Nursing Process

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis? A) A cluster of several significant cues of data that suggest a particular health problem B) A single, definitive cue that is closely associated with a common diagnosis C) A cue that can be verified by objective, medical data D) A group of related nursing diagnoses that exist within the same NANDA-approved domain

A) A cluster of several significant cues of data that suggest a particular health problem

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."

A) Assessment data about the client should be collected continuously

What is the unique focus of nursing implementation? A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment

A) Client response to health and illness

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? A) Educate the client about the benefits of early mobilization and offer to assist him. B) Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing. C) Show the client the expected outcomes on his clinical pathway that relate to mobilization. D) Document the client's noncompliance and reiterate the consequences of delaying mobilization.

A) Educate the client about the benefits of early mobilization and offer to assist him.

Which example reflects client variables that influence outcome achievement? Select all that apply. A) The client was born with cystic fibrosis. B) The nurse works at a hospital in a diverse community. C) Nursing interventions are consistent with standards of care. D) The client is a college graduate and is employed. E) The client engages in activities associated with Ramadan.

A, D, E

Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

A, D, E

A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the client's vital signs after ambulation. B) Ask the client's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

D) Ask another student to help with ambulation.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

D) Clustering

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A) Explain to the daughter the wishes of the client. B) Arrange a meeting between the physician and daughter. C) Contact the imaging center to schedule the testing. D) Persuade the client to agree to the daughter's request.

A ) Explain to the daughter the wishes of the client

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment B) Personnel C) Equipment D) Patient and visitors

A) Environment Feedback: Providing an environment for the client that is more conducive to privacy and, ultimately, to her elimination needs is necessary in this case. The equipment itself (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client herself are not central to the client's new problem.

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"? A) Etiology B) Problem C) Defining characteristics D) Client need

A) Etiology

An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A) Facilitate communication between the different professionals and attempt to coordinate care. B) Educate the client about the unique scope and focus of each member of the health care team. C) Modify the client's plan of care to better reflect the commonalities between the different disciplines. D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.

A) Facilitate communication between the different professionals and attempt to coordinate care

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment

A) Impaired urinary elimination

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

A) Ineffective airway clearance as evidenced by inability to clear secretions

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem

A) Is written as a two-part statement

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A) My husband has been ill and I don't have anyone to help me care for him. B) I have learned to prepare foods differently so they are low in fat. C) My neighbor walks with me around the neighborhood every morning. D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day.

A) My husband has been ill and I don't have anyone to help me care for him.

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data? A) No problem B) Possible problem C) Actual problem D) Clinical problem

A) No problem

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

A) Notify me right away if the client's systolic blood pressure is 170 or greater.

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

A) Nurse-health care team

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Incorporate subjective and judgmental terminology.

A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked

A) Post-trauma syndrome related to being attacked

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem

A) Presuming to know the factors contributing to the problem

Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed? A) Psychosocial background of clients B) Developmental stage of clients C) Ethical and legal considerations D) Resources

A) Psychosocial background of clients

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care? A) Research findings B) Resources C) Current standards of care D) Ethical and legal guides to practice

A) Research findings

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care

A) Selecting nursing interventions to meet expected outcomes

Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care B) Dependence C) Competence D) Discipline

A) Self-care

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A) Sitting with the client to encourage her to talk B) Telling the laboratory technician to speed up the results C) Calling the physician for an order for an anxiolytic D) Educating the client about reducing risk factors

A) Sitting with the client to encourage her to talk

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.

A) The client is more vulnerable to certain problems than other individuals would be.

Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.

A) The nurse identifies that the client does not tolerate activity.

The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

A) The registered nurse

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe

A) To identify a life-threatening problem

When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

A) Use the client's own words placed in quotation marks

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) Validate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis

A) Validate the nursing diagnosis

A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) disturbed thought processes B) related to C) Alzheimer's disease D) incoherent language

A) disturbed thought processes

Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

A, B, D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."

A, C, D

Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.

A, E; The client's chemotherapy causes him nausea and loss of appetite, The patient has been experiencing fatigue in recent weeks.

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

A- Avelox (moxifloxacin) 400 mg daily Feedback: Among the JCAHO's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drugadministration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommendswriting "daily" in the order.

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes? A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

Ans: A Feedback: A common error made when writing client outcomes includes the nurse expressing the client outcome as a nursing intervention. The other mentioned criteria for writing client outcomes are correct.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

Ans: A Feedback: An example of a long-term outcome is "Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? A) Physiologic B) Safety C) Love and belonging D) Self-actualization

Ans: A Feedback: Because basic human needs must be met before a person can focus on higher-level needs, client needs may be prioritized according to Maslow's hierarchy. Physiologic needs, including the need for oxygen, are the most basic and have the highest priority.

Which intervention does the nurse recognize as a collaborative intervention? A) Teach the client how to walk with a three-point crutch gait. B) Administer spironolactone (Aldactone). C) Perform tracheostomy care every eight hours. D) Straight catheterize every six hours.

Ans: A Feedback: Collaborative interventions are treatments initiated by other providers, such as pharmacists, respiratory therapists, physical therapists, and other members of the health care team. Teaching the client how to walk with crutches would be a collaborative intervention. Administering medications, performing tracheostomy care, and catheterizing a client require a physician's order and are physician-initiated interventions.

A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome? A) "I'm not interested one bit in wearing an artificial hand." B) "I'm worried that I'm going to get some really strange looks when I wear this thing." C) "I don't have a clue how this thing goes on and comes off." D) "I don't understand the technology that's used in this artificial hand."

Ans: A Feedback: It is imperative that interventions and outcomes be valued by the client. The client's resistance to using a prosthesis likely invalidates the outcome that addresses his technique for its use. The other statements express cognitive and affective learning needs that would need to be addressed, but none of those precludes his eventual mastery of the prosthesis.

What common problem is related to outcome identification and planning? A) Failing to involve the client in the planning process B) Collecting sufficient data to establish a database C) Stating specific and measurable outcomes based on nursing diagnoses D) Writing nursing orders that are clear and resolve the problem

Ans: A Feedback: One of the most important considerations in outcome achievement is to encourage the client and family to be as involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability that the outcomes will be achieved.

The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following? A) Psychomotor B) Affective C) Cognitive D) Holistic

Ans: A Feedback: Psychomotor outcomes describe the client's achievement of new skills, such as the safe and aseptic care of a new fistula. Cognitive outcomes are focused on knowledge and effective outcomes address values, beliefs, and attitudes. Outcomes are not classified as holistic.

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following? A) Reduction in the time spent on care planning B) Increased autonomy related to the nursing care planning process C) Enhanced individualization of a care plan D) Increased nursing expertise in care planning

Ans: A Feedback: The benefits of using computerized plans include ready access to a large knowledge base; improved record keeping, with resultant improvement in audits and quality assurance; documentation by all members of the health care team; and reduced time spent on paperwork. Research cautions that computerized systems for client care planning contribute to loss of autonomy, loss of individualization of care, and loss of nursing expertise.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

Ans: A Feedback: The client has successfully met this outcome, and the nurse should note the time and date that it was achieved in the client's plan of care. The outcome should not be removed from the plan of care and it is unnecessary to have the original author of the plan update it. Further observation may or may not be necessary at dinner time, but an evaluative statement should nonetheless be recorded at the present time.

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the healthcare facility. The nurse determines the client's priorities for care using which of the following? A) Assessment skills B) Nursing books C) Client's records D) Supervisor's advice

Ans: A Feedback: The nurse should use assessment skills to determine the priority of nursing care for the client. Books on nursing can give only the theoretical aspect of nursing care. Client's records reveal information about the client's condition but do not convey the client's needs. Advice from supervisors can be taken if confronted with a problem.

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"

C) "ineffective airway clearance related to thick mucus"

The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A) Appropriate staffing B) Effective decision making C) True collaboration D) Skilled communication

Ans: A Feedback: Appropriate staffing ensures that client needs are effectively matched with nurse competencies. In this scenario, the nurse is ill-prepared to care for the client. The nurse needs structured training to learn about the nursing care of portacaths. Skilled communication requires health team members to communicate in a respectful, non-intimidating manner with colleagues. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses, and between nurses and other health team members. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? A) Neither appendicitis nor acute pain B) Both appendicitis and acute pain C) Appendicitis D) Acute pain

C) Appendicitis

The correct sequence of steps for performance improvement is: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change. A) 1, 2, 3, 4 B) 1, 4, 2, 3 C) 4, 1, 2, 3 D) 1, 2, 4, 3 E) 1, 3, 2, 4

Ans: A Feedback: The correct sequence of steps for performance improvement is (1) discover a problem; (2) plan a strategy using indicators; (3) implement a change; and (4) assess the change; if the change is not met, plan a new strategy.

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply. A) They demonstrate the impact that nurses have on the system of healthcare delivery. B) They standardize and define the knowledge base for nursing curricula and practice. C) They limit the number of appropriate nursing interventions to be selected. D) They hinder the teaching of clinical decision making to novice nurses. E) They enable researchers to examine the effectiveness and cost of nursing care.

Ans: A, B, E Feedback: Using NIC/NOC standardized language demonstrates the impact that nurses have on the system of health care delivery; standardizes and defines the knowledge base for nursing curricula and practice; facilitates the selection of appropriate nursing interventions; facilitates the teaching of clinical decision making to novice nurses; enables researchers to examine the effectiveness and cost of nursing care; assists educators to develop curricula that better articulate with clinical practice; assists administrators in planning more effectively for staff and equipment needs; promotes the development and use of nursing information systems; and communicates the nature of nursing to the public.

In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply. A) A client in a long-term care facility who had a stroke B) A client who is recovering from a broken leg C) A client who insists on using the bathroom instead of a bedpan D) A client who appears confused after taking pain medication E) A pregnant client whose contractions are progressing as anticipated

Ans: A, C, D Feedback: The work of setting priorities demands careful critical thinking. When planning nursing care, the nurse should consider the following: Have changes in the client's health status influenced the priority of nursing diagnoses? Have changes in the way the client is responding to health and illness (or the plan of care) affected those nursing diagnoses that can be realistically addressed? Are there relationships among diagnoses that require that one be worked on before another can be resolved? Do several client problems need to be dealt with together.

Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

Ans: A, C, E Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (eat), how well (75%) under what circumstances (not always included), and by when (May 5). Understand and know are vague and are not action-oriented.

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Ans: A- Client complaints of pain Feedback: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A) "How do I best cluster these data and cues to identify problems?" B) "What problems require my immediate attention or that of the team?" C) "What major defining characteristics are present for a nursing diagnosis?" D) "How do I document care accurately and legally?"

Ans: B Feedback: Questions to facilitate critical thinking during outcome identification and planning include those related to setting priorities, such as "Which problems require my immediate attention or that of the team?" and "Which problems are most important to the client?"

Which of the following groups of terms best describes a nurse-initiated intervention? A) Dependent, physician-ordered, recovery B) Autonomous, clinical judgment, client outcomes C) Medical diagnosis, medication administration D) Other health care providers, skill acquisition

Ans: B Feedback: A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

Ans: B Feedback: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician's order. A physician's order is required for the nurse to administer drugs, such as oxygen. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching client how to transfer, assisting with coughing and deep breathing, and monitoring intake and output do not require a physician's order.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A) Evaluate the need for antibiotics. B) Resolve the client's anxiety. C) Provide preoperative education. D) Prepare the client for surgery.

Ans: B Feedback: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow the written plan of care. B) Make recommendations for revising the plan of care. C) Ask another health care professional to design a plan of care. D) State "goal will be met at a later date."

Ans: B Feedback: Client outcomes are meaningless unless the nurse evaluates the client's progress toward their achievement. If the plan is not achieved (not met), recommendations for revising the plan of care are included in the evaluative statement.

A nurse is discharging a client from the hospital. When should discharge planning be initiated? A) At the time of discharge from an acute healthcare setting B) At the time of admission to an acute health care setting C) Before admission to an acute health care setting D) When the client is at home after acute care

Ans: B Feedback: Discharge planning is best carried out by the nurse who worked most closely with the client and family. In acute care settings, comprehensive discharge planning begins when the client is admitted for treatment.

Which of the following is not appropriate in writing client-centered measurable outcomes? A) The client or a part of the client B) A flexible time frame C) Observable, measurable terms D) The action the client will perform

Ans: B Feedback: In writing client-centered measurable outcomes, a target time is required. This target time specifies when the client is expected to be able to achieve the outcome. The other options given (the client or part of the client; observable and measurable terms; the action the patient will perform) are all part of client-centered measurable outcomes.

Which of the following is an example of a well-stated nursing intervention? A) Client will drink 100 mL of water every 2 hours while awake. B) Offer client 100 mL of water every 2 hours while awake. C) Offer client water when he complains of thirst. D) Client will continue to increase oral intake when awake.

Ans: B Feedback: Nursing interventions describe in writing the specific nursing care to be implemented for the client. They include information that answers the questions who, what, where, when, and how.

A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have? A) The written outcomes are designed to meet nursing goals B) To encourage the client and family to be involved C) To discourage additions by other healthcare providers D) Why the nurse believes the outcome is important

Ans: B Feedback: One of the most important considerations in writing outcomes is to encourage the client and family to be involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability the goals will be achieved.

