Craven - Ch. 15

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"

A male client 30 years of age is postoperative day 2 following a nephrectomy. Which statement by the client indicates a readiness to start ambulating?

"I know it is important that I start moving as soon as possible after surgery."

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

The nurse receives an order for 100mg of morphine sulfate IM to a postoperative client and knows that the usual dose is 10mg. Which question is most appropriate for the nurse to ask the provider?

"Is the ordered dose of 100mg correct?"

The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required?

"Nursing interventions must be approved by other members of the health care team."

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

An older adult client with a diagnosis of pneumonia is producing large amounts of secretions with his cough and is occasionally gurgling when he breathes. The nurse has responded by increasing the height of the client's bed and suctioning the client's mouth. The nurse has most likely performed which of the following?

An independent nursing action

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

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

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply.

Collecting additional client data Modifying the client plan of care

Which activities does the nurse engage in during the evaluation phase? Select all that apply.

Collects data to determine whether desired outcomes are met Assesses the effectiveness of planned strategies Adjusts the time frame to achieve the desired outcomes

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders

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

Communication

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP?

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.

A hospitalized client has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. The client reports feeling mortified to attempt a bowel movement on a commode at the bedside, where staff and other clients can hear. The nurse should respond by modifying which resource?

Environment

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?

Implement the ABC guide of pain management.

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls.

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses

The nurse in a clinic located in a high-rise building on a university campus has noted that many of the homeless clients who are supposed to receive care for HIV/AIDS have missed their appointments. When questioned, several of the clients stated to the nurse that the clinic is difficult to find and in an intimidating environment. Which variable does the nurse identify as being inadequately addressed for these clients?

Psychosocial background and culture

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Sitting with the client to encourage the client to talk

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

A nurse is caring for a postoperative client after a scheduled ileostomy. Which action by the nurse reflects an effective cognitive outcome?

The client identifies three strategies for minimizing leakage of an ileostomy bag.

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.

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome?

Ask the client to demonstrate self-injection of insulin.

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.

A nurse recently attended a conference that focused on management of acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information from the conference. Which resource is the nurse using to enhance practice?

Evidence-based practice

A nurse is evaluating the plan of care for a client in the clinic. Which actions should the nurse perform, as classic elements of evaluation? Select all that apply.

Identifying evaluative criteria and standards Collecting data to determine whether criteria and standards are being met Interpreting and summarizing findings Terminating, continuing, or modifying the plan of care

A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing what?

Individual peer review

A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?

Laboratory data

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment?

Perform vital signs and blood glucose level.

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions.

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.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. Which would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

Which scenario represents a nurse demonstrating the critical thinking process?

assessing whether physician help is needed

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"

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean?

Written plans are developed that specify nursing activities for this skill.

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?

"My grandchildren have moved in with us while their parents are going through financial difficulties."

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?

"My wife's been gone for about 7 months now."

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of:

outcome evaluation.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

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.

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client.

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evauation process will take place?

A nursing audit

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?

As soon as possible

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.

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.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?

Assess the client's blood pressure to determine if the medication is indicated.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action?

Reassess whether the client still needs the urinary catheter.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?

Evaluate the use of current pain relief measures.

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

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect?

Evaluation

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A nurse finds that a client is not achieving the set outcomes for care and reviews the plan. Which are appropriate actions for the nurse to take while reviewing the plan of care? Select all that apply.

Modify the nursing diagnosis. Make the outcome statement more realistic. Adjust the time limits on the outcome statement. Increase the complexity of the outcome statement.

What activity is carried out during the implementing step of the nursing process?

Planned nursing actions (interventions) are carried out.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in the client's care.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education?

The client demonstrates administration of insulin.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education.

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.

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.

Which factor should the nurse most consider when determining which interventions would best meet the needs of a client?

The client's response to health and illness

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?

The condition of the skin over bony prominences

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Based upon chart reviews, it is determined that documentation on a telemetry unit is inadequate and incomplete. What is an appropriate nursing response to this problem?

The nurse educator reviews the legal reasons for careful and complete documentation.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement.

Which action by the nurse is an example of peer review?

The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

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.

What must occur before physician-initiated interventions can be carried out?

The physician gives a verbal or written order.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

To be sure the intervention is safe