142 final

The nurse is developing goals for a client who has been admitted for an acute myocardial infraction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed

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

Determine the clients willingness to follow the regimen

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery

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?

Finances of the client

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Meeting the care needs of clients

The nurse assesses a clientafter total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse?

Notify the health care provider.

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

A nurse assesses the vital signs of a client who is one day post operative following a colostomy. The nurse then uses the data to update the clients plan of care. What are the actions considered?

Ongoing planning

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

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

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

"Demonstrated steps"

The nurse is attending a conference on evidence based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions"

The expected outcome for a client with a new diagnosis of diabetes mellitus is "client will describe appropriate actions when implementing the prescribed medication routine". Which statement by the client indicated the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin"

What are specific measurable and realistic statements of goal attainment?

Outcomes

Which situations observed by a nurse should the nurse report to the nurse manager for quality assurance? Select all that apply.

A nurse administers medications to the wrong client. A nurse assesses a client after sneezing into the nurse's hands. A nurse delays answering call lights to an abusive client.

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

The post-amputation client is seen by the home health nurse. One client outcome included preventing exposure to infection. Which finding would indicate to the nurse that this outcome was met?

Absence of fever

What nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

A nurse suspects that the client with Chron's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurses most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required

The nurse is preparing to administer a blood pressure medication to a client. To ensure the clients safety, what is the priority action for the nurse to take?

Assess the clients blood pressure to determine if the medication is indicated

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm

Which is an appropriate expected outcome for a client?

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

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement?

Physical changes

When the nurse enters the room to assess the clients vital signs, the client insists that the nurse perform hand-washing. What is the nurses most appropriate action?

Praise the client for taking an active role in the clients care

What action is a responsibility of the nurse in the nurse-nurse team relationship?

Provide creative leadership to make the nursing unit a challenging place to work

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement?

Psychomotor

A nurse prepares to care for a client who has just been admitted to the health care facility. Which activity will the nurse perform first?

Collect data.

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

Which action should the nurse perform in the evaluation phase?

Revise the plan of care.

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment?

Substance abuse

A nurse is caring for a postoperative client after a scheduled ileostomy. Which action by the nurse reflects an effective cognitive outcome?

The client identifies three strategies for minimizing leakage of an ileostomy bag.

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?

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

The joint commission encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient?

The patient has developed peritonitis.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome.

Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse then makes a judgment and documents a statement summarizing those findings. This statement is called:

an evaluative statement.

The nurse is caring for a client admitted to the hospital for renal calculi. Which is the action to take first?

assess for bladder distention

Which scenario represents a nurse demonstrating the critical thinking process?

assessing whether physician help is needed

a nurse administers a antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

client is normotensive

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

discharge planning

A nurse is performing a sterile dressing change on a clients abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there was no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize:

equipment and personnel

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

inadequate staffing.

A nurse is using a standardized plan of care for a client. Which action would be the most important for the nurse to do?

individualize the plan to the client

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

nurse case manager

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for the client?

over the next 24 hour period, the client will walk the length of the hallway assisted by the nurse

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed:

peer review

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

revise or modify the client care plan.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

surveillance

When auscultating a clients 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?

surveillance

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?

throughout the client's hospital admission

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"please tell me your thoughts about treating this diagnosis"

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as?

. rationale

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the clients orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self care as possible

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurses suggestion and evaluate its usefulness

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

Physical changes

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?

Quality by inspection

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply

The client denies need for education The client is blind

The nurse is caring for a 10 year old client who is newly diagnosed with a seizure disorder. What variable would alter the nurses plan for educating the client and parent?

The client has a 12 year old sister who has been treated for a seizure disorder for 3 years

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:

condition

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. What is the nurse's most appropriate action?

reassess whether the client still needs the urinary catheter

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards.

A nurse is documenting evaluation of the care provided for an infant born with Down syndrome. Which nursing actions exemplify the appropriate documentation process? Select all that apply.

After the data have been collected to determine client outcome achievement, the nurse writes an evaluative statement to summarize the findings. The nurse writes a 2-part evaluative statement that includes a decision about how well the outcome was met, along with client data that support the decision. The nurse has three decision options for how goals have been met.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurses most appropriate action?

Collaborate with other disciplines to revise the discharge plans

A nurse is reviewing a client's plan of care. What would the nurse determine is a problem related to the assessment phase of the nursing process?

Database does not reflect changes in the client condition.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate how to apply and remove elastic support stockings.

Which are components of an evaluative statement? Select all that apply.

Description of how the client outcome was met Client data that support how the outcome was met

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?

Discovering a problem

A client tells the nurse , "my doctor has told me to have a blood transfusion, but I am a jehovah's witness and i cant take one". What is the nurses most appropriate intervention?

Discuss possible alternatives to a blood transfusion with a physician

What is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for the client?

The nurse in a Burn Intensive Care Unit (BICU) is caring for a 3-year-old boy who was burned with scalding hot water. He has burns covering 75 percent of his body. His condition is critical but stable. At 1000, the nurse reassesses the client and finds that he is agitated and pulling at his endotracheal tube. What would be the nurse's priority?

Ensuring that the endotracheal tube is secure

The client will demonstrate cast care prior to discharge" is which type of evaluative statement?Psychomotor

Psychomotor

For the second time this week, a nurse reports to the nurse manager failing to perform an ordered dressing change due to a lack of time. The nurse manager recognizes that the nurse normally is very punctual and known to provide good care for clients and that the unit census has been very high this week. However, the nurse manager knows that quality care must be provided and reports this occurrence. Which approach to quality assurance does this scenario represent?

Quality as opportunity

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

Quality assurance

a client with hypertension being seen for follow up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurses most appropriate action?

Report the findings to the physician for further plans

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the clients needs?

Start from clients knowledge, teach about diet modifications, and check for learning

Which are cognitive client outcomes? Select all that apply.

The client identifies signs and symptoms of hypoglycemia. The client describes how to perform progressive muscle relaxation. The client lists the side effects of digoxin.

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statemen(s) would help the nurse most appropriately interpret these data?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet.

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

which nursing actions reflect the implementing step of the nursing process? Select all that apply.

referring the client to community resources providing health education to reduce health risks using evidence based interventions individualized for the client

Which roles are a responsibility of the nurse in the nurse - health care team relationship? Select all that apply

serve as a liaison between the client and family and the health care team coordinate the inputs of the multidisciplinary team into a comprehensive plan of care

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

standardized

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

what assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply

the client discusses the specifics of what was taught during the session the client is able to answer the nurses questions the client verbalizes understanding of the instructions