Intro Test 2 Practice Questions

A mother brings her infant into the clinic for a well baby visit. The mother was concerned when she left the hospital about being able to get the infant to latch on for breast feeding. Which of the following is an appropriate evaluative statement?

"8FEB2016. Goal met. Mother reports that breast feeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight." ex: The evaluative statement should include the time frame, a judgement as to whether the goal was met and data to support the decision.

A mother is bringing her infant into the the clinic for a well baby check. The infant's weight gain is on target for age. A correctly written evaluative statement is which of the following?

"8FEB2016. Goal met. The infant's weight gain is appropriate for age." ex: An appropriately written evaluative statement should be dated, clearly state the judgement as to whether the outcome was met, and provide data to support the judgment.

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse?

"A nurse is still responsible for utilizing critical thinking to determine the validity of the nursing diagnoses generated." explanation: While computerized documentation systems may select nursing diagnoses, the nurse is still responsible for applying the diagnoses using critical thinking to clients. The computer system is intended as an aid, not to replace the nurse.

The act of analyzing and synthesizing cues requires:

critical thinking. explanation: During clustering, critical thinking is used to analyze and synthesize cues.

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'" explanation: Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

A new graduate nurse has come to your unit to work. She asks the charge nurse what the difference is between collecting data in the patient assessment and in the evaluation phase of the nursing process. The charge nurse bases her response on her knowledge of which of the following statements?

"Data collected in the patient assessment identifies patient health issues, whereas data collected in the evaluation phase is to determine if patient outcomes are being achieved." ex: Data collected in the nursing assessment identifies patient health problems, whereas data collected in the evaluation phase is to determine if patient outcomes are being achieved. Data collected for assessment and elation are used for different purposes. Data collected for evaluation is used to determine if patient goals are being met, and data from the nursing assessment is used in an ongoing manner as it relates to the health issues identified.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions." ex: Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin." explanation: The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage, and conditions that require contact with the health care provider.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?" explanation: A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 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 husband has been ill and I don't have anyone to help me care for him." ex: Common factors that contribute to a client not following the plan of care include lack of family support, inability to afford treatment, limited access to treatment, and adverse physical or emotional effects of treatment. The burden of caring for her husband may be placing stress on the client, and causing her blood pressure to be elevated despite engaging in health promotion (taking walks) and blood pressure-lowering activities (taking their medication and preparing food).

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." explanation: Nursing diagnoses are identified by the nurse to serve as a framework for planning care for a client. Nursing diagnoses guide the nurse toward appropriate interventions. Insurance is not billed with nursing diagnoses. Nursing diagnoses do not validate the medical diagnosis. Nursing diagnoses are not used to determine the amount of nursing care required.

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis." explanation: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client.

A client has been diagnosed with appendicitis and scheduled for an open appendectomy. How should the nurse document a potential complication related to this client's diagnosis and treatment?

"PC: Atelectasis related to surgery" explanation: To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." "Client is at risk of impaired lung function due to anesthesia" could be risk statement but impaired lung function could also be a chronic problem. "Potentially complicated respiration as a result of surgery" is a vague diagnosis. "Risk for respiratory arrest due to anesthesia" would be relevant for the operating nurse and not a postoperative potential complication.

A nurse must call a health care provider to request a prescription for a client who is experiencing pain unrelieved by the previous medication prescribed. When the nurse makes the call, the provider screams at the nurse and states, "Just do what the prescription says! I am not giving you another prescription for pain medication!" What is the best response by the nurse?

"Speaking to me that way is unacceptable. We should work together for the benefit of the client." ex: The nurse should inform the health care provider that the response is inappropriate and that the nurse is entitled to respectful conversation. The behavior of the health care provider should also be reported. The major issue is client care and this should be a top priority for the health care team. The other responses do not deal with this situation to prevent the behavior occurring again.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" explaination: An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan explanation: Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners explanation: Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a newantihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

Which expected client outcome is an example of a psychomotor outcome? Select all that apply.

Accurately drawing up insulin. Safely ambulating using a walker. ex: Examples of psychomotor outcomes include accurately drawing up insulin and ambulating safely using a walker. Identifying signs and symptoms of infection is an example of a cognitive outcome. Rating pain as a 2 on a 10-point scale is a physiologic outcome. An example of an affective outcome is reporting increased confidence in testing blood sugar.

While performing an assessment on a young client the nurse is using the Functional Health Pattern Model. When recording the facts that the client exercises daily, hikes weekly, and plays on a softball team regularly, under which heading should these data be clustered ?

Activity/Exercise explanation: When using the Functional Health Patterns Model the amount of activity, exercise, leisure, recreation and ADL are things needed to be recorded under the Activity/Exercise heading. Nutritional is related to food intake and food preferences. Sleep/rest is about how much sleep or rest the client states they obtained daily or weekly. Health management refers to annual examination and specialists a client sees or allowed by health care insurance.

A nurse writes down the following outcome for a depressed client: "By 6/9/12, the client will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?

Affective explanation: Affective outcomes describe changes in client values, beliefs, and attitudes. Psychomotor outcomes describe the client's achievement of new skills. Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Realistic is not a term used to define outcomes, even though outcomes should be realistic.

The nurse is collecting data on a client presenting to the medical short-stay unit for a colonoscopy. A client reports to the nurse that he quit smoking six months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

Affective outcome ex: Affective outcomes pertain to changes in client values, beliefs, and attitudes and are more complex to evaluate. Changes in behaviors, such as the cessation of smoking or nutritional changes that lead to weight loss, are examples of affective outcomes. Cognitive outcomes involve an increase in client knowledge and are evaluated by asking the client to repeat information or perform a skill. Psychomotor outcomes describe the client's achievement of a new skill. Physiologic outcomes result in physical changes and are evaluated through physical assessment.

Which of the following is classified as a nursing diagnosis?

Grieving explanation: Grieving is a nursing diagnosis per the latest NANDA-I Taxonomy. The other choices are medical diagnoses.

As part of the plan of care, a nurse administers scheduled pain medication to a postoperative client with a pain level of 6 on a 0 to 10 scale. Which action best represents the next step in the nursing process?

Assess pain level in 30 minutes. ex: Since administering a pain medication is implementing the plan of care, the next step would be to reassess the client's pain level. By reassessing the client's pain, the nurse knows if the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Assessing the respiratory rate is an appropriate intervention, but 40 minutes is much too long to wait. The nurse must first assess the client's pain level before ambulating the client. Giving a p.r.n. dose of analgesic for breakthrough pain first requires assessment of the pain level.

One hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. What is the nurse's first action?

Assess the client's blood pressure. ex: When the nurse administered the blood pressure medication, the nurse was aware of possible adverse reactions. When the client reports feeling dizzy and lightheaded, the nurse's most appropriate action is to assess to see if hypotension is the cause of the client's discomfort. Assessing the client's blood glucose level and reviewing the results of lab testing would be additional steps to determine the cause of the client's symptoms. The nurse would not convey the client's report of feeling dizzy to the physician until the assessment was complete.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD. explanation: The nurse has theorized that the client is noncompliant because of a lack of knowledge. Therefore, the nurse must assess what knowledge the client has. The severity of the client's illness has no bearing on how compliant the client is. The client's financial resources and access to health care may be other causes of noncompliance, but that is not the nurse's theory as to what is causing the client's difficulties.

Which step in the nursing process is the careful taking of a history and a nursing examination?

Assessment explanation: Assessment is the careful observation and evaluation of a client's health status, which includes a thorough health history and nursing examination. During the nursing diagnosis, the nurse reports or analyzes data (according to level of practice) to identify and define problems. Planning involves several steps: setting priorities, defining expected or desired outcomes or goals, determining specific nursing interventions, and recording the plan of care. Evaluation involves carrying out the written plan of care, performing the interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

An older adult client is being admitted into the hospital for treatment of a fractured hip. Which part of the nursing process would be carried out first ?

Assessment explanation: Assessment is the first part of the nursing process that must be performed in order to determine the need for nursing care. Nursing diagnosis can then be determined to give guidance to actual and potential health problems. Once established, outcome planning can began and this will in turn drive the development of interventions to be implemented. The final phase of the nursing process is evaluation, when the results of the interventions are reflected upon to determine if the client outcomes have been met.

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which initial step of the nursing process is this nurse performing?

Assessment explanation: The assessment phase of the nursing process is the data collection phase, which includes establishing a database through a physical assessment. Measuring vital signs is an example of establishing a database through physical assessment. Diagnosis refers to the second step in the nursing process, during which identification of client problems occurs. Implementation involves the actual performing of planned nursing interventions. Evaluation involves determining if established client goals have been met.

The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment explanation: The nursing process is a systematic method used by the nurse and client. Assessment is the first step to determine the needs for client care. Next is planning which is based on the assessment obtained. Implementation is delivering the nursing interventions developed. Evaluation is reviewing the interventions and if the goals were met that were developed in the planning stage.

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence explanation: Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source?

Client explanation: The client is the primary source of information. The spouse, health care records, and primary care physician are considered secondary sources.

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

Client himself explanation: As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client's wife, friends, and test results would be secondary sources of data.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normal tensive. explanation: A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 mmHg and 120/80 mmHg. The other options do not directly indicate successful control of hypertension.

Which of the following outcomes is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2016." explanation: A fully measurable outcome should include a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter). The outcome "Client will progress from clear fluid diet to full fluid diet without experiencing nausea" lacks a target time. The outcome "Increase client's diet from clear fluids to full fluids by 12/15/2016" expresses the outcome as a nursing intervention. The outcome "Client will maintain adequate intake with no reports of nausea by 12/15/2016" does not define the performance criteria sufficiently, since "adequate intake" is an imprecise term.

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis?

Client's report of increased consumption of alcohol explanation: The client's increased consumption of alcohol is an unhealthy coping mechanism. The client's other statements indicate healthy ways of dealing with the illness.

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?

Clinical reasoning explanation: Clinical reasoning is the process of making a nursing judgment that will provide safe and quality care.

The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?

Cognitive and technical skills Explanation: The nurse used cognitive and technical skills to interpret this cardiac rhythm. Cognitive and technical skills equip nurses to manage the clinical problems stemming from the client's changing health or illness state. Interpersonal and ethical skills are essential for concerns related to the client's broader well- being.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of what type of outcome?

Cognitive outcome ex: Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be what type of problems?

Collaborative health problems explanation: If problems require physician-prescribed and nurse-prescribed actions, they are collaborative health problems.

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. ex: In addition to knowing what type of data to collect to determine outcome achievement, it is important to know when to collect the data based upon established time criteria. It is important for the nurse to evaluate client outcome achievement as early as possible and not wait until discharge, when the plan of care cannot be modified. Evaluation of the client's attainment of outcome goals is determined by the nurse, client, and the client's family. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement.

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data explanation: Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem- focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client?

Complete a systematic nursing history and nursing examination. explanation: Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs and is obtained by a nursing history and nursing examination. Generalizations should be avoided and interpretations should not be made based on client behaviors; rather, client behaviors should be assessed as what they are.

A staff nurse has asked the nursing student to perform an intervention that the nursing student has not been educated to perform? What is the appropriate approach for the nursing student to take?

Consult with your nursing instructor before performing the procedure. explanation: Whenever you are asked by a staff nurse to perform an intervention for which you lack education, you should consult with your instructor to see if you should attempt to perform it with supervision. Under no circumstances should you attempt to perform interventions beyond your capacity without supervision, even if instructed to do so by a staff nurse. Delegating the intervention to an unlicensed assistive personnel member is not an acceptable option, as you likely are not familiar with the education of this individual.

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast. The client refuses to look at surgical site and states, "I'm ugly. My husband will no longer find me desirable." What is the etiology?

Decreased ability to cope with surgical removal of right breast explanation: The etiology identifies the factors that contribute to the unhealthy client response or problem. Disturbed Body Image identifies what is unhealthy about the client, indicating the need for change. The client's statements and refusal to look at the surgical site are defining characteristics that validate the existence of the problem.

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." Identify the problem statement in this nursing diagnosis.

Deficient fluid volume explanation: The problem statement is "Deficient Fluid Volume." "Insufficient fluid intake" is the etiology in this nursing diagnosis. Defining characteristics include "blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." The phrase "hot, dry climate" is not a component of this nursing diagnosis statement.

The nurse is writing outcomes that are measurable for a client. What verbs will the nurse use in order to write these outcomes?Select all that apply.

Define Verbalize explanation: The verb should indicate the action that is to be performed. Examples include define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate.

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen ex: The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel (UAP) is inappropriate because it is not in accordance with her capabilities.

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem?

Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. ex: Upon recognizing that the nursing diagnoses are not up-to-date, an effective approach by the nurse manager is to establish a process for periodic review of the plan of care. This review process will require deletion of nursing diagnoses that have been resolved and, conversely, adding new diagnoses as needed. Implementing concept mapping will not correct the problem of poorly updated nursing diagnoses, as concept mapping requires the identification of nursing diagnoses. Developing interviewing and assessment skills is an important component of the assessment phase of the nursing process. Also, one nurse should not be responsible for updating nursing diagnoses for all client care plans on the unit.

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

Diagnosing Explanation: Analysis of client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve is a function of the diagnosis step of the nursing process. Assessing involves collection, validation, and communication of client data. Implementation is carrying out the plan of care. Evaluating is measuring the extent to which the client has achieved the outcomes specified in the plan of care.

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?

Disturbed body image related to the incision scar explanation: The client is concerned about the surgery scar on the neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms, and injury related to surgical outcomes are also not related to the client's concern.

The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit, and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent?

Effective decision making ex: Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations. Appropriate staffing ensures that client needs are effectively matched with nurse competencies. Micromanagement would be demonstrated by the manager not asking for opinions and proceeding with decision making without input. Meaningful recognition highlights the value each nurse brings to the work for the organization, such as certification.

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

Imbalanced nutrition: less than body requirements explanation: Another common mistake is to write "Lack of adequate nutrition" as the nursing diagnosis. The most appropriate nursing diagnosis would be Imbalanced Nutrition: Less than Body Requirements.

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside, where staff and other clients can hear her. The nurse should respond by modifying which of the following resources?

Environment ex: Providing an environment for the client that is more conducive to privacy and, ultimately, to her elimination needs is necessary in this case. The equipment itself (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client herself are not central to the client's new problem.

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0-10. There is an order for IV pain medication every 4 hours PRN. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0-10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. To assure that this client's plan of care is appropriate the nurse must evaluate the client's response to the intervention of administering pain medication. Evaluation must take place before determination of the need for modification can be made. Therefore calling the surgeon and modifying the plan of care is not appropriate at this time, and continuing to make rounds on other clients does not address this client's needs specifically.

Which stage of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation Evaluation is assessment and review of the quality and suitability of the care given, and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected and desired outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process?

Evaluation explanation: Evaluation is the step of the nursing process when the nurse evaluates the results of a nursing action. The nurse needs to determine if the client's pain has been relieved and monitor for any untoward effects. Assessment is the first step where the nurse gathers all the information. Planning occurs when information is gathered and the nursing diagnosis is generated. Implementation is the activation of nursing interventions.

The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?

Evaluation explanation: The nurse is collecting data to evaluate the effectiveness of a medication that was administered. This does not involve planning or implementation. Appraising is not a discrete part of the nursing process.

A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history?

Family explanation: Family members or significant others, if available, can provide information for a client who is confused or incapacitated.

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?

Family explanation: The family is aware of the client's past experiences and accomplishments. Thus, the nurse should allow for the involvement of support people, particularly family

The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview?

Focus full attention on the client. explanation: During an interview with a client the nurse must give the person their full attention. The nurse should not put the focus on notes, the computer, or any interventions that must be carried out as it can be portrayed as a non caring behavior. The nurse should give all the attention to the client during an assessment looking for subjective cues and displaying empathy.

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused assessment explanation: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems.

Which activities does the nurse perform during the diagnosing stage? Select all that apply.

Identify factors contributing to the client's health problem. Prioritize the client's health problems with input from the client. Validate the identified health problems with the clients. explanation: During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, validates the identified health problems with the clients, and prioritizes the client's health problems with input from the client. The nurse establishes plan priorities with the client and family during the outcome identification and planning. The nurse collects data to monitor quality and effectiveness of nursing practice during the evaluation stage.

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs explanation: Maslow uses a hierarchy of five sets of human needs to organize data with physiological needs, such as the need for oxygen, at the top. Gordon's (1994) framework identifies 11 functional health patterns and organizes client data into these patterns. The human response patterns organize data according to human responses to interventions. A medical model used to organize data collection with which all nurses are familiar is the body systems model. This method organizes data collection according to organ and tissue function in various body systems.

Which of the following best defines nursing diagnoses?

Identification of client problems that nurses can treat independently explanation: Nursing diagnoses are written to describe client problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other health care professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential client problems.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

Identifies factors causing undesirable response and preventing desired change explanation: The cause of the patient health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the patient goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Patient strengths are identified during the nursing diagnosis phase.

A nurse who is caring for a client admitted to the patient care unit with acute abdominal pain formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

Impaired comfort explanation: Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have disturbed body image, disturbed sleep patterns, or activity intolerance, but all these are secondary to pain.

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired physical mobility related to pain explanation: "Impaired physical mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired movement due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective physical mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.

A client is brought to the emergency room in respiratory arrest and immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?

Impaired spontaneous ventilation explanation: Ineffective spontaneous ventilation is the most appropriate nursing diagnosis for the client because they are unable to breathe as the result of respiratory failure. Ineffective breathing pattern is appropriate when the client has difficulty breathing due to a high respiratory rate. Ineffective airway clearance is an inaccurate diagnosis here because the airways are clear and not blocked by secretions. Additionally, the diagnosis of impaired gas exchange is inappropriate because there is no known lung pathology or anemia.

When the nurse is administering furosemide 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent?

Implementation Explanation: Implementation refers to the action phase of the nursing process, in which nursing care is provided.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which of the following steps of nursing process is the nurse using?

Implementation ex: In this scenario, the nurse is administering a medication. Because an action is being carried out this is the implementation step of the nursing process. The assessment phase would include the nurse assessing the client prior to giving the medication to ensure that it is an appropriate action. The planning step is when a plan of care is developed for this client. Evaluation should occur after medication administration to evaluate the outcome of the action.

Identifying the kind and amount of nursing services required is a possible solution for:

Inadequate staffing. ex: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen, while educating the client to become an assertive healthcare consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client. explanation: standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure ulcer, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has priority?

Ineffective Airway Clearance related to retention of secretions explanation: High-priority nursing diagnoses, such as Ineffective Airway Clearance, pose the greatest threat to the client's well-being and should be addressed by the nurse first. The priority is to airway, breathing and circulation before any of the other other body systems.

Assessment of a client with difficulty breathing reveals that he has thick, tenacious secretions in his trachea and bronchi and excessive sputum with coughing. His respiratory rate is slightly increased. When developing this client's plan of care, which nursing diagnostic label would be most appropriate?

Ineffective airway clearance explanation: Based on the assessment, the nurse should identify specific cues, such as the thick secretions, excessive sputum, and coughing, which would indicate a problem with a clear airway. Although the client may be experiencing problems with his activity level or a disruption in his sleep from coughing, there is no indication that either of these is occurring. The client's respiratory rate is increased; however, he is breathing independently.

A nurse has delegated a task to an unlicensed assistive personnel (UAP) member. How will this nurse assure that this UAP understands the instructions to perform this task?

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. explanation: Instruct the UAP to repeat the nurse's instructions to be sure they have communicated clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

Before conducting a health assessment on a client, what should the nurse do first?

Introduce herself to the client. explanation: The nurse should introduce herself to the client, and explain the nature and purpose of the health assessment.

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving. explanation: Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?

It helps deliver holistic, goal-oriented, individualized care. explanation: This record provides a means of communication among members of the health care team and facilitates delivering holistic, goal-oriented, individualized care. A care plan is not a teaching log; it does not verify staffing and it is not intended to provide the client with information about treatments.

Which is a characteristic of person-centered care?

It is a framework for providing care. Explanation: The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person- centered care aims to provide specific care to people based on individual needs.

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?

Make changes in the plan of care based upon assessment data. explanation:A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.

The nurse, in collaboration with the client's family, is assigning priorities related to the care of the client. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing client problems?

Maslow's hierarchy of needs explanation: Maslow's hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the client. The focus for the client assessment is on the client and not the availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of client problems. Family member statements can be included later after the assessment of the client is performed.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. explanation: A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions.

An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood sugars. The outcome for this client is to maintain blood sugars between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood sugar on the body and assure that the client has the resources to be compliant. Evaluation reveals that the clients blood sugar remains out of range and that the outcome has not been met. What is the most appropriate action by the nurse?

Modify the plan of care to find alternative ways to meet client needs. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Upon evaluation, this client had not met the outcome. Therefore the most appropriate response by the nurse is to modify the plan of care to find alternative ways of meeting this client's needs. Reevaluating the plan of care at a later date and referring to the social worker does not address this clients needs in a timely fashion. Terminating the plan of care is not appropriate if the client has not found a way to address the problems identified in the nursing diagnosis.

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015. Explanation: Goals must be patient-centered, specific, measurable, attainable, realistic, and timebound. Mr. Conner will demonstrate proper care of stoma by 29MAR2015; has all of these characteristics. Explain to Mr. Conner the proper care of the stoma by 29MAR2015; is a nursing intervention. Mr. Conner will know how to care for his stoma by 29MAR2015 is not measurable. The patient demonstrating a technique is measurable, will know is not measurable. Mr. Conner will be able to care for stoma and cope with psychological loss by 29MAR2015; contains two goals in one statement.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

Nausea explanation: Subjective data are those which the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis. explanation: Nurse-initiated interventions are derived from the nursing diagnosis and do not require a physician's order. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client.

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

Nurses ex: Peer review is the evaluation of one staff member by another staff member on the same level of the hierarchy of the organization. Peer review is not done by the unit manager, clients, or visitors.

The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant ex: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student ex: The nurse should avoid delegating this client to the nursing assistant. Suctioning and the association evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant.

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective explanation: Measurable and observable urine output is an example of objective data. Objective data are also called signs or overt data. Subjective data are information perceived only by the affected person. Subjective data are also called symptoms or covert data.

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data?

Objective explanation: Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other that the person experiencing them. They include vital signs, moist skin, and refusal to eat or drink. Subjective data is data that the client feels or states. Usually subjective data is document in the client's record as quotations. A hunch is a feeling or guess based on intuition rather than known facts. Intution is the ability to understand something immediately, without the need for conscious reasoning.

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12 hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones explanation: It is impossible to give quality care without knowledge of changes in the client's status. Ongoing data collection is critical to the deletion or modification of old problems and identification of new problems. Even though it will give the new graduate experience this is not why the assessment is done twice a 12 hour shift. A policy is developed to maintain agency consistency. Nurses have professional accountability and not just following an agency policy.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning explanation: Ongoing planning is carried out by any nurse who interacts with the client, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting.

The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data?

Pain rating is 7 explanation: Subjective data is information perceived only by the affected person. Only the person experiencing pain can assign a rating to it. Objective data is observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Lung sounds, pupils, and presence of edema are all examples of objective data.

The nursing supervisor visits the emergency department and informs the department manager that tornado victims are expected to arrive within the hour. The department manager indicates the department has been slow and requests information regarding possible numbers of victims. The department manager reports supplies were just fully stocked, but two nurses are ill with influenza and were unable to report for their shift. Which resource does the department manager need to organize to respond to the disaster?

Personnel ex: A sufficient number of nurses are needed to respond to the disaster. The department is functional and is not full of clients and sufficient supplies are available.

Prior to the first postoperative visit post gastrectomy, the client will have a weight loss of 10 lb (4.50 kg). This is an example of which type of evaluative statement?

Physical changes ex: Psychomotor outcomes are those that are related to new skill attainment , cognitive outcomes are related to achieving greater knowledge, affective outcomes are related to feelings and attitudes and physical changes are related to actual body changes in the individual which is represented by the 10 lb (4.50 kg) weight loss.

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing explaination: Determining the correct length of the NG tube to insert is an example of the planning that is necessary in order to conduct this nursing action. The actual insertion of the NG tube would constitute an implementation.

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

The nursing student has been assigned to a pediatric hospital floor next week. The student understands that he or she is expected to be able to use the syringe pump with the clinical instructor when giving medications. The student has never used this pump before and is anxious. What is the most appropriate way for the student to lessen the anxiety associated with the clinical rotation?

Practice using the pump in the lab setting if it is available and with instructor permission. explanation: Nurses are expected to possess certain technical skills in order to function in today's technologically advanced health care setting. Some students have a natural ability to pick up these skills and others need to practice. One of the most appropriate ways for a student to lessen anxiety regarding the use of technical skills is to practice using the equipment and become more familiar with the procedure before the experience occurs. Attempting to use the equipment without instruction can be dangerous to the client. Other students are not the experts at using this equipment and therefore may not be the best resource for information about equipment or procedures. Waiting until the day of the rotation does not lessen anxiety and does not allow the student time for practice.

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply.

Prevent the problem.Reduce or eliminate risk factors. Monitor the client's status. ex: Nursing interventions appropriate for risk nursing diagnoses include preventing the problem, reducing or eliminating risk factors, and monitoring the client's status. Promotion of higher-level wellness addresses actual nursing diagnoses, while collection of additional data to rule out the diagnosis would be necessary for possible nursing diagnoses.

Which of the following is a correctly written nursing intervention? Select all that apply.

Provide 5 to 6 small meals daily.Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings. explanation: Nursing interventions are nurse-centered, action-oriented, and describe specifically what the nurse is doing (how, when, where, how often, how long, or how much). Providing 5 to 6 small meals, repositioning the client, and providing opportunities for expression of concerns and feelings are correctly written interventions. "Understand" and "know" are vague and are not action-oriented; it is unclear who is to perform these actions. Medication side effects and signs/symptoms of infection represent content that the nurse should know and teach to clients.

Which nursing actions reflect the implementing step of nursing process? (Select all that apply.)

Providing health education to reduce health risksReferring the client to community resources, when necessary Using evidence-based interventions individualized for the client ex: Examples of the implementing step include using evidence-based interventions individualized for the client; providing health education to reduce health risks; and referring the client to community resources, when necessary. Selection of nursing interventions occurs in the planning step. Determining the client's response to nursing interventions occurs in the evaluating step.

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

Quality assurance ex: Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.

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. What is the nurse's mostappropriate action?

Reassess if the urinary catheter is still necessary for the client. ex: Before any intervention is implemented, the nurse should assess if the intervention is still indicated. Since the client has reported voiding, the nurse should take measures to see if the client is still retaining urine. The nurse cannot tell the client the catheter is necessary until after the assessment is complete. The nurse should wait until the assessment is complete before deciding whether the catheter is indicated.

Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology explanation: The health problem and etiology have been reversed. Impaired Skin Integrity related to prolonged immobility is the correct format.

Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?

Risk for impaired skin integrity related to bed rest explanation: An at-risk nursing diagnosis, as defined by NANDA-I, "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community."

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be of the priority, keeping in mind the client's condition?

Risk for infection explanation: Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs their already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority.

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?

Risk for injury explanation: Clients with Alzheimer disease are highly prone to injuries. Risk of injury may also be precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in older age groups. Consequently, it is very important for the nurse to provide a safe and secure environment. Impaired physical mobility, self-care deficit, and impaired memory are also present but are not the highest priority.

Which is a responsibility of the nurse in the nurse-health care team relationship? Select all that apply.

Serve as a liaison between the client and family and the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care. ex: Responsibilities of the nurse in the nurse-health care team relationship include serving as a liaison between the client and family and the healthcare team, and coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel. Educating the family to be informed and assertive consumers of healthcare is a role responsibility in the nurse-client-family relationship.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client. explanation: Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication.

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Standardized explanation: Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Standing orders ex: Standing orders allow the nurse to initiate action that ordinarily require the order of a physician, such as administer naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.

A hospital is evaluating its policies and procedures. What type of evaluation is the hospital conducting?

Structure ex: A structure evaluation or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment, organizational characteristics, policies and procedures, fiscal resources, and personnel resources. Process/implementation evaluation determines whether program activities have been implemented as intended. Outcome/effectiveness evaluation measures program effects in the target population by assessing the progress in the outcomes or outcome objectives that the program is to achieve. Quality evaluation does not exist.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data?

Subjective explanation: Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by anyone else. Examples are feeling nervous, nauseated, or chilly, to name a few. Objective data from the client is measurable such as vital signs. Intuition is the ability to understand something immediately, without the need for conscious reasoning. A hunch is a feeling or guess based on intuition rather than known facts. The client verbalized a statement and expressed a feeling but did use reasoning or guess as a basis for the feeling.

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends. explanation: Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Utilizing previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

The nursing student asks the nurse about nurse-initiated and physician- initiated interventions. Which of the following is a nurse-initiated intervention?

Teach client how to splint abdominal incision when coughing and deep breathing. explanation: A nurse-initiated intervention is an autonomous action based on scientific rationale, which a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nursing-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action?

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. ex: The most important priority is to ensure the client's safety. Since the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Since the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase

Termination phase explanation: The nurse highlights the key points of the interview during the termination phase. During the preparatory phase the nurse prepares the setting for the interview and reviews any available information about the client. Introductions take place during the introductory phase, and the nurse outlines expectations for the interview. The nurse collects subjective data during the working phase.

Who or what is the primary source of information for a nursing history?

The client explanation: The client is the primary (and usually the best) source of information. Unless specified otherwise, it is assumed that the data recorded in the nursing history were collected from the client. Previous records can be merged into the current health care record but the client is the center of the assessment. Family members may be asked about the history of the client if the client is unable to provide the information. Other health care personnel are not used in the interview of the client.

Which client outcome is an example of a psychomotor outcome?

The client demonstrates stair climbing using a quad cane. ex: Psychomotor outcomes describe the client's achievement of new skills, such as stair climbing using a quad cane. An affective outcome involves changes in the client's values, beliefs, and attitude, such as meal preparation and testing blood sugar before meals. Cognitive outcomes demonstrate increases in client knowledge, such as manifestations of digoxin toxicity.

Which client outcome is an example of a cognitive outcome?

The client identifies three strategies for minimizing leakage of an ileostomy bag. ex: Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client, such as blood sugar values and pulse rate. Psychomotor outcomes describe the client's achievement of new skills, such as taking a radial pulse.

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

The client is able to explain when and why he needs to check his blood sugar. ex: The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome. Demonstration of the technique constitutes a psychomotor outcome, while the expression of a desire for change is an affective outcome. The maintenance of healthy blood sugars is a physiologic outcome.

Which client outcome is a cognitive outcome? Select all that apply.

