Fundamentals Exam #2 Practice questions

A mother brings an infant into the clinic for a well-baby visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding. and the nurse finds that the baby is gaining weight appropriately. Which is an appropriate evaluative statement for this client? "8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight." "8FEB2016. Goal met." "Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight." "Goal met"

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? "How do you protect yourself when having sex?" "Do you use condoms?" "How many sexual partners have you had in the past 6 months?" "Are you in a committed relationship?"

"How do you protect yourself when having sex?"

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? "Is there anything else we should know in order to care for you better?" "What are your expectations from us and from yourself in your care?" "What practices have you found especially helpful in other settings?" "What do you envision for your care while you're here at the facility?"

"Is there anything else we should know in order to care for you better?"

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now." "I sort my medication into an organizer every week." "My daughter has been staying with me the past few weeks."

"My wife's been gone for about 7 months now."

The nurse reports for duty in the emergency department and notes the following clients for which the nurse will be assuming care. After receiving the hand-off report, which client should the nurse prioritize for care? 21-year-old male with possible fracture 7-year-old male with hand laceration 24-year-old female with cough and fever 12-year-old female with asthma attack

12-year-old female with asthma attack

For which client would a standardized plan of care most likely be appropriate? A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy A client who was admitted for shortness of breath and who has been diagnosed with pneumonia A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

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? An algorithm An order set Guidelines A standardized care plan

A standardized care plan

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Activity and rest Nutrition Health promotion Self-perception

Activity and rest

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? Potential nursing diagnosis Risk nursing diagnosis Health promotion nursing diagnosis Actual nursing diagnosis

Actual nursing diagnosis

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? Weigh client as needed. Administer a daily multivitamin. Administer a high-calorie diet, excluding wheat, rye, and oats. Monitor for allergies.

Administer a high-calorie diet, excluding wheat, rye, and oats.

Which client situation most likely warrants a time-lapse nursing assessment? A client is being admitted to a general medicine unit after spending several days in the intensive care unit. The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Administer a prescribed medication to decrease the client's blood glucose level. Identify outcomes for the client with the client's input. Follow up with the client later to determine whether the client's laboratory test results improve. Analyze the data and create an individualized nursing diagnosis.

Analyze the data and create an individualized nursing diagnosis.

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? Preparation Intelligence Anxiety Previous knowledge

Anxiety

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 Precision Relevance Accuracy

Clarity

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? Client is drowsy after lunch. Client reports no headache. Client lipids are within range. Client is normotensive.

Client is normotensive.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will eat small meals of bland foods for 3 days. Client will have formed stools within 24 hours. Client will maintain adequate hydration within 2 days. Client will identify the food that caused the condition within 3 hours.

Client will have formed stools within 24 hours.

Which parties are essential for the nurse to include in the implementation of a client's plan of care? Client, surgeon, and physician Client, family, and physician Client, physician, and hospital director Client, physical therapist, and nursing staff

Client, family, and physician

Which group of terms best defines assessing in the nursing process? Nurse-focused, establishing nursing goals Problem-focused, time-lapsed, emergency-based Designing a plan of care, implementing nursing interventions Collection, validation, communication of client data

Collection, validation, communication of client data

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools

Constipation related to irregular evacuation patterns

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? Continue to collect assessment data. Contact the client's health care provider. Consult with a more experienced nurse. Document the data for future reference.

Consult with a more experienced nurse.

A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take? Review the procedure in the procedure manual before performing the intervention. Delegate the intervention to an unlicensed assistive personnel. Perform the procedure and inform the charge nurse of the results. Consult with the charge nurse before performing the procedure.

Consult with the charge nurse before performing the procedure.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action? Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. Coordinate with the other disciplines to determine if all the tests scheduled are necessary. Review the physician's progress notes to determine if any of the tests are not indicated. Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis? Composition Dysfunction Qualifications Descriptors

Descriptors

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? Administer an additional liter of intravenous fluids. Determine whether the prescribed treatment was effective. Check the client's skin turgor. Formulate a plan of care based on risk for dehydration.

Determine whether the prescribed treatment was effective.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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? Beginning the plan without family to help Failing to update the written plan of care Developing the plan without client input Choosing actions that do not solve the problem

Developing the plan without client input

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 the client's refusal with hospital risk managers. Discuss the client's options with other church members. Discuss the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the physician.

Discuss possible alternatives to a blood transfusion with the physician.

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? Chronic pain Disturbed sleep pattern Hyperthermia Social isolation Powerlessness

Disturbed sleep pattern

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? Educational Maintenance Supervisory Surveillance

Educational

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? Changing the dressing to prevent infection Ensuring that the endotracheal tube is secure Providing medication for agitation Repositioning to prevent pressure injuries

Ensuring that the endotracheal tube is secure

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice 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? Teamwork and collaboration Person-centered care Informatics Evidence-based practice

Evidence-based practice

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time Point out potential nursing care plan goals while assessing Ask if the client would like the door opened or closed when finished Explain the nurse will need to touch the client during the assessment

Explain the nurse will need to touch the client during the assessment

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? Feedback from the family Time and resources The client's condition Finances of the client

Finances of the client

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? Vomiting Fluid volume deficit Gastrointestinal upset from food poisoning Slow skin turgor

Gastrointestinal upset from food poisoning

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? Instruct the client in nonpharmacologic pain management. Medicate the client with the ordered pain medication. Go to the client and assess the client's pain. Determine the frequency of pain medication.

Go to the client and assess the client's pain.

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to unsafe home environment Child Abuse related to unsafe home environment High Risk for Injury related to impaired home management High Risk for Injury related to abusive parents

High Risk for Injury related to unsafe home environment

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? Imbalanced Nutrition: Less than Body Requirements related to decreased appetite Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food Imbalanced Nutrition: Less than Body Requirements related to CVA Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

Giving medication occurs in which step of the nursing process?

Implementation

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. Include the rationale for the interventions. Identify the appropriate nursing diagnoses. Expect to modify the plan significantly.

Individualize the plan to the client.

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Acute Dyspnea Bronchial Pneumonia Ineffective Airway Clearance Asthma Attack

Ineffective Airway Clearance

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? Impaired Comfort Ineffective Breastfeeding Disturbed Sleep Pattern Risk for Impaired Parenting Readiness for Enhanced Parenting

Ineffective Breastfeeding

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? Ineffective Coping related to client's inability to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Risk for Injury related to client's mismanagement of disease Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen

Ineffective Health Maintenance related to client's denial of illness

Which statement best conveys the role of intuition in nurses' problem solving? In experienced nurses, intuition can be a valid replacement for scientific problem solving. Intuition is an unreliable mode of thinking that should be avoided. Intuition is reliable when those nurses implementing it have a special "gift." Intuition can be a clinically useful adjunct to logical problem solving.

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

Which statement best explains why continuing data collection is important? It is the most efficient use of the nurse's time. It is difficult to collect complete data in the initial assessment. It enables the nurse to revise the care plan appropriately. It meets current standards of care.

It enables the nurse to revise the care plan appropriately.

Which is a characteristic of person-centered care? It can be used in hospital settings. It is a framework for providing care. It is independent of other disciplines. It involves general care for all clients.

It is a framework for providing care.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge Deficit: Medications related to new medical diagnosis Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management Ineffective Airway Clearance related to bronchial constriction

Knowledge Deficit: Medications related to new medical diagnosis

Which are examples of objective data? Select all that apply. A client's report of pain A client's temperature A client's report of being unable to breathe Breath sounds on auscultation Laboratory test results

Laboratory test results, Breath sounds on auscultation, A client's temperature

Which are examples of subjective data? Select all that apply. Edema Light-headedness Anxiety Laceration Nausea

Light-headedness, Anxiety Nausea

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. Emphasize to the client the importance of following the treatment plan. Explain to the client the benefits of ambulation. Ambulate the client and medicate later.

Medicate the client and wait to ambulate later.

The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client? Risk for Visual Deficit Risk for Neonatal Jaundice Neonatal Jaundice Visual Deficit

Neonatal Jaundice

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Notify the physician for additional orders. Consult with another nurse to validate the assessment. Decrease stimulation and allow the client to rest. Document the client's level of consciousness.

Notify the physician for additional orders.

Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. Nurse-initiated interventions are actions performed to diagnose a medical problem. Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions require a physician's order.

Nurse-initiated interventions are derived from the nursing diagnosis.

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value? Primary Secondary Objective Subjective

Objective

Which nursing skill uses all five senses? Documentation Listening Observation Caring

Observation

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 the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? Once the client is admitted to the nursing unit from postanesthetic recovery As soon as possible after the client's surgery Once the client has received a discharge order On the client's admission to the hospital

On the client's admission to the hospital

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

Ongoing

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? The nurse will help the client ambulate the length of the hallway once a day. The client will become mobile within a 24-hour period. Offer to help the client walk the length of the hallway each day. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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

The nurse has measured from the tip of the client's nose to the 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 nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client? Apparent Possible Potential Actual

Possible

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

Prioritize the nursing diagnoses.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. Number of years in profession Professionalism Respect for client Competence Caring

Professionalism Respect for client Competence Caring

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

Psychomotor

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? Magnet status Quality assurance Peer review Quality improvement

Quality assurance

In the implementation step of the nursing process, which activity is the nurse's first priority? Reassess client's needs. Differentiate between subjective and objective data. Document nursing care. Prioritize evaluation of care.

Reassess client's needs.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? Assessment Reflection Evaluation Memorization

Reflection

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 nurse's most appropriate action? Reinforce the instructions for the treatment regimen to the client. Report the findings to the physician for further plans. Inform the client that the blood pressure medication will have to be changed. Interview the family to determine if the client is giving accurate information.

Report the findings to the physician for further plans.

What should the nurse do prior to performing an initial assessment on a newly admitted client? Tell the client that the nurse will do an assessment only if it's convenient. Introduce the members of the health care team to the client. Review the records available on the client. Report to the charge nurse what needs to be done for the client.

Review the records available on the client.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? The cellular metabolism of glucose Medications used to treat diabetes mellitus Risk factors for and prevention of diabetes mellitus The severity of the client's disease

Risk factors for and prevention of diabetes mellitus

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Allergy Response related to latex allergy Risk for Injury related to latex allergy

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Deficient Community Health related to chemical plant Knowledge Deficit related to effects of chemical plant pollution Risk for Infection related to community contamination Risk for Community Contamination related to possible environmental pollution

Risk for Community Contamination related to possible environmental pollution

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? Pneumonia Hypertension Congestive heart failure Risk for falls

Risk for falls

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? Low self-esteem Lack of support Feelings of not belonging Risk of self-harm

Risk of self-harm

Which statement is true of the nursing process? Trial-and-error problem solving is an efficient use of the nurse's time. It is a valid alternative to using intuition to respond to nursing situations. Scientific problem solving can occur within the nursing process. It is more appropriate in medical surgical settings than community health care.

Scientific problem solving can occur within the nursing process.

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? Set priorities using client care standards. Seek research about the disorder. Follow institutional guidelines. Consult with another nurse.

Seek research about the disorder.

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

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

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg? Subjective Explanatory Objective Severe

Subjective

The nurse identifies which types of data when performing an assessment? Select all that apply. Subjective Intuition Critical thinking Objective Hunches

Subjective Objective

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Supportive Psychosocial Coordinating Supervisory

Supportive

While auscultating a client's 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 Psychomotor Educational Maintenance

Surveillance

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? Tell the UAP that a different UAP should ambulate the client. Tell the UAP not to ambulate the client at this time. Tell the UAP that the RN will assist the UAP with the client's ambulation. Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.

Tell the UAP that the RN will assist the UAP with the client's ambulation.

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 asks the nurse to repeat the instructions. The client verbalizes understanding of the instructions. The client tells the nurse that the client's spouse will handle the care. The client discusses the specifics of what was taught during the session. The client is able to answer the nurse's questions.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

Which is the primary reason for a nurse collecting data continuously on a client? It gives the nurse more information to document on the client. Most facilities require it for reimbursement. It makes the client feel as if the nurse is spending more time with the client. The client's health status can change quickly.

The client's health status can change quickly.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client is watching television. The client states, "I can breathe easier now." The client's respiratory rate decreases. The client's family asks if the client is going to be okay. The client's oxygen saturation level increases.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases.

The Joint Commission (TJC) 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 clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse explains each procedure twice to prevent client questions from wasting time. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine.

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

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 outcome should indicate what the nurse will do. The nurse has omitted the defining characteristics. The nurse has not made any error in writing the outcome. The nurse has omitted the time frame.

The nurse has omitted the time frame.

After analyzing the assessment data of a morbidly obese client, the nurse includes the nursing diagnosis of Altered nutrition: more than body requirements in the client's plan of care. Which is the best example of outcome identification and planning for this client using the nursing process? The nurse does not include long-term goals for this client because the nurse knows they would be unrealistic. The nurse only allows the client to set long-term goals because the client will not be able to meet the outcomes quickly. The nurse includes short-term goals each of which describes multiple client behaviors so that they can be accomplished quickly. The nurse involves the client in developing a comprehensive and individualized plan of care with specific outcomes.

The nurse involves the client in developing a comprehensive and individualized plan of care with specific outcomes.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? The nurse should determine what laboratory tests are critical at this time. The nurse should determine the length of time the client has been in the hospital. The nurse should determine the client's last laboratory results. The nurse should determine the reason for the client's refusal.

The nurse should determine the reason for the client's refusal.

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? The parent states, "A member of my church gives me a break twice a week." The parent states, "I attend support group meetings when I am able to go." The parent states, "I make sure that I get regular exercise." The parent states, "I cannot allow anyone else to help because they won't do it right."

The parent states, "I cannot allow anyone else to help because they won't do it right."

When performing an assessment, the nurse should focus most on the developmental stage for which client? Middle-age adult Toddler Young adult Adolescent

Toddler

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? Subject Performance criteria Conditions Verb (action)

Verb (action)

Which is an example of a psychomotor outcome? Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. The client will verbalize understanding of the need to continue to take medications as prescribed. The client's skin will remain smooth, moist, and without breakdown or ulceration. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day.

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

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: dependent nursing diagnoses. collaborative nursing diagnoses. actual or potential nursing diagnoses. syndrome nursing diagnoses.

actual or potential nursing diagnoses.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: comprehensive planning. ongoing planning. discharge planning. initial planning.

discharge planning.

The primary purpose of nursing implementation is to: help the client achieve optimal levels of health. improve the client's postoperative status. identify a need for collaborative consults. implement the critical pathway for the client.

help the client achieve optimal levels of health.

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. identifies the unhealthy response preventing desired change. suggests client goals to promote desired change. identifies client strengths.

identifies factors causing undesirable response and preventing desired change.

The purpose of obtaining a nursing history is to: assist the physician to establish a medical diagnosis. identify actual and potential health problems. focus on objective physical data specific to the client. minimize the time required to establish a nursing diagnosis.

identify actual and potential health problems.

The nurse recognizes that identifying outcomes/goals must include: involvement of the client and family. involvement of the nurse manager and other staff nurses. input from the physician. input from the multidisciplinary team.

involvement of the client and family.

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: intervention. objective data. nursing diagnosis. outcome.

outcome

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: the client record from the physician's office. the focus assessment done when admitted to the ER. the health record from a previous admission. the initial comprehensive client assessment.

the initial comprehensive client assessment.

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? during the first home health care visit once the primary care physician has written a discharge order when the client is discharged throughout the client's hospital admission

throughout the client's hospital admission

The nurse is aware that nursing diagnoses are: within the nursing scope of practice to develop and client-focused. collaborative and depend on the medical diagnosis. based on assessment data and the primary care provider's input. dictated by the medical diagnoses and change day by day.

within the nursing scope of practice to develop and client-focused.