PassPoint - The Nursing Process

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

"By discharge, the client correctly identifies three potassium-rich food sources."

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool."

A new nurse will be monitoring a client during a moderate sedation procedure for the first time, and is discussing this with the charge nurse. Which statement made by the newly graduated nurse will the charge nurse verify as accurate?

"Complete vital signs should be charted at least every 5 minutes during the procedure."

The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor?

"Let's discuss how we can meet our clients' needs."

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse?

"We will continue to use antibiotics to treat the pneumonia."

The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?

"You are not authorized to view all of the details on the client."

A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which is the most appropriate statement by the manager?

"You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care."

The nursing instructor is discussing protecting clients' rights with nursing students. The students should identify that which events are technology privacy safeguards used in nursing? Select all that apply.

-The nurse refrains from taking clients' photographs. -The nurse obtains consent for hospital admission announcement. -The nurse secures health care records for employee access only. -The nurse accesses assigned client medical records.

The nurse is triaging trauma clients in an emergency room. Which clients are at risk for developing shock? Select all that apply.

-a 16-year-old female with a large burn -a 33-year-old male with spinal injuries

The nurse on a medical unit is providing discharge instructions to a 52-year-old male client, diagnosed with Clostridioides difficile (C. diff), about preventing the spread of this infection at home.

-wash hands with soap and water after using the toilet, -wash hands with soap and water before eating or preparing food, -use bleach to clean surfaces in the home

The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN?

52-year-old client with lung cancer admitted for acute dyspnea

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?

A referral.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours?

Client 4, Client 3, Client 2, Client 1

Following the creation of an ileostomy, a client states, "I'm really worried about how I'm going to manage this thing." What should the nurse do first?

Determine the client's exact concerns about the ileostomy.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician.

A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, "I heard that she does not have any labor and birth nursing experience." Which is the nurse's most appropriate action?

Discuss the colleague's behavior in private.

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response?

Explain that this information cannot be disclosed without the client's permission.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation?

Inform the nurse that selling supplements to clients is a conflict of interest.

A nurse on the crisis team in the emergency department is caring for a client who is angry and is experiencing delusional episodes. The client says to the nurse, "I'm going to kill my wife and chop her up to get rid of her." What is the nurse's priority action in this situation?

Notify the wife that she may be in danger.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

P wave

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP?

Reassign the UAP to a client requiring basic tasks that the UAP has mastered.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

The nurse manager overhears comments made between two nurses. The first nurse repeatedly makes comments that focus on the second nurse's skin color and race. The second nurse is observably offended. Which action by the nurse manager to address the behavior of the first nurse would promote a quality practice environment?

Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated.

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP?

The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

The entry should include clearer descriptions of the client's mood and behavior.

A client with hepatitis B is visiting with a sibling when the client's I.V. catheter dislodges and bleeds onto the surface of the bedside table. Which action, if observed, would cause the nurse to intervene?

The nursing assistant uses tissue to blot up the blood.

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the physician's and nurse's names.

The nurse has just received the change-of-shift report on clients in the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia

The nurse is beginning the shift and is planning care for six clients on the postpartum unit. Three of the clients have immediate needs, and three of the clients are listed as "stable." For the best utilization of time and client safety, the nurse should make rounds on which client first?

a birth parent who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?

a client at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago, and leaking green amniotic fluid

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care?

an older adult client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea

During the planning step of the nursing process, the nurse

establishes short- and long-term goals.

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?

evaluation

The nurse assesses a client with a 5 inch × 2 inch (12.7 cm x 5 cm) stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges, and there is a moderate amount of yellowish-tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. What is the primary nursing goal for this client?

keeping the pressure of bed linens off the area

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

A student nurse requires additional teaching when identifying what factor as contributing to a client's increased risk for infection?

proper nutrient intake

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process?

providing education about documenting blood pressure readings

When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?

pulling the ear pinna back, up, and out

A client with a platelet disorder has a platelet count of less than 150,000/μL (150 × 109/L). The nurse should instruct the client to avoid which activity?

straining to have a bowel movement

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent?

the surgeon

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP's prescriptions?

verify the prescription for 5% dextrose in water.

A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which is the most appropriate response by the OHN?

"Accurate results will be obtained by testing at 3 months and again at 6 months."

The nurse-manager on the oncology unit wants to improve documentation of the effectiveness of analgesic medication within 30 minutes after administration. What should the nurse-manager do first?

Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?

Inform the other nurse that the viewed screen resulted in a breach of confidentiality.

A client who does not speak English is to be discharged from the hospital following outpatient surgery. Using an interpreter, the nurse reviewed all postoperative instructions, including the need to come in for the follow-up appointment in 2 weeks. The nurse also explained the reconciled medication list, including when to resume taking each medication and the signs and symptoms that would require a call to the health care provider. To ensure the client will continue ongoing care management, the nurse should do what next?

Schedule follow-up visits, and inform the client of dates and times.

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?

a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain

An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which response by the nurse is the most appropriate?

"I understand your concern. I'll call the physician to review the results with you."

Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which statement indicates the primary reason the nurse manager would perform an investigation to determine the causes of the falls?

"I would like to establish the causes and trends related to client falls."

A 45-year-old client diagnosed with colon cancer states, "I don't want any treatment. I haven't seen any family members in 25 years. I'm a loner. Besides, I'll decide when and how I want to die." In which order of priority from first to last should the nurse perform the actions? All options must be used.

-Ask the client about thoughts of suicide. -Ask the client what methods for suicide are available. -Express concern for the client's feelings and safety. -Tell the client that the primary care provider will ask for a psychiatric consult.

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.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

-Provide explanations and support to the client. -Attend to the client's physical needs. -Report any signs of abuse to appropriate agencies.

A nurse is obtaining consent for a bone marrow aspiration. Which action(s) should the nurse take? Select all that apply.

-Witness the client signing the consent form. -Evaluate that the client understands the procedure. -Verify that the client is signing the consent form of their own free will. -Determine that the client understands postprocedure care.

Which action performed by a nurse will increase the risk of liability? Select all that apply.

-assisting a client on ordered bed rest to walk to the toilet -asking unlicensed assistive personnel to assess a client's wound -providing information to a caller about a client's diagnosis and treatment

When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply.

-encouraging client turning and repositioning every 2 hours -having call bell within easy reach -initiating hospital fall risk protocols

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply.

-needs oxygen at 2 L/min. -has a "do not resuscitate" prescription. -uses the bedpan. -has been in normal sinus rhythm for 6 hours.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.

-that there was adequate disclosure of information -that the client understood the information -that there was voluntary consent on the client's part -that the client has full awareness of the potential complications

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take?

Arrange for the pump to be refilled in the hospital.

The nurse works to reduce the number of children involved in automobile crashes who were not wearing seat belts. Which strategy is the most effective?

Attend a school board meeting to advocate for classes teaching children seat belt safety.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse?

Continue to assess the client, allowing the officer to assume responsibility for the handcuffs.

A nurse working the night shift observes that another nurse falls asleep in the lounge after an initial assessment of assigned clients. The nurse remains asleep for 4 hours and then wakes to complete client rounds. What is the best action by the nurse who observes this behavior?

Discuss the situation with the nurse, including the safety implications of sleeping.

The nurse is caring for a client scheduled for surgery who, on the morning of the scheduled operation, states a desire to cancel it. What would be the best response by the nurse?

Explore reasons why the client wishes to cancel the surgery, clarify concerns, and reinforce that there can be a change.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do?

Find another nurse to cover the unit and send the nurse back to the surgery unit.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation?

It provides quick access to abnormal findings.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take?

Note that the nurse caring for the client cannot be a witness.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client.

A nurse working on an acute care urology unit is assigned to a client who requires hourly urine measurement. The previous two urine measurements have been within normal limits. The next urine measurement is now due, but the nurse is busy and running late with medication administration. Which action should the nurse take?

Obtain the urine measurement as scheduled and request help with medications.

The health care provider has prescribed intravenous chemotherapy to be administered to a client every day for the next week. The nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response?

Send the client to the oncology floor for administration of the medication.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem?

Speak to the coworker upon return to the unit.

The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?

Talk to the mother first and decide on a location that is mutually agreeable.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be?

The nurse should ask the person to talk to the family directly.

An older adult who is alert and oriented is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a nightlight in the bathroom.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated?

Wetness in the sterile cloth on top of the nonsterile table has been noted.

When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face?

adjusting to retirement, deaths of family members, and decreased physical strength

Which intervention is an example of primary prevention?

administering a measles, mumps, and rubella immunization to an infant

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?

checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title

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

In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?

orders for antibiotics

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment?

speech therapist

The nurse is preparing to begin discharge planning with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process?

the client's identified needs and goals

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client?

use of all drugs taken in the last 18 months