FUND PREP U- CH 16,17,18,19
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 end of week."
A new graduate nurse has come to your unit to work. She asks the charge nurse what the difference is between collecting data in the client assessment and in the evaluation phase of the nursing process. The charge nurse bases her response on her knowledge of which statement?
"Data collected in the nursing assessment identifies patient health problems, whereas data collected in the evaluation phase is to determine if patient outcomes are being achieved."
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 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 will test my glucose level before meals and use sliding scale insulin."
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."
Which authoritative statements guide current professional nursing practice?
ANA standards of nursing practice
A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?
Ask a skilled nurse to assist with the procedure.
The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate?
Ask the client if information can be given to the parent.
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?
Ask the client to verbalize the medication regimen and diet modifications required.
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?
Assess the client to determine the cause of the pain.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?
Assess the client's blood pressure to determine if the medication is indicated.
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?
Assess the client's response to the ambulation.
Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?
By 18AUG2015, client will demonstrate improved motion in left arm.
A nurse has been providing discharge teaching to a client with type 1 diabetes. Which outcome indicates that the teaching has been effective?
By a certain date, the client will verbalize signs and symptoms of hypoglycemia.
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?
Calling the client information desk to find out the room number of the family member
Which is an appropriate expected outcome for a client?
Client will ambulate safely with walker in the room within 3 days of physical therapy.
The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?
Client will maintain nutritional intake without pain or diarrhea.
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 nurse's most appropriate action?
Collaborate with other disciplines to revise the discharge plans.
The nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, while 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.
A nurse is planning nursing interventions for clients 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.
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?
Delay the instruction until the visitors leave.
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?
Discontinue the education and attempt at another time.
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 I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?
Discuss possible alternatives to a blood transfusion with the physician.
Which action should the nurse take during the evaluation phase of the nursing process?
Document reassessment of pain after medication administration.
A nurse is caring for a client, who was admitted 2 days ago, following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?
Encourage hourly use of the incentive spirometer.
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.
When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting?
Ensure that the client's name appears on all pages.
An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?
Explain the reason why information cannot be disclosed.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
Identifies factors causing undesirable response and preventing desired change
A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?
Include the client and the client's power of attorney in the discussion.
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?
Individualize the plan to the client.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?
Inform the client what to expect after the surgery.
The nurse recognizes that identifying outcomes/goals must include:
Involvement of the patient and family
As the nurse bathes a client, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?
It enables the nurse to revise the care plan appropriately.
The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?
Medicate the client and wait to ambulate later.
The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly?
Mr. Conner will demonstrate proper care of stoma by 3/29/15.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
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
When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?
Praise the client for taking an active role in his care.
The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?
Provide client assistance to the bedside commode.
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?
Reassess the appropriateness of the method of instruction.
A nurse is preparing to implement interventions identified on the clent's plan of care. Before implementing any intervention, which action would the nurse take first?
Reassess the client to determine if the action is needed.
A client with hypertension being seen for follow-up care has a blood pressure of 160/100. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?
Report the findings to the physician for further plans.
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?
Revise the care plan to allow the client to ambulate to the bathroom independently.
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?
Seek research about the disorder.
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
The nursing student is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?
Tell the student that the RN will assist the student with the client's ambulation.
A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem?
The client is able to explain when and why he needs to check his blood sugar.
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?
The client is free of falls.
A nurse manager tends to use the quality by inspection method of ensuring quality on the unit. Which actions, taken by this manager, are evidence of use of this technique? Select all that apply.
The manager threatens to "write up" a nurse if the nurse is late to work again. The nurse requests transfer off the unit for a nurse who has made three medication errors in three months.
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 nursing action reflects evaluation?
The nurse assesses the client's response to pain medication.
A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?
The nurse evaluates the client's goal/outcome achievement.
A nurse is planning care for a client who has just been diagnosed with type 2 diabetes. Which nursing action is performed during the planning step of the nursing process?
The nurse selects nursing measures, including patient teaching
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?
Upon her admission to the hospital
Which of the following is categorized as a psychomotor outcome?
Within 2 days of education, the client's wife will demonstrate abdominal dressing change.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
a flow sheet
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:
a referral
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
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.
are specific are realistic can be measured
A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?
asking if the client feels less anxious 30 minutes after administering the medicine
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 does the nurse collect information to evaluate this outcome?
at the completion of each meal
Which nursing action can be categorized as a surveillance or monitoring intervention?
auscultating of bilateral lung sounds
Nurses are involved in many types of evaluation. All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?
clients and their care
A client is about to leave the hospital after having surgery for a fractured left femur. It is now in a plaster cast. The client asks how long before the cast will be dry. The nurse notes on the client's plan of care a learning outcome stating "Client will verbalize appropriate cast care upon discharge." This represents what type of outcome?
cognitive
The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:
cognitive outcome
A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating 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 the she discontinued breastfeeding. The nurse evaluates the original goal as:
completely unmet.
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?
developing the plan without client input
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
discharge planning
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?
documentation
After the nursing plan of care has been developed, the nurse knows that:
each encounter with the client is an opportunity to reassess and revise the plan of care if necessary.
A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
educational
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
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
A client with a recently fractured left femur has been reluctant to comply with his physical therapy for fear of the pain associated with movement. A goal for this client is to attend therapy treatments 3 times each day. The nurse is evaluating the goal for this client. The client states, "I don't like therapy; it hurts, but I have been going twice a day." The client chart has an entry from the last shift nurse stating the client went to therapy 2 times with encouragement. The nurse evaluates the goal as:
goal partially met.
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?
identifying risks and ensuring future safety for clients
A large university hospital has commissioned a multidisciplinary group to review client records following discharge in order to evaluate client outcomes and the character and quality of nursing care that clients receive. What type of evauation process will take place?
nursing audit
A nurse is reviewing the plan of care for a client and notes : "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." How does the nurse interpret this statement?
outcome criteria
What are specific measurable and realistic statements of goal attainment?
outcome criteria
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?
outcome evaluation
The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?
outcome evaluation
A group of nurses of 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. The nurses know that this program is termed:
peer review
Prior to the first postoperative visit postgastrectomy, 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
The mother brings her 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 what type of outcome statement?
physical changes
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
progress notes
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
psychomotor
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?
quality assurance
The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse?
right circumstance
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include?
risk factors and prevention of diabetes mellitus
A client has just been admitted to the clinical unit. The nurse is providing her with the expectations she may have of the health care she will receive. She is told that she will not be harmed by any errors that might be made and she can expect to be safe in the facility. This assurance represents which expectation of the health care environment?
safety
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?
standardized
The terms "criteria" and "standard" are often used interchangeably but actually have distinct, separate definitions. "The levels of performance accepted by, and expected of, nursing staff or other health team members" is known as:
standards
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
A nurse is working as part of a quality assurance team that uses the American Nurses Association model. The team is evaluating the resources of the facility as well as the physical facilities and equipment. Which type of evaluation is the team engaged in?
structure evaluation
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?
supportive intervention
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 the need for education the client is blind
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?
the nurse has omitted the time frame
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access to the client's records?
those directly involved in the client's 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?
updating the diet orders in the client's plan of care