Foundations Chapter 13 PrepU

Educational

A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?

condition.

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:

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

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 indicates the outcome expectation has been met?

"I walk daily wearing low-heeled shoes."

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Teach client how to splint abdominal incision when coughing and deep breathing.

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?

Outcome criteria

What are specific measurable and realistic statements of goal attainment?

Nurses do carry out interventions in response to a physician's order.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Psychomotor

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Identifies factors causing undesirable response and preventing desired change

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

Cutting up food and opening drink containers for the client

Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs?

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

Which is an appropriate expected outcome for a client?

Altered Gas Exchange

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Within 2 days of education, the client's wife will demonstrate abdominal dressing change.

Which of the following is categorized as a psychomotor outcome?

Nurse-initiated interventions are derived from the nursing diagnosis.

Which statement correctly describes a nurse-initiated intervention?

Narcotic pain medication to treat pain

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for the client?

updating the diet orders in the client's plan of care

A client is required to be n.p.o. for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

Resolve the client's anxiety.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Ongoing Planning

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Client will have formed stools within 24 hours.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Upon her admission to the hospital

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Nursing Outcome Classification

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

Client is normal tensive.

A nurse administers an 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?

Start from client's knowledge, teach about diet modifications, and check for learning.

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Ongoing planning

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

A standardized care plan

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?

developing the plan without client input

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Outcome evaluation

A nurse is caring for a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

rationale.

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 assistance with position change is provided every 2 hours to prevent pressure ulcers. What is the portion of "assistance to prevent pressure ulcers" portion of this statement described as?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with dietitian regarding appropriate foods.

A nurse is caring for a client with a bowel obstruction that has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

Nursing interventions

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include?

establishing priorities identifying expected client outcomes selecting evidence-based nursing interventions Communicating the plan of nursing care

A nurse is planning care for clients in a physician's office. Which actions will the nurse perform during this step of the nursing process? Select all that apply.

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

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

can be measured are realistic are specific

A nurse is reviewing the outcome criteria that were developed for a client. The nurse determines that the criteria are appropriate because which characteristic is met? Select all that apply.

Individualize the plan to the client.

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

Supportive intervention

A nurse is working with a client who is having a difficult time accepting her new diagnosis of type II diabetes. The nurse pulls up a chair next to the client's bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?

Seek research about the disorder.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?

At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care.

A nurse is writing outcomes for clients in a rehabilitation facility. Which guidelines should the nurse consider? Select all that apply.

intervention.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

Physiologic

According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is:

Standardized

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath.

An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome?

Start from client's knowledge, teach about diet modifications, and check for learning.

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 client's needs?

"Please tell me your thoughts about treating this diagnosis."

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?

The nurse has omitted the time frame.

The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?

A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care?

Assess tracheostomy for patency.

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. Which outcome statement is structured correctly?

Discharge Planning

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

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

The nurse is determining realistic nursing interventiosn for a client on bed rest after a colon resection. What interventions would best meet the needs of this client? Select all that apply.

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. By 4/5/15, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress.

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.

The client identifies three foods high in potassium by August 8.

The nurse recognizes that an example of a cognitive outcome is:

involvement of the client and family.

The nurse recognizes that identifying outcomes/goals must include: