Nursing Fundamental- Nursing Processing

The nursing care plan is: A written guideline for implementation and evaluation. A documentation of client care. A projection of potential alterations in client behaviors A tool to set goals and project outcomes.

A written guideline for implementation and evaluation.

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift

A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals

A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP.

During assessment, the nurse: (select all that apply) A: Collects data B: Organizes data C: Documents data D: Validates data E: Prioritizes data

A: Collects data B: Organizes data C: Documents data D: Validates data

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The nurse is functioning according to: 1. Protocol 2. Standing order 3. Nursing care plan 4. Intervention strategy

Answer: 1. Protocol Rationale: Guides decisions and interventions for specific health care problems or conditions.

Evaluation is: 1. Only necessary if the health care provider orders it. 2. An integrated, ongoing nursing care activity 3. Begun immediately before the patient's discharge. 4. Performed primarily by nurses in the quality assurance department.

Answer: 2. An integrated, ongoing nursing care activity. Rationale: Whenever you have contact with a patient, you continually make clinical decisions and redirect nursing care; this is an ongoing process.

Measuring the patient's response to nursing interventions and his or her progress toward achieving goals occurs during which phase of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Nursing diagnosis

Answer: 2. Evaluation Rationale: Determines whether the patient's condition or well-being has improved after the application of the nursing-process.

The criteria used to determine the effectiveness of a nursing action are based on the: 1. Nursing diagnosis 2. Expected outcomes 3. Patient's satisfaction 4. Nursing interventions

Answer: 2. Expected outcomes. Rationale: They are the expected favorable and measurable results of nursing care.

Which of the following is the correctly stated nursing diagnosis? 1. Needs to be fed related to broken right arm 2. Impaired skin integrity related to fecal incontinence 3. Abnormal breath sounds caused by weak cough reflex 4. Impaired physical mobility related to rheumatoid arthritis.

Answer: 2. Impaired skin integrity related to fecal incontinence. Rationale: It is the patient's actual of potential response to the health problem

The following statement appears on the nursing care plan for an immunosuppressed patient: "The patient will remain free from infection throughout hospitalization." This statement is an example of a(n): 1. Long-term goal 2. Short-term goal 3. Nursing diagnosis 4. Expected outcome

Answer: 2. Short-term goal Rationale: An objective behavior or response that you expect a patient to achieve in a short times, usually less than 1 week.

When a patient-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to: 1. Rewrite the same plan until the goal is met. 2. Continue with the same plan until the goal is met. 3. Repeat the entire sequence of the nursing process to discover needed changes. 4. Conclude that the goal was inappropriate or unrealistic and eliminate it from the plan.

Answer: 3. Repeat the entire sequence of the nursing process to discover needed changes. Rationale: If the goals have not been met, you may need to adjust the plan of care by the use of interventions, modify or add nursing diagnoses with appropriate goals and expected outcomes, and redefine priorities.

The following statements appear on a nursing care plan for a patient after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and patient remains afebrile." These statements are examples of: 1. Long-term goals 2. Short-term goals 3. Nursing goals 4. Expected outcomes

Answer: 4. Expected outcomes Rationale: The measurable change in a patient's condition that you expect to occur in response to the nursing care.

The second part of the nursing diagnosis statement: 1. Is usually stated as a medical diagnosis 2. Identifies the expected outcomes of nursing care 3. Identifies the probable cause of the patient problem 4. Is connected to the first part of the statement with the phrase "related to".

Answer: 4. Is connected to the first part of the statement with the phrase "related to" Rationale: It is associated with the patient's actual or potential response to the health problem.

A nursing diagnosis: 1. Identifies nursing problems. 2. Is not changed during the course of a patient's hospitalization. 3. Is derived form the physician's history and physical examination. 4. Is a statement of a patient response to a health problem that requires nursing intervention.

Answer: 4. Is the statement of a patient response to a health problem that requires nursing intervention. Rationale: Provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is responsible.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

Characteristics of the nursing process include: (select all that apply) A: It is nursing centered B: It is universally applicable in all settings C: It is individual and autonomous D: Decision making is involved in each phase of the nursing process E: Data from each phase is used in the next phase

B: It is universally applicable in all settings D: Decision making is involved in each phase of the nursing process E: Data from each phase is used in the next phase

As goals, outcomes, and interventions are developed, the nurse must: Be in charge of all care and planning for the client. Be aware of and committed to accepted standards of practice from nursing and other disciples. Not change the plan of care for the client. Be in control of all interventions for the client.

Be aware of and committed to accepted standards of practice from nursing and other disciples.

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.

A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: Notifying the physician Calling the wound care nurse Changing the wound care treatment Consulting with another nurse

Calling the wound care nurse

The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A client's family attending a diabetic teaching session. Canceling physical therapy sessions on the weekend. Normal VS and absence of wound infection in a post-op client. A client demonstrating accurate medication administration following teaching.

Canceling physical therapy sessions on the weekend.

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D. Target time Rationale: The outcome goal does not state the target time frame for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."

To initiate an intervention the nurse must be competent in three areas, which include: Knowledge, function, and specific skills Experience, advanced education, and skills. Skills, finances, and leadership. Leadership, autonomy, and skills.

Knowledge, function, and specific skills

When establishing realistic goals, the nurse: Bases the goals on the nurse's personal knowledge. Knows the resources of the health care facility, family, and the client. Must have a client who is physically and emotionally stable. Must have the client's cooperation

Knows the resources of the health care facility, family, and the client.

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: Length of time the current treatment has been in place The spouse's reaction to the client's dressing change Client's concern about the current treatment Physician's reluctance to change the current treatment plan

Length of time the current treatment has been in place

Nursing interventions classification (NIC) interventions

Nursing interventions classification (NIC) interventions offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes.

General nursing process

Orderly, step-by-step process... Client is evaluated (Assessment) Data are collected and analyzed (Diagnosis) Plan of care is determined and set into motion (Planning & Implementation) Client is monitored, evaluated (Evaluation) Care plan is revised as needed (Evaluation)

Identify the two components of "knowing the patient"

a. A nurse's understanding of a specific patient. b. A nurse's subsequent selection of interventions.

Explain the two terms : Diagnostic reasoning Inference

a. Diagnostic reasoning: Analytical process for determining a patient's health problems and selecting proper therapies. b. Inference: The process of drawing conclusions from related pieces of evidence and previous experience with the evidence.

Define the following terms related to implementation. a. Direct care b. Indirect care

a. Direct care are treatments performed through interactions with patients. b. Indirect care are treatments performed away from the patient but on behalf of the patient.