Foundations Exam 1 Chapter 10 PrepU

A hospital client has an aggressive fungal infection in his right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills? A. Documenting the condition of the client's orbit and the procedure of the dressing change in an accurate and timely manner B. Maintaining aseptic technique when performing the dressing change C. Understanding the anatomy and physiology of the affected parts of the client's body D. Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

ensuring the client's privacy during dressing changes and providing an explanation during the procedure

A client who has limited finances and limited capacity for education requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, she must first: A. develop a relationship with the client. B. engage the services of a social worker. C. determine what care has been provided. D. Implement critical-thinking skills.

implement critical-thinking skills.

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats. What is the most appropriate intervention for this client with a nursing diagnosis of imbalanced nutrition: less than body requirements?

Administer 2500 calorie (10,500 kJ) diet, excluding wheat, rye, and oats

Nurses use the nursing process to plan care for clients. In which cases is the nursing process applicable? Select all that apply. A. When nurses work with clients who are able to participate in their care B. When families are clearly supportive and wish to participate in care C. When clients are totally dependent on the nurse for care D. When families are not supportive and do not wish to participate in care.

All the above

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include: A. Resilient, authoritative, reactive, and private. B. Self-aware, honest, persistent, and authentic. C. Creative, oriented to success, self-determination, and perfection. D. Curious, other-directed, fallible, and humble.

B. Self-aware, honest, persistent, and authentic.

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.

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply. Client's previous admission record Client Client's children Client's physician Client's caregiver

Client's previous admission record Client's children Client's physician Client's caregiver

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? Reflection Clinical reasoning Assessment Caring

Clinical reasoning

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client? A. Make educated generalizations about the client's health to determine focused client problems. B. Complete a systematic nursing history and nursing examination. C. Have a nursing student perform the assessment and report it back to the nurse. D. Make interpretations based on client behaviors.

Complete a systematic nursing history and nursing examination.

Which action exemplifies the purpose of evaluation in the nursing process?

Continue, modify, or terminate nursing care.

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process?

Diagnosis

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

Evaluation

nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. A. Impaired mobility B. Imbalanced nutrition C.Pneunomia D. Ineffective coping E. Heart failure

Impaired mobility Imbalanced nutrition Ineffective coping

The nurse is completing rounds and notices the client has slumped down in bed. The nurse assists the client to settle more comfortably, but the client grimaces and tenses the body. The nurse does a complete pain assessment, checks the time of last analgesic, and prepares the medication. Giving the medication is which step of the nursing process? A. Assessment B. Implementation C. Evaluation D. Planning

Implementation

When the nurse administers pain medication to a postoperative client, the phase of the nursing process that is occurring is: A. assessment. B. implementation. C. nursing diagnosis. D. planning.

Implementation

Which is a characteristic of person-centered care?

It is a framework for providing care.

Which statement regarding critical thinking in nursing is true? A. It supplies validation for reimbursement. B. It is a systemic way of thinking. C. It makes judgment based on conjecture. D. It shows trends and patterns in client status.

It is a systemic way of thinking.

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Diagnosis Evaluation Planning Implementation

Planning

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

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: A. Expect him to be drowsy, and let him rest. B. Evaluate the abdominal dressing for drainage. C. Administer pain medication. D. Complete postoperative assessment.

complete postoperative assessment.

An obese client is in the clinic to be started on a weight loss plan. The client loves to eat, The favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for this client? The client will:

create an exercise plan that is realistic and valued.

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. The nurse is demonstrating: A. reflection-in-action. B. critical reflectivity. C. reflective skepticism. D. clinical reasoning.

critical reflectivity

Which action is performed in the implementation step in the nursing process? A. documenting the nursing care and client responses B. identifying measurable outcomes C. selecting nursing interventions D.documenting the plan of care

documenting the nursing care and client responses

Use of the nursing process in health care allows the nurse to address the needs of the client. The nursing process: A. Provides a universally applicable framework for nursing activities. B. Targets desired outcomes for particular illnesses, procedures, or conditions. C. Is a method of nursing established in 1955. D. Was developed for use by students in nursing assignments.

provides a universally applicable framework for nursing activities.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse

uses critical thinking to direct care for the individual client.

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement?

"If I give this medication, the client probably will be sleepy."

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking? "Is there another way to look at this situation?" "How could we find out if that is true?" "Could you elaborate on that point a bit more?" "Could you be more specific in you observations?"

"Is there another way to look at this situation?"

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process. 1 Establishing the database 2 Measuring how well the client has achieved desired outcomes 3 Establishing priorities 4 Carrying out the plan of care 5 Modifying the plan of care (if indicated) 6 Interpreting and analyzing client data

1, 6, 3, 4, 2, 5 Establishing the database Interpreting and analyzing client data Establishing priorities Carrying out the plan of care Measuring how well the client has achieved desired outcomes Modifying the plan of care (if indicated)

The clinical nurse manager understands that which types of knowledge are required for competent clinical reasoning in nursing? Select all that apply. A. Organizes and manages time efficiently B. Understands nursing and medical terminology C. Demonstrates basic mathematical problem solving D. Commits to organizational mission and values E. Performs safely and never makes a mistake

A, B, C Demonstrates basic mathematical problem solving Organizes and manages time efficiently Understands nursing and medical terminology

Which statements are true regarding the evaluation phase of the nursing process? Select all that apply. A. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. B. Evaluations should be documented daily in the client record. C. Evaluation is the last part of the nursing process. D. Only factors that positively affect the outcome should be identified during evaluation. E. Evaluation does not involve nursing assessment.

A, B, C The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. Evaluations should be documented daily in the client record. Evaluation is the last part of the nursing process.

The ability to communicate clearly through documentation is a critical nursing skill. Which statements accurately describe the role of documenting in the nursing process? Select all that apply. A. It is helpful to practice documentation while learning any given nursing activity. B. The content of the client report and nursing documentation helps to establish nursing priorities in a practice setting. C. Because data collection is ongoing and responsive to changes in the patient's condition, it should be documented in the final step of the nursing process. D. The client record is the chief means of communication among members of the interdisciplinary team. E. If a nurse is accused of negligent care, a nurse's word that he or she faithfully assessed the client's needs, diagnosed problems, and implemented and evaluated an effective plan of care is his or her best defense. F. Legally speaking, a nursing action not documented is a nursing action not performed.

A, B, D, F The client record is the chief means of communication among members of the interdisciplinary team. Legally speaking, a nursing action not documented is a nursing action not performed. It is helpful to practice documentation while learning any given nursing activity. The content of the client report and nursing documentation helps to establish nursing priorities in a practice setting.

When developing a nursing plan of care and associated client outcomes, which should the nurse recognize? Select all that apply. A. Outcomes can be short- and long-term. B. A plan of care should be comprehensive, including the initial, ongoing, and discharge planning. C. Only the client is involved in outcome setting, not the family. D. All plans of care are the same for each client with certain medical diagnosis. E. Outcome setting allows for individualization of the plan of care.

A, B, E A plan of care should be comprehensive, including the initial, ongoing, and discharge planning. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

Which statements are true about the implementation phase of the nursing process? Select all that apply. A. Care provided during implementation should be documented in the client's chart. B. Implementation is only carried out by nursing professionals. C. Implementation is the process of carrying out the plan of care. D. All interventions carried out during this phase must be accompanied by a physicians order. E. This phase promotes wellness and restores health.

A, C, E Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? Select all that apply. A. resisting "easy answers" to client problems B. Thinking based on the opinions of others C. Acting like a "know-it-all" D. Being open to all points of view E. accepting the status quo F. thinking "outside the box"

A, D, F Being open to all points of view resisting "easy answers" to client problems thinking "outside the box

The nurse is developing a plan of care for a client with a fractured femur, is in traction, and will be restricted to bed for some time. Which domain should the nurse look to for developing a nursing diagnosis based on this client's musculoskeletal health problems? A. Activity/Rest B. Self-perception C. Health Promotion D. Nutrition

Activity/Rest

The nurse is caring for a client that presents with polydipsia, polyphagia, and polyuria. The clients labs reveal in increased Hb A1C, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? A. Administer a prescribed medication to decrease the client's blood sugar. B. Follow-up with the client to see if the lab work improves. C. Identify outcomes for the client with his or her input. D. Analyze data and create an individualized nursing diagnosis.

Analyze data and create an individualized nursing diagnosis.

The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the most appropriate nursing action?

Assess the client's back visually.

