Taylor Review Questions - Teaching

A nurse is assisting a client with his bed bath. The client states "I can do it myself". Which is the nurse's best response?

"I will set up your bath for you. I will come back and help you with your bath." RATIONALE: The nurse must value and support the client becoming independent in care.

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes RATIONALE: People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan RATIONALE: Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?

A wellness diagnosis RATIONALE: The client is seeking information related to healthy practices. Wellness diagnoses are formulated to assist the client to meet that need. The client has no health problem or possible problem, so an actual diagnosis, a risk diagnosis, and a possible diagnosis are inappropriate.

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment?

Adds depth to existing information RATIONALE: A focus assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focus assessment does not suggest possible problems facing the client but rather rules our or confirms the client's problems. A focus assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

A nurse is developing a client's plan of care. As part of the planning interventions, the nurse incorporates a set of steps to follow as a means for decision making for care. Which structured methodology is the nurse including in the plan?

Algorithm RATIONALE: An algorithm is a set of steps that approximates the decision process of an expert clinician and is used to make a decision; these clinical rules are typically embedded in a branching flow chart. A procedure is a set of "hot to" action steps for performing a clinical activity or task. A standard of care is a description of an acceptable level of client care or professional practice. A clinical practice guideline is a statement or series of statements outlining appropriate practice for a clinical condition or procedure.

The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which statement made by a nursing student indicates a need for further instruction?

All data collected needs to be validated. RATIONALE: Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:

Alopecia RATIONALE: Most commonly, hair loss is caused by cancer treatment.

What would be a nursing priority when assessing a client who weights 250 lbs and stands 5ft 3 in tall?

Assess blood pressure with a large cuff. RATIONALE: When assessing an obese client, a larger blood pressure cuff will likely be needed in order to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an ECG are ordered. Diet education may or may not be warranted depending on the cause of the obesity.

The nurse is determining realistic nursing interventions for a client on bed rest after a color resection. What interventions would best meet the needs of this client? SATA

Assist the client with deep breathing exercises with the use of incentive spirometry every hour. Turn the client and change position every 2 hours Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours. RATIONALE: Client's on bed rest must have a medical order to begin ambulation and the intervention should be more specific. Acetaminophen must be prescribed by a licensed practitioner in the inpatient setting. The use of incentive spirometry and deep breathing exercises every hour is specific and realistic, as is changing position every 2 hours, and providing the client with a splint to encourage coughing.

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment?

Client RATIONALE: The client is the primary, and usually the best source of information when doing an assessment. The medical record may also provide information only if the client has been at the health care facility before. The charge nurse is responsible for care of the unit clients. The primary physician would provide medical care based on the medical assessment.

A client has a diagnosis of Bathing/Hygiene Self-care deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?

Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain. RATIONALE: Bathing/hygiene self-care deficits resulting from hospitalizations and complications require return of strength and motor abilities. An appropriate goal is for the client to actively and independently participate in hygiene and self-care. In order for the nurse to document that the outcome was met, the nurse must see the client perform the activity.

Providing client education before discharge is an important nursing tool. It supports learning, self esteem, and confidence. Which statement supports this principle?

Client education focuses on identified home needs. RATIONALE: Client education is a therapeutic relationship that should focus on the client's specific needs. A client's educational needs can differ; educational needs change with acute or chronic conditions, short- or long-term health conditions, or ones that will require temporary or long-term adjustments to client lifestyles. Client's also have unique values, beliefs, cognitive abilities, and preferential ways of learning that affect involvement and educational outcomes that are unique to each client. Allowing clients to share their beliefs, culture, and preferences enables nurses to better understand this uniqueness and to individualize education to the client's needs.

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

Client will participate in self-care measures by the end of the week RATIONALE: Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care.

A client with a right facial droop and dysphasia after a stroke has the nursing diagnosis "Impaired Swallowing". Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite. RATIONALE: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these actions will improve oral intake by the client with dysphasia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus.

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 fo the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client. RATIONALE: Confronting the nurse and explaining the danger for the client is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance; it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the client.

While caring for a client who has a problem related to digestion a nurse has been referred by the primary care provider to be seen by a gastroenterologist. Which part of the client record should the nurse look at to see the recommendations made by the gastrointestinal specialist?

Consultation RATIONALE: The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "consultation". Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

A nurse is planning nursing interventions for client on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?

Date the nursing interventions when written and when the plan of care is reviewed. RATIONALE: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where how often, how long, or how much). The interventions should directly relate to the goal/outcomes, not be a separate entity. The physician does not approve and sign the interventions because they are nursing interventions.

A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated?

Discuss the occurrence with the coworker. RATIONALE: The first step is to confront the coworker. If the behavior continues or the nurse does not seem to understand the gravity of the mistake, it would be appropriate to discuss the situation with the charge nurse. It makes no difference if the client and coworker have a previous relationship or not, given the unprofessional nature of the incident. The client-nurse boundary should be protected. Apologizing to the client may draw attention to the issue.

Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following?

Finances of the client RATIONALE: Each of these factors contributes to the prioritization of nursing diagnoses, except the client's finances. The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks "Why are you making a trochanter roll?". After reviewing the image, which response by the nurse to the student would be most accurate?

I am placing the new linens under the rolled, soiled linens to avoid contamination. RATIONALE: When making an occupied bed, it is important for the nurse to use clean linen and make the near side of the bed first. Then, the nurse places the bottom sheet in the center of the bed. Next, the nurse opens the sheet and pulls the bottom sheet over the corners at the head and foot of the mattress. Next, the nurse pushes the sheet toward the center of the bed, pulling it taut and positioning it under the old linens to avoid contaminating the new linen. In the image, the position of the client is for making an occupied bed, not for assessing the skin as the old linen is covering the client's skin. The nurse is not tucking the draw sheet tightly; it is the fitted (bottom) sheet that is displayed in the image.

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial RATIONALE: The Joint Commission has mandated that each client have a documented nursing admission assessment that follows institutional policies.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide. RATIONALE: Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients items. RATIONALE: Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

When a client says "I don't care if I get better; I have nothing to live for, anyway". Which type of counseling would be appropriate?

Motivational counseling RATIONALE: The most appropriate counseling for the situation at hand would be motivational counseling. With motivational counseling, the nurse would discuss feelings and incentives with the client. Short term counseling focuses on the immediate problem or concern of the client or family. It can be a relatively minor concern or major crisis, but in any case, it needs immediate attention. Long term counseling extends over a prolonged period. A client might need the counsel of the nurse at daily, weekly, or monthly intervals. A client experiencing a developmental crisis, for example, might need long term counseling. Professional counseling is a general term.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student. RATIONALE: The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?

Passive abduction with assistance. RATIONALE: Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team.

The nursing supervisor is presenting the staff nurse with yearly performance evaluations. What type of evaluation is the supervisor presenting to the staff?

Process evaluation RATIONALE: Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent. The phases of the nursing process are used as the framework for the evaluation of nursing care.

The nurse manager observes one of the unit nurses failing to wash her hands upon entering a client room. Hospital protocol is washing hands before and after entering a client room. The nurse manager knows that this is an example of:

Quality by inspection RATIONALE: Quality by inspection is met by nurses watching for deficient workers and removing them in an effort to prevent harm to clients.

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

Revise or modify the patient care plan RATIONALE: Evaluation using the functional health approach provides a framework for organizing and evaluating data.

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. RATIONALE: Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic client's should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

The is nurse assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? Client states "I don't want to live anymore. My family hates me and I am so tired of being sick. I have a gun and I a, seriously thinking of killing myself". The patient reports a 30 year heavy smoking habit and having a cough for about six months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. His lips are slightly bluish in color.

Risk for suicide RATIONALE: The patient who talks to suicide and has a plan to implement it should be taken seriously, making this the priority diagnosis. The other choices are important but could be addressed following interventions for suicide prevention.

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal source that the client has to help her attain her self-care goals?

She has motivation to participate in self-care.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action?

Standing orders RATIONALE: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider ordered that expedite the provider order process.

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention RATIONALE: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of client's and changes from previous states.

During a meeting, the nursing staff was reminded that learning takes place in four progressive stages. Place the stages of learning in their order of progression.

The client reported the first symptom that appeared. A family member reminded the older adult to take pain relief medication on alternate days. The client is now eating three servings of vegetables per day. An adolescent organizes a "safe sex" seminar. RATIONALE: The client reporting the first symptom that appears is an example of an individual recognizing what has been taught. A family member reminding the older adult to take aspirin tablets on alternate days is an example of an individual's ability to explain or apply the information taught. An adolescent organizing a safe sex seminar is an example of an individual's ability to independently use the new learning. These are examples of the four progressive stages of learning in ascending order.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? SATA

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. RATIONALE: After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that his wife will handle his care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

While applying dressings to a client's wound, the nurse teaches the client about his wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind?

The nurse and client relationship is based on mutual sharing and negotiation. RATIONALE: When providing nursing care, the teaching-learning relationship between the nurse and client is special, characterized by mutual sharing, advocacy, and negotiation. Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process. Unlike some traditional views, nurses are not experts who generously bestow knowledge upon clients, nor do they barter knowledge for compliance. Both images represent the relationship as a power imbalance in which nurses, because of their knowledge and expertise, control the situation.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner?

Their readiness to learn is often related to a developmental task or social role. RATIONALE: An adults readiness to learn is often related to a developmental task or social role. The previous experience of the adult is a rich resource for learning. Most adults' orientation to learning is that material should be useful immediately. Peer group acceptance is a critical issue for the adolescent group and not adults.

the nurse is preparing to delegate a bath for a 90 year old client who is non responsive and has mild skin breakdown. Which type of bath will the nurse delegate to the UAP?

Traditional bed bath with linen change RATIONALE: A traditional bed bath with linen change provides the greatest opportunity for full cleansing. The client is unable to perform assistance with a shower, and is not a candidate for a bed bath. Although a bag bath may be useful, the traditional bed bath with linen change provides the best opportunity for infection control in observance of the mild skin breakdown that has been noted.

A registered nurse is overseeing the care of several residents of a long term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)?

Using a tool to remove a contact lens that has adhered to the resident's eye. RATIONALE: A contact lens that present a challenging removal should be addressed by the nurse rather than delegated to UAP. This is due to the potential for injury to the resident's eye. All of the other listed tasks can be safely delegated to UAP.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. What outcome is the priority for the client?

Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. RATIONALE: Outcomes should be specific, measure-able, attainable, realistic, and time bound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short term outcome, and using verbs that are not observable. Safety is a priority for all clients. Clients with thought and mood disorders may present a risk of harm to self or others because of distorted thinking. Therefore, the ability of the client to mingle with others without violence is the highest priority.

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem RATIONALE: Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.