While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes? A) Community Specific Outcomes Classification (CSO) B) The Nursing-Sensitive Outcomes Classification (NOC) C) State Specific Nursing Outcomes Classification (SSNOC) D) Department of Health and Human Resources Outcomes Classification (HHROC)

Ans: B Feedback: Resources for identifying appropriate expected outcomes include the Nursing-Sensitive Outcomes Classification (NOC) (Chart 3-6) and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

Which of the following client outcomes best describes the parameters for achieving the outcome A) The client will eat a well-balanced diet. B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow. C) The client will cleanse his wound with soap and water and apply a dry sterile dressing. D) The client will be without pain in 24 hours.

Ans: B Feedback: The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow possesses all parameters for achieving the outcome.

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority? A) The need to have nutrition B) The need to feel good about oneself C) The need to live in a safe environment D) The need for love from others

Ans: B Feedback: When setting priorities, it is best to first meet the needs that the client believes are most important. In this situation, the woman is not refusing food altogether; rather, she wants to feel good about herself (self-esteem) when she does eat.

What role of the nurse is crucial to the prevention of fragmentation of care? A) Advocate B) Educator C) Counselor D) Coordinator

C) Counselor

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply. A) Professional physicians' organizations B) State Nurse Practice Acts C) The Joint Commission D) The Agency for Health Care Research and Quality E) The Patient Health Partnership

Ans: B, C, D Feedback: To plan health care correctly, the nurse must be familiar with standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. These standards include the law, national practice standards, specialty professional nursing organizations, The Joint Commission, the Agency for Health Care Research and Quality, and employers.

In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Ans: B- Source-oriented record Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians,nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system? A) Kardex care plans B) Computerized plans of care C) Clinical pathways D) Student care plans

Ans: C Feedback: Clinical pathways (critical pathways, CareMaps) are tools used to communicate the standardized interdisciplinary plan of care for clients. The emphasis in case management is on clearly stating expected client outcomes and the specific times targeted to achieve these outcomes.

Which of the following illustrates a common error when writing client outcomes? A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m. B) Client will demonstrate correct sequence of exercises by next office visit. C) Client will be less anxious and fearful before and after surgery. D) On discharge, client will list five symptoms of infection to report.

Ans: C Feedback: Common errors when writing client outcomes include expressing the outcome as a nursing intervention, using verbs that are not observable and measurable (as is done here), and writing vague outcomes (also done here).

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care? A) Problem statement B) Defining characteristics C) Etiology of the problem D) Outcomes criteria

Ans: C Feedback: In contrast to the client goals, which are suggested by the problem statement of the diagnosis, it is the cause of the problem (etiology) that suggests the nursing interventions. Effective nurses select nursing interventions that specifically address factors that cause, or contribute to, the client's problem.

Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

Ans: C Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (ambulate), how well (10 feet), under what circumstances (with a walker), and by when (October 12). Understand is vague and not action-oriented. The outcomes regarding eliminating a stool and self-administering insulin are missing the time frame.

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived? A) The defining characteristics B) The related factors C) The problem statement D) The database

Ans: C Feedback: Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection. B) On discharge, client will be free of infection. C) On discharge, client will be able to list five symptoms of infection. D) During home care, nurse will not observe symptoms of infection.

Ans: C Feedback: To be measurable, outcomes should have a subject (client or part of the client), verb (action to be performed), conditions (not always included), performance criteria (observable, measurable), and target time (to achieve the outcome).

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made? A) Expressed the client outcomes as a nursing intervention B) Wrote vague outcomes that will confuse other nurses C) Included more than one client behavior in the outcome D) Used verbs that are not observable and measurable

Ans: C Feedback: Two client behaviors have been included in the outcome statement: drawing up insulin and identifying four signs and symptoms.

The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation B) Process evaluation C) Outcome evaluation D) Structure evaluation

Ans: C Feedback: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, whereas process evaluation focuses on the nature and sequence of activities carried out by implementing the nursing process. There is no design evaluation.

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: C Feedback: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Psychomotor outcomes describe the client's achievement of new skills.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Ans: C Feedback: The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Ans: C- Client's record Feedback: The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation? A) Kardex B) Case management C) Critical pathways D) Concept map care plan

Ans: D Feedback: A concept map care plan is a diagram of client problems and interventions. The nurse's ideas about client problems and treatments are the "concepts" that are diagrammed. These maps are used to organize client data, analyze relationships in the data, and enable the nurse to take a holistic view of the client's situation (Schuster, 2002).

What is the primary purpose of the outcome identification and planning step of the nursing process? A) To collect and analyze data to establish a database B) To interpret and analyze data so as to identify health problems C) To write appropriate client-centered nursing diagnoses D) To design a plan of care for and with the client

Ans: D Feedback: The primary purpose of outcome identification and planning is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

B) Outcomes

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A) Assessment B) Outcome identification C) Implementation D) Evaluation

Ans: D Feedback: Assessing the client's response to a diuretic medication is an example of evaluation. During assessment, the nurse collects and synthesizes data to identify patterns. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

Ans: D Feedback: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

Ans: D Feedback: Documentation in a timely manner can help avoid errors.

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario? A) No problem B) Possible problem C) Actual problem D) Clinical problem

B) Possible problem

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? A) Assessment B) Diagnosing C) Planning D) Implementing E) Evaluating

Ans: E Feedback: The nurse is collecting evaluative data to determine whether or not the client is achieving the therapeutic response to the bronchodilator.

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family

B) Safety of the immediate enviornment

Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual

B) Technical

What is the focus of a diagnostic statement for a collaborative problem? A) The client problem B) The potential complication C) The nursing diagnosis D) The medical diagnosis

B) The potential complication

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Possible nursing diagnosis D) Wellness diagnosis

B) Actual nursing diagnosis

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the client if visitors should remain in the room. C) Tell the client to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

B) Ask the client if visitors should remain in the room

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. A) Dysphagia B) Bowel Incontinence C) Impaired swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis

B) Bowel Incontinence C) Impaired swallowing D) Impaired Physical Mobility

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation

B) Disturbed body image

Which of the following client care concerns is clearly a nursing responsibility? A) Prescribing medications B) Monitoring health status changes C) Ordering diagnostic examinations D) Performing surgical procedures

B) Monitoring health status changes

What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses

B) Nursing diagnoses

Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

B, D

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

C) "Do you take anything to help your constipation?"

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem? A) "I often have diarrhea after I eat spicy foods." B) "My skin is so dry I just can't keep from scratching." C) "I get out of breath when I walk a few steps." D) "I just feel so bad about myself these days."

C) "I get out of breath when I walk a few steps."

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes

C) Disturbed body image related to the incision scar

Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of healthcare. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

C) Educate the family to be informed and assertive consumers of healthcare

The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) Considering the hearing level of older adults B) Failing to consider visual deficits that occur with aging C) Ignoring the developmental needs of older adults D) Meeting needs for sensory input and exercise

C) Ignoring the developmental needs of older adults

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses? A) Defining the domain of nursing practice B) Informing patients of their care C) Improving communication among nurses D) Structuring curricular content

C) Improving communication among nurses

The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

C) Nurse-client-family

What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

C) Planned nursing actions (interventions) are carried out.

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

C) Respond to the postoperative client's question that baths are given only in the morning.

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client. C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.

C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

C) The nurse transfers responsibility but is accountable for the outcome

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) To collect information about subjective and objective data B) To correlate nursing and medical diagnostic criteria C) To identify etiologies of health problems D) To evaluate mutually developed expected outcomes

C) To identify etiologies of health problems

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

C) Written plans are developed that specify nursing activities for this skill

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a: A) medical diagnosis. B) nursing diagnosis. C) collaborative problem. D) goal for care.

C) collaborative problem.

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply. A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

C, D, E

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you. Do you agree?"

D) "I think fatigue is a problem for you. Do you agree?"

Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care? A) Time management, communication, and establishing a support system. B) Establishing a support system, a sense of humor, and self-awareness. C) Self-awareness, preparation for crisis, and stress management. D) A sense of humor, anticipation of loss, and developing negative body image.

D) A sense of humor, anticipation of loss, and developing negative body image

The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client. B) Failure to approach the client caringly. C) Failure to seek the client's input in the plan of care. D) Failure to provide culturally sensitive care.

D) Failure to provide culturally sensitive care

What characteristic of a competent nurse practitioner enables nurses to be role models for clients? A) Sense of humor B) Writing ability C) Organizational skills D) Good personal health

D) Good personal health

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

D) In the eyes of the law, if it is not documented, it was not done Feedback: Nurses must carefully document each intervention. The legal truth is "if it wasn't documented, it wasn't done."

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.

D) Keep an open mind and trust your intuition when formulating diagnoses.

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? A) Nursing interventions must be consistent with standards of care and research findings. B) Nursing interventions must be culturally sensitive and individualized for the client. C) Nursing interventions must be compatible with other therapies planned for the client. D) Nursing interventions must be approved by other members of the health care team.

D) Nursing interventions must be approved by other members of the health care team.

A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths? A) Nothing; this observation is not important. B) The mother is just behaving as all mothers do. C) A baby is not capable of having strengths. D) Nurturing is a strength for developing infants.

D) Nurturing is a strength for developing infants.

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

D) Risk for body image disturbance

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify? A) The expected outcome of the plan of care B) A cue to determining a health problem C) The major defining characteristic of a health problem D) The health state or problem of the client

D) The health state or problem of the client

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe

D) To be sure the intervention is safe

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths

D) To establish a database to identify problems and strengths

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach

A) Auscultation of the lungs

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.

A) Clarify discrepancies of assessment data with the client

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client's wife B) Medical documents C) Test results D) Assessment data

A) Client's wife

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.

A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model

A) Human needs (Maslow) model

The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery

A) Information regarding the client's gait

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.

A) Measure the client's oral temperature

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

A) Sharp pain in the knee

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.

A) The client's airway should be assessed

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.

A) The nurse should practice interviewing strategies

Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

A, B, E A nurse working in a physician's office puts out a sign-in sheet for incoming clients.; Two nurses are overheard talking about a client through the door of an empty client room; A nurse calls out the name of a client who is seated in the waiting room. Feedback: Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.

A, B; A client has trouble reading an informed consent, but states he does not need glasses; An elderly client explains that the black and blue marks on his arms and legs are due to a fall.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

A- Vulnerability to legal liability since nurse's safe, routine care is not recorded Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required. B) Learn to give quality care during designated work period. C) Use a team conference to develop a consistent plan of care. D) Educate the client to become an assertive health care consumer.

Ans: A Feedback: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting? A) Retrospective evaluation B) Peer review C) Nursing audit D) Concurrent evaluation

Ans: A Feedback: A retrospective audit uses post-discharge questionnaires to collect data. A nursing audit is a method of evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care (or the process by which these outcomes were achieved). Concurrent evaluation involves direct observations of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is done for the purpose of professional performance improvement.

The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, "I refuse to admit defeat." This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague's incompetent practice? A) Report the nurse's practice and have the nurse manager address the matter. B) Encourage the nurse to attend an in-service on IV starts. C) Reassure the nurse that this is a difficult skill and give her feedback on her performance. D) Document an unmet outcome in the client's plan of care.

Ans: A Feedback: According to the study Silence Kills: The Seven Crucial Conversations for Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler, 2005), an appropriate response to incompetence is to report the matter and enlist the manager to conduct follow-up. Reassuring the nurse and encouraging education are not sufficient responses to incompetence. This action does not constitute an unmet outcome on the part of the client.

A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met B) Outcome partially met C) Outcome not met D) Outcome inappropriate

Ans: A Feedback: After data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings. The three decision options are met, partially met, and not met. In this case, the nurse's judgment is that the client has met the expected outcome of smoking cessation.

The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: A Feedback: An affective outcome involves changes in the client's values, beliefs, and attitude, such as participating in water aerobics. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011." Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate? A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids" B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate." C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation." D) "12/14/2011 Outcome met."

Ans: A Feedback: An evaluative statement should include both the decision about how well the outcome was met along with data that support this decision. Characterizing the client's ambulation as "inadequate" is not sufficiently precise. Stating that this outcome was met with the use of a cane contradicts the original terms of the outcome.

A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A) Discover the problem. B) Plan a strategy. C) Implement a change. D) Assess the change.

Ans: A Feedback: Each nurse must decide how to respond when he or she perceives that client care is being compromised. The four steps listed are all components of the process of performance improvement, with discovering the problem being the first step.

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit. B) Use them to identify deficient workers for removal or demotion. C) Cross-reference them with client satisfaction reports from the unit. D) Use them to identify individuals who would benefit from probationary measures.

Ans: A Feedback: It is most beneficial for the manager to frame incident reports as sources of improvement, which can improve both client care and the work environment. Punitive follow-up by demotion, probation, or removal is likely to create reluctance among staff to complete incident reports. Cross-referencing incident reports with client satisfaction reports is unlikely to result in substantial improvements to the unit's care and culture.

Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire. B) Direct observation of nursing care. C) Client interview during hospitalization. D) Review of client's chart during hospitalization.

Ans: A Feedback: Retrospective evaluation may use postdischarge questionnaires and client interviews, or chart reviews after the client has been discharged. Concurrent evaluation occurs while the client is receiving care and may include the following: direct observation of nursing care and client interviews; and direct observation of chart reviews during hospitalization.

The nurse has responded to a client's request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care? A) Information B) Science C) Cooperation D) Individualization

Ans: A Feedback: The Institute of Medicine's Committee on Quality Health Care in America has identified aspects of care that clients can reasonably expect. One of these expectations is information, which is manifested by allowing clients access to their medical records. Other characteristics that clients can expect are knowledge-based care (science), coordination between professionals (cooperation), and respect for client choices and preferences (individualization).

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

Ans: A Feedback: The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client. B) Collect information on abnormal functions. C) Identify the client's health-related problems. D) Select appropriate nursing interventions.

Ans: A Feedback: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

Which client outcome is a physiologic outcome? Select all that apply. A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

Ans: A, B, C Feedback: Physiologic outcomes are physical changes in the client, such as pain ratings and blood pressure and HA1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection.

Which activity does the nurse engage in during evaluation? Select all that apply. A) Collect data to determine whether desired outcomes are met. B) Assess the effectiveness of planned strategies. C) Adjust the time frame to achieve the desired outcomes. D) Involve the client and family in formulating desired outcomes. E) Initiate activities to achieve the desired outcomes.

Ans: A, B, C Feedback: The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage. During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes.

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) gt (greater than)

Ans: A, B, E Feedback: The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply. A) Base care on continuous healing relationships. B) Customize care based on available resources. C) Keep the nurse as the source of control. D) Share knowledge and allow for free flow of information. E) Practice evidence-based decision making.

Ans: A, D, E Feedback: The Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) suggests 10 new rules to redesign and improve care: (1) care based on continuous healing relationships, (2) customization based on client needs and values, (3) the client as the source of control, (4) shared knowledge and the free flow of information, (5) evidence-based decision making, (6) safety as a system property, (7) the need for transparency, (8) anticipation of needs, (9) continuous decrease in waste, and (10) cooperation among clinicians.

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

Ans: A- "Client complaining of abdominal pain rated at 8/10." Feedback: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? A) Continue the plan of care with the aim of helping the client achieve the outcomes. B) Terminate the plan of care since it does not accurately reflect the client's abilities. C) Modify the plan of care to better reflect the client's current functional ability. D) Replace the client's individualized plan of care with a clinical pathway.

Ans: A- Continue the plan of care with the aim of helping the client achieve the outcomes. Feedback: Nurses regularly evaluate clients' progression toward the achievement of outcomes that are specified in plans of care. When clients need more time to achieve desired outcomes, it is appropriate to continue with the existing plan of care. It is not necessary to terminate the plan of care and modification may be premature. Abandoning the plan and replacing it with a clinical pathway is counterproductive to the continuity of care.

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Ans: A- Data, information, knowledge Feedback: According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA,2001, p. vii).

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Ans: A- Information is documented in separate forms by each health care personnel. Feedback: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

Ans: A- Means of identifying risks Feedback: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Ans: A- Narrative notes Feedback: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Ans: C- Individualize it to the specific client. Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) Focus charting

Ans: A- Problem-oriented medical record (POMR) Feedback: The POMR is organized around a client's problems rather than around sources of information. With POMRs, all healthcare professionals record information on the same forms. The advantages of this type of record are that the entire healthcare team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care. B) Modify the plan of care. C) Continue the plan of care. D) Re-evaluate the plan of care.

Ans: A- Terminate the plan of care. Feedback: The nurse will terminate the plan of care when each expected outcome has been achieved. Modifying the plan of care is necessary if there are difficulties in achieving the outcomes. Re-evaluating each step of the nursing process is a step in the modification of a plan of care. Continuing the plan of care occurs if more time is needed to achieve the outcomes.

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

Ans: A- Writing the client's name on the student care plan Feedback: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

Ans: B Feedback: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self administer the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection B) Asking the client to demonstrate self-injection of insulin C) Asking family members how much trouble the client is having with injections D) Asking the client how comfortable he or she is with injections

Ans: B Feedback: Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill.

When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client's needs, the charge nurse is performing an evaluation termed ... A) process evaluation B) structure evaluation C) outcome evaluation D) summary evaluation

Ans: B Feedback: Structure evaluation focuses on the attributes of the setting or surroundings where health care is provided.

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured. B) The colleague should inform the nurse that a full report of the incident needs to be made. C) The colleague should monitor the client closely for any adverse effects of the fall. D) The colleague should report the incident in a peer review of the nurse.

