Chapter 13 fundies

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which initial step of the nursing process is this nurse performing?

Assessment

An older adult client is being admitted into the hospital for treatment of a fractured hip. Which part of the nursing process would be carried out first ?

Assessment

The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment

Which step in the nursing process is the careful taking of a history and a nursing examination?

Assessment

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?

Clinical reasoning

The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?

Cognitive and technical skills

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client?

Complete a systematic nursing history and nursing examination.

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

Diagnosing

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0-10. There is an order for IV pain medication every 4 hours PRN. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0-10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process?

Evaluation

The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?

Evaluation

Which stage of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation

When the nurse is administering furosemide 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent?

Implementation

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving.

Which is a characteristic of person-centered care?

It is a framework for providing care.

An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood sugars. The outcome for this client is to maintain blood sugars between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood sugar on the body and assure that the client has the resources to be compliant. Evaluation reveals that the clients blood sugar remains out of range and that the outcome has not been met. What is the most appropriate action by the nurse?

Modify the plan of care to find alternative ways to meet client needs

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

The nursing student has been assigned to a pediatric hospital floor next week. The student understands that he is expected to be able to use the syringe pump with the clinical instructor when giving medications. The student has never used this pump before and is anxious. What is the most appropriate way for the student to lessen the anxiety associated with the clinical rotation?

Practice using the pump in the lab setting if it is available and with instructor permission.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

On a typical day shift, 7 am to 7 pm, the nurse-client ratio on a busy floor is higher than usual because a member of the health care team called in sick for the day. Which example shows a nurse practicing with a good sense of legal competence?

The nurse follows the chain of command and requests help for the tasks that she can not complete and that are important to the client care on the floor that day.

In which situation would the nurse be most justified in implementing trial-and-error problem solving?

The nurse is attempting to landmark an obese client's apical pulse.

The nursing process is based upon the process of problem solving. The nurse attempts t obtain a blood pressure on the client's right arm, then on the left arm, then on the left lef, and finally on thw right leg, whwre the blood pressure js obtained. Wbat tyoe if problem solving did the nurse use

Trail and error problem solving

The orderly progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

Which activity is the clearest example of the evaluation step in the nursing process?

checking the client's blood pressure 30 minutes after administering captopril.

When the nurse administers pain medication to a postoperative client, the phase of the nursing process that is occurring is:

implementation.

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using:

intuitive problem identification

The nurse is caring for a newly admitted client. How can a nurse obtain a more complete database for this client?

perform a comprehensive client assessment

client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?

starting a new, large-gauge intravenous site on the client, and priming the infusion tubing