The client lists the side effects of digoxin (Lanoxin).The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia. ex: Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker. An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.

An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome?

The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath. explanation: Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning. ex: The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120. This is asignificant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse explanation: Nurses are responsible for alerting the appropriate healthcare professional whenever assessment data differ significantly from the client's baseline indicating a potentially serious problem. The nursing supervisor is not directly involved in the care of the client. The charge nurse is responsible for the whole unit and assisting nurses as needed. The client does not need to report the increase to the healthcare professional as this is not their role in the healthcare setting.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care. ex: In evaluation, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care.

Which of the following nursing actions reflects evaluation?

The nurse assesses urine output following administration of a diuretic. Ex: Assessing the client's response to a diuretic medication is an example of evaluation. Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Auscultating the client's lungs and abdomen is an example of assessment. Setting a tolerable pain rating with the client is an example of planning.

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. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath. ex: It is important for the nurse to encourage the client to achieve independence in self-care. The nurse would best accomplish this by encouraging the client to gradually do more for himself. There is no evidence that the client's recovery is progressing too slowly. There is no indication that an early discharge would be beneficial for the client. There is also no indication that the family is doing too much for the client. The client is not fully capable of self-care and will still need the assistance of family.

On a typical day shift, 7 am to 7 pm, the nurse-client ratio on a busy floor is higher than usual because a member of the health care team called in sick for the day. Which example shows a nurse practicing with a good sense of legal competence?

The nurse follows the chain of command and requests help for the tasks that she can not complete and that are important to the client care on the floor that day. explanation: Nurses that develop caring relationships prize themselves on recognizing the ethical and legal implications on their practice. Accountability of the care nurses provide is a prime component in the caring relationship. A nurse that is competent and understands the ethical and legal boundaries guiding practice will know when he or she needs assistance and will seek it in order to provide competent care to clients. Accountability of medication administration requires that the nurse know about the medication that is being administered, asking a coworker is not an appropriate method of verifying correct medication dosage. Documentation should be performed based on the policies and procedures of the facility in which the nurse practices. Leaving scheduled tasks undone for another shift is not practicing accountably.

The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame. explanation: Outcomes are client-centered, use action verbs, identify measureable criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted.

Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply.

The nurse identifies that a client's pain is not being adequately treated. The nurse documents the client's response to suctioning.The nurse determines the client did not lose the expected 2 lb (0.90 kg). ex: Examples of evaluation include documenting the client's response to suctioning and making a judgment that the client did not reach the expected outcome of a 2-lb (0.90-kg) loss or adequate pain control. Setting an anxiety rating with the client is an example of planning. Performing tracheostomy care is an example of implementation.

In which situation would the nurse be most justified in implementing trial- and-error problem solving?

The nurse is attempting to landmark an obese client's apical pulse. explanation: Trial-and-error problem solving can be dangerous to the client. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese client's heart, does not pose a threat to the client and a reasonable amount of "hunting" for the apical pulse may be necessary.

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

The nurse manager provides the staff nurse feedback regarding job performance for the previous year. ex: Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review.

While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate?

The nurse should consult with another nurse for that colleague's description of the assessment or observations explanation: When a nurse suspects that his or her own personal bias or stereotyping is influencing data collection, the nurse should consult with another nurse. It is also best to describe observed behavior, rather than interpret the behavior. The nurse should obtain information from the family after obtaining permission from the client.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self- administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate?

The outcome is not observable or measurable The verb in this outcome "know" is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use his or her nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data?

The skin of a client who has liver failure has a yellowish tint. explanation: Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Reports of nausea, feeling very anxious, and reports of dizziness are subjective data. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person.

Which are essential components for delegating nursing care? Select all that apply

The task is delegated to a person with sufficient knowledge and skill for completing the task.Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel. The unlicensed assistive personnel can verbalize what information is to be reported to the nurse. ex: Essential components of effective delegation include delegating the task to to a person with sufficient knowledge and skill for completing the task; communication of clear and specific instructions by the nurse to the unlicensed assistive personnel; and validation of understanding by the unlicensed assistive personnel regarding information to be reported to the nurse. The steps of the nursing process remain the responsibility of the nurse and are not delegated to unlicensed assistive personnel.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care. ex: Quality-assurance (QA) programs enable nursing to be accountable to society for the quality of nursing care. They are a response to the public mandate for professional accountability. QA programs do not facilitate increased enrollment, specify how resources are to be used, or increase retention of nurses.

A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

Time-lapse explanation: Like the focus assessment, the time-lapse reassessment determines the status of problems already identified. Because of varying time intervals between reassessments, a complete review of all functional health patterns is carried out.

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving explanation: The nurse is using trial-and-error problem solving. This type of problem solving involves testing any number of solutions until one that works for the problem is found. In this situation, the nurse attempts to obtain a blood pressure reading on three extremities before finally achieving success on the right leg, and this required the nurse to test a number of locations.

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent?

True collaboration ex: True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses, and between nurses and other health team members. Skilled communication requires health team members to communicate in a non-intimidating manner with colleagues, allowing all voices to be heard regarding a matter. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.

The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful?

Trust and confidence explanation: Successful assessments begin with the trust and confidence an interpersonal competent nurse aspiration. Although enthusiasm can be helpful being aggressive and forceful will turn the client off as being too domineering. A low keyed and timid nurse may not exemplify patient advocate characteristics which are essential in the nurse/client relationship.