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? A. Assessment B. Implementation C.Planning D. Diagnosis

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? A. Assessment B. Evaluation C. Planning D. Implementation

Assessment

A nursing student is shadowing a registered nurse for a day in the clinical area as part of the student's orientation for clinical rotation. The student asks the nurse, "Do you really use the nursing process when caring for your clients?" Which responses by the nurse would be appropriate? Select all that apply. A. "Yes, but you need to remember that it focuses on the care of adult clients." B."Yes, the nursing process is essential for identifying medical diagnoses." C. "Yes, it helps to emphasize the client's active role in making decisions." D. "Yes, it's important for providing individualized care to each client." E. "Yes, the nursing process is an orderly way of solving client problems.

C, D, E "Yes, it's important for providing individualized care to each client." "Yes, the nursing process is an orderly way of solving client problems. "Yes, it helps to emphasize the client's active role in making decisions."

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time? A. Contact the lactation consultant and ask if the plan of care needs to be modified. B. Refer the couplet to a nutritionist. C. Terminate the plan of care because evaluation reveals that the outcome has been met. D. Modify the plan of care to follow-up more frequently to assure that the outcome will be met.

C. Terminate the plan of care because evaluation reveals that the outcome has been met.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? Determine whether the prescribed treatment was effective. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor. Administer an additional liter of intravenous fluids.

Determine whether the prescribed treatment was effective.

The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying? A. Enjoying the rewards of mutual interchange B. Developing ethical/legal skills C. Developing accountability D. Establishing caring relationships

Developing accountability

Which step of the nursing process involves reporting or analysis of data to identify and define health problems? Implementation Assessment Planning Diagnosis

Diagnosis

The nurse is caring for a client who states that he hears voices in his head that tells him to do bad things. When the nurse enters the client's room, he is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? A. Document that the client is talking back to the voices in his head. B. Do not document this assessment because he could be using his Bluetooth to talk to his family. C. Document this assessment based on the client's behaviors. D. Do not document this assessment because it is subjective.

Document this assessment based on the client's behaviors.

The nurse is caring for an obese client that needs to be turned every 2 hours. Which nursing action is an example of reflection for action?

During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After the shift is over, the nurse wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers.

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 understands that research has demonstrated that a common source of hospital-acquired infections in clients with IV infusions is the hub on the IV tubing. Which Quality and Safety Education for Nurses (QSEN) competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

Evidence-based practice

A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply. Interviewing Inspecting Palpating Auscultating Percussing

Inspecting Auscultating Percussing Palpating

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

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

The nurse formulates client outcomes based on the understanding that the outcomes should be:

Measurable

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and upon evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? A. Add additional nursing diagnosis to meet the client's health needs. B. Change the nursing diagnosis because the client's problem was falsely identified. C. Reassess the client for more symptoms of deficient fluid volume. D. Modify the plan of care and interventions to meet the client's needs.

Modify the plan of care and interventions to meet the client's needs.

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? A. Nursing Process B. Reflection C. Experience D. Clinical reasoning

Nursing Process

The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe, but is relieved some when getting up to go the bathroom. What is the nurse's best determination based on this assessment? A. Even with pain, the client is ambulatory and therefore ready for discharge. B. More assessment would be beneficial to determine if pain medication is desirable. C. That the client should not be ambulating with pain. D. That the client's pain is really not that bad because he or she can ambulate.

More assessment would be beneficial to determine if pain medication is desirable.

Which statements are true about informatics in nursing practice based on QSEN competency? Select all that apply. Nurses should value technologies that support error prevention and care coordination. Computers do not help with communication, but deter it because of the lack of personal interaction. Utilization of information services helps to support decision-making. The use of informatics can help manage knowledge and mitigate error. Informatics only involves documentation of timely and accurate charting.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision-making.

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: A. subjective data. B. outcome. C. nursing diagnosis. D. intervention.

Outcome

Which is the most appropriate example of the assessment phase of the nursing process? A. Palpating a mass in the right lower quadrant of the abdomen B. Evaluating the temperature of a client given medication for a fever C. Including a nursing diagnosis of Acute Pain in the client's plan of care D. Documenting the administration of a medication provided for pain

Palpating a mass in the right lower quadrant of the abdomen

The student nurse has been assigned to a pediatric hospital floor next week. The student understands that he or she 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? A. Attempt to use the equipment even without practice, eventually it can be figured out. B. Practice using the pump in the lab setting if it is available and with instructor permission. C. Call other students and ask them about the equipment in order to become more familiar with the procedure. D. Don't stress about it, wait until the day of the rotation and inform the instructor that you do not know how to use the equipment.

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

A nurse has developed a plan of care for an adult client. What nursing function is important when using a nursing diagnosis to guide the care of this client? A. Prioritize the nursing diagnoses. B. Keep resolved nursing diagnoses as part of the plan of care in case the problem returns. C. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. D. Do not allow the client to review his or her nursing diagnoses.

Prioritize the nursing diagnoses.

What is the best example of person-centered care provided by a registered nurse? Development of a plan of care for a new admission Reassuring a client that is anxious about a procedure Administration of pain medication every 4 hours to a client that is postoperative Insertion of a nasogastric tube (NGT) for gastric decompression

Reassuring a client that is anxious about a procedure

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

Reflection

Which statement is true of the nursing process? A. It is a valid alternative to using intuition to respond to nursing situations. B. Scientific problem solving can occur within the nursing process. C. Trial-and-error problem solving is incongruent with the nursing process. D. It is more appropriate in medical-surgical settings than community health care.

Scientific problem solving can occur within the nursing process.

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? A. Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest. B. Recognize how the approach affects client care, and describe why you have to do things your way. C. Approach the client as part of the job, and complete nursing care quickly to promote comfort.

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

Which intervention is the most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of deficient knowledge?

Teach the client how to administer insulin

Which outcome does the nurse recognize as being the most appropriate for the client with a nursing diagnosis of risk for infection? A. The client has a normal temperature and no signs and symptoms of infection. B. The client understands what symptoms to monitor for. C. The client takes his temperature daily. D. The client takes the prescribed antibiotic.

The client has a normal temperature and no signs and symptoms of infection.

The nurse is caring for a morbidly obese client with a very high body mass index (BMI). After analyzing the assessment data, a nursing diagnosis of Altered nutrition: more than body requirements is included in the client's plan of care. What is the best example of outcome identification and planning for this client using the nursing process? A. The client is involved in developing a comprehensive and individualized plan of care with specific outcomes. B. Long-term goals are not required because many times they are unrealistic. C. The nurse only allows the client to set long-term goals because there is no way the client will be able to meet the outcomes quickly. D. Short-term goals describe multiple client behaviors so that they can be accomplished quickly.

The client is involved in developing a comprehensive and individualized plan of care with specific outcomes.

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? A.Instead of documenting every 2 hours per hospital protocol, the nurse documents a detailed shift assessment and an end of shift note to cover what has happened during the shift. B. Because the nurse is so busy there is no time to look up the safe dose for a medication, instead she asks a coworker that has been a nurse on the floor for 10 years about the medication. C. 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. D. It is so busy that some tasks just can not be done and therefore the nurse will just leave those tasks for the night shift, including the 4 pm labs.

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.

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? Intuitive thinking Trial-and-error problem solving Scientific problem solving Critical thinking

Trial-and-error problem solving

A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?

What happened?

The orderly progression of steps of the nursing process is: A.diagnosis, implementation, assessment, evaluation, and planning. B. assessment, diagnosis, planning, implementation, and evaluation. C. implementation, planning, evaluation, assessment, and diagnosis. D. planning, assessment, diagnosis, evaluation, and implementation.

assessment, diagnosis, planning, implementation, and evaluation.

A nurse is caring for a post-operative client 1 day after a total abdominal hysterectomy. Which nursing intervention demonstrates caring? A.assisting the client to sit up in a chair B. notifying the healthcare provider of lab results C. monitoring vital signs D. assessing the abdominal incision

assisting the client to sit up in a chair

A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is a newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in this client? The client will: A. log all meals in a diary for the next 6 weeks. B. maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). C. not exhibit signs and symptoms of hypo-/hyperglycemia. D. maintain a normal Hb A1C.

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L).

A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process. obtains the client's weight daily. obtains the client's vital signs identifies risk for fluid volume excess determines that the client's fluid balance is stabilized develops a realistic goal for monitoring fluid balance prepares an individualized strategy for addressing risk

obtains the client's vital signs identifies risk for fluid volume excess develops a realistic goal for monitoring fluid balance prepares an individualized strategy for addressing risk obtains the client's weight daily. determines that the client's fluid balance is stabilized

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged? A. identifying a positive situation B. thinking about relationships involved C. reevaluating experience in light of ideas D. recalling a sequence of events

reevaluating experience in light of ideas