Fundamentals final exam prof foster( west coast college)
Total Questions : 64
Showing 25 questions, Sign in for moreA nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Explanation
A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.
Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.
The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
Explanation
A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
Explanation
A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.
The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.)
Explanation
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.
The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.)
Explanation
A. Applying knowledge of disease processes is essential in preventing the spread of infections and understanding transmission routes.
B. Proper disposal of supplies is crucial in minimizing the risk of cross-contamination and infection spread.
C. Checking the negative-pressure system is critical to ensure it functions properly to contain airborne pathogens.
D. Hand hygiene is a key practice in preventing infection and should be performed before and after patient contact in both scenarios.
E. This statement is misleading; while some precautions may overlap, there are specific differences that must be addressed in interventions for airborne versus contact precautions.
F. It is important for patients in airborne precautions to wear a mask during transportation to prevent the spread of infectious particles.
The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)
Explanation
A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.
B. The outer glove package should be removed by tearing it open to access the gloves inside.
C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.
D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.
E. Laying the glove package on a clean flat surface above the waistline prevents contamination.
F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.
The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.)
Explanation
A. Communication signs for airborne precautions are necessary to inform staff and visitors about the required precautions for TB, which is spread via airborne transmission.
B. A surgical mask is not adequate for TB; instead, an N95 respirator is required to filter out the airborne particles effectively.
C. The N95 respirator, gown, gloves, and eyewear are essential personal protective equipment for caring for a patient with tuberculosis. The N95 respirator specifically protects against inhaling infectious particles.
D. Negative-pressure airflow in the room is critical for tuberculosis patients to prevent airborne contaminants from spreading to other areas of the facility.
E. A private room is required to isolate the patient and reduce the risk of transmission to other patients and staff.
F. A communication sign for droplet precautions is not applicable as tuberculosis is primarily transmitted via airborne routes, not droplet transmission.
The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?
Explanation
A. This observation indicates proper body alignment as the arms hanging comfortably at the sides suggest relaxation and good posture.
B. The edge of the seat should not be in contact with the popliteal space; there should be a small gap to prevent pressure and improve circulation.
C. While the feet should be supported on the floor, they should be flat rather than flexed at the ankles for optimal alignment.
D. The body weight should be distributed between the buttocks and thighs, not just on the buttocks, to promote comfort and good posture.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.
Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area?
Explanation
A. After a nurse is exposed to blood from a cut by a used scalpel, it is crucial to test the patient for bloodborne pathogens (e.g., HIV, hepatitis B, hepatitis C) and to offer post-exposure prophylaxis or treatment to the nurse if indicated.
B. While removing gloves and disposing of them properly is part of standard infection control practices, it is not the primary process required after an exposure incident.
C. Although the nurse should report the incident, providing a medical evaluation should follow the protocols established by the facility, not just the manager's assessment.
D. Properly disposing of the scalpel in a sharps container is necessary for safety but does not directly address the required process for managing exposure to blood.
A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse?
Explanation
A. While the patient may have been in a life-threatening situation, this point is not necessarily a direct indictment of the nurse’s actions but rather a justification for performing CPR.
B. The prosecution will likely focus on whether the CPR was performed according to accepted standards of care. If it can be shown that the technique was inappropriate or negligent, this would support the claim of malpractice.
C. Performing CPR according to policy may serve as a defense for the nurse, emphasizing adherence to established protocols.
D. While it is true that older adults with brittle bones may be at risk for fractures, this is a known risk of CPR, and the prosecution will aim to demonstrate specific negligence or failure in technique rather than just acknowledging inherent risks.
A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
Explanation
A. Identifying immobility hazards requires clinical judgment and assessment skills that are beyond the scope of nursing assistive personnel.
B. Determining the level of comfort is a subjective assessment that should be done by a nurse to ensure accurate interpretation of the patient’s condition.
C. Changing the patient's position can be safely delegated to nursing assistive personnel, as it is a straightforward task that does not require advanced clinical judgment.
D. Assessing circulation involves evaluating the patient's vital signs and other parameters, which should be performed by a nurse to ensure comprehensive care and assessment.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
Explanation
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.
An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance?
Explanation
A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.
The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
Explanation
A. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.
B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.
C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.
D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
Explanation
A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.
A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating?
Explanation
A. Patient-centered care emphasizes understanding the patient’s needs and preferences, but it does not specifically address practice gaps.
B. Quality improvement focuses on identifying and addressing discrepancies between current practices and best practices, aiming to improve patient care outcomes.
C. Teamwork and collaboration involve working effectively with others to provide care, not directly identifying practice gaps.
D. Safety is about preventing harm to patients, but quality improvement is more focused on systematic evaluation and process improvement.
A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
Explanation
A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?
Explanation
A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.
A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Explanation
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct?
Explanation
A. Notifying the health care provider is not the most appropriate first action, as parental consent is needed.
B. Contacting the United Network for Organ Sharing is premature without consent from the parents.
C. Since the patient is a minor, parental consent is generally required for organ donation. Instructing the patient to discuss this desire with their parents is essential for obtaining legal consent.
D. Preparing the organ donation form is also premature, as minors cannot legally consent without parental approval.
An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor?
Explanation
A. Competent nurses have typically worked in a specific area for 2-3 years, developing an understanding of patient care specific to that field.
B. Proficient nurses have advanced understanding and experience, allowing them to see care situations as whole parts rather than in separate steps.
C. In a new specialty area, the nurse is considered a novice, as they lack experience and expertise in obstetrics despite previous nursing experience.
D. Advanced beginners have some experience but still need support; however, this would apply only if the nurse had some previous obstetric experience.
A nurse has compassion fatigue. What is the nurse experiencing?
Explanation
A. Compassion fatigue is characterized by burnout and secondary traumatic stress, which result from prolonged exposure to caring for patients in distress and trauma, leading to emotional exhaustion.
B. Lateral violence and intrapersonal conflict involve hostile behavior and internal personal issues, which do not define compassion fatigue.
C. While physical and mental exhaustion can occur with compassion fatigue, they are not the defining aspects without the context of prolonged trauma exposure.
D. Short-term grief and a single stressor do not capture the chronic nature of compassion fatigue, which builds over repeated exposure to others' suffering.
Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)
Explanation
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.
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