Quiz: Chapter 18 Planning Nursing Care

The nurse prepares for health care provider initiated and collaborative interventions. What should the nurse do before implementing the interventions? Select all that apply. 1 Clarify orders. 2 Implement procedures as ordered by the healthcare provider. 3 Administer medications as ordered by the healthcare provider. 4 Determine whether the intervention is appropriate for the client. 5 Determine if the collaboration of other care disciplines is required.

1 Clarify orders. 4 Determine whether the intervention is appropriate for the client. 5 Determine if the collaboration of other care disciplines is required. Clarifying an order is important to prevent errors. The nurse with a strong knowledge base recognizes the error and seeks to correct it. The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures. Above all, it is most important to determine if the client requires care from other health disciplines. When preparing for health care provider initiated or collaborative interventions, the nurse should not automatically implement the therapy but determine whether it is appropriate for the client. Text Reference - p. 242

A nurse gives information to nursing students about nursing interventions classification. What are the levels of the nursing interventions classification model? Select all that apply. 1 Domains 2 Classes 3 Prior level 4 Lower level 5 Interventions

1 Domains 2 Classes 5 Interventions There are three levels of the nursing interventions classification model. These levels are classes, domains, and interventions. Domains are the highest level of the model. At the highest level, domains use broad terms to organize the more specific classes and interventions. Classes offer useful clinical categories to which one can refer to while selecting interventions. The third level of the model involves individual interventions. It is defined as any treatment based on clinical judgment and knowledge that a nurse performs for achieving the client outcomes. Client outcomes are the desired changes in the client once an intervention is performed. Prior level and lower level are not the levels of the nursing interventions classification model. Text Reference - p. 242

The nurse is preparing a nursing care plan for a client with a hernia. What are the basic concepts that a nursing care plan should emphasize? Select all that apply. 1 Nursing diagnoses 2 Illness management 3 Diagnosis and treatment 4 Specific nursing interventions 5 Goals and expected outcomes

1 Nursing diagnoses 4 Specific nursing interventions 5 Goals and expected outcomes Generally, a nursing care plan includes nursing diagnoses, goals and expected outcomes, specific nursing interventions, and a section for evaluation findings so that any nurse can quickly identify a client's clinical needs and situation. Illness management, diagnosis, and treatment are not part of the nursing care plan. Text Reference - p. 244

A 72-year-old client has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the client's oxygen saturation to be lower than normal. The physician diagnoses the client as having pneumonia. Prioritize the nursing diagnoses identified for this client. 1. Impaired gas exchange 2. Ineffective self-health management 3. Risk for activity intolerance

1. Impaired gas exchange 2. Risk for activity intolerance 3. Ineffective self-health management The client's oxygenation status is the priority in this situation. The client's condition creates the risk for activity intolerance, making this an intermediate priority for which the nurse must monitor. Ineffective self-help management is a long-term goal that might be applicable if the client has physical limitations at the time of discharge. Text Reference - p. 237

A nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the client's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The client is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the client. How should the nurse prioritize the following events? 1. The client's vital signs change, showing a drop in blood pressure. 2. The client expresses concern about pain control. 3. The charge nurse approaches the nurse and requests a report at end of shift. 4. The family comes to visit the client

1. The client's vital signs change, showing a drop in blood pressure. 2. The client expresses concern about pain control. 3. The family comes to visit the client 4. The charge nurse approaches the nurse and requests a report at end of shift. A change in vital signs is the first priority, and the change could be related to the client's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Pain control is the next priority , because if it is severe, it affects the client's ability to rest after surgery and be able to perform necessary activities. Attending to the family is important to lend the client needed support, but it is not an initial priority. Finally the nurse must attend to urgent client needs before completing a report. Text Reference - p. 237

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? 1 The goals of care will always be more long term. Correct2 The client and family need to be able to independently provide most of the health care. 3 The client's goals need to be mutually set with family members who will care for him or her. Incorrect4

2 The client and family need to be able to independently provide most of the health care The expected outcomes need to address what can be influenced by interventions. A community-based health care setting such as home health must work with clients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Stating that the goals of care will always be long term is not accurate; goals will be short term and long term, depending on the client's condition. Stating that the client's goals need to be mutually set is true for any health care setting. Stating that expected outcomes need to address what can be influenced by interventions is an error; the outcomes allow you to direct your evaluation of care. Text Reference - p. 247

A client has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the client will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following client care goals are long term? 1 Client will explain relationship of insulin to blood glucose control. 2 Client will self-administer insulin. 3 Client will achieve glucose control. 4 Client will describe steps for preparing insulin in a syringe. It will take time for the client who is medically unstable to achieve glucose control. The goals of explaining the relationship of insulin to blood glucose control and the self-administration of insulin are short term and should be met before discharge. "Client will describe steps for preparing insulin in a syringe" is not a goal but an outcome statement for the goal" Client will self-administer insulin." Text Reference - p. 239

3 Client will achieve glucose control. It will take time for the client who is medically unstable to achieve glucose control. The goals of explaining the relationship of insulin to blood glucose control and the self-administration of insulin are short term and should be met before discharge. "Client will describe steps for preparing insulin in a syringe" is not a goal but an outcome statement for the goal" Client will self-administer insulin." Text Reference - p. 239