NURS 203 Test 3 FINAL

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Altered Gas Exchange

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

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

Which nursing action can be categorized as a surveillance or monitoring intervention?

Auscultating of bilateral lung sounds

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 normotensive.

Which guideline should the nurse follow when including interventions in a plan of care?

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

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

Determine the client's willingness to follow the regimen.

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.

Identify the three elements of comprehensive planning.

Initial Planning Ongoing Planning Discharge Planning

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?

Narcotic analgesic to treat pain

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

Nurse Care Manager

Differentiate nurse initiated interventions, physician-initiated interventions, and collaborative interventions?

Nurse initiated intervention- actions performed by a nurse without physician order. Physician-initiated intervention-( you have to have physician order) action initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor's orders. Collaborative interventions- treatments initiated by other providers and carried out by a nurse.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

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?

Outcome

What are specific measurable and realistic statements of goal attainment?

Outcomes

The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

Updating the diet orders in the client's plan of care

What verbs should the nurse use to write outcomes that are measurable? Select all that apply.

Verbalize Define

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health

What is a Kardex care plan?

pertinent information about the patient

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:

physiological.

What is computerized plan of nursing care?

same as Kardex only computerized. Has drop downs.

What is plan of nursing care (patient care plan)?

the written guide that directs the efforts of the nursing team working with patients to meet their health goals

Which actions occur during the initial planning of client care? Select all that apply.

-The nurse who performs the admission nursing history and physical assessment makes the initial plan. -After the initial plan is developed, the nurse prioritizes nursing diagnoses. -The nurse identifies client goals and the related nursing care in the initial plan.

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

Assess the client to determine the cause of the pain.

Ongoing Planning

Carried out by any nurse who interacts with patient; keeps the plan to date; states nursing diagnoses more clearly; develops new diagnoses; makes outcomes more realistic and develops new outcomes as needed; identifies nursing interventions to accomplish patient goals

Discharge Planning

Carried out by the nurse who worked more closely with the patient; begins when the patient is admitted for treatment; uses teaching and counseling skills effectively to ensure home-care behaviors are performed competently

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

Communicate with the physician for additional orders.

What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply.

Communicating nursing to non-nurses Allocating nursing resources Teaching decision making Developing information systems

Initial planning

Developed by the nurse who performs the nursing history and physical assessment; addresses each problem listed in the prioritized nursing diagnoses; identifies appropriate patient goals and related nursing care

Which action is a nursing intervention that facilitates lifespan care?

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?

Encourage hourly use of the incentive spirometer.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

Establishing priorities Identifying expected client outcomes Selecting evidence-based nursing interventions Communicating the plan of nursing care

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client understands proper wound care techniques?

Include family members or other caregivers in the education.

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.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately.

Which are characteristics of appropriate client outcome statements? Select all that apply.

Measurable Realistic Specific SMART Goals: Specific, Measurable, Attainable, Realistic, Timely

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

Medicate the client and wait to ambulate later

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.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

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

Nursing assistant who is a nursing student

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?

Ongoing

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

Risk of self-harm

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?

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

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

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

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

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

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?

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

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)

Which is an example of a psychomotor outcome?

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

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

intervention.

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

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

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

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

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

Does this task fall within the scope of a UAP?

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

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

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?

On the client's admission to the hospital

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

Psychomotor

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

What is consultation?

a process in which two or more people with varying degrees of experience and expertise discuss a problem and its solution

What is clinical pathway (critical pathway, care map)?

case management tools used to communicate the standardized, interdisciplinary plan of care

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.

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

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

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

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

Reassess the appropriateness of the method of instruction.

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?

Return the client to bed and provide pain relief measures.

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

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

What are short term and long term goals?

Short term goals-may be accomplished in a specific time period (Less than one week). Long term goals- requires a longer period (may be longer than a week) to be achieved and may be used as discharge goals.

Which is an example of a nurse-initiated intervention?

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

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply.

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse.

Discuss Maslow's Hierarchy of Needs.

1. Physiological Needs - Includes the need for air , water, food , and sex 2. Security Needs - Includes the need for safety, order, and freedom from fear or threat 3. Affiliation Needs - Includes the need for love, affection, feelings of belonging, and human contact 4. Esteem Needs - Includes the need for self-respect, self-esteem, achievement, and respect from others 5. Self Actualization Needs - Includes the need to grow, to feel fulfilled, to realize one's potential Maintains that people have many needs, and they are continually striving to fulfill the needs they have not yet satisfied. The practical implications of this theory for motivation in organizations are many.

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

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

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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

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.

What 3 helpful guides can one utilize to prioritize patient problems?

Maslow's Hierarchy of Needs Patient preferences Anticipated future problems

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?

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

The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which types of intervention? Select all that apply.

Psychosocial Supportive Physical

Describe the purpose and benefits of outcome identification and planning.

Purpose: Design plan of care for and with patient that once implemented, results in prevention, reduction, or resolution of the patient's health problems and attainment of patient's health expectations, as identified in patient outcomes Benefits: 1. Individualized patient care 2. Continuity of care 3. Priorities set 4. Coordinate care 5. Promote nurse's professional development 6. Create record used for evaluation, reimbursement, and legal purposes 7. Facilitate communication

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

Reassess whether the client still needs the urinary catheter.

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

Risk factors for and prevention of diabetes mellitus

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 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.

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

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

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize:

equipment and personnel.

Discuss patient preference

first meet the needs that the patient thinks are more important as long as this order does not interfere with other vital therapies

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

Discuss anticipation of future problems in nursing?

nurses must apply their knowledge base to consider the potential effects of different nursing actions. for example assigning a low priority to a diagnoses that the patient wants to ignore but can result in harmful future consequences

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

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

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

Discontinue the education and attempt at another time.

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

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

Describe 5 common problems related to planning, there possible causes, and remedies?

Failure to involve the patient,insufficient data collection,outcomes stated too broadly,nursing orders that do not solve problems,failure to update the care plan

Describe how patient goals/expected outcomes and nursing orders are derived from nursing diagnoses.

From the problem statement you get the goals, outcomes, objectives. Etiology we get our interventions. Patient goals/expected outcomes- nursing orders are derived from nursing Dx. Cognitive- describing increases in Pt knowledge or intellectual behaviors. Psycho motor - describes pts. achievements of new skills. Affective- describes changes in pt values, beliefs and attitudes.

What is a nursing intervention?

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes