Nursing Process PrepU (with explanations)

The correct progression of steps of the nursing process is: A. assessment, diagnosis, planning, implementation, and evaluation. B. planning, assessment, diagnosis, evaluation, and implementation. C. diagnosis, implementation, assessment, evaluation, and planning. D. implementation, planning, evaluation, assessment, and diagnosis.

A. assessment, diagnosis, planning, implementation, and evaluation. 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. ("ADPIE")

How should the nurse ensure that care is not legally negligent? A. Verbally reporting assessments to the client's physician B. Keeping private notes about the care given to each assigned client C. Documenting the nursing actions in the client's record D. Tape recording complete information for each oncoming shift

C. Documenting the nursing actions in the client's record Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.

A nurse administers medications to a client. Which step of the nursing process would the nurse perform next? A. Assessing B. Diagnosing C. Evaluating D. Planning

C. Evaluating The five systematic steps of the nursing process are assessment, diagnosing, planning, implementation, and evaluation. Implementation means carrying out the written plan of care and performing interventions, such as administering medications. Evaluation of client goals follows implementation of nursing interventions. If interventions have been effective, the client goal has been met. Assessing is the first step in which data is collected. Diagnosing is the second step in which the client problem, that the nurse is able to treat, is identified. Planning occurs after identification of the nursing diagnoses.

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? A. Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats B. Administer a daily multivitamin C. Monitor for allergies D. Weigh client as needed

A. Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats Because this client is underweight and has an allergy to wheat, rye, and oats, administering a diet with 2,500 calories (10,460 kJ) and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

Which step of the nursing process involves setting long-term goals and short-term expectations? A. Planning B. Assessment C. Evaluation D. Implementation

A. Planning Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Assessment is careful observation and evaluation of a client's health status. 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. Evaluation is the assessment and review of the quality and suitability of the care given and the client's responses to that care.

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? A. Activity and rest B. Health promotion C. Nutrition D. Self-perception

A. Activity and rest A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

Which activity is the clearest example of the evaluation step in the nursing process? A. Checking the client's blood pressure 30 minutes after administering captopril B. Taking a client's blood pressure on both arms at the beginning of a shift C. Recognizing that the client's blood pressure of 172/101 is an abnormal finding D. Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading

A. Checking the client's blood pressure 30 minutes after administering captopril 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, whereas recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? A. Administer a prescribed medication to decrease the client's blood glucose level. B. Analyze the data and create an individualized nursing diagnosis. C. Follow up with the client later to determine whether the client's laboratory test results improve. D. Identify outcomes for the client with the client's input.

B. Analyze the data and create an individualized nursing diagnosis. The second part of the nursing process is the analysis of data that can help determine nursing diagnoses. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analzye these findings to help to determine the most appropriate nursing diagnosis. Once the nursing diagnosis is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.

Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using? A. Assessing B. Planning C. Implementing D. Evaluating

C. Implementing During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step. Assessing is collecting information, such as vital signs and laboratory values. Planning is developing interventions focused on the assessment. Evaluating is the last stage, in which the nurse evaluates the plan of care.

Which interpersonal skill is essential to the practice of nursing? A. Performing technical skills knowledgeably and safely B. Maintaining emotional distance from clients and families C. Keeping personal information among shared clients confidential D. Promoting the dignity and respect of clients as people

D. Promoting the dignity and respect of clients as people Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship. Keeping emotional distance is not part of the caring component of nursing. Keeping clients' personal information confidential is an ethical and legal skill. Performing technical skills is essential, but technical skills are not interpersonal skills.

Put the phases of the nursing process in the correct order. A. Planning B. Evaluation C. Implementation D. Diagnosis E. Assessment

E, D, A, C, B: Assessment, Diagnosis, Planning, Implementation, Evaluation The correct order of the phases of the nursing process is: assessment, diagnosis, planning, implementation, and evaluation.

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A. Assessing B. Diagnosing C. Planning D. Implementing

A. Assessing Assessment, the systematic and continuous collection and communication of data, such as asking questions and obtaining vital signs, allows analysis of data to identify problems and strengths of clients, which is diagnosing. During outcome identification and planning, the nurse and client mutually identify expected outcomes and agree on nursing interventions necessary to meet these outcomes. The nurse implements the care plan, adapting it to each person, documenting nursing actions and client responses. After implementation, the nurse and client evaluate the effectiveness of the plan based on achievement of outcomes, and determine whether the plan should be continued, modified, or terminated.

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? A. Cognitive and technical skills B. Interpersonal and ethical skills C. Cognitive and ethical skills D. Interpersonal and technical skills

A. Cognitive and technical skills 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.

What is the *best* way for a nurse to obtain a full set of data when performing an assessment of a client? A. Complete a systematic nursing history and nursing examination. B. Have a nursing student perform the assessment and report it back to the nurse. C. Make educated generalizations about the client's health to determine focused client problems. D. Make interpretations based on client behaviors.

A. Complete a systematic nursing history and nursing examination. 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. Interpretations should not be made based on client behaviors; rather, client behaviors should be assessed as what they are.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? A. Develop an additional nursing diagnosis to meet the client's health needs. B. Change the nursing diagnosis because the client's problem was falsely identified. C. Modify the plan of care and interventions to meet the client's needs. D. Reassess the client for more symptoms of deficient fluid volume.

C. Modify the plan of care and interventions to meet the client's needs. The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.

Which group of terms best describes the nursing process? A. Nursing goals, medical terminology, linear B. Nurse-centered, single focus, blended skills C. Patient-centered, systematic, outcome-oriented D. Family-centered, single point in time, intuitive

C. Patient-centered, systematic, outcome-oriented The nursing process is a patient-centered, systematic, outcome-oriented method of caring that provides a framework for nursing practice. It is nursing practice in action. It is not nurse- or family-centered. It is focused on client, not nursing, goals. It has multiple foci, not just one focus. Although the nursing process is presented as an orderly and linear progression of steps, in reality, there is great interaction and overlapping among the five steps. No single step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously. Nursing practice requires the use of blended competencies, not blended skills. The nursing process is systematic, not intuitive.

Which statement indicates that a plan to assist a client in developing and following an exercise program has been effective? A. "I have just been too busy to do my daily exercises." B. "I guess I will begin the activity we discussed next week." C. "I know I should exercise, but my health is not very good." D. "I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."

D. "I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day." During the evaluation step of the nursing process, the nurse evaluates the effectiveness of the plan of care in terms of client goal achievement. Only the client statement indicating positive and measurable results provides evidence that the exercise program has been effective. Excuses for not exercising and statements indicating procrastination do not provide evidence that the exercise program has been effective.

The nurse administers pain medication to a postoperative client. In which phase of the nursing process is this occurring? A. Assessment B. Nursing diagnosis C. Planning D. Implementation

D. Implementation The components of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. Administering medication is the implementation of a prescribed activity to a client within the nursing process. Assessment is the first phase of intervention, in which the nurse gathers information to develop a nursing diagnosis and plan appropriate nursing care to be implemented.

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? A. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. B. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. C. Do not allow the client to review the client's own nursing diagnoses. D. Prioritize the nursing diagnoses.

D. Prioritize the nursing diagnoses. After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnoses. It is the nurse's responsibility to prioritize the nursing diagnoses, thereby prioritizing the care of the client. Resolved nursing diagnoses should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing diagnoses should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client, and therefore the client should be aware of what is included.