisher printed the journal. Scholars, clinical experts, or scientific researchers in the field wrote the articles. At least 10 authors have collaboratively written the articles. The articles have careful footnoting and citation references. The articles are peer-reviewed. - ANSWER ✔️ Scholars, clinical experts, or scientific researchers in the field wrote the articles. The articles have careful footnoting and citation references. The articles are peer-reviewed

What steps are important in the process of transforming facts into knowledge? Select all that apply. - ANSWER ✔️ Data Information Knowledge Wisdom

Which are examples of data the nurse may collect while providing care to the client? Select all that apply. Current evidence-based practices Policy and procedure information Physical assessment findings Medications Laboratory findings - ANSWER ✔️ all. Current evidence-based practices Policy and procedure information Physical assessment findings Medications Laboratory findings

what is the purpose of the bar code scanner? - ANSWER ✔️ to confirm the accuracy of medications

Which client most benefits from telehealth? A hospitalized client A client within walking distance of the healthcare provider A client in a surgery outpatient facility A client in a rural community - ANSWER ✔️ a client in a rural community

What are the best ways for a nurse to protect client information within the electronic health record? Select all that apply. Change the password often. Discuss the chart with a colleague. Make the password complex. Log off the computer when not in use. Show the screen to the client's family when discussing the client's information. - ANSWER ✔️ change the password often, make the password complex, log off the computer when not in use.

As a new grad on the acute care floor, Madge worked diligently to obtain patient information and supplies in preparation for the healthcare provider's rounds. Which image was the new nurse demonstrating? - ANSWER ✔️ Handmaiden

When comparing the roles of Madge and Bryan as new nursing grads, which roles and functions would they have in common? Select all that apply. Direct care provider Communicator Client/family educator Counselor Leader - ANSWER ✔️ All.

At the time of Bryan's graduation with his BSN degree, Kathy decides to enroll in an RN to BSN program to obtain her degree. What new opportunities will be available for Kathy with this additional education? Select all that apply. Applying for graduate school Providing community care

Becoming a charge nurse Working as a nurse practitioner Performing research - ANSWER ✔️ Applying for graduate school Providing community care. Performing research

Bryan finds himself feeling unprepared and frustrated in his new grad role. He tells his mom, "I do fine when I've done something before, but every day there seems to be a new skill that I haven't performed yet." His mom reassures him that things will get easier as he becomes exposed to more experiences. Which stage of Benner's model is Bryan demonstrating? - ANSWER ✔️ Advanced Beginner

Over dinner one evening, Bryan asks his grandmother whether she was ever a member of the American Nurses Association (ANA). She responds by saying, "I'm not sure what that is." What is Bryan's best response? - ANSWER ✔️ The ANA focuses on the political process as a way of improving healthcare legislation."

During Kathy's BSN program, she has to give a presentation about the use of informatics in nursing as a part of the Quality and Safety Education for Nurses (QSEN) standards. Which examples from her workplace could Kathy share? Select all that apply. The time clock to record her hours worked The electronic health record to record and communicate patient care The computer order entry system to communicate between departments The barcode scanner for medication input safety

The security monitoring camera to track visitors - ANSWER ✔️ The electronic health record to record and communicate patient care The computer order entry system to communicate between departments The barcode scanner for medication input safety

After a year as a medical-surgical nurse in an acute care facility, Bryan tells his mom that he's more passionate about preventive care than he is about health restoration. To which care location should Kathy direct him? - ANSWER ✔️ community health

Bryan decides to advance his practice and begins applying to nurse practitioner education programs. During an interview, he is asked which factors are most influential in changing the face of healthcare. Which of the following ANSWER ✔️ s is correct? -

ANSWER ✔️ consumers are becoming more educated and demanding more choices

In which ways is a nurse able to advance his or her practice? Select all that apply. Earning a doctorate in Nursing Practice Becoming certified to work in pediatrics Obtaining certification in wound care Obtaining certification in chemotherapy Becoming certified in emergency nursing - ANSWER ✔️ all

The nurse is explaining that she works with homebound clients who cannot get to ambulatory care for treatment. Which health care setting is the nurse working in? - ANSWER ✔️ Home care

Which roles are commonly used by nurses during a given shift? Select all that apply. Leader Case manager Educator Advocate Organizer - ANSWER ✔️ leader, case manager, educator, advocate

A nurse who is able to identify and achieve objectives is demonstrating which aspect of Benner's model? - ANSWER ✔️ expert

Which organization represents nurses around the world to ensure quality nursing care for all? The American Nurses Association The International Council of Nursing The National League for Nursing The World Health Organization - ANSWER ✔️ The International Council of Nursing

If the body is overheating, it will compensate with - ANSWER ✔️ vasodilation

when a patient temperature increases, the pulse rate also increases. This finding would be - ANSWER ✔️ Normal

while assessing Mr. Brown's respiratory rate, you also observe that his chest expands fully on inspiration. His respiratory depth would be considered? - ANSWER ✔️ DEEP

At the beginning of a visit, the nurse assesses Mr. Broda's blood pressure and finds it is 116/76 mm Hg. During the visit, Mr. Broda receives some disturbing news about a diagnostic test. If his blood pressure was reassessed at that time, you would expect it to: - ANSWER ✔️ rise

When a patient's blood pressure decreases, his pulse increases. This finding would be: - ANSWER ✔️ normal

Which blood pressure Korotkoff sound represents the systolic reading? - ANSWER ✔️ 1st sound

What are the primary vital signs of the nursing assessment? Select all that apply. - ANSWER ✔️ Temperature Pulse Respiratory rate Blood pressure

The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure,

107/66 mm Hg. Which findings are abnormal? Select all that apply. - ANSWER ✔️ Temperature Pulse Respiratory rate

_____________ pressure is peak blood pressure against arterial walls. - ANSWER ✔️ systolic

What information is needed when assessing the respiratory vital signs? Select all that apply. - ANSWER ✔️ rhythm, effort, depth, and rate

Mr. Lu is admitted with abdominal pain. His oral temperature is 100.4°F (38°C), the pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are: - ANSWER ✔️ abnormal

Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are: - ANSWER ✔️ normal

Ms. Hernandez has a temperature of 102.5°F. Antipyretic medication is ordered for a temperature higher than 39°C. Can the nurse safely administer the medication? - ANSWER ✔️ yes

Ms. Weakly presents to the emergency department with difficulty breathing. Her respiratory rate is 28 breaths/min and her pulse is