Ans: B Feedback: The colleague should tell the nurse that a full report needs to be made. If appropriate, the colleague could help the nurse identify what contributed to her not raising the bed railings in an effort to prevent it from happening in the future.

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

Ans: B Feedback: The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is non therapeutic.

Which activity does the nurse perform during the evaluating stage? Select all that apply. A) Validates with the client the problem of constipation. B) Collects data to determine the number of catheter-associated infections on the nursing unit. C) Increases the frequency of repositioning from every two hours to every one hour. D) Sets a goal of ambulating from bed to room door and back to bed. E) Identifies smoking and sedentary lifestyle as risk factors for hypertension.

Ans: B, C Feedback: During the evaluation stage, the nurse modifies the plan of care if desired outcomes are not achieved (increased frequency of repositioning) and collects data, such as number of infections, to monitor quality and effectiveness of nursing practice. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, such as smoking and sedentary lifestyle, and validates the identified health problems (such as constipation) with the clients. The nurse establishes plan priorities and sets goals with the client and family during the outcome identification and planning.

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flowsheet C) Narrative note D) SOAP note

Ans: C- Narrative note Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation? Select all that apply. A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered. B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home. C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems. D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions. E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.

Ans: B, C, D Feedback: The following items are good advice for nurses experiencing burnout: Learn to give quality care during designated work period; leave on time; avoid the temptation to do the work of others; and leave work concerns at work. After establishing a reputation for delivering quality nursing care, seek creative solutions for nursing problems (strategies to increase nursing resources, motivation, morale) and try them — hopefully with a support network. View concerns as challenges rather than overwhelming obstacles. Develop a realistic sense of how much nursing care (and of what quality) can be delivered with existing resources. If resources do not permit quality care, explore change strategies within the institution. If administration is not supportive, explore other practice settings.

In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

Ans: B, C, E Feedback: A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or post procedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

Ans: B- A. Jones, RN Feedback: Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Ans: B- Charting by exception Feedback: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Ans: B- Intervention carried out Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flowsheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

Ans: B- May be up as desired Feedback: The abbreviation "up ad lib" means the client may be up as desired.

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

Ans: B- Minimum data set Feedback: Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for theassessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home healthcare industry.

Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift."

Ans: C- "Following oxygen administration, vital signs returned to baseline." Feedback: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C- Problem selected Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organize entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

The client's expected outcome is "The client will maintain skin integrity by discharge". Which of the following measures is best in evaluating the outcome? A) The client's ability to reposition self in bed. B) Pressure-relieving mattress on the bed. C) Percent intake of a diet high in protein. D) Condition of the skin over bony prominences.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.

An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation? A) A 10% reduction in the number of ventilator-associated pneumonia B) A 5% increase in the number of nosocomial catheter-related urinary tract infections C) 40% of all client rooms in the facility are private and equipped with a computer D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.

Ans: D Feedback: Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as the number of ventilator-associated pneumonia and nosocomial catheter-related urinary tract infections. Structure evaluation focuses on the environment in which care is provided, such as the number of private rooms equipped with a computer.

When a nursing supervisor evaluates the staff nurse's performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation

Ans: D Feedback: Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent.

The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered. B) Client identifies signs and symptoms of recurrence of infection. C) Client coughing and deep breathing every one hour. D) Client no longer requires oxygen.

Ans: D Feedback: The client who is maintaining adequate oxygenation would not require oxygen. The client could be able to do the other three options and still have problems with oxygenation.

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

Ans: D Feedback: The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D- Cross out the incorrect statement with a single line. Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Ans: D- Graphic record Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Ans: D- Nursing care rounds Feedback: Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client's bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

Ans: D-"Client states pain is a 9 on a scale of 1 to 10." Feedback: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations ofbehavior, generalizations, and words such as "good."

Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."

B) "Can you think of anything else you would like to tell me?"

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

B) Focused

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

B) Focused assessment

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

B) Focused assessment

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

B) Nausea

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

C) "Mr. Koeppe, tell what you do to take care of yourself"

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

C) "Tell me more about what caused your pain"

The nurse is reviewing information about a client and notes the following documentation "client is confused". The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data

C) An inference

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin

C) The nurse asking if the client is having pain

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency

C) Time-lapsed

Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

C) nausea, abdominal pain

A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia

C, D, E; Using the nursing process to diagnose a blocked airway, Interviewing privately a client suspected of being a victim of abuse, Checking with the family about the data supplied by a client suffering from dementia

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

D) "Unable to palpate femoral pulse in left leg"

What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care

D) To plan appropriate nursing care

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

D) sitting at a 45-degree angle to the bed