Consider the following statement: "The client ambulated with the assistance of a cane without incident during his physical therapy session." Which part of the outcome criteria does the portion in italics represent?

Verb (action) explanation: The action is one of the essential pieces of a nursing outcome criteria statement.

Which of the following is categorized as a psychomotor outcome?

Within 2 days of education, the client's wife will demonstrate abdominal dressing change. explanation: Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new skills. Cognitive outcomes describe an increase in the client's knowledge. Affective outcomes describe changes in client values, beliefs, and standards.

What information provides the nurse with accuracy when developing a nursing diagnosis?

a set of clinical cues explanation: Each piece of client information is considered a clinical cue; a set of clinical cues forms a cluster that is present if the diagnosis is accurate.

The orderly progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation. Explanation: The nursing process is a systematic method that directs the nurse and client and includes the following sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to:

body systems. explanation: The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. While systematic, this strategy tends to ignore spiritual and psychosocial considerations.

Which activity is the clearest example of the evaluation step in the nursing process?

checking the client's blood pressure 30 minutes after administering captopril. explanation: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, while recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

When the nurse prepares to discharge a client, and subsequently evaluate the effectiveness of the patient care, the nurse should determine whether the:

client's goals have been achieved. ex: Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.

A nurse is catheterizing a client. Which action illustrates respect for the client's privacy?

closing the door to the room ex: It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. The client's pajamas cannot be left on as this may compromise the sterile procedure. Asking another nurse to assist and not watch is helpful. There is not need to discuss with the family as the client does not have any cognitive issues from the stem.

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

clustering significant data cues explanation: Data clustering involves grouping client data or cues that point to the existence of a client health problem. When formulating a nursing diagnosis, the nurse identifies the client health problem related to an etiology and includes subjective and objective data that support the existence of the actual or potential health problem. The nurse identifies contributing factors in the etiology portion of the nursing diagnosis. The nurse validates the nursing diagnosis, often with the client, after a tentative one is formulated.

The nursing diagnosis taxonomy provides nursing with:

common language. explanation: Professions require a sound scientific base; the nursing process is nursing's scientific base. To achieve this scientific foundation, nursing requires a taxonomy, or classification system, to provide a structure for nursing practice.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome

developing the plan without client input explanation: Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care.

When the nurse administers pain medication to a postoperative client, the phase of the nursing process that is occurring is:

implementation explanation: Implementation refers to the action phase of the nursing process, in which nursing care is provided.

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using:

intuitive problem identification. explanation: Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family. explanation: One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Patient centered care focuses on the client needs and desires and not the physician, the nurse manager, or interdisciplinary actions.

A client has come into the clinic for a postoperative visit. The client states that the postoperative pain continues to be 6 on a 0 to 10 rating scale. The nurse evaluates the client and the current plan of care. Based on the information provided by the client, the nurse should:

modify the plan of care. ex: The nurse should evaluate the current status of the client and modify the plan of care to better meet the needs of the client at this time. There is no need to terminate the entire plan of care, while continuation with the current plan will most likely keep the client dealing with pain. The nurse should ask the client if he is taking his pain medication as part of the assessment, not call the pharmacy.

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

objective data. explanation: Yellow-green purulent wound drainage is an example of objective data. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Subjective data are information perceived only by the affected person. Only the person experiencing pain can assign a rating to it. Making a judgment derived from data cues is an inference. An inference must be validated with subjective and/or objective data cues.

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

outcome evaluation. ex: Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.

The nurse is caring for a newly admitted client. How can a nurse obtain a more complete database for this client?

perform a comprehensive client assessment explanation: By having a more complete database from several sources, including the client, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other health care professionals, health records, and literature review.

The process of nursing diagnosis carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a client's kidney failure?

reporting signs and symptoms related to the client's kidney failure explanation: In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the physician.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

sitting at eye level with the client explanation: When the client responds to a question, convey interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks.

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 her to talk ex: Supportive interventions include recognizing the need for encouragement, unconditional acceptance of behaviors, and the positive effects of being present for clients during stress or crisis. To support the anxious client, the nurse should sit with her and encourage her to talk. Telling the laboratory technician to speed up the results, or calling the physician and taking orders for anxiolytics are inappropriate supportive interventions. Educating the client about reducing risk factors is an educational intervention.

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 aspect of the nurse's execution of this order demonstrates technical skill?

starting a new, large-gauge intravenous site on the client, and priming the infusion tubing explanation: 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.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission ex: It is important to evaluate client outcomes early and frequently. Reserving evaluation for the time of discharge or after discharge is inappropriate, even if the designated time criteria for the outcome specifies "by time of discharge."

Implementation of the plan of care is most successful when:

the nurse includes family members and other health care professionals. explanation: Family members and support people, as well as other health care professionals, may be involved in the implementation of the plan of care. The plan of care is best implemented when clients who are able and willing to participate have the maximum opportunity to provide self-care. Clients and their support systems should be involved in decision making. The nurse will continue to collect data and modify the plan of care during the implementation phase. All activities should be documented during the implementation phase.

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

to ambulate the client to a bedside chair explanation: The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, like helping the client return to activities of daily life, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem explanation: Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.