midterm fund

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? Remind the client that the client is responsible for the client's own health care decisions. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form. Ask the client whether the client is afraid that the spouse will be angr

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

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplinary team? By the next clinic visit, the nurse will discuss the client's feelings around infertility. After visiting the clinic, client will indicate a desire for adoption. By discharge from the fertility clinic, the client will achieve full-term pregnancy. Client will understand the importance of follow-up laparoscopic examination.

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome? Choosing actions that do not solve the problem Stating outcomes too broadly Failing to update the written plan of care Beginning the plan without family to help

Choosing actions that do not solve the problem

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 reports no headache. Client lipids are within range. Client is drowsy after lunch. Client is normotensive.

Client is normotensive.

Which is an appropriate expected outcome for a client? After attending sibling classes, client will be happy about a new baby and demonstrate feeding. Client will ambulate safely with walker in the room within 3 days of physical therapy. By the next clinic visit, client will report taking antihypertensive medication. Client will perform complete ostomy care while bathing on the second postoperative day.

Client will ambulate safely with walker in the room within 3 days of physical therapy

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? Include the rationale for the interventions. Identify the appropriate nursing diagnoses. Individualize the plan to the client. Expect to modify the plan significantly

Individualize the plan to the client.

Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions require a physician's order. Nurse-initiated interventions are actions performed to diagnose a medical problem. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.

Nurse-initiated interventions are derived from the nursing diagnosis. pg 394

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning Discharge Ongoing Outcome Initial

Ongoing Page 390

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client's family asks if the client is going to be okay. The client's oxygen saturation level increases. The client's respiratory rate decreases. The client states, "I can breathe easier now." The client is watching television.

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

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a physiologic outcome. an affective outcome. a psychomotor outcome. a cognitive outcome.

a cognitive outcome. 451

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: comprehensive planning. discharge planning. initial planning. ongoing planning.

discharge planning

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? Educational Supervisory Surveillance Maintenance

educational

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: an order set. a guideline. an algorithm. a critical pathway.

guideline

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

outcome

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: objective data. outcome. intervention. nursing diagnosis.

outcome.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? Psychosocial Psychomotor Surveillance Maintenance

psychomotor

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? "Demonstrated steps" "Great response" "Extremely well-mannered" "Inadequate skills"

"Demonstrated steps"

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "Moving away from client care is a necessary step to advancing my career." "I provide a critical service that is necessary for financial reimbursement." "Even though I do not provide care to clients, my work is very important." "I provide indirect care to my clients by coordinating their treatment with other disciplines."

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

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? "You need to stop smoking for us to effectively combat this disease." "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?" "What are your plans after discharge?"

"Please tell me your thoughts about treating this diagnosis."

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious A 68-year-old woman with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who is talking rapidly on a cell phone A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly

A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? Another nurse manager Another registered nurse with critical care certification One of the staff critical care physicians Another staff nurse from the medical-surgical unit

Another registered nurse with critical care certification

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? Determine the client's reaction to the medication in the past. Tell the client to report any side effects experienced. Ask the client to verbalize the purpose of the medication. Assess the client's blood pressure to determine if the medication is indicated.

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

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? Assess the client's response to the ambulation. Discuss the client's feelings about the illness. Document the client's ambulation. Inform the client when ambulation is scheduled next.

Assess the client's response to the ambulation.

Which parties are essential for the nurse to include in the implementation of a client's plan of care? Client, physician, and hospital director Client, surgeon, and physician Client, physical therapist, and nursing staff Client, family, and physician

Client, family, and physician

Which action is appropriate when evaluating a client's responses to a plan of care? Reinforce the plan of care when each expected outcome is achieved. Terminate the plan of care upon client discharge. Continue the plan of care if more time is needed to achieve the goals/outcomes. Terminate the plan if there are difficulties achieving the goals/outcomes.

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

A nurse is evaluating a client to determine outcome achievement. The nurse determines that the client's outcome was partially met. When documenting the evaluative statement, the nurse records which other information? The client's verbal agreement of the outcome not being met The reason the outcome was only partially met The revision to the initial outcome identified Data that support the decision of the outcome being partially met

Data that support the decision of the outcome being partially met

Which guideline should the nurse follow when including interventions in a plan of care? Make sure each nursing intervention does not describe the action the nurse should perform. Make sure the attending physician approves of and signs the nursing interventions. Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed.

Date the nursing interventions when written and when the plan of care is reviewed.

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? Do not document this assessment because the client could be using a wireless device to talk to family. Document this assessment based on the client's behaviors. Document that the client is talking back to the voices in the client's head. Do not document this assessment because it is subjective.

Document this assessment based on the client's behaviors.

Which is the priority question for the nurse to consider before implementing a new intervention? Will I need someone to assist me? What equipment do I need? How much experience do I have with this treatment? Does this treatment make sense for this client?

Does this treatment make sense for this client?

Which action is a nursing intervention that facilitates lifespan care? Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Educate family members about normal growth and development patterns. Identify coping strategies for the family that have worked in the past. Teach contraceptive options for planned pregnancy.

Educate family members about normal growth and development patterns.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? Reassess in 4 hours and document the findings. Provide oral pain medication before ambulation. Promote oral fluid intake between meals. Encourage hourly use of the incentive spirometer.

Encourage hourly use of the incentive spirometer.

The nurse works as a client advocate for an older adult client admitted with hyponatremia. Which action can the nurse take to help the client advocate for oneself? Coordinate client activities. Encourage the client to ask questions. Incorporate therapeutic use of self. Help the client with skin care.

Encourage the client to ask questions.

Which is an independent (nurse-initiated) action? Administering medication to a client Helping to allay a client's fears about surgery Meeting with other health care professionals to discuss a client Executing physician orders for a catheter

Helping to allay a client's fears about surgery

Which are characteristics of appropriate client outcome statements? Select all that apply. Short-term Realistic Measurable Broad in scope Specific

Measurable Realistic Specific

A computerized information system developed to classify client outcomes is the: Clinical Care Classification System Nursing Outcome Classification system NANDA-International list International Classification of Diseases

Nursing Outcome Classification system

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? Offer to help the client walk the length of the hallway each day. The nurse will help the client ambulate the length of the hallway once a day. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. The client will become mobile within a 24-hour period.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

Which statement on a plan of care should a nurse identify as a nursing intervention? The client will correctly demonstrate deep-breathing exercises after education. Readiness for Enhanced Communication Perform range-of-motion exercises to all of the client's joints each morning. The client self-administered insulin correctly following education.

Perform range-of-motion exercises to all of the client's joints each morning.

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? Affective Psychomotor Physical changes Cognitive

Psychomotor 439

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? Insert the urinary catheter as ordered to relieve the urinary retention. Instruct the client that the catheter is essential to check for urinary retention. Inform the client that the catheter will no longer be necessary. Reassess whether the client still needs the urinary catheter.

Reassess whether the client still needs the urinary catheter.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom. Revise the care plan to allow the client to ambulate to the bathroom independently.

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

Which action should the nurse perform in the evaluation phase? Carry out treatment procedures. Revise the plan of care. Set priorities for care. Record interventions.

Revise the plan of care.

hich are characteristics of one who has developed critical thinking skills? Curious, other-directed, fallible, and humble Creative, oriented to success, self-determined, and perfectionistic Resilient, authoritative, reactive, and private Self-aware, honest, persistent, and authentic

Self-aware, honest, persistent, and authentic

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

Surveillance

Which are psychomotor outcomes? Select all that apply.

The client accurately draws up insulin. The client safely ambulates using a walker.

Which characteristic is the most important indicator of high-quality nursing practice? The nurse takes measures to ensure accurate medication administration. The nurse considers the individual needs of clients. The nurse follows the policies and procedures of the institution. The nurse is organized and efficient in client care.

The nurse considers the individual needs of clients.

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. The outcome should indicate what the nurse will do. The nurse has not made any error in writing the outcome. The nurse has omitted the defining characteristics.

The nurse has omitted the time frame.

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

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? Verb (action) Performance criteria Conditions Subject

Verb (action)

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

outcomw

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement? Cognitive Affective Physical changes Psychomotor

physcial changes

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: subjective. process. outcome. goal. structure.

structure 447

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client tries using relaxation as a means to cope." "Client will list positive coping strategies and use them." "Client will identify one coping strategy to try by end of week." "Client will learn to cope more effectively."

"Client will identify one coping strategy to try by end of week."

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? "The Agency for Healthcare Research and Quality is a resource for evidence-based practice." "I can learn about evidence-based practice by reading professional nursing journals." "Nursing interventions should be supported by a sound scientific rationale." "I must conduct research to validate the usefulness of my nursing interventions."

"I must conduct research to validate the usefulness of my nursing interventions."

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan with problems that are easily solved A plan derived from a consensus of opinions of all staff members A plan designed to support the client physically A plan made in conjunction with the hospital's ethics committee

A plan designed to support the client physically

"The client will verbalize appropriate cast care on discharge" represents which type of outcome? Cognitive Psychomotor Affective Physical change

Cognitive

The client will verbalize appropriate cast care on discharge" represents which type of outcome? Cognitive Psychomotor Physical change Affective

Cognitive 439

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? Communicate with the physician about additional orders. Instruct the client to make alternate living arrangements. Inform the family that it is not possible to change the discharge plans. Collaborate with other disciplines to revise the discharge plans.

Collaborate with other disciplines to revise the discharge plans.

Which statement related to the evaluation of outcome attainment for a client is correct? Celebrating outcome achievement with a client often interferes with attainment of future goals. The nurse should initially evaluate the plan of care at the time of the client's discharge. Evaluation of the client's attainment of outcome goals is determined by the nurse and physician. Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. pg 440

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

Ensuring that the endotracheal tube is secure

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client? Dysfunctional Family Processes; family contact daily. Impaired Walking; unilateral neglect. Altered Mobility; able to tie shoes. Ineffective Coping; verbalizes support systems.

Ineffective Coping; verbalizes support systems.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses are responsible for reminding physicians to implement orders. Nurses do carry out interventions in response to a physician's order. Nurses are not legally responsible for these interventions. Nurses do not carry out physician-initiated interventions.

Nurses do carry out interventions in response to a physician's order.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? Once the client is admitted to the nursing unit from postanesthetic recovery On the client's admission to the hospital As soon as possible after the client's surgery Once the client has received a discharge order

On the client's admission to the hospital

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. Recognize how the approach affects client care, and describe why you have to do things your way. Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest. Approach the client as part of the job, and complete nursing care quickly to promote comfort.

Show respect for the client, and engage in open communication in getting to know the client

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Ask the client's learning style, then teach diet information using that style. Present the client with videos and books about diet changes that reduce inflammation. Start from client's knowledge, teach about diet modifications, and check for learning. Answer the client's questions about diet alterations, and then evaluate understanding.

Start from client's knowledge, teach about diet modifications, and check for learning.

A nurse is working as part of a quality assurance team that uses the American Nurses Association model. The team is evaluating the resources of the facility as well as the physical facilities and equipment. Which type of evaluation is the team engaged in? Outcome evaluation Process evaluation Structure evaluation Quality by inspection

Structure evaluation

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? Collaborative Surveillance Maintenance Supportive

Surveillance

Which is an example of a nurse-initiated intervention? Teach the client how to splint an abdominal incision when coughing and deep breathing. Administer oxygen at 4 L/min per nasal cannula. Administer a 1000-mL soap suds enema. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain.

Teach the client how to splint an abdominal incision when coughing and deep breathing.

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education? The client reports testing blood sugar before meals. The client identifies signs and symptoms of hypoglycemia. The client identifies correct insulin injection sites. The client demonstrates administration of insulin.

The client demonstrates administration of insulin.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. The client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. The parents have comprehensive insurance coverage for their family's medical care.

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

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? By 08/02, the client will state three therapeutic methods of reducing stress. The client will understand the effects of smoking related to heart disease. By 8/02, the client will state when to notify the health care provider after discharge By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.

The client will understand the effects of smoking related to heart disease.

Which nurse is using criteria to determine expected standards of performance? The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. The nurse manager provides the staff nurse feedback regarding job performance for the previous year. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

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

which nurse is using criteria to determine expected standards of performance? The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. The nurse manager provides the staff nurse feedback regarding job performance for the previous year.

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

Which of the following best summarizes the evaluation step of the nursing process? The nurse and client measure achievement of planned outcomes of care. The nurse completes a health assessment to establish a database. The client and family have met health care goals and no longer need care. The nurse and client identify nursing diagnoses and appropriate interventions.

The nurse and client measure achievement of planned outcomes of care.

A nurse is following the rules recommended by the Institute of Medicine's Committee on Quality of Health Care in America to help redesign and improve client care. Which nursing actions are based on these rules? Select all that apply. The nurse customizes care based on client needs and values. The nurse bases care on evidence-based decision making. The nurse becomes the source of control for client care. The nurse promotes shared knowledge and the free flow of information. The nurse acknowledges that continuous decrease in waste improves client care. The nurse customizes care based on availability of resources.

The nurse customizes care based on client needs and values. The nurse bases care on evidence-based decision making. The nurse promotes shared knowledge and the free flow of information. The nurse acknowledges that continuous decrease in waste improves client care.

nurse is following the rules recommended by the Institute of Medicine's Committee on Quality of Health Care in America to help redesign and improve client care. Which nursing actions are based on these rules? Select all that apply. The nurse becomes the source of control for client care. The nurse customizes care based on availability of resources. The nurse bases care on evidence-based decision making. The nurse customizes care based on client needs and values. The nurse acknowledges that continuous decrease in waste improves client care. The nurse promotes shared knowledge and the free flow of information.

The nurse customizes care based on client needs and values. The nurse bases care on evidence-based decision making. The nurse promotes shared knowledge and the free flow of information. The nurse acknowledges that continuous decrease in waste improves client care. 442-444

A new mother is having difficulty breastfeeding a newborn. A goal was established stating that the infant would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding 4 days ago. The nurse evaluates the original goal as: met. inappropriately chosen for this client. partially met. completely unmet.

completely unmet.

A nurse is evaluating the plan of care for a client in the clinic. Which actions should the nurse perform, as classic elements of evaluation? Select all that apply. Documenting only the facts related to the plan of care Collecting data to determine whether criteria and standards are being met Terminating, continuing, or modifying the plan of care Interpreting and summarizing findings Identifying evaluative criteria and standards

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

After the nursing plan of care has been developed, the nurse knows that: each encounter with the client is an opportunity to reassess and revise the plan of care, if necessary. the plan of care can only be changed by the nurse who developed it. the responsibility for the assessment of the client has ended. the plan will be followed by other health care providers and filed with the client's chart upon discharge.

each encounter with the client is an opportunity to reassess and revise the plan of care, if necessary.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? Time and resources Finances of the client Feedback from the family The client's condition

finances of the client 419

The primary purpose of nursing implementation is to: help the client achieve optimal levels of health. improve the client's postoperative status. implement the critical pathway for the client. identify a need for collaborative consults.

help the client achieve optimal levels of health.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: suggests client goals to promote desired change. identifies factors causing undesirable response and preventing desired change. identifies the unhealthy response preventing desired change. identifies client strengths.

identifies factors causing undesirable response and preventing desired change.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? -Once the client has received a discharge order -As soon as possible after the client's surgery -On the client's admission to the hospital -Once the client is admitted to the nursing unit from postanesthetic recovery

on the client's admission to the hospital

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

outcome evaluation.

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: Quality and Safety Education for Nurses (QSEN) American Association of Critical-Care Nurses (AACN) Peer review Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

peer review

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? Affective Physical changes Psychomotor Cognitive

physcial changes 451

The primary purpose for evaluating data about a client's care according to a functional health approach is to: meet accreditation standards. determine implementation of medical orders. revise or modify the client care plan. evaluate the need for health care consultations.

revise or modify the client care plan

"The levels of performance accepted by and expected of nursing staff or other health team members" defines: criteria. evidence-based practice. evaluation. standards.

standards.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: goal. outcome. process. structure. subjective.

structure.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: process. outcome. goal. subjective. structure.

structure.

Which nurse is using criteria to determine expected standards of performance? The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. The nurse manager provides the staff nurse feedback regarding job performance for the previous year. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

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

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up? The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. The nurse explains each procedure twice to prevent client questions from wasting time.

the nurse encourages the client to participate in all treatment decisions as the center of the health care team 423

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? during the first home health care visit once the primary care physician has written a discharge order throughout the client's hospital admission when the client is discharged

throughout the client's hospital admission