(Answered) Exam 1: Fundamentals of Nursing | Complete Solutions, Summer 2024

(Answered) Exam 1: Fundamentals of Nursing | Complete Solutions, Summer 2024 The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? a. lying flat b. sitting up c. lying flat with feet raised slightly d. lying prone The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3. A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6 What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision. The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! d. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill. A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. it is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making. A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? a. Travelbee's b. Watson's c. Benner's d. Swanson's Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion Feedback: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills, while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills. A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable Feedback: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously. A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills Feedback: Interpersonally skilled nurses establish and maintain caring relationships that facilitate the achievement of valued goals, and simultaneously affirm the worth of those in the relationship. They are, among other things, able to work collaboratively with the health care team to reach valued goals Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily. When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive Feedback: Technical skills are used to carry out treatments and procedures Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential. The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3. A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6 While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurse’s best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity. A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse's best choice of transfer equipment for this client who cannot bear weight on either leg? A) Powered-stand assist B) Transfer chair C) Repositioning lift D) Gait belt Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning instruction is best to give the client when using the friction-reducing sheet? A) Cross the arms across the chest and keep the legs straight. B) Cross the arms across the chest and cross the legs. C) Keep the arms at the sides and the legs crossed. D) Keep the arms folded loosely at the abdomen and the legs straight. When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? A) Allow the client to keep standing for several minutes until balance returns. B) Use the call bell to summon the assistance of another nurse. C) Return the client to the bed. D) Place the client into the wheelchair. When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? A) To prevent hyperextension of the neck B) To prevent pressure on the arms C) To lower the client's center of gravity D) To decrease the effort needed to move the client The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated? A) Reverse Trendelenburg B) Supine C) Sitting D) Semi-Fowler's A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall? A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the client. C) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D) The nurse should gently slide the client down his or her body to the floor. Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device? A) A comatose client who is being taken for x-rays B) An alert client after knee replacement surgery who is being assisted to ambulate C) An obese client who has Alzheimer's disease and is being escorted to the shower room D) A car accident victim with fractures in both legs who is being moved to another room A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly?