NURSING PROCESS

inadequate staffing.

Identifying the kind and amount of nursing services required is a possible solution for

throughout the client's hospital admission

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?

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:

Finances of the client

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?

Quality assurance

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

PC: Decreased Cardiac Output related to cardiac tissue damage

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

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:

Impaired Physical Mobility related to pain

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Seek research about the disorder.

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?

Health promotion nursing diagnosis

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Quality by inspection

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance?

A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation?

involvement of the client and family.

The nurse recognizes that identifying outcomes/goals must include:

As soon as possible after a client presents for care

When is the best time for a nurse to take a client's health history?

Demonstrated steps"

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

The nurse should determine the client's normal bowel elimination pattern.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

Document reassessment of pain after medication administration.

Which action should the nurse take during the evaluation phase of the nursing process?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

Which client situation most likely warrants a time-lapse nursing assessment?

A cluster of clinical cues

Which information ensures accuracy when the nurse is developing a nursing diagnosis?

Focus full attention on the client.

Which is recommended when conducting a client-nurse interview?

Respect for client Competence Professionalism Caring

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

functional assessment

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

Decreased ability to cope with surgical removal of right breast

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?

Notify the physician for additional orders.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Diminished breath sounds in left lower lobe

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications.

The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement?

discharge planning.

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

Activity and rest

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?

Fear related to change in health status Pain related to cardiac tissue damage

The nurse is planning care for a client who has experienced a myocardial infarction. Which would likely be appropriate nursing diagnoses for the nurse to select for this client? Select all that apply.

Discover a problem. Plan a strategy using indicators. Implement a change. Evaluate a change.

To improve quality care for clients, there are four steps that the nurse recognizes as being crucial for the process. Place them in the correct order. Use all options.

Outcomes

What are specific measurable and realistic statements of goal attainment?

the interventions planned must be within the nurse's scope of practice.

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

Reporting signs and symptoms related to the client's kidney failure

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

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

Which is an appropriate expected outcome for a client?

A client report of shooting pain up the left leg

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

The nurse assesses urine output following administration of a diuretic.

Which nursing action reflects evaluation?

Quality improvement focuses on processes, data, and statistical thinking.

Which statement regarding quality improvement or quality assurance is correct?

Focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Surveillance

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?

Collect client subjective and objective data.

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Notify the health care provider immediately

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?

The client is able to explain when and why the client needs to check the blood glucose level.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

Disturbed Body Image related to loss of hair

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Decreased level of consciousness

A client with advanced Alzheimer's disease has a nursing diagnosis of "Risk for Aspiration." What would the nurse select as an appropriate etiology for this diagnosis?

On the client's admission to the hospital

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?

Readiness for Enhanced Knowledge: Childhood Immunizations

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Determine whether the prescribed treatment was effective.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Confront the nurse and explain how this could be dangerous for the client.

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Encourage hourly use of the incentive spirometer.

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?

Organizing the existence of cues Generating possible diagnoses Comparing cues to possible diagnoses Conducting a focused data collection Validating diagnoses

A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnoses for a client. Place the steps in the order that they would occur from first to last during this process.

Knowledge Deficit: Medications related to new medical diagnosis

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Determine the client's willingness to follow the regimen.

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

The plan of care only contains standard knowledge that most nurses would implement if there was no plan of care. Long-term goals are vague. Outcomes are incorrectly developed. Nursing orders are superficial.

A nurse is reviewing the plan of care for a client. Which should the nurse identify as problems related to the planning phase of the nursing process? Select all that apply.

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

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

Activity-exercise

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?

premature closure.

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

The client reports an inability to get adequate restful sleep. The client states, "I can't handle all of this." The client has difficulty concentrating on the details of treatment options.

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

Reassess the client to determine whether the action is needed.

Before implementing any planned intervention, which action should the nurse take first?