Nursing Process Questions

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority with the most important (classified as high) listed first 1. constipation 2. anticipated grieving 3. ineffective airway clearance 4. ineffective tissue perfusion

3,4,1,2 Ineffective Airway clearance Ineffective tissue perfusion Constipation Anticipated grieving

The RN has received her client assignment and assessing the clients, which client would the RN need to develop a care plan 1st?

A client who has fever, is diaphoretic, and restless

For clients to participate in goal setting they should be

Alert, and have some degree of independence

As goals, outcomes, and interventions are developed the nurse must

Be aware of and committed to accept standards of practice from nursing and other disciples.

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to

Discuss & Review advised strategies with CNS

Which of the following nursing interventions are written correctly?

Elevate head of bed 30 degrees before meals

When developing a nursing care plan for a client with a fractured right tibia the nurse includes in the plan of care independent nursing interventions including

Elevate the leg 5 inches above the heart

The following statements appear on the nursing care plan for a client after a mastectomy? Incision site approximated; absence of damage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of:

Expected Outcomes

Which of the following statements about the nursing process is most accurate?

The state of board examinations for professional nursing practice now use the nursing process rather than medical specialities as an organizing concept

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations priorities are determined by client's

Urgency of problems

The nursing care plan is

a written guideline for implementation and evaluation

A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers

calling the wound care nurse

Well formulated client centered goals should?

meet intermediate; include preventative health care; include rehabilitation needs.

To initiate an intervention the nurse must be competent in 3 areas which include:

Knowledge, Function and Specific Skills

When establishing realistic goals, the nurse:

Knows the resources of the health care facility, family, and the client

When calling the nurse consultant about different client-centered problems, the primary nurse is sure to report the Following

Length of time the current treatment has been in place

Collaborative Interventions are therapies that require:

Multiple health care professionals

After determining a nursing diagnosis of Acute Pain the nurse develops the following appropriate client centered goal

Pain intensity reported as a 3 or less during hospital stay

Once a nurse assesses a client's condition and identifies appropriate nursing diagnosis, a

Plan is developed for nursing care

The planning step of the nursing process includes which of the following activities

Setting goals & selecting interventions

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an)

Short Term Goal

The nursing is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action & analysis?

Canceling physical therapy sessions on the weekend

The nurse writes an expected outcome statement in measurable terms. An example is

Client will report pain acuity less than 4 on a scale of 0-10

Planning is a category of nursing behaviors in which

Client-centered goals & expected outcomes are established