Nursing Process
A nurse is caring for a client immediately following an appendectomy . The nurse should assign which nursing diagnosis the highest priority ?
Acute pain
When caring for a client with nonresectable colon cancer , which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort ?
Acute pain
A 35 - year - old female client is diagnosed with aplastic anemia . Which is the most important nursing measure to incorporate into the client's plan of care ?
Alternate periods of activity with rest to decrease fatigue .
admitted to the medical unit with severe A nurse is creating a personalized plan of care for a client being bronchitis who reports harsh , nonproductive cough and is currently a smoker . List the nursing interventions in the appropriate order utilizing the nursing process . All options must be used .
Assess the client to identify the primary problem for this admission . Select the appropriate nursing diagnosis of ineffective airway clearance . the cough and clear mucus . Assist the client to form a plan to minimize Educate the client on different ways to stop smoking cigarettes . Ask if the client wants you to obtain an order for a nicotine patch . Reassess frequently the client's cough and the desire to smoke .
An 80 - year - old woman has been suffering from knee pain for the past 3 years . The client requires a knee replacement and has diminished mobility . The most appropriate nursing diagnosis is
Chronic pain related to knee disability as defined by guarded gait
A nurse enters a patient's room and finds that the patient has fallen on her way to the bathroom . Which of the following is a prudent nursing intervention for this patient ?
Document the incident , assessment , and interventions in the patient's medical record .
The nurse is caring for a client who is experiencing an asthma attack . Ten minutes after administering an inhaled bronchodilator to the client , the nurse returns to ask if the client's breathing is easier . The nurse is engaging in which phase of the nursing process ?
Evaluating
The nurse assesses urine output following administration of a diuretic . Which step of the nursing process does this nursing action reflect ?
Evaluation
During a nurse's visit to the client's home , the client states , " I have pain in my right knee . " The nurse assesses the client's right knee . This is a
Focused assessment
A nurse is admitting a client in the crisis center who has been raped . Which is the priority nursing intervention ?
Give the client immediate support and allow for privacy .
A 1 - year - old child is admitted to the hospital with sickle cell crisis . Which intervention does the nurse anticipate will be included in the child's plan of care ?
IV fluid therapy
After assessing a client , the nurse formulates several nursing diagnoses . Which of the following would the nurse identify as an actual nursing diagnosis ?
Impaired urinary elimination .
When the nurse is administering Lasix 20 mg to a patient in congestive heart failure , what phase of the nursing process does this represent ?
Implementation
The nurse is planning with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy . What should the nurse do ?
Provide positive reinforcement for skills achieved .
A client on a stretcher in the emergency department begins to thrash around , slap the sheets , and yell , " Get these bugs off of me . " The client is disoriented and has a blood pressure of 189/75 mm Hg and a pulse of 96 bpm . The friend who is with the client says , " My friend was drinking a lot 3 days ago and asked me for money to get more vodka , but I didn't have any . " What should the nurse do in order of priority from first to last ? All options must be used .
Remind the client that they are in the hospital and the nurse is with them . Implement constant observation . Administer haloperidol and lorazepam IM as prescribe . Monitor vital signs every 15 minutes . Obtain a prescription to place the client in restraints , if needed . Chart the client's response to the interventions .
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client . Which would most likely contribute to the achievement of this goal ?
administering famotidine as ordered
A severe acute respiratory syndrome ( SARS ) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute ? .
airborne precautions
The nurse is caring for a client experiencing acute abdominal pain . What is the first action by the nurse ?
auscultation of all four quadrants using a stethoscope
A nurse is caring for a group of clients on a medical - surgical floor . Which client is at greatest risk for developing pneumonia ?
client with a nasogastric tube
A nurse is assigned to a client who , after medication teaching session , began receiving amitriptyline hydrochloride to treat depression . One week after starting this drug , the client refuses to take the medication , reporting that it has caused blurred vision , dry mouth , and constipation , but it hasn't improved the client's mood . Which nursing diagnosis is appropriate for this client ?
deficient knowledge ( treatment regimen ) related to inadequate understanding of teaching
A nurse is conducting a spiritual assessment on a client admitted for surgery and developing a plan of care based on this assessment . To help ensure that the nurse is most successful in meeting the client's spiritual needs and promote a comfortable working relationship with the client , which aspect would be most important initially for the nurse ?
developing an awareness of one's own beliefs about the connection between spirituality and health
A nurse is caring for a client admitted to the inpatient psychiatric unit . When is it most important to introduce information about the end of the nurse - client relationship ?
during the orientation phase
Using the nursing process to make ethical decisions involves following several steps . Which step is the nurse implementing when the nurse reflects on the decision - making process and the role it will play in making future decisions ?
evaluating
A client is admitted with multiple pressure ulcers . When developing the client's diet plan , the nurse should include
ground beef patties . Explanation : Meat is an excellent source of complete protein , which this client needs to repair the tissue breakdown caused by pressure ulcers . Oranges and broccoli supply vitamin C but not protein . Ice cream supplies only some incomplete protein , making it less helpful in tissue repair .
When assessing a neonate 1 hour after birth , the nurse notes acrocyanosis of both feet and hands , measures an axillary temperature of 95.5 ° F ( 35.3 ° C ) an apical pulse of 110 beats / minute , and a respiratory rate of 64 breaths minute . Which assessment would be the most concerning for the nurse?
hypothermia
A client in the intensive care unit has a nursing diagnosis of Social isolation . Which action would the nurse include in the care plan ?
involving the client and family in planning care
Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer The client will :
maintain adequate nutrition through oral or parenteral feedings .
Which nursing intervention is appropriate for a client with an arm restraint
monitoring circulatory status every 2 hours
The client comes to the clinic reporting diagnosis of L5 - S1 herniated disk impinging on the activity restriction and sexual dysfunction . Tests are completed and a right nerve root is made by the healthcare provider . What assessment findings should the nurse expect to note ?
pain radiating down the right leg
A client with appendicitis is experiencing excruciating abdominal pain . An abdominal X - ray film reveals intraperitoneal air . What should the nurse prepare the client for ?
surgery
The nurse is documenting in the client's health record . Which information is most appropriate for the nurse to record as objective data ? Select all that apply .
Client's blood pressure is 120/80 mm Hg ; pulse 76 bpm ; respirations 14 breaths / min Client's dressing is intact with scant amount of serous drainage . Client ambulated to end of hallway .
A client is experiencing shortness of breath , lethargy , and cyanosis . These three cues provides organization or
Clustering
Nursing diagnoses that require physician - prescribed and nurse - prescribed actions would be
Collaborative health problems
Which activity does the nurse engage in during evaluation Select all that apply
Collect data to determine whether desired outcomes are met . Assess the effectiveness of planned strategies . Adjust the time frame to achieve the desired outcomes .
When changing a wet - to - dry dressing covering a surgical wound , what should the nurse do ?
Cover the wet packing with a dry sterile dressing
The nurse , after gathering data , analyzes the information to derive meaning . The nurse is involved in which phase of the nursing process ?
Diagnosis
A client is using patient - controlled analgesia ( PCA ) to manage postoperative pain . What should the nurse do when assisting the client with the PCA
Document the client's response to pain medication .
A nurse assesses the abdomen of a patient before and after administering a small - volume cleansing enema . What condition would be an expected finding ?
Increased bowel sounds .
A client is receiving chemotherapy for cancer . The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia . To which nursing diagnosis should the nurse give the highest priority ?
Ineffective tissue perfusion : cerebral , cardiopulmonary , GI
The client's plan of care is created by the nurse using which guideline for nursing practice ?
Nursing process
A nurse is caring for a client who has been hospitalized with schizophrenia . The client has had this disorder for 8 years and is now displaying regression , increased disorganization and inappropriate social interactions . Which nursing intervention will best help this client meet self - care needs ?
Provide client with assistance in hygiene , grooming , and dressing .
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer . Which intervention should the nurse include on the plan of care ?
Test all stools for occult blood .
Which of the following is a correctly written client goal ? Select all that apply .
The client will identify five low - sodium foods by October 9 . The client will rate pain as a 3 or less on a 10 - point scale by 5 pm today . The client will eat at least 75 % of all meals by May 5 .
A client is admitted to an inpatient psychiatric unit . After the assessment and admission procedures have been completed , the nurse states , " I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom . " What is the rationale for communicating these planned nursing interventions ?
To attempt to establish a trusting relationship
regarding hospice care would the nurse include in the teaching plan ? Select all that apply . A nurse is caring for a terminally ill cancer client who is being transferred to hospice care . Which information
The focus of care is on controlling symptoms and relieving pain . A multidisciplinary team provides care . Bereavement care is provided to the family .
Which of the following data regarding a patient with a diagnosis of colon cancer are subjective ? Select all that apply .
The patient's chemotherapy causes him nausea and loss of appetite . The patient has been experiencing fatigue in recent weeks .
A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism . Which outcome would the nurse determine as most appropriate for this client ?
The client's intake and output are balanced . Explanation : During the planning step of the nursing process , the nurse identifies expected client outcomes , establishes priorities , and develops the care plan . This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement . The other statements do not resolve the problem of fluid volume deficiency .
