Chapter 9 Practice Quiz

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate?

"12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids"

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps"

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.

-The client's respiratory rate decreases. -The client states, "I can breathe easier now." -The client's oxygen saturation level increases.

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking whether the client feels less anxious 30 minutes after administering the medicine

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?

Effectiveness of intervention including current pain scale, time frame, and client self-report.

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?

Evaluating

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statemen(s) would help the nurse most appropriately interpret these data?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.

A nurse delegates a specific intervention to an unlicensed assistive personnel (UAP). What implications does this have for the nurse?

The nurse transfers responsibility but is accountable for the outcome.

While implementing the plan of care for a client, the nurse uses interpersonal skills. What would the nurse most likely use?

communication

What is one advantage of having a standard classification of nursing interventions?

to standardize nomenclature (names or terms)

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention.