FUNDS 2 FINAL

The client is having problems swallowing fluids and as a result is dehydrated. Which is the most appropriate way of phrasing the problem in a diagnostic statement?

"Deficient fluid volume"

A client has developed a swelling in the throat as a result of the medication's side effect. The client is having problems swallowing fluids and has developed dehydration. How should the nurse state the etiology of the problem when creating a diagnostic statement?

"Effect of medication therapy"

The nurse observes that the client has had a productive cough with thick, purulent sputum several times in the past hour. Which form of problem solving prompts the nurse to notify the physician?

Critical thinking

Which statement describes the best technique for identifying that a written error was made in a manual record sheet?

Cross out the incorrect statement with a single line.

What does critical thinking in problem-solving involve?

Forming ideas or concepts that are mental pictures of reality

What is an example of subjective data?

Frowning

A nurse is planning the care of a client with a stomach infection and high fever. Which expected outcome should the nurse include for this client?

The client's temperature will come down to normal range in 2 days.

The nursing process provides individualized care that is accountable. What is the nursing role in the implementation step of the nursing process?

Giving of actual nursing care

A nurse is conducting the health interview with a client. While interpreting the data obtained from the health interview, which action should the nurse take to provide the most effective interpretation of this data?

Grouping similar data from the interview into clusters.

During a change of shift reporting, a nurse has to substitute for the nurse who was primarily responsible for the care of a client. Which process would be most effective for the nurse's change-of-shift reporting?

Prepare a written summary for the oncoming nurse.

Which type of note does the nurse enter into the medical record at regular intervals to summarize the client's condition or response to treatment?

Progress

When initiating the implementation phase of the nursing process, the nurse implements which phase first?

Put the nursing care plan into action.

Which statement accurately guides the nurse when prioritizing nursing diagnoses?

Rank nursing diagnoses in terms of importance.

Which interventions should a nurse implement to the plan of care of a client whose condition is not improving? Select all that apply.

Reassess the client, Reevaluate the interventions, and Revise the plan of care

Which document would be most helpful in determining the client's ability to perform activities of daily living?

Resident assessment protocol (RAP)

Which are examples of objective data? Select all that apply.

Restlessness, "Get out of my room and leave me alone", and Very quiet

A nurse is caring for a client who is having an extended recovery period. Which intervention would be most effective in improving care for this client?

Review the client's health record.

Which step should the nurse take in planning for the client's discharge?

Set new goals after the old ones are met.

The nurse has to document information to maintain the health record of the client. Which nursing action is required for each charting entry?

Signing the record with first initial, last name, and classification.

Which information about the client's condition should the nurse identify as objective data?

Size, location, and color of the wound

What information should be identifiable when reviewing a client's medical diagnosis? Select all that apply.

The disease a person has or is believed to have, The physiologic manifestations of the illness, A basis for prognosis, and The foundation for future medical treatment decisions

What is the nurse's primary responsibility to the client after collecting assessment data?

Working to identify nursing diagnoses and a plan of care.

Which nursing statement is an example of an interpersonal nursing skill?

"I'll stay with you until your daughter arrives."

Which assessment question should a nurse ask as part of the auditory observation of a client?

"Is it alright to listen to your heart?"

Which response by the nurse demonstrates trial and error problem-solving method?

"Let's see if the new medication helps your nausea better than the last medication did."

Which statement identifies objective data concerning the client?

"My blood pressure is usually 130/82"

Which statement by the nurse identifies the step of the nursing process that is similar to formulating a tentative solution in the scientific problem-solving method?

"Please be sure to give the client an explanation for all care you provide."

Which is the correct sequence for evaluating nursing care?

1- Analyzing the client's responses 2- Identifying factors contributing to success or failure 3- Planning for future nursing care

What is the correct sequence when composing diagnostic statement?

1- Problem 2- Etiology 3- Signs and symptoms

Which is the correct sequence for the planning of nursing care?

1- Setting priorities 2- Establishing expected outcomes 3- Selecting nursing interventions 4- Writing a nursing care plan

A nurse performs a sterile dressing change. Which type of skill is the nurse performing?

A nurse performs a sterile dressing change. Which type of skill is the nurse performing?

Which data entry systems are examples of focus charting? Select all that apply.

APIE, PIE, and DARE

Which statements accurately describe interdependent nursing actions? Select all that apply.

Actions are performed collaboratively with other healthcare providers and Primary care provider may be one of several care prescribers

Which are examples of the technical skills a nurse uses when implementing client care? Select all that apply.

Administering an injection, Inserting a urinary catheter, and Talking with a client about what tends to trigger their depression

A client is admitted to an assisted living facility for continuing memory care for dementia. Who will be involved with the ongoing planning of the client's care at the assisted living center?

All healthcare team members involved in the ongoing care of the client

What is the primary purpose of the evaluation phase of the care planning process?

Analyzing the client's responses

A nurse is observing the progress of an older adult client started on a new medication for dementia. Which is a critical point for the nurse to consider when collecting subjective data about the client and the response to the new medication for dementia?

Assessing the client's body language and nonverbal gestures.

Which statement demonstrates an accurate understanding of the process of problem-solving?

Basic skill of identifying a problem and taking steps to resolve it

What information would be included in the documentation of the client's biographical data? Select all that apply.

Birth date, Name, and Age

When initiating the evaluation phase of the nursing process, who is in the pivotal role?

Client

Which characteristics must be present in an expected outcome? Select all that apply.

Client oriented, Specific, Reasonable, and Measurable

A client has had severe diarrhea for 4 days and a nursing diagnosis of fluid volume deficit related to active fluid loss has been identified for the client. Based on this information, which expected outcome is the most complete?

Client will intake 2,500 mL over next 24 hours.

When considering the implementation of nursing care, what does the action phrase "share it" mean?

Communicating among the healthcare team

While recording the client's condition, what information should the nurse classify as subjective data? Select all that apply.

Complains of nausea, Upset about brother's death, and Client's frame of mind

A nurse is obtaining information about a client's heart condition. Which intervention should the nurse implement when assessing the client?

Consider the client's family history of similar ailments.

A nurse is required to care for a client who is admitted to a healthcare facility. Which steps should the nurse take during the nursing implementation phase of client care? Select all that apply.

Continuing the collection of data, Documenting care provided to client, and Communicating information to the healthcare team

Which statement describes the purpose of progress records?

Describes the treatment and responses of the client

What are the goals for performing a nursing assessment? Select all that apply.

Determining a client's health status, Identifying the client's possible risk factors, and Confirming the client's actual problems

Which actions should the nurse take during the evaluation phase of client care? Select all that apply.

Determining if client's pain has been managed and Noting that the client now needs assistance with walking

A female client arrives at a healthcare facility stating, "I have a really bad case of heartburn." Which question should the nurse ask initially to validate this interpretation?

Do you have a history of digestive problems?

Which nursing interventions are helpful when considering the facility's need to be financially accountable? Select all that apply.

Document all the treatments given to each client, Verify the use of special equipment required to provide safe client care, and Record all billable services in the appropriate health records.

Which intervention should the nurse perform to measure the effectiveness of nursing care?

Document observable evidence.

Which nursing action is a component of the implementation phase of nursing care?

Documenting client care

Which is the primary goal for maintaining a healthcare record for the client in particular?

Documenting the ongoing health status of the client

What independent actions does the nurse perform when implementing care to the client prescribed an antipyretic for an intermittent fever? select all that apply.

Documenting when the medication is administered, Applying cool compresses to the client, and Monitoring the client's vital signs

Which intervention should the nurse implement to facilitate continuity of care?

Ensure documentation of the client's appearance, behavior, and responses.

What steps should a nurse take when engaging in discharge planning? Select all that apply.

Ensuring that the client or family has the necessary instructions, Carefully documenting all instructions that were given to the client, and Providing client and/or family a copy of the follow-up plan of care

The nurse documents, "client walked 40 ft and reported no shortness of breath." Which part of the nursing process does this statement represent?

Evaluation

Which step of the nursing process should the nurse follow before determining whether a client is meeting the planned short-term goals identified in the plan of care?

Evaluation

Which statement is the foundation upon which a nurse manages the care of multiple client simultaneously?

Every client has an individualized nursing care plan.

The steps in the nursing process lead to specific results. The characteristics of the nursing process are critical to its effectiveness. Based on this information, which description best demonstrates a continuous approach to nursing care?

Existing nursing process must be redesigned spontaneously to fit the most current and highest priority needs.

The nurse is reviewing a chart updated using the charting by exception format. Where would the nurse find the client's most recent lung sounds?

Flow sheets

What information would be documented in the recent health history of a client? Select all that apply.

Hypoactive bowel sound

The nurse has analyzed data regarding the client's chief concern. Which information should the nurse include in the nursing diagnosis?

Identification of the nursing care problem

What is the best description of a nursing diagnosis?

Identification of the nursing care problem based on analysis of data

Which nursing intervention should the nurse perform to evaluate the nursing care plan?

Identify factors that contribute to success or failure of goals.

What is the correct sequence for the first four steps of scientific problem-solving?

Identify the problem, Gather information relative to the problem, Formulate tentative solutions and choose preferred solution, and Plan action to test suggested solution

A client is admitted to a medical unit for complications of type 1 diabetes mellitus and all the following nursing diagnoses are appropriately included in the care plan. Which nursing diagnosis would be the priority at this time?

Imbalanced nutrition: less than body requirements related to inability to use glucose

A nurse is formulating a three-part diagnostic statement for a client who had a motor vehicle accident. The client has bruises on the anterior chest and is unable to move independently when sitting up or lying down. Which diagnostic statement should the nurse document?

Impaired mobility of anterior chest related to the motor vehicle accident AEB bruises and swelling

The nurse is administering medications to a client. In what stage of the nursing process is the nurse engaging?

Implementation

A nurse is required to prepare a discharge plan for a client. Which component should the nurse include in the client's discharge plan?

Plans for follow-up visits

A client who has sustained injuries as a result of a car accident is having trouble sleeping and constantly relives the incident. What diagnostic statement should nurse make for this client?

Posttrauma response related to the automobile accident AEB nightmares, insomnia

Which statement accurately describes the correct use of a nursing care plan?

Individualize the nursing care plan to represent all unique aspects of client care.

A client is admitted for complications of a concussion following a motor vehicle accident. Which type of care plan will be implemented for the client?

Individualized nursing care plan

Which nursing diagnosis has the priority?

Ineffective airway clearance

A nurse is conducting the admission interview with a sexually active female client who is reporting warts in the vaginal area. What information should the nurse group with the above data to form a data cluster? Select all that apply.

Instances of unprotected sex and Number of sexual partners

What information accurately describes the intellectual skills required of a professional nurse?

Involves knowing and understanding essential information

What statements describe the character of the nursing process? Select all that apply.

Its dynamic, its continuous, Its systematic, and Its client focused

A nurse makes an entry in a client's chart that includes documentation about the client's routine care, the nurse's observations, and client problems. The nurse arranges the documentation in a chronological order, from the time the nurse started the shift until the nurse documented in the client's record. Which type of documentation best describes what the nurse did in the client's chart?

Narrative

What step of the nursing process should the nurse complete before notifying a physician of a client's emergency admission?

Nursing assessment

Which step in the nursing process is similar to the identification of the problem in the scientific problem-solving process?

Nursing diagnosis

Which step of the nursing process should the nurse complete before identifying goals for care and possible therapeutic nursing interventions to meet them?

Nursing diagnosis

A nurse has completed the data analysis of a client's nursing history. What should be included in the nursing diagnosis?

Nursing priorities

The nurse is preparing for the admission interview of the client. When collecting data, what information should the nurse classify as subjective data? Select all that apply.

The client's description of their pain, Client's concern about paying for the visit, and Client reasons for delaying the visit for 2 days

A nurse is analyzing the data collected from a client's medical interview. The client reported a prolonged cough that had lasted for one month, along with chest pain. The nurse reports the matter to the physician who concludes that the problem requires medical treatment. Which conclusion should the nurse make regarding the client's condition?

The client's problems require a medical diagnosis.

Which description best demonstrates a systematic approach to nursing care?

The nurse follows specific, orderly, and logical steps based on the client's most important and often most vital needs.

What characteristic of a nursing care plan allows care for specific client needs?

The nursing care plan is client-oriented.

The nursing process provides individualized care that is accountable. What action demonstrates the nursing role in the assessment step of the nursing process?

The nursing process provides individualized care that is accountable. What action demonstrates the nursing role in the assessment step of the nursing process?

Which aspect of a client's plan of care has nursing priority?

The plan has to protect the client's safety.

What statement describes the implementation of dependent nursing actions?

The primary care provider's orders regarding medication or treatments must be followed explicitly by the nurse

Which statement accurately describes aspects of computerized charting?

The system provides speed and convenience for both entering and retrieving information.

A nurse is caring for a client in a healthcare facility who is about to be transferred to another healthcare facility for specialized care. Which data would be most helpful to ensure continuity of care?

Transfer notes summarizing care.

A client continuously reports alternating episodes of constipation and diarrhea. The nurse gives the client a different prescribed medication each day to determine an effective treatment. Which method of problem solving is the nurse implementing?

Trial and error

A nurse is conducting the nursing health interview with a client. Which types of information would be included in the activities of daily living section of the nursing history? Select all that apply.

Typical eating and drinking habits of the client, Exercise routines practiced by the client, and Sleep patterns of the client

What type of observation is the nurse making when assessing a rash on the client's hands?

Visual

What client focused information should the nurse document in the client's manual health record?

Vital signs

The nurse is preparing for the admission interview of the client. When collecting data, what information should the nurse classify as objective data? Select all that apply.

Vital signs, Laboratory tests, and Client is afraid

Which intervention should the nurse perform as part of the nursing diagnosis process?

Which intervention should the nurse perform as part of the nursing diagnosis process?

What is the rationale for the use of the accepted NANDA-I approved nursing diagnoses?

Words and terms are the actual diagnostic labels on which the entire client-oriented nursing statement is built.

The nurse is preparing a two-part diagnostic statement for a client diagnosed with dyspnea who has been a long-time smoker. What phrasing should the nurse use to document the problem in the diagnostic statement?

impaired breathing pattern