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A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?
clinical judgement
in what order should an RN perform the steps of the nursing process
assessment, analysis, planning, implementation, evaluation
a nurse is reviewing the concept of critical thinking with a newly licensed nurse. which of the following statements should the nurse make
critical thinking is the foundation for clinical decision making
a nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. the nurse should identify that this is an example of which of the following steps of the nursing process
planning
a nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 minutes ago. which of the following steps of the nurisng process is the nurse peforming
evaluation
a nurse is caring for a client who has been wheezing. the nurse asks an AP to use a stethescope and listen tothe patients lung sounds to determine if their wheezing has improved. this is an example of which of the following concepts
delegation of the wrong test
a charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. which of the following skills should the nurse plan to include in the discussion
inference, creativity, inductive reasoning
a nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. which of the following steps of the nursing process is the nurse using
assessment
a charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. which of the following factors should the charge nurse include
availability resources, awareness of client status, support from the other staff
a nurse is caring for a client who is in an acute care facility. the nurse should recognize that the clients care requires clinical reasoning when it is complicated by which of the following factors
complex clinical situations, ongoing client and family concerns
a charge nurse is teaching a newly licensed nurse about the concept of team nursing. which of the following statemtnes by the newly licensed nurse indicated an understanding of the teaching
nurses will pair together for an assigned group of clients
A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?
"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level."
A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?
I should try to escape or put a barrier between myself and the client
I should try to escape or put a barrier between myself and the client
I will include the client and caregivers in the discharge discussion
A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?
The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues.
A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?
right task
A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?
make a list and prioritize a plan
a nurse is speaking with a client who is non compliant in performing dialy blood glucose testing regimen. which of hte following repsonses should the nurse make
“what is preventing your consistency with your daily blood glucose checks”
a nurse is caring for a client who is being transferred to another unit, but teh receiving nurse is unavailable to take report. which of the followinng concepts is being violated that could place the client at risk
continuity of care
a nurse has recieved change of shift report on four clients. which of the following cleints should teh nurse plan to see first
a client who has audible wheezing during respirations
maslows pyramid
physiological, safety, love and belonging, esteem, self actualization
a nurse has received change of shift for a group of clients. which should the nurse see first
a client who is receiving a blood transfusion and reports urticaria
a nurse at a providers office is reviewing the records of several clients. which should be priority
a client who reports new chest pain
which patient needs priority care
patient who received digoxin and has a heart rate of 48/min
a nurse is caring for a client who reports feeling inferior and states that they are not good enough. the nurse should recognize taht these feelings fall under which of the following categories of maslows heirarchy of needs
self esteem
a nurse is assessing a client using the abcde approach. the nurse has already assessed the clients airway and breathing status. which of teh folloiwng assessments should the nurse perform next
blood pressure
a nurse is assisting with client triage at the scene of a mass casulaity event. which of the following clients should the nurse recommend for transport first
client who has an abdominal wound that is actively bleedign
a nurse is assessing a client using abcde. which of hte folloiwng actions should the nurse take when completeing teh exposure component of this priotiry assessment
observe lower extremities for dvt
measure client temp
assess client for bruising
a nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of hte following priority setting frameworks should the nurse use to prioritize client assessment
abcde
a nurse is caring for a client who is confused and is trying to remove their peripehal IV. using the least restrictive priority setting framework, which of the following actions should the nurse take first
cover the IV with elastic bandage
a nurse is providing education on priority setting frameworks to a group of newly licensed nurses. which of the following statements should teh nurse make regarding safety and risk reduction priority setting framework
this framework assigns the highest priority to the situation that poses a threat to the clients physical well being
a nurse is performing an admission assessment on a client. using the safety and risk reduction priority setting framework, which of teh following findings should the nurse identify as the priority
the client reports dizziness when standing
a nurse is caring for a client who reports new onset of abdominal pain. the nurse should assign the clients condition to which of teh following categories when prioritizing care
urgent
a nurse is admitting a patient who has hypertension. using the nursing process, which of the folllowing actiosn should the nurse take first
perform a physical assessment
a nurse is caring for a patient who is recieving palliative care. which of teh following non pharm nuring interventions should the nurse provide to the client
therapeutic touch
a nurse is assisting with teaching a client who has a history of alcoholism and is to be discharged following cataract surgery, about using non pharm therapies. which of the following statements indicates an understanding of the teaching
i will practive meditating when i feel stressed
a nurse is assisting in recommending clients for chiropractic treatment. which of the following clients should the nurse recommend
a client who has shoulder pain
a nurse is teaching a client about food choices that promote immunity and healing. which of the following foods is the best source of vitamin c
1 cup of strawberries
a nurse is caring for a client who follows a vegan diet and reports lethargy. which of teh following interentions should the nurse implement
request a prescription for b12 supplements
a nurse is assisting with teaching a class about using holistic nursing interventions to car for clients. which of the following information should the nurse include
holistic nurses empower clients to actively participate in their own care
a nurse is caring for a client who has a sunburn. the nurse should identify that which of the following herbal supplements is used to treat sunburns
aloe vera
a nurse is reinforcing teaching about traditional chinese medicine to a clinet. which of the following statemtns by the client demonstrates an understanding of the teaching
i will practice tai chi every day
a nurse is assisting with teaching a class about fda regulation of nutritional supplements which of teh following information should the nurse include
a nutritional supplement contains at least one nutritional component
a nurse is caring for a patient who is schedules for emergency appendectomy and reports increased anxiety. which of the following statemtns should the nurse make to implement a complementary health strategy
try to take slow deep breaths in and out
a nurse is planning complementary therapy for a client who has breast cancer. which of the following is a complementary therapy that the nurse can implement
massage therapy
a nurse is caring for a client who asks about naturopathy. the nurse should include taht which of the following is a component of naturopathy
dietary supplements
exercise
traditional chinese medicine
homeopathy
a nurse is assisting with providing an in service for staff members about complementary and integrative health. which of the following statemtns by a staff member indicates an understanding of teaching
scented oils might decrease discomfort
a nurse is completing a preop health history for a client who reports taking several herbal supplements. which of the following herbal supplements is the priority for teh nurse to report
ginkgo biloba
a nurse is assissting a massage therapist to identify the best client for massage therapy. which of the followign clients shoul the nurse recommend
client who has postpartum depression
a nurse is caring for a client who asks about using aromatherpay for nausea. which of the following scents should the nurse recommend
peppermint, ginger, orange
a nurse is assisting with an in service for staff members about culturally competent care. which of the following information should the nurse include about traditional native american beliefs
music can produce healing energy
a nurse is assisting with teaching a newly licensed nurse about holistic nursing. which of the following information should the nurse include
use deep breathing to promote relaxation in clients, encourage clients to use guided inagery to decrease pain, apply essential oils to treat anxiety
a nurse is explaining the practice of ayurveda to a newly licensed nurse. the nruse should include that ayurveda is based on establishing a balance between th body, mind, and spirit with which of the following elements
earth, sky, water
a nurse is assisting with teaching a client about homeopathy. which of teh following clients statemtns indicates an understanding of the teaching
homeopathy believes a substance that can cause a disease can also cure it
which of the following indicates oxygen toxicity
ringing in the ears
a nurse is caring for a client who has atelectasis. the nurse should identify that which of the following substances is required to keep the clients alveoli from collapsing and causing atelectasis
surfactant
a nurse is auscultating a clients heart sounds and hears a low pitches whooshing or blowing sound over the apex of the heart. the nurse should identify that this indicates which of teh following
murmur
a nurse is planning to measure the cardiac output of a client who had a myocardial infarction. which of the following data should the nurse use to calculate the clients cardiac output
stroke volume
a nurse is caring for a client who has a history of asthma and is wheezing. which of the following actions should the nurse take first
obtain oxygen saturation
normal finding of copd includes
clubbing of the fingers
a nurse is caring for a client who has left sided heart failure. which of teh following findings should the nurse expect
crackles in teh lungs
a nurse is planning care for a group of clients on cardiopulmonary unit. which of the followoing clients should the nurse plan to see first
a patient who reports dyspnea when walking to the bathroom
a nurse is providing teaching for a client who has a new prescription for incentive spirometer. which of teh following should the nurse include
use the incentive spirometer every hour while awake
a nurse is discussing ventilation and perfusion with a newly licensed nurse. the nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following location s
alveoli
a nurse is providing teaching for a client who has a new prescription for a cpap machine to treat obstructive sleep apnea. which of the following statemtns should the nurse include
cover ur nose with cpap machine
a nurse is reviewing the medical hisotyr of a client with heart disease and a narrowed valve. what should the nurse expect
stenossi
a nurse is obtaining a health history for a client. which of the following should the nurse identify as risk factors for heart disease
diet high in saturated fats, smoking for 25 years, sednetary lifestyle
electrical flow through heart
sa node, av node, bundle of his, right and left bundle branches, purkinje fibers
a nurse is perfomring chest percussion therapy on a client. which of the following actions shoudl the nurse take
listen for a hollow sound when performing chest percussion therapy
a nurse is suctioning a patient tracheostomy using an open system. which of teh following actions shold the nurse take first
administer 100% oxygen before the procedure
a nurse is caring for a client who is receiving supplemental oxygen for hypoxia. the nurse should identify that which of teh following can cause hypoxia
smoke inhalation
a nurse is assessing a cleint who is being discharged. the nurse notes that the client has regular and quiet breathing. the nurse should identify this breathing pattern as which of teh following
normal breathing
a nurse is teaching a client who has an abdominal incision about coughing and deep breathing. what order should the nurse instruct the client to perform
take a deep breath
hold breath for several seconds
exhale slowly
brace incison with a pillow and try to cough deeply
a nurse is caring for a client who requires 1 l of oxygen. how should this be delivered
nasal canula
a nurse is caring for a client who has a chest tube. which of the following actions should the nurse take
monitor the client for subcutaneous emphysema
a nurse is caring for a client who requires 7 l of oxygen to maintain oxygen saturation. which of the following oxygen devices delivers shold the nurse expect to use
simple face amsk
a nurse is providing teaching fora. client who has a prescription for home oxygen. which of teh following isntructions should th enurse include
no smoking sign, attach oxygen containers to a fixed object, notify fire department that oxygen is used in home
a nurse is discussing atrial fibrilaiton with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understaning of atrial fib
atrail fib is caused by electrical signals outside of the SA node
a nurse is teaching a newly licensed nurse about pulmonary function tests. the nurse should include that which of hte following is the vital capacity
the maximum volume of air that is expired after a maximum inspiration
a nurse is caring for a client who requires assistance with ADLs who should the patient be referred to
occupational therapist
a nurse is preparing a presentation for a group of clients who are schedules for joint replacemetn surgery. which of the follwing ifnoramtion should the nurse paln to indluce regarding flexion of a joint
contraction of a muscle results in flexion of joint
a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. the nurse should plan to assess the client for which of the following
diminished awareness of body position and balance
kyphosis
rounded upper back with pelvis tilted forward
a nurse is caring for a client who is at risk for developing atelectasis. which of the following actions should the nurse take
remind teh client to use incentive spirometer
a nurse is preparing to transfer a client form a bed to a wheelchair. which of the following actions by the nurse demonstrates proper use of body mechanics
looking at the client face to face when transferring teh client
atrophy
muscles becoming smaller and weaker
a nurse is teaching a client who has an unsteady gait about how to use a walker. which of the following instructions should the nurse include
the top of the walker should be at the level of your waist
a nurse is caring for a client who requires maximum assistance to transfer from the bed to a chairl which of the folloiwng pieces of equipment should the nurse use
mechanical lift
a nurse is caring for a patient who requires total assistance with mobility. what eqiptment should the nurse use
mechanical lift
a nurse is assessing a client mobility and notes one of the clients feet drags behind them when ambulating, what is the patient experiencing
foot frop
muscles are responsible for
body posture
a nurse is performing a focused assessment on an older adults mobility, waht is an age related change
increased curavture of the thoracic spine
a nurse is perfomring a skin assessment on a client who has a wound on their heel that is blisterd and lighter in color than the clients skint one. what type of wound damage is this
damage into teh skin layer
patient position for pnehmonia
prone
a nurse is discussing proper body mechanics with a group of APs. what should the nurse include
a stable center of gravity increases stability and balance
a wide base lowers the center of gravity
tighten abdomen
what position prevents atelectasis
fowlers
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