Nursing Process (PREPU Questions) CHP. 16 - PLANNING

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

Client is normotensive.

Which is an appropriate expected outcome for a client? By the next clinic visit, client will report taking antihypertensive medication. After attending sibling classes, client will be happy about a new baby and demonstrate feeding. Client will ambulate safely with walker in the room within 3 days of physical therapy. Client will perform complete ostomy care while bathing on the second postoperative day.

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

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? Failing to update the written plan of care Developing the plan without client input Beginning the plan without family to help Choosing actions that do not solve the problem

Developing the plan without client input

Which statement correctly describes a nurse-initiated intervention? 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 actions deemed to have a low risk of harm to the client.

Nurse-initiated interventions are derived from the nursing diagnosis.

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? On the client's admission to the hospital Once the client has received a discharge order Once the client is admitted to the nursing unit from postanesthetic recovery As soon as possible after the client's surgery

On the client's admission to the hospital

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? "You need to stop smoking for us to effectively combat this disease." "What are your plans after discharge?" "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?"

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

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 A standardized care plan Guidelines

A standardized care plan

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? Expect to modify the plan significantly. Individualize the plan to the client. Include the rationale for the interventions. Identify the appropriate nursing diagnoses.

Individualize the plan to the client.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses are not legally responsible for these interventions. Nurses do not carry out physician-initiated interventions. Nurses are responsible for reminding physicians to implement orders. Nurses do carry out interventions in response to a physician's order.

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

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? Initial Outcome Discharge Ongoing

Ongoing

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. Set priorities using client care standards. Follow institutional guidelines. Consult with another nurse.

Seek research about the disorder.

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Start from client's knowledge, teach about diet modifications, and check for learning. Answer the client's questions about diet alterations, and then evaluate understanding. Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style.

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

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? Performance criteria Verb (action) Conditions Subject

Verb (action)

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

discharge planning.

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 take my medications between meals for maximum effect." "I will take insulin until my blood sugar levels are normal." "I will test my glucose level before meals and use sliding scale insulin." "I will mix insulin glargine with insulin lispro at bedtime."

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

Which is an example of a nurse-initiated intervention? Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. Administer a 1000-mL soap suds enema. Teach the client how to splint an abdominal incision when coughing and deep breathing. Administer oxygen at 4 L/min per nasal cannula.

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

Which outcome for a client with a new colostomy is written correctly? The client will be able to care for stoma and cope with psychological loss by 3/29/20. The client will know how to care for the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20. Explain to the client the proper care of the stoma by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20.

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

The nurse has omitted the time frame.

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record. The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. The nurse repositions the client to the client's back and documents the intervention in the client's record. The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.

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

involvement of the